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Ann Thorac Surg 1997;63:988-992
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Safe and Effective Method of Stabilization for Coronary Artery Bypass Grafting on the Beating Heart

Department of Cardiothoracic Surgery, McGill University, Montreal, Quebec, Canada

Accepted for publication October 22, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Background. There is an emerging interest in performing coronary artery bypass grafting on the beating heart. This study examines the efficacy and safety of two types of coronary artery stabilizers developed to perform coronary artery bypass grafting on the beating heart.

Methods. Four dogs underwent left internal mammary artery to left anterior descending artery anastomosis using a retractor-fixed stabilizer. Measurements of hemodynamic indices and range of motion of the targeted arteriotomy were done before and after application of the stabilizers. Patency of the anastomosis was evaluated by angiography. To clinically validate the safety of this stabilizer, we collected data on 150 patients from centers that had access to the retractor-fixed stabilizer.

Results. All animals survived the procedure with no ischemic changes or hemodynamic alterations. A significant reduction in range of motion (mm) of the left anterior descending coronary artery was achieved after application of the stabilizers. Angiographic studies showed good anastomotic patency. Histologic examination showed no myocardial injury. Patient data revealed successful completion of the anastomosis, with conversion to sternotomy or cardiopulmonary bypass in 1 patient each. Intraoperative and postoperative myocardial infarctions occurred in 1 patient each, with one in-hospital death.

Conclusions. Significant stabilization of targeted coronary arteries allowing the performance of safe and reliable anastomosis on a beating heart can be achieved using the stabilizer.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
See also page 980.

Currently, the majority of coronary artery bypass grafting (CABG) operations are performed with cardiopulmonary bypass (CPB). Using CPB for CABG operations allows performance of coronary artery anastomosis in a steady, bloodless field with myocardial protection, yielding an excellent patency rate on long-term follow-up [1]. Nevertheless, CPB is associated with several adverse effects, such as bleeding, neurologic complications, tissue edema, myocardial injury, and potential failure to wean the patient off the pump [1–4]. Many of these complications can be attributed to mechanical and immunologic alterations of blood components [1, 5–7]. In addition, the use of an aortic cross-clamp to exclude the heart may add to the risk of myocardial, aortic, and neurologic complications [8]. More recently, serious persistent cognitive defects have been noted to develop in patients subjected to CPB regardless of the duration of CPB [9].

As such, there has been a revival of interest in performing CABG without using CPB or aortic occlusion on a beating heart [1 ,7, 10–18]. Hence, establishing simple and safe surgical techniques that provide a steady and bloodless coronary anastomotic field is essential for successful CABG on a beating heart.

In this study, we evaluated the efficacy (stability of the coronary artery and patency of the anastomosis) and safety (effect on hemodynamic measurements and myocardial tissue injury) of two novel types of coronary artery stabilizers, a retractor-fixed and a hand-held stabilizer (CardioThoracic Systems, Inc, Cupertino, CA), in facilitating the performance of a left internal mammary artery-to-left anterior descending coronary artery (LIMA-to-LAD) anastomosis on a beating canine heart. In addition, preliminary operative data from several European and North American centers were collected on 150 patients who underwent CABG on a beating heart using the retractor-fixed stabilizer.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Experimental Design
Two types of stabilizers, hand-held and retractor-fixed, were evaluated in this study (Figs 1A, 1B).

View larger version (87K): [in this window] [in a new window]   Fig 1. . The two types of coronary artery stabilizers: (A) hand-held, (B) retractor-fixed (CardioThoracic Systems, Inc, Cupertino, CA).

A small left anterior thoracotomy (8 cm) was then performed at the fifth intercostal space, followed by complete mobilization of the LIMA under direct vision. The pericardium opposite the LAD was incised and suspended to the chest wall with 3-0 sutures. At this point, baseline hemodynamic indices and coronary artery range of motion were measured three consecutive times. Range of LAD motion (mm) was measured with a high-resolution laser displacement sensor (model LB-1000; Keyence Corp, Woodcliff Lake, NJ). The laser sensor was calibrated before each session. After identification of the arteriotomy point on the LAD, the laser emitter and sensor were positioned above the coronary artery with the laser beam targeted over the center of the planned incision site on the LAD. Range of motion (mm) was defined as the difference in the maximum and minimum displacement of the LAD over a 10-second interval.

