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Ann Thorac Surg 1996;62:1545-1548
© 1996 The Society of Thoracic Surgeons

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Current Review

Minimally Invasive Coronary Artery Bypass Grafting

Division of Cardiothoracic Surgery, University of D'Annunzio, Chieti, Italy; Bristol Heart Institute, University of Bristol, , England; and the State University of New York at Buffalo, Buffalo, New York

	Abstract

Top Footnotes Abstract Introduction Evolution of the Procedure Surgical Technique Indications Results Concerns Future Developments References

 
Minimally invasive coronary artery bypass grafting has recently been introduced into cardiac surgery. The procedure promises to become an important addition to the surgical treatment of coronary artery disease. This current review gives a historical perspective and an overview of this growing field, based on the experience of three international centers with experience with minimally invasive coronary artery bypass grafting. It is predicted that the field will grow, and that future generation of cardiac surgeons will have to become familiar with this new procedure.

	Introduction

Top Footnotes Abstract Introduction Evolution of the Procedure Surgical Technique Indications Results Concerns Future Developments References

 
Minimally invasive coronary artery bypass (MICAB) is the term used to describe a group of novel cardiac procedures. For the purpose of this review, MICAB is defined as an intervention that does not require median sternotomy or the use of cardiopulmonary bypass (CPB). The incision in the chest wall is small, and the aorta, in any portion, is not the direct source of inflow of blood supply to the bypass grafts.

	Evolution of the Procedure

Top Footnotes Abstract Introduction Evolution of the Procedure Surgical Technique Indications Results Concerns Future Developments References

 
Minimally invasive coronary artery bypass grafting (CABG) is the result of the work of original and creative work of earlier and recent surgeons who performed cardiac operations without CPB. In 1967, Kolessov [1] first reported bypass to the left anterior descending coronary artery (LAD) and marginal branch of the circumflex coronary artery without CPB through a left thoracotomy. Favaloro [2], Garrett and colleagues [3], Trapp and Bisarya [4], and Ankeney [5] also performed CABG without CPB from 1968 to 1975. Later, they abandoned the procedure as CPB and cardioplegia allowed for precision and access to all arteries of the heart. Coronary artery bypass grafting without CPB was revived by Benetti and co-workers [6, 7] and by Buffolo and co-workers [8, 9] who simultaneously reported their preliminary experience. Both groups [10, 11] have recently reported their total experience with excellent results. The advantages of CABG without CPB have been confirmed by others [12–14].

Benetti and colleagues [15] seem to be the first surgeons who suggested that CABG could be performed through a small left thoracotomy with the aid of a thoracoscope. Benetti [16] presented his ideas at the International Symposium on Myocardial Protection in Chicago in October 1994. At the International Workshop on Arterial Conduits for Myocardial Revascularization held in Rome in November 1994, Benetti and Sani [17] and Subramanian [18] demonstrated the clinical use of MICAB. Spence [19] also presented MICAB experimental studies done on dogs. Benetti and co-workers [20, 21] later reported the technique. Calafiore and associates [22] popularized MICAB through a small left anterior thoracotomy and reported the world's largest series, extending the indications to patients with multivessel coronary artery disease. Preliminary clinical experience with MICAB has recently been published by other groups [23–25].

	Surgical Technique

Top Footnotes Abstract Introduction Evolution of the Procedure Surgical Technique Indications Results Concerns Future Developments References

