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Ann Thorac Surg 1996;62:591-593
© 1996 The Society of Thoracic Surgeons

Case Report

Revascularization Using Angioplasty and Minimally Invasive Techniques Documented by Thermal Imaging

Robert W. Emery, MD, Ann M. Emery, RN, Thomas F. Flavin, MD, Mark D. Nissen, MD, Michael R. Mooney, MD, Kit V. Arom, MD, PhD

Cardiac Surgical Associates, Minneapolis, Minnesota

Accepted for publication February 29, 1996.


   Abstract
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 Footnotes
 Abstract
Introduction
 Comment
 References
 
Minimally invasive direct coronary artery bypass grafting offers mortality and morbidity advantages to selected patients. To broaden indications for such, an appropriate and combined disciplinary approach using angioplasty and minimally invasive direct coronary artery bypass grafting is described in a patient requiring reoperative grafting. Documentation of patency of new left internal mammary artery-to-left anterior descending artery anastomoses performed without the use of cardiopulmonary bypass was obtained intraoperatively using a Thermal Imaging Camera.


   Introduction
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 Abstract
 Introduction
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Following reports of significant series of patients undergoing coronary bypass grafting without the use of cardiopulmonary bypass (CPB), approaches to coronary bypass using smaller incisions have been developed, such that minimally invasive direct vision bypass (MIDCAB) techniques are being used more frequently [1]. This process is rapidly evolving, and multiple approaches, customized to the individual patient, have been reported [2–5]. These approaches are limited such that, most commonly, those vessels on the anterior surface of the heart and those to which the internal mammary artery is accessible may be bypassed. Patients with disease of vessels on the posterior aspect of the heart, or lesions distal to areas of arteries into which grafts may be placed, are currently not candidates for a minimally invasive approach. Further, with operation via the MIDCAB approach being performed on the beating heart without the use of CPB, a technically more difficult procedure is expected, and there is no way to accurately document patency of the newly applied graft, once in place. This report serves to describe a case in which a cross-disciplinary approach was used to complete revascularization and to operatively document effective bypass grafting.

A 74-year-old woman presented with progressive angina pectoris (New York Heart Association class IV); she had undergone coronary bypass grafting 10 years prior with saphenous vein grafts to the left anterior descending artery (LAD) and the circumflex marginal branch. Angiography revealed total occlusion of the native LAD with occlusion of the previously placed saphenous vein graft. There was a widely patent saphenous vein graft to a large obtuse marginal branch, and the dominant right coronary artery did not contain disease. A circumflex coronary extension in the atrioventricular groove feeding the posterolateral ventricular wall had a high-grade lesion (Fig 1AGo). To avoid full reoperation in this fragile elderly woman, we undertook a combined approach to therapy. Angioplasty was performed on the circumflex artery (Fig 1BGo). Three days later, MIDCAB, placing the left internal mammary artery to the LAD without the use of CPB, was performed via a left anterior thoracotomy using an interrupted suture technique described previously [5]. After completion of the coronary anastomosis, but before release of an occluding Serrefine clip on the IMA, the surface of the heart was cooled with topical saline solution. An IVA-2000 Thermal Imaging Camera (Opgal, Kermail, Israel) was focused on this area of the heart and the clip was released, allowing flow through the anastomosis into the LAD. As can be seen in Figures 2AGo through 2CGo, there was immediate filling of the LAD with progressive warming of the cool portion of the heart, indicating flow through the bypass graft. The patient was extubated 1 hour postoperatively and transferred from the intensive care unit with monitoring lines and the chest tube discontinued the evening of the operation. She was discharged from the hospital on her third postoperative day, asymptomatic.



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  		Fig 1. . (A) High-grade lesion of the circumflex coronary artery lying in the atrioventricular groove. (B) Circumflex coronary artery after successful angioplasty.

