Dear Editor, With great interest, I read the article by Flécher et al1 and congratulate them on the quality of the review carried out on the history of surgical treatment of cardiac wounds. It is an exciting topic, so I would like to briefly comment on some facts narrated in this work.The well-known surgical approach to the heart, described by Larrey in the subxiphoid region, should not be placed in a close historical relationship with the pericardiotomy he performed in 1810 through a thoracotomy. It was not until 1824 that, after treating a soldier who had suffered a penetrating wound between the xiphoid appendix and the 7th costal cartilage, the French surgeon began experimenting on cadavers in search of a faster route to the heart. In 1829 he proposed his oblique subcostal incision which is currently practically not used.2During Milton’s service in Egypt, he surely performed several thoracic surgeries in extremis situation, but there is no evidence to support the claim that median longitudinal sternotomy (MLS) was created during an emergency approach3 or that has been designed for this type of procedure. When he decided to operate on a living human being on January 25, 1897, he used it for an elective total sternectomy in a patient with sternal tuberculosis and ruled out its use in patients with true mediastinal tumors, who needed more urgent surgeries.On the other hand, it can hardly be said that MLS is currently the gold standard for cardiac surgeons to safely and quickly manage a cardiac stab wound. In patients such as those shown in the article,1 an approach using a MLS would be very difficult since lateral mobilization of the costal wall during the necessary separation of the two halves of the sternum would displace the knife, causing probably fatal bleeding.In the emergency room, the gold standard for quickly managing a penetrating cardiac injury is anterolateral thoracotomy in the fifth intercostal space. A 1906 article on experimental surgery in dogs has led some authors to mistakenly consider Spangaro to be the creator of this incision.4 They forget that in 1893 Daniel Hale William performed his famous pericardioraphy (the second in history) precisely using that approach.5References1. Flécher E, Leguerrier A, Nesseler N. An odyssey of suturing cardiac wounds: Lessons from the past. J Card Surg. 2020;35(7):1597-9.2. López de la Cruz Y, Quintero Fleites YF. Modifications to the classic simple-longitudinal inferior pericardiotomy (Sauerbruch technique). CorSalud. 2019;11(3):225-32.3. Milton H. Mediastinal Surgery. Lancet. 1897;1:872 - 5.4. Pust GD, Namias N. Resuscitative thoracotomy. International Journal of Surgery. 2016;33:202-8.5. Buckler H. Doctor Dan. Pioneer in American surgery. Boston: Little, Brown and Company; 1954.Correspondence: “July 26” Ave., No. 306, Apt. 18. Santa Clara. Villa Clara. Cuba. Postal code: 50 200. E-mail:
Dear Editor,With great interest, I read the article by Yim and associates1 and congratulate them for the quality of the review carried out on the internal mammary artery harvesting techniques. However, I would like to help clarify some aspects specifically related to the history of this procedure.The skeletonized IMA harvesting technique is usually considered to be newer than pedicle dissection. Actually, when Arthur Vineberg first implanted an IMA in a human heart in 1950, he only separated the arterial vessel from the chest wall. For more than a decade, only arteries were implanted according to Vineberg’s proposed method, and it wasn’t until the early 1960s that William Sewel proposed implanting a pedicle into the myocardium, that also contained the internal mammary vein and other tissues (”pedicle operation”) with the intention of draining excess blood and avoiding the formation of myocardial hematomas.2It is also incorrect to claim that skeletonized IMA harvesting was introduced due to concerns offered by reduced sternal blood flow and potential mediastinitis. In January 1972, David Galbut and his group introduced systematic skeletonized harvesting into their series of patients revascularized with bilateral internal mamary arteries, some time before that procedure began to be linked with deep sternal wound infections. Galbut probably only took advantage of obtaining longer arteries and easier construction of sequential anastomoses.2Furthermore, when Cunningham first described the IMA’s skeletonized harvesting technique in 1992 he specified that to avoid thermal injury to the artery, it was extremely important to keep the cautery setting on low throughout the dissection.3 After this advice, smoke never seems to have been a concern for surgeons, so it was hardly the reason for the introduction of harmonic technology in IMA dissection, which was also initially used in the “open harvesting” technique.4Finally, I consider it curious that this review does not include the semiskeletonization technique, introduced in 19975 and currently used by various groups.References1. Yim D, Wong WYE, Fan KS, Harky A. Internal mammary harvesting: Techniques and evidence from the literature. J Card Surg. 2020;35(4):860-7.2. López de la Cruz Y, Nafeh Abi-Rezk M, Betancourt Cervantes J. Internal mammary artery harvesting in cardiac surgery: an often mistold story. CorSalud. 2020;12(1):64-76.3. Cunningham JM, Gharavi MA, Fardin R, Meek RA. Considerations in the skeletonization technique of internal thoracic artery dissection. Ann Thorac Surg. 1992;54(5):947-50.4. Higami T, Kozawa S, Asada T, Shida T, Ogawa K. Skeletonization and harvest of the internal thoracic artery with an ultrasonic scalpel. Ann Thorac Surg. 2000;70:307-8.5. Horii T, Suma H. Semiskeletonization of Internal Thoracic Artery: Alternative Harvest Technique. Ann Thorac Surg. 1997;63:867-8.Note: The author of this manuscript is not an employee of any agency of the Cuban government; he is only a cardiovascular surgeon in a public hospital. The author of this manuscript also does not represent the Cuban government in relation to this “letter to the editor”.