 
The patient is anesthetized and intubated with a single endotracheal tube and hemodynamic monitoring. Although initially used, a double-lumen endotracheal tube is not necessary, except when thoracoscopic dissection of the mammary artery is planned. Short-acting anesthetic agents are used, as extubation of the patient in the operating room is routine. The chest is opened through a fourth or fifth intercostal space incision and the pericardium is opened longitudinally. The LAD is identified and inspected. Rightward displacement of the LAD, intramyocardial LAD, and calcified LAD are contraindications to the procedure. A laterally positioned LAD requires more extensive dissection of the left internal mammary artery (LIMA) or extension of the LIMA with the inferior epigastric artery. If difficulties are encountered, a conventional operation is performed through a median sternotomy. The LIMA is harvested through the same incision with or without the aid of a thoracoscope. One or more costal cartilages may be resected to achieve better visualization and dissection of the full length of the LIMA. The artery can be harvested as a pedicle or as a skeletonized vessel. As mentioned earlier, inadequate length of the LIMA can be dealt with by thoracoscopic dissection of the entire LIMA or by inferior epigastric artery extension [22]. Meticulous care is needed to avoid damage to the artery. The patient is heparinized (1 mg/kg), and diluted papaverine is injected into the pedicle and intraluminally into the LIMA through a blunt-tipped cannula. Traction sutures are applied to the edges of the pericardium. After selection of a site for construction of the anastomosis and assessment of the length of the LIMA, distal and proximal control of the LAD is required. A snare of 4/0 Prolene (Ethicon, Somerville, NJ) or silicone suture can be applied proximally and distally to the site selected for the anastomosis. Alternatively, the vessel can be opened and a Flow-Rester placed intraluminally. The surgical blower (Visu-Flow, Research Medical, Midvale, UT) is used for visualization [26]. Electrocardiographic changes, arrhythmias, and ventricular fibrillation are rare events during occlusion of the LAD. Traction sutures can be applied to the visceral pericardium lateral to the LAD, thereby allowing for better stabilization of the artery. Alternatively, a suction device (Medtronic Inc, Minneapolis, MN) or a stabilizer (CTS Inc) can be used. Short-acting ß-blockers or calcium channel blockers are used to reduce heart rate when necessary. The LAD to LIMA anastomosis is performed using a 7/0 or 8/0 running Prolene suture, either as a single suture or as two strategical ly placed sutures at the toe and heel of the LIMA. Some surgeons prefer interrupted sutures. At completion of the anastomosis, heparin is reversed with protamine sulfate. Closure of the chest is as in any standard thoracotomy, leaving a pleural tube for drainage. An intrapleural catheter is placed for pain control. The patient is extubated in the operating room or shortly thereafter. Patency of the artery is confirmed by standard Doppler (velocity) echocardiography intraoperatively and by duplex scanning of the LIMA early and late postoperatively in every patient. This is usually done 2 to 3 hours postoperatively and 24 hours after operation. Diastolic flow predominates in a patent LIMA [22]. Most centers report early discharge from hospital and significant cost savings associated with this procedure [22].

	Indications

Top Footnotes Abstract Introduction Evolution of the Procedure Surgical Technique Indications Results Concerns Future Developments References

 
At present, single-vessel coronary artery disease involving the LAD is the primary indication for MICAB. Most frequently, the patient will have recurrent disease after angioplasty or stent, or will have a lesion that is not amenable to angioplasty. This is the case in ostial lesions and in complex or multiple lesions of the LAD. Patients with multivessel coronary artery disease in whom the LAD is the major vessel and who have other small coronary vessels, or who have other vessels with mild peripheral stenosis, can be offered this procedure. Patients considered to be at high risk for standard CABG because of associated diseases (eg, renal failure, chronic obstructive pulmonary disease) and redo operation for LAD stenosis are candidates for this procedure. Finally, some patients with multivessel disease may be approached by a combination of MICAB and angioplasty or stenting techniques. Minimally invasive CABG to other arteries, such as right internal mammary artery to right coronary artery, radial artery T anastomosis to LIMA–LAD–circumflex, inferior epigastric extension of LIMA, and gastroepiploic artery to right coronary artery, is another option.

	Results

Top Footnotes Abstract Introduction Evolution of the Procedure Surgical Technique Indications Results Concerns Future Developments References

 
The largest experience with MICAB was recently reported by Calafiore and colleagues [22]. From November 1994 to December 1995, 155 of 162 patients underwent LIMA to LAD anastomosis using MICAB. In 68 patients (43.8%) the operation was urgent. Coronary angiography revealed isolated LAD lesion in 78 patients (50.3%), two-vessel disease in 50 patients (32.2%), three-vessel disease in 27 patients (17.4%), and critical left main stenosis in 4 patients (2.6%). The LIMA was anastomosed directly to the LAD in 144 patients, with interposition of the inferior epigastric artery in 11 patients. In 2 patients, the diagonal branch was also grafted using the inferior epigastric artery from the LIMA. One patient (0.6%) died 38 days after the operation of multiorgan failure. Two patients were reoperated on for bleeding. Mean intensive care unit stay was 4.2 ± 6 hours, and 77% of the patients were discharged from the hospital on the second postoperative day. All patients had echocardiographic/Doppler assessment of the LIMA and 53 had early postoperative angiograms. The LIMA was patent in 95.5%. Nine patients (4.5%) underwent early reoperation for graft failure and 2 patients for late graft failure. One additional patient had successful percutaneous transluminal coronary angioplasty of the proximal LAD (protected by LIMA) for an anastomotic stenosis. At mean of 5.6 months of follow-up, 143 patients (92.2%) were alive, asymptomatic, and free of cardiac events.

	Concerns

Top Footnotes Abstract Introduction Evolution of the Procedure Surgical Technique Indications Results Concerns Future Developments References

 
Long-term results of MICAB remain to be defined. A clinical trial comparing conventional LAD bypass to MICAB has not been conducted. Although the investigators believe that long-term patency of the LIMA to the LAD using either technique should be the same, this is not proven at present. Concerns regarding the steal syndrome have been raised. There are two opposing views on this issue: one is that thoracoscopic operation is needed to harvest the full length of the LIMA to ligate all of the LIMA branches. The other view is that only a short segment of the LIMA needs to be dissected to reach the LAD, and that branches are not important. Calafiore and co-workers [22] have demonstrated reactive hyperemia after completion of the anastomosis in every case in which adenosine was injected into a temporarily occluded LIMA. This indicates either that the steal syndrome is not a problem or that reactive hyperemia is present even with open LAD branches. They also believe that the adequacy of the distal vascular bed of the LAD is one of the most important factors contributing to the steal phenomenon. Most surgeons using the MICAB procedure have not reported steal syndrome, although a longer period of follow-up will be needed to fully address this important question.

