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Ann Thorac Surg 1997;64:616-622
© 1997 The Society of Thoracic Surgeons
Department of Cardiovascular and Thoracic Surgery, St. Vincent Hospital and Health Care Center, Indianapolis, Indiana
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Abstract |
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 TopFootnotes Abstract IntroductionMaterial and MethodsResultsCommentReferences |
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Methods. Group A consisted of 23 consecutive patients from September 1995 to July 1996 who underwent single vessel redo CABG of the left anterior descending artery with the left internal mammary artery using a limited anterior thoracotomy without cardiopulmonary bypass; group B consisted of 12 consecutive patients from November 1984 to July 1994 who underwent the same procedure using a median sternotomy with cardiopulmonary bypass. The two groups were similar with regard to age, sex, preoperative ejection fraction, and risk stratification.
Results. Mortality, cerebrovascular accidents, myocardial infarctions, and reoperations for bleeding were not significantly different between the groups. However, the patients in group A had significant reductions in atrial fibrillation, time to extubation, transfusions required, and length of cardiac recovery and hospital stay. With a mean of 12 ± 6 months of follow-up, 87% of the patients in group A (20 of 23) are alive and asymptomatic. Actuarial survival rates for the patients in group B at 1, 2, and 10 years are 83%, 83%, and 72%, respectively.
Conclusions. Minimally invasive single-vessel redo CABG can be performed safely and may reduce the morbidity associated with conventional single-vessel redo CABG.
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Introduction |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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The incidence of reoperative (redo) coronary artery bypass grafting (CABG) has increased because of the rise in the number of patients who have undergone initial CABG, many of whom had their operations in an era when the left internal mammary artery (LIMA) was not used routinely. In the past, conventional reoperation has been associated with increased morbidity and mortality, primarily as a result of surgical misadventure during repeated sternotomy, atheromatous emboli from patent but diseased vein grafts, and incomplete myocardial protection. Alternative strategies have evolved to circumvent these complications and include the more liberal use of femoral cannulation, the "no-touch" technique during cardiac dissection, antegrade-retrograde cardioplegia, and single aortic cross-clamping [1]. There remains, however, a subset of patients who are too high risk to undergo conventional redo CABG or who have only single-vessel left anterior descending artery (LAD) disease and might benefit from a less invasive approach to redo myocardial revascularization.
In selected patients who require redo revascularization of the circumflex artery, right coronary artery, and LAD, several reports have described the use of left or right thoracotomy as an alternative to sternal reentry [2–5]. These approaches often use formal thoracotomy in conjunction with femoral cannulation and cardiopulmonary bypass (CPB), and cannot be termed minimally invasive. Recent reports of minimally invasive direct coronary artery bypass (MIDCAB) grafting of the LAD artery with the LIMA describe a limited anterior thoracotomy without CPB, but have reported only a few redo operations [6, 7]. This retrospective report compares perioperative outcomes observed in patients who underwent redo grafting of the LAD with the LIMA using a minimally invasive approach with those who underwent the same procedure using a conventional repeated sternotomy with CPB.
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Material and Methods |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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. During the period in which the patients in group A were identified, 1,366 isolated coronary operations were performed, which included 132 redo procedures (9.6%).
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Surgical Technique
Conventional redo CABG as performed in the patients in group B was carried out by standard methods similar to those historically described [10]. Current recommendations, such as the use of a no-touch technique and retrograde cardioplegia, were not used routinely during the period that the patients in group B were identified.
Minimally invasive direct coronary artery bypass grafting has been in continuous evolution since our first case in July 1995. Our experience involves 170 cases and includes the 23 redo MIDCAB operations reported in this series. The MIDCAB operation as described herein is our current technique. Anesthesia includes short-acting inhalation agents supplemented with low-dose narcotics and propofol; most patients are extubated at the conclusion of the case. A single lumen endotracheal tube is used routinely; ventilation with a decreased tidal volume and an increased respiratory rate provides excellent visualization of the heart, even in patients with emphysema. Patients are positioned supine and are prepared and draped as if they are undergoing a conventional CABG procedure. External defibrillator pads are used on all patients and the CPB machine is available but not primed.
A fourth or occasionally fifth intercostal incision is made, beginning 3 to 4 cm lateral to the sternal border (Fig 1A). The pleural cavity is entered and the lung is packed out of the field. The costal cartilages are not divided and the ribs are not resected. Before harvesting the LIMA, a standard small thoracic retractor is positioned, the pericardium is identified and incised, and the LAD is located. Identification of the LAD artery often is easier in a redo MIDCAB procedure because the LAD almost always has been bypassed previously and the vein graft acts as a guide. In contrast, identification of the LAD in a primary MIDCAB operation sometimes can be difficult, particularly when there is significant epicardial fat or the LAD is displaced medially or laterally. If MIDCAB grafting is ill advised because of anatomic considerations or inadequate exposure, this approach is abandoned. A conventional redo operation then can be performed if the patient is a candidate for CPB. However, if the MIDCAB approach appears feasible, then the operation proceeds using the MIDCAB System (Cardiothoracic Systems Inc, Cupertino, CA), which consists of two disposable retractors and a regional cardiac wall stabilizer.