After baseline measurements, the effects of both types of coronary artery stabilizers on LAD range of motion and hemodynamic function were evaluated before and after the application of each stabilizer three consecutive times (Fig 2).

View larger version (89K): [in this window] [in a new window]   Fig 2. . The retractor-fixed stabilizer positioned intraoperatively with the left anterior descending coronary artery (LAD) running between the two feet of the stabilizer. Note the infrared laser beam fixed on the arteriotomy point of the LAD. A laser sensor (not shown) is positioned directly above to calculate the LAD range of motion.

Animal Care
All animals were given humane care in compliance with the Animal Care Committee regulations of the Montreal General Hospital and McGill University, as well as with the "Principles of Laboratory Animal Care" formulated by the National Society for Medical Research and the "Guide for the Care and Use of Laboratory Animals" prepared by the National Academy of Sciences and published by the National Institutes of Health (NIH publication 85-23, revised 1985).

Clinical Data
Data forms requesting intraoperative and postoperative in-hospital information on patients undergoing CABG on the beating heart using the stabilizer were collected and analyzed retrospectively. Data included patient demographics, prior revascularization procedures, type of grafts used, and coronary arteries grafted. Intraoperative complications including conversion to sternotomy, the need to use CPB, intraoperative arrhythmias, and myocardial infarction were noted. In-hospital and 30-day morbidity and mortality were also recorded.

Statistical Analysis
Statistical analysis of the data was performed using factorial analysis of variance with a commercially available software package (Statview 4.0, Abacus Concepts, Berkeley, CA) on a Macintosh personal computer. All hemodynamic and range of motion measurements are presented as mean ± standard error of the mean.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Experimental Results
All animals survived the procedure and maintained excellent hemodynamic measurements. Application of both stabilizers had no adverse effects on heart rate, arterial blood pressure, pulmonary artery pressure, cardiac output, or arterial oxygen saturation (Table 1).

Angiographic examination of the anastomosis revealed good patency (Fig 3). Histologic examination demonstrated normal anastomotic arteries and myocardial tissue at the site of and adjacent to stabilizer application.

View larger version (100K): [in this window] [in a new window]   Fig 3. . Angiogram of the left internal mammary artery-to-left anterior descending coronary artery anastomosis from an extracted heart, showing good lumen patency.

Conversion to sternotomy was needed in 1 patient (0.6%). Another patient required emergent installation of CPB (0.6%). Two patients had perioperative arrhythmias (1.3%), and 1 patient had intraoperative bleeding (0.6%). There were no perioperative deaths, and the incidence of perioperative acute myocardial infarction was 0.6% (1 patient). One patient had a postoperative acute myocardial infarction that was not in the region of the anastomosis. The 30-day and in-hospital mortality was 0.6%. Because these data were collected from a variety of North American and European centers, hospital stay was widely different from one center to another.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Current methods of CABG are generally safe and efficient, although several complications and disadvantages continue to arise with the use of CPB and cardiac arrest. Most important of these are the added risk of hemorrhage, inadequate cardiac preservation leading to myocardial ischemia or infarction, and neurologic events including cognitive dysfunction. The latter has recently been recognized as an important and common complication regardless of the duration of CPB. The need to address these concerns as well as the desire to minimize other potential risks (ie, sternal wound infection, dehiscence, and pain) stimulated interest in developing less invasive open heart surgical techniques.

The recent success of minimally invasive surgical interventions in abdominal and thoracic surgery [19] led to a surge of interest in performing CABG through a small anterior thoracotomy on a beating heart without CPB. Many centers have reported excellent results in performing off-pump CABG in select subgroups of patients with stenotic, well-collateralized LAD or right coronary artery lesions [1, 7]. In one of the largest clinical reports on myocardial revascularization without extracorporeal circulation (700 patients), Benetti and associates [10] reported a morbidity and mortality rate of 4% and 1%, respectively, with a 90% probability of survival at 7 years. Pfister and colleagues [1] previously compared the results of mortality and morbidity in 220 patients undergoing CABG without CPB with a matched number of on-pump controls. No statistically significant difference in mortality was observed in all subgroups of patients undergoing CABG with or without CPB. However, requirements for postoperative blood transfusions and low cardiac output syndrome occurred significantly less frequently in off-pump patients. In their clinical series, patients with severely impaired left ventricles and the elderly particularly benefited from off-pump techniques. As well, the elimination of personnel and material expenses associated with extracorporeal pump operation, lower morbidity rates, quicker patient recovery, and fewer hospital days in off-pump CABG patients have resulted in substantial cost savings in several centers [20, 21].

