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Ann Thorac Surg 1996;61:1664-1665
© 1996 The Society of Thoracic Surgeons
DR ROBERT W. EMERY (Minneapolis, MN): Doctor Calafiore, I congratulate you, your co-investigators, and your colleagues who are bringing us back to the future. We, at the Minneapolis Hearts Institute, began a program of minimally invasive bypass operations 6 months ago and have completed single- or double-vessel procedures in 25 patients via left anterior thoracotomy, right anterior thoracotomy, or a ministernotomy with results comparable with yours. I have found the operation to be easier on the patients but more difficult for the surgeon.
Because of some concern around construction of the anastomosis, we have documented anastomotic patency in the operative field using a thermal imaging camera (OPGAL, Jerusalem, Israel). The camera is directed to the anterior surface of the heart, a large black area gently cooled with topical iced saline solution around the distribution of the LAD after removal of the distal occluding clip on the LAD. The serrafine clip on the mammary artery, and the proximal LAD occluder are in place.
After release of the LIMA occluder, a white streak in the middle of the field demonstrates warm blood flowing from the internal mammary artery into the cooled heart, assuring intraoperatively the patency of the anastomosis. This has offered us confidence in an aggressive approach to continue this program.
Your pioneering efforts are greatly appreciated.
DR CALAFIORE: Thank you very much.
DR LAWRENCE I. BONCHEK (Lancaster, PA): I too congratulate Dr Calafiore and associates on their innovative and superior results. My colleagues and I have been interested in this procedure, but before initiating an approach that inevitably involves certain compromises, we thought it important to review our experience with conventional isolated internal mammary artery grafting of the LAD.
Since 1983 we have had experience with 168 patients. Importantly, 16% were operated on emergently for percutaneous transluminal coronary angioplasty failure (of a total of 35 patients who had emergency operation). Elective operation was performed in only 21% of the patients. The postoperative length of stay in 1995, which reflects the recent trend toward shorter hospital discharge and is much more relevant than our earlier experience, was 4.4 days. The average hospital cost for elective patients in 1995, which I consider comparable with the type of patient who would undergo this procedure, was $8,300. There were no deaths and no strokes. The rate of reoperation for bleeding was 1%. One deep sternal infection and two perioperative infarctions occurred, and only 5 patients needed inotropic support at any time postoperatively.
I want to emphasize that these results are not presented in the spirit of controversy; rather, we hope that these results will be a useful benchmark against which to compare less invasive operations. We would not wish to compromise the long-term results of an operation that has proved to be the best that we can do, namely, conventional internal mammary artery to the LAD, merely for the sake of convenience.
I have two questions, among many others that I could ask. We know that even small thoracotomies can cause chronic pain. What has been your experience in this regard?
Second, what is your approach to patients who have a stenosis in a high diagonal branch of the LAD that may be out of your surgical field? Is there a temptation to minimize such lesions to avoid a sternotomy?
DR CALAFIORE: In our series we had no patient with chronic pain; however, the number of patients is not sufficient to generalize.
In a patient with a stenosis of an important diagonal branch, we perform a median sternotomy; the LAST operation is not suitable for all the patients. But, if possible, a percutaneous transluminal coronary angioplasty of the diagonal branch after a successful LIMA–LAD anastomosis can be scheduled. This staged approach was done in our institution in some selected cases with good results. Furthermore, this can be a good point of meeting with cardiologists.
DR LEONARDO LIMA (Paris, France): I congratulate Dr Calafiore on his excellent paper. I would like to make a few comments and ask several questions.
My colleagues and I had a patient who was operated on using the same technique and who in fact could not be discharged from the intensive care unit as he continued to have angina. A repeat angiogram showed no anastomotic stenosis and no supraclavicular stenosis. However, a large collateral branch issuing from the LIMA was confirmed by Doppler to be the origin of a steal syndrome. He was discharged in good health after a second intervention, during which the collaterals were ligated.
In La Pitie Hospital (Paris), along with Dr Nataf and Prof Gandjbakhch, we have used another approach to this particular kind of patient. In our opinion, it is important to harvest the LIMA by a thoracoscopic approach as this method produces a mammary artery of just the correct length, with no kinking and no steal syndrome. It is not a difficult technique, only requiring 20 minutes. The thoracotomy required is minimal (4 cm) and the bypass graft can be carried out on the beating heart without cardiopulmonary bypass.
In certain cases, we consider myocardial protection to be essential. This is achieved by means of an intracoronary shunt. We have operated on 14 patients using these techniques with good results in all cases.
I have two questions. First of all, in your series you state that 10% of your patients do not have a mammary artery of sufficient length and in these cases you have performed a LIMA–epigastric artery anastomosis before epigastric–LAD anastomosis. Do you think that the epigastric artery will provide the same long-term results as the LIMA?
Second, kinking seems to be a problem in this kind of patient. How may it best be avoided?