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). With a fourth intercostal incision, this retractor is designed to expose the entire LIMA by elevating the third and fourth ribs and depressing the first and second ribs. The LIMA is harvested superiorly to within 1 to 2 cm of the subclavian vein, and inferiorly to just below the level of the incision. The LIMA is left in situ while the second MIDCAB retractor is positioned, which is capable of providing regional cardiac wall stabilization during the anastomosis. Intravenous heparin (5,000 U) is administered and the LIMA is divided distally and its flow assessed. A soft clamp is applied to the pedicle and the distal LIMA is prepared as usual.
The cardiac wall stabilizer now is attached to the retractor platform and positioned to provide exposure and stabilization of the anastomotic site (see Fig 1C). Only the anterior surface of the vessel is dissected, which aids in stabilization during the anastomosis. Whereas pericardial adhesions negate some motion of the heart during a redo MIDCAB procedure, the stabilizer provides important regional cardiac wall stabilization and is a critical advance in the technique of MIDCAB grafting. Since the introduction of regional cardiac wall stabilization, short-acting ß-blockers and adenosine have not been used.
The LAD now is opened after a period of uneventful test occlusion and after the administration of lidocaine (100 mg). An appropriately sized intraluminal Flowrester (Biovascular, Inc, St. Paul, MN) is inserted into the LAD. This creates a dry field and eliminates the use of constricting proximal and distal stay sutures. Arrhythmias are rare events. Although ischemic changes sometimes are seen electrocardiographically, these resolve with the completion of the anastomosis.
The LIMA-to-LAD anastomosis is performed using either a single running 7-0 Prolene (Ethicon, Somerville, NJ) or two 7-0 Prolene sutures beginning at the heel and toe of the anastomosis. Patency of the completed anastomosis is impossible to confirm visually or with palpation. Intraoperative Doppler ultrasound evaluation of the LIMA, demonstrating significant diastolic flow, provides reassurance of patency, but is very subjective. A completion angiogram should be the gold standard, but the capability and equipment are lacking in our current operating room. Intraoperative quantification of LIMA blood flow, using a Transonic Flow Probe (Transonics Systems, Inc, Ithaca, NY), has been very encouraging.
Intracostal bupivacaine blocks are placed before chest closure. Epidural and interpleural catheters are not used. The lungs are inflated to ensure that the LIMA pedicle is not stretched. Closure of the chest is performed as usual, along with insertion of a 28F posterior/apical chest tube. Patients are extubated routinely in the operating room and transferred to the standard open heart recovery unit. Postoperative pain management is accomplished for the first 24 hours with a patient-controlled analgesia pump and ketorolac (Toradol; Roche Laboratories, Inc, Nutley, NJ), and then by oral narcotics.
Data Collection
All parameters recorded for this study were obtained from hospital records or from a cardiac patient database (Heartbase) compiled by the Indiana Heart Institute. Cardiac recovery length of stay was defined as the time in hours between arrival at the unit and transfer to a progressive care unit. Length of hospital stay was defined as the number of days from operation to hospital discharge.
All statistical analyses were conducted using JMP Statistical Discovery Software (SAS Institute, Inc, Cary, NC). Statistical analyses of mean and ratio differences were determined by t test and 
2 analyses, respectively. Parameter differences were considered to be statistically significant at a p value of 0.05 or less.
Patient Follow-up
Six patients from group A, as part of a broader prospective trial involving all MIDCAB operations at our institution, were selected randomly to undergo cardiac catheterization and duplex/Doppler ultrasound examination 3 months after operation. Four additional patients also underwent postoperative angiography. No patients from group B underwent postoperative angiography. Follow-up for both groups was 100% and involved an outpatient clinic visit 6 weeks after operation, with late follow-up consisting of chart reviews and a telephone interview. Follow-up for group A ranged from 6 to 17 months (mean, 12 ± 6 months), whereas follow-up for group B ranged from 30 to 146 months (mean, 98 ± 29 months).
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Results |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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. No patients in group A had to have their MIDCAB incision converted to a sternotomy. All 23 patients in group A were extubated in the operating room at the conclusion of the case, compared with none of the patients in group B.
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The 2 postoperative deaths in group B occurred in patients operated on emergently after failed percutaneous intervention of diseased LAD vein grafts. Hemodynamic instability developed in both patients in the catheterization laboratory, but they were stabilized with intraaortic balloon pumps. Both patients suffered perioperative myocardial infarctions, and 1 required reoperation for bleeding. Death in these 2 patients was due to massive myocardial infarction and multisystem organ failure, respectively. Group B also had 1 late death; an 82-year-old man died of "natural causes" 8 years after his redo CABG.
Ten patients from group A underwent postoperative angiograms. Six of these patients, as participants in a larger prospective MIDCAB trial, were assigned randomly to undergo angiographic and duplex/Doppler ultrasound evaluation 3 months after operation (Fig 2). Anastomoses were widely patent in all 6 randomly selected patients. In addition, the Doppler/duplex ultrasound that was obtained before catheterization was 100% predictive of patency.