There is definitely a learning curve in the performance of MICAB. Accustomed to operating on arrested hearts on CPB, surgeons may experience difficulties when first doing this procedure. It may be advisable to gain experience first on CABG with median sternotomy and beating heart [21]. The ever-present fear that arrhythmias, electrocardiographic changes, and ventricular fibrillation may occur during LAD occlusion is a barrier for beginners. It is advisable to have CPB on stand-by. Some surgeons place guidewires in the femoral artery and vein for emergency percutaneous cannulation. Other surgeons use femorofemoral bypass. Adhesive defibrillator pads are placed routinely in the chest wall of patients undergoing this procedure. Contractility is routinely assessed by transesophageal echocardiography during LAD occlusion. If contractility decreases, the artery is unsnared and then repeatedly snared and unsnared. In this case, contractility is usually maintained. This is probably an example of ischemic preconditioning. This was confirmed recently by Menasché and associates [27] showing an increase in creatine kinase and lactate after only 3 minutes of occlusion. Hopefully preconditioning drugs, such as adenosine, can be used to avoid regional hypocontractility.

Angelini and co-workers [28] have used an integrated approach to the management of patients with coronary artery disease by combining the left anterior small thoracotomy procedure to the LAD with angioplasty/stenting of other coronary vessels during the same admission. This approach may broaden the use of MICAB in selected groups of patients who have critical lesion of the LAD in combination with stenosis of other arteries. This integrated approach may extend minimally invasive management to patients with multivessel and left main disease. This approach must be reevaluated on long-term assessment of stent patency as antiplatelet agents, such as reopros cannot be used at the same setting.

Cost containment may be a spin-off of MICAB procedures [22]. However, MICAB should not be viewed as the answer to this complex issue.

	Future Developments

Top Footnotes Abstract Introduction Evolution of the Procedure Surgical Technique Indications Results Concerns Future Developments References

 
Minimally invasive CABG has raised great enthusiasm among cardiac surgeons and cardiologists. It is expected that technical advances will simplify the procedure, making it safer and yielding predictable patency rates. It is likely that endoscopy will play an important role in dissection of arterial conduits, such as LIMA or right internal mammary artery (to avoid the steal syndrome) and gastroepiploic artery. Automatic suture stapling devices for construction of the anastomoses may soon become available. Laser welding or gluing of the LAD to LIMA anastomosis may become feasible, although hand suturing has been the hallmark of a perfect anastomosis during coronary artery operations. Stabilization of the heart during construction of the anastomosis is an important aspect of the procedure, and devices are being developed that will aid the surgeon during this critical part. The role of preconditioning by repeated occlusion of the vessel with a period of reperfusion between occlusions, before construction of the anastomosis, remains to be defined. Intraluminal shunts and shunts from peripheral arteries to the distal vessels are being developed. The use of peripheral CPB may become important, as demonstrated in the Stanford studies [29], in which the aorta can be occluded and the coronary sinus can be cannulated through the jugular vein. The use of strobe lights to help surgeons operate on a moving target is being evaluated. The local administration of cardioplegic agents during LAD occlusion may afford protection to areas of the heart affected by LAD occlusion. It is expected that MICAB will be extended to all arteries of the heart using a variety of conduits. Further evaluation of the integrated approach [28] may allow for MICAB/angioplasty during the same admission as a means to totally revascularize the myocardium. Undoubtedly minimally invasive techniques will be tried in other cardiac procedures. Some are already being experimented upon, such as pericardial drainage, pericardial biopsy, insertion of an automatic implantable cardioverter defibrillator, and valvular operations. It is too early to predict whether these more complex cardiac procedures, such as valvular operations and aneurysm repairs, will be performed using the minimally invasive approach without compromising safety.

Future generation of cardiac surgeons, especially those in training, will have to become familiar with minimally invasive cardiac procedures, especially MICAB. We predict that MICAB will grow and will become popular among cardiac surgeons, patients, and institutions. It is important that we continue to evaluate the safety and efficacy of MICAB as it relates to conventional techniques of myocardial revascularization.

	Footnotes

Top Footnotes Abstract Introduction Evolution of the Procedure Surgical Technique Indications Results Concerns Future Developments References

 
Address reprints requests to Dr Salerno, The Buffalo General Hospital, 100 High St, Buffalo, NY 14203.

	References

Top Footnotes Abstract Introduction Evolution of the Procedure Surgical Technique Indications Results Concerns Future Developments References

 

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