 


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  		Fig 2. . (A) Thermal image of the anterior surface of the beating heart through a small anterior thoracotomy. The black portion of the figure indicates myocardium locally cooled with iced saline solution. (B) The white line in the upper right corner indicates the flow of warm blood via the newly constructed left internal mammary artery-to-left anterior descending artery anastomoses immediately after removal of the occluding Serrefine clip. (C) The following frame 1 second later indicates further rewarming of the heart by the flow of warm blood from the left internal mammary artery.

 

   Comment
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 Abstract
 Introduction
 Comment
References
 
The performance of bypass grafting without the use of CPB, through a limited incision, is becoming more common and has gained media attention early in its development. The complications of CPB are well-known, and in selected patients regional ischemia can be induced for a period of time to perform an anastomosis without untoward effect [1, 3]. A minimally invasive approach is highly desirable, particularly in elderly patients and in reoperative patients, where increased risk to the effects of the operative procedure and cardiopulmonary bypass have been documented [6]. In the reported case, combined techniques of angioplasty and MIDCAB allowed the patient revascularization and recovery with a shortened postoperative course, and without the complications of CPB. The use of the Thermal Imaging Camera documented patency of the bypass graft, in spite of the increased technical difficulty of working with the beating heart. Subramanian and associates [3] recently reported 96 patients having MIDCAB without CPB. Of 63 patients studied angiographically postoperatively, 3 had occluded grafts and required reoperation; this is consistent with left internal mammary artery graft loss in routine coronary operations when performed on CPB in a larger prospective study [7]. Diagnosis of graft occlusion at the completion of the procedure may have eliminated the need for reoperation by correction of the anastomosis at the original procedure. A prior report on the use of intraoperative thermal imaging indicated an effect on operative decision-making in nine instances, in 8 of 50 patients (16%) studied. Revision of grafts or placement of additional bypass grafts indicated the further usefulness of such an imaging device [8]. The use of a simple technique such as thermal imaging to document graft patency, coupled with cross-disciplinary techniques, may increase the applicability of minimally invasive procedures to higher-risk patients, obviating certain aspects of morbidity from the procedure and allowing broader application of MIDCAB techniques.


   Footnotes
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 References
 
Address reprint requests to Dr Emery, Cardiac Surgical Associates, PA, 920 E 28th St, Suite 420, Minneapolis, MN 55407.


   References
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 References
 

  1. Benetti FJ, Naselli G, Wood M, Geffner L. Direct myocardial revascularization without extracorporeal circulation. Chest 1991;100:312–6.[Abstract/Free Full Text]
  2. Robinson MC, Gross DR, Zeman W, Stedje-Larsen G. Minimally invasive coronary artery bypass grafting: a new method using an anterior mediastinotomy. J Cardiac Surg 1995;10:529–36.[Medline]
  3. Subramanian VA, Sani G, Benetti FJ, Calafiore AM. Minimally invasive coronary bypass surgery: a multi-center report of preliminary clinical experience [Abstract]. Circulation 1995;92(Suppl 1):645.
  4. Stanbridge R, Symons GV, Banwell PE. Minimal-access surgery for coronary artery revascularization [Letter]. Lancet 1995;346:837.[Medline]
  5. Arom KV, Emery RW, Nicoloff DM. Mini-sternotomy for coronary artery bypass grafting. Ann Thorac Surg 1996;61:1271–2.[Abstract/Free Full Text]
  6. Khan SS, Kupfer JM, Matloff JM, Tsai TP, Nebsim S. Interaction of age and preoperative risk factors in predicting operative mortality for coronary bypass surgery. Circulation 1992;86(Suppl 2):186–90.
  7. Goldman S, Copeland J, Moritz T, et al. Internal mammary artery and saphenous vein graft patency: effects of aspirin. Circulation 1990;82(Suppl 4):237–42.
  8. Mohr FW, Matloff J, Grundfest W, et al. Thermal coronary angiography: a method for assessing graft patency and coronary anatomy in coronary bypass surgery. Ann Thorac Surg 1989;47:441–9.[Abstract/Free Full Text]



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