Despite the potential advantages of performing off-pump CABG on a beating heart, several limitations persist that hamper its greater use. Most notable is the technical challenge of performing coronary anastomosis on a moving targeted coronary artery. Current surgical techniques used to stabilize the coronary artery for the purpose of anastomosis on a beating heart include application of epicardial sutures, finger stabilization, or pharmacologic slowing of the heart rate, such as with administration of ß- or calcium-blockers. The inconsistency of each of these methods is a major drawback and a limitation to its wide applicability.

We have developed two simple and reliable coronary artery stabilizers that allow the performance of LIMA anastomosis to a well-stabilized arteriotomy point on the LAD. Both types of stabilizers significantly reduced targeted LAD motion and allowed easy performance of a LIMA to LAD anastomosis. No untoward effects on any of the measured hemodynamic indices were noted during the application of either type of stabilizer. Despite the small caliber of canine coronary arteries, the anastomosis was shown to be done properly by angiographic evaluation. Furthermore, the lack of any histologic evidence of injury to the epicardium and myocardium directly beneath or adjacent to the position of the stabilizer is reassuring and may indicate a potential advantage over other stabilization techniques such as epicardial traction sutures or suction, which may tear the epicardium or bruise the tissue.

Preliminary data on 150 patients subjected to CABG on the beating heart revealed successful completion of the anastomosis, with the need to convert to a sternotomy incision in only 1 patient and the emergent utilization of CPB in another. This and the low incidence of complications confirm the safety and efficacy of the retractor-fixed stabilizer. The adequacy of the anastomosis, however, should be determined by angiographic studies on appropriate follow-up. This and other information would clearly be the subject of another report.

In conclusion, significant improvement in stabilization of the coronary artery can be achieved with both types of stabilizers. Using the retractor-fixed stabilizer allows performance of a reliable LIMA-to-LAD anastomosis with ease and with no untoward effects on the heart or cardiovascular hemodynamic indices. The retractor-fixed stabilizer continues to be evaluated clinically, with increasing numbers of patients undergoing a variety of anastomoses on the beating heart. We believe that this instrument provides excellent stabilization of targeted coronary artery segments and facilitates the anastomosis.

	Acknowledgments

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
This work was funded in part by a grant from the Canadian Heart and Stroke Foundation. Stabilizer equipment tested was provided by CardioThoracic Systems, Inc, Cupertino, California. We acknowledge the following individuals and institutions for contributing to the Registry: Federico J. Benetti, Benetti Foundation, Argentina; Joachim Cremer and Axel Haverich, Medizinische Hochschule Hannover, Hannover, Germany; Marco Zenati, University of Pittsburgh, Pittsburgh, PA; Paul A. Spence, University of Louisville, Louisville, Kentucky; Valavanur A. Subramanian, Lennox Hill Hospital, New York, New York; Paul J. Corso and Albert J. Pfister, Washington Hospital Center, Washington, DC; Jan G. Granjean and Piet W. Boonstra, University Hospital Groningen, Groningen, the Netherlands; and Antonio M. Calafiore, University of Chieti, Chieti, Italy.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 
Address reprint requests to Dr Shennib, The Montreal General Hospital, 1650 Cedar Ave, Suite L9-120, Montreal, Que, H3G 1A4, Canada.

Doctor Shennib is a clinical advisor with CardioThoracic Systems, Inc. Jodi Akin is a manager of clinical affairs with CardioThoracic Systems, Inc.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment Acknowledgments References

 

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Hani Shennib Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Shennib, H. Articles by Akin, J. Search for Related Content PubMed PubMed Citation Articles by Shennib, H. Articles by Akin, J. Related Collections Related Article