DR CALAFIORE: The mammary artery in some patients is not enough long to reach a very lateral LAD. As we routinely use inferior epigastric artery for coronary artery bypass grafting, it is very easy for us to harvest this conduit to lengthen the mammary artery. We think that this is an easy and safe technique to reach the LAD in every position. For this reason I am not concerned about the length of the mammary artery.
Kinking of the mammary artery was, of course, one of the steps in our learning curve. With increasing experience, we can modulate the length of the LIMA according to the LAD position.
No patients in this series had a steal syndrome. Even if some anecdotal cases are reported, the steal syndrome is not a real problem.
DR VALAVANUR A. SUBRAMANIAN (New York, NY): I congratulate Professor Calafiore for superb clinical results of a large series of this operation in a very short time. When my colleagues and I introduced this operation in April 1994 we had one concept in our mind; this is a different operation than the traditional midline sternotomy off-pump cardiopulmonary bypass. In fact, the first operation I did off pump was a minithoracotomy bypass.
When we performed a midline sternotomy incision for conventional coronary bypass, it occurred to us that we were perhaps approaching the left coronary system from a wrong incision, because the left side of the coronary arterial system is on the left side of the chest. Therefore, the anterior portion of the pericardium and the mediastinal structures in the anterior thoracotomy are preserved as the heart is much closer to the surface and the anastomosis is easier. I still have concern regarding the wider population of surgeons who are going to embark on this operation. The two important technical points of this operation are the length of the mammary artery and the actual meticulous performance of the anastomosis on a beating heart. We believe that it is important to have enough length of the mammary artery, and we have been excising the fourth costal cartilage routinely. I have one question to Dr Calafiore: You had an 8.3% incidence of inferior epigastric artery use. Is it because of the too laterally placed LAD or is it because the length of the mammary artery is not enough in that incision?
The second point is, how can we make the anastomosis in this operation more comfortable and easier to do so that it could be applied widely to the cardiac surgical community? We are working on several ways to immobilize the coronary artery. A mechanical stabilization platform, as proposed by the Utrecht group, is one direction we are currently assessing. We are also looking at some pharmacologic maneuvers to stop the heart momentarily to place the key heel and toe sutures in the LAD. I do not think that there is going to be a tremendous amount of evolution of this part of the operation to make this safer for most of the cardiac surgeons. Until we do that, this operation is going to continue to be limited to a few technical experts.
DR CALAFIORE: The necessity to elongate the LIMA with an inferior epigastric artery was due to a lateral LAD.
DR SUBRAMANIAN: Do you have any suggestion to slow the heart rate or make it so perfect that we can do the anastomosis easier? Raising the comfort level of the anastomosis is very important for this operation to be widely practiced.
DR CALAFIORE: I agree with you.
DR FEDERICO BENETTI (Santa Fe, Argentina): I congratulate Dr Calafiore for the nice presentation. I have only two comments. First, we prefer to go more lateral. There is a direct relationship between using the scope and the length of the incision in our experience. Also, we prefer to take all of the length of the mammary artery and clip all the branches because we need to reproduce the same situation that you have with the sternotomy. If we have a good immediate patency rate, we assume that is the same situation in normal coronary operations in the long term.
Second, I think that it is very important for the average surgeon to train, to do some cases by a sternotomy without a pump. I notice in this period of time that the surgeons who have been trained before without a pump perform the procedure more comfortably.
DR NOEL L. MILLS (New Orleans, LA): I might just make a short comment. I think we are all very interested in this technique. It has drawn a lot of interest, and we're looking at it carefully. I think we have to be careful not to abdicate our responsibility of performing a complete revascularization with this procedure, thereby urging the cardiologist to do more angioplasties on vessels that can be reached by this approach. Issues of cost containment should not dictate what may not be best for our patients in the long run.
DR CARY W. AKINS (Boston, MA): In cardiac surgery and, indeed, in angioplasty incomplete revascularization has been clearly identified as a main contributor to higher hospital morbidity and mortality and long-term complication rates. If you are going to make the argument that this can be applied as a "culprit lesion" approach to people with multiple vessel disease, it seems to me that you need longer follow-up. Second, if you have a significant amount of anastomotic irregularities, which seemed to me in one group to be about 10%, if you are going to focus your operation on the LAD, then the LAD operation has to be done right.
DR CALAFIORE: No, it is not 10%. It is 4%.
DR AKINS: In one group that was followed up by both echocardiography and angiography, you have documented this.
DR CALAFIORE: In the early postoperative period we follow up the patients only with Doppler flow evaluation. We reserve angiography only to those cases where the Doppler echocardiography shows only a systolic pattern or doubtful flow. The percentage of occluded anastomoses in this group is higher because of selection of patients.
Related Article
Ann. Thorac. Surg. 1996 61: 1658-1663.
This article has been cited by other articles:
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  H. Hirose and A. Amano Stroke Rate of Off-pump Coronary Artery Bypass; Aortocoronary Bypass Versus in-Situ Bypass Angiology, November 1, 2003; 54(6): 647 - 653. [Abstract] [PDF]
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