SYNOPSIS
       The authors describe their experience in 25 patients with the right gastroepiploic artery (RGEA) for bypass of the right coronary artery (RCA) without using cardiopulmonary bypass or full sternotomy. Eleven patients had only RCA disease (RGEA graft) and the remaining 14 patients had LAD disease (LITA graft and RGEA-RCA graft). 5/25 patients required a saphenous vein interposition graft to achieve adequate length to reach the coronary artery and one of these five had an inferior epigastric artery interposition graft to the LITA as well. No heart stabilization device was used. There was no mortality. Postoperative angiograms were accomplished in 23/25 patients; 19 (82.6%) RGEA and all LITA grafts were patent. The authors conclude that the indications for MIDCABG can be effectively extended to patients with LAD and RCA disease through the use of LITA and RGEA grafts.

COMMENTARY
       The authors demonstrate the technical feasibility of using the RGEA to bypass the distal RCA on a beating heart without a stabilizing device. One might debate the minimally invasive nature of an operation requiring a laparotomy and partial sternotomy in 5 patients, the addition of an anterior thoracotomy with the removal of the 4th costal cartilage in 14 patients, and the need to extend the length of the conduit with an interposition graft in 5 patients. The long term effect on patency of grafts lengthened with saphenous vein are not known. One of the reported advantages over the RIMA is the increased length of the RGEA in reaching distal RCA branches.
       If an interposition graft is required to achieve adequate length of the RGEA, then why not use the RIMA? The RGEA is, however, a reasonable option that deserves consideration in planning the MIDCABG approach best suited for each individual patient.