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With 12 ± 6 months of follow-up, 87% of the patients in group A (20 of 23) are alive and asymptomatic after operation. One patient has class II angina and is being treated medically. Actuarial survival rates for patients in group B at 1, 2, and 10 years are 83%, 83%, and 72%, respectively.
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Comment |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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One of the principal drawbacks of less invasive coronary operations is the question of the accuracy of the coronary anastomosis and its long-term patency when performed on the beating heart. Excellent results with conventional coronary grafting of the LAD with the LIMA using CPB have been well documented, with 10-year patency rates of 85% to 95% [15, 16]. Benetti [17], Buffolo [18, 19], and Fanning [20], and their colleagues, have demonstrated similar graft patency rates of 84% to 93% with off-pump bypass using a median sternotomy approach. However, healthy skepticism remains concerning the adequacy of off-pump bypass and the potential for late stenosis [21]. These concerns are magnified further when off-pump bypass is performed through a minimally invasive incision. Benetti [22], Calafiore [6, 23], and Subramanian [7], and their associates, have demonstrated the feasibility of the MIDCAB operation and, more importantly, have reported excellent short-term and midterm patency rates of 91% to 95% as determined angiographically and with duplex/Doppler ultrasound. Although no long-term studies of MIDCAB patency rates are available, these encouraging short-term results should persist in view of the documented long-term durability of the LIMA-to-LAD anastomosis once it has been performed successfully [16].
Several additional concerns regarding MIDCAB operations remain. Arrhythmias and hemodynamic instability are rare events and were not observed in this series. The regional ischemia produced during the short period of LAD occlusion during the anastomosis is well tolerated and is similar to the experience with percutaneous transluminal coronary angioplasty. Intraluminal coronary shunts are in development and may be particularly helpful in redo MIDCAB operations in which interruption of a patent vein graft to a poorly collateralized, proximally occluded LAD is not well tolerated.
The potential development of a steal syndrome, through uninterrupted proximal LIMA collaterals, is controversial. Because coronary perfusion occurs during diastole and collaterals perfuse during systole, competition between territories should not occur unless there is poor LAD runoff or stenosis of the distal LIMA. Thoracoscopic harvest of the LIMA has been advocated to avoid the potential for the steal syndrome and to obtain maximum LIMA length [24, 25]. Since adopting our current retractor system, we have not seen an advantage to thoracoscopic LIMA harvest. The LIMA lift retractor (see Fig 1B) has nullified the potential for the steal syndrome by allowing full-length dissection of the mammary pedicle to within 1 to 2 cm of the subclavian vein. Calafiore and colleagues [6] have reported the need for composite grafts in 8.3% of MIDCAB procedures because of a laterally located LAD and inadequate LIMA length. Complete mobilization of the proximal LIMA has allowed adequate LIMA length without the use of any composite grafts in this series.
A controversial application of the MIDCAB procedure for patients with multivessel disease is the integrated approach proposed by Angelini and co-workers [26]. This hybrid procedure combines MIDCAB grafting of the LAD with staged percutaneous transluminal coronary angioplasty/stenting of stenotic non-LAD vessels. Cardiologists have advanced percutaneous catheter management of multivessel coronary artery disease as being efficacious and associated with a low morbidity despite a high rate of reintervention [27]. However, they are very aware of the durability and long-term benefits of the LIMA-to-LAD graft [28, 29]. This integrated approach, therefore, has tremendous appeal by offsetting the invasiveness of conventional CABG but retaining the benefits of LIMA grafting. Several concerns warrant a cautionary approach. The extensive anticoagulation currently required during stenting may increase the bleeding complications from the surgical field. Most important, the medically accepted current failure rate of percutaneous transluminal coronary angioplasty/stenting should not compromise the excellent long-term surgical results obtained in patients with multivessel disease who are acceptable candidates for CPB. Our experience with hybrid procedures has been positive and includes 4 patients. We have found these procedures to be a practical alternative for patients with multivessel disease who are not candidates for conventional coronary operations (Fig 3).
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Minimally invasive direct coronary artery bypass grafting is being driven by a health care system that is eager to contain costs by emphasizing less invasive procedures. In addition, the MIDCAB procedure has become a potent marketing tool where competition for patients is vigorous. These extraneous forces should not influence the critical evaluation of this operation. Rather, a reduction of postoperative morbidity, without a compromise in quality, should be the primary motivation for adopting this procedure. Our results support that redo MIDCAB grafting, in selected patients, achieves this goal. Furthermore, it may extend myocardial revascularization to a high-risk subset of patients who otherwise would be denied intervention if MIDCAB grafting were not in the surgeons' armamentarium.
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Footnotes |
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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Address reprint requests to Dr Allen, 8333 Naab Road, Suite 300, Indianapolis, IN 46260.
This article has been selected for the open discussion forum on the STS web site: ***http://www.sts.org/annals
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TopFootnotesAbstractIntroductionMaterial and MethodsResultsCommentReferences |
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