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Ann Thorac Surg 1997;64:710-714
© 1997 The Society of Thoracic Surgeons

Original Article: Cardiovascular

Minimally Invasive Coronary Artery Bypass: A Series With Early Qualitative Angiographic Follow-up

Inderjit S. Gill, FRCS(C), Gerald M. FitzGibbon, LRCP&S(Ireland), Lyall A. J. Higginson, FRCPC, Azim Valji, FRCSC, Wilbert J. Keon, FRCS(C)

Departments of Cardiothoracic Surgery and Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada

Accepted for publication April 1, 1997.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background. Notwithstanding the advantages offered by minimally invasive coronary bypass, valid concerns have been raised about the technical accuracy of the distal anastomoses that can be fashioned on a beating heart. The main objective of our study was to undertake early and complete qualitative angiographic graft analysis in all patients undergoing this procedure.

Methods. All enrolled patients (25) from January to October 1996 who had bypass done by one surgeon via left minithoracotomy (19) or median sternotomy (6) on a beating heart underwent postoperative angiography within 4 to 6 hours. These angiograms were then reviewed for qualitative analysis and compared with a similar series done under conventional cardioplegic arrest.

Results. There was 97.5% graft patency (28/29) and no anastomotic occlusions. One internal thoracic artery was damaged. There was no mortality and no perioperative myocardial infarctions. All patients are alive and symptom free. The follow-up is 100% complete and ranges from 15 days to 11 months. Of the 26 anastomoses that could be assessed, 21 (81%) were grade A and 5 (19%) were grade B. In comparison, 24/25 (96%) of the anastomoses fashioned on an arrested heart by the same surgeon were grade A (p = 0.175).

Conclusions. Minimally invasive coronary bypass can be carried out effectively and safely in a select group of patients, and the development of stabilizing devices and proper instrumentation should further improve results.


   Introduction
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 Footnotes
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Conventional coronary operations with cardiopulmonary bypass and cardioplegic arrest are both safe and effective. Increasing awareness of the damaging effects of cardiopulmonary bypass [1, 2] and blood transfusion [3, 4], coupled with the economic impact of extended intensive care unit and hospital stays, have spurred efforts towards "minimally invasive" operations [5, 6]. However, valid concerns have been raised about the technical accuracy of the distal anastomosis made on a beating heart [7–9].

The present study was undertaken to define this issue in a consecutive series of selected patients having minimally invasive direct coronary artery bypass grafting (MIDCABG). We assessed by early selective angiography the quality of the distal anastomosis fashioned on a beating heart with pharmacologic bradycardia.

All patients consented to postoperative angiography, which was done 4 to 6 hours postoperatively. These angiograms were qualitatively categorized as described by FitzGibbon and associates [10]. We now report the results in our first 25 patients undergoing this procedure.


   Material and Methods
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 Footnotes
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Between January and October 1996, 25 patients had MIDCABG procedures at the University of Ottawa Heart Institute. We defined these operations as those done without cardiopulmonary bypass and aortic cross-clamping. Preoperative data on the patients are given in Table 1Go.


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  		Table 1. . Preoperative Data
 
Patients were candidates with isolated left anterior descending artery (LAD) disease not amenable to angioplasty/stenting (21) or patients who were deemed poor surgical risks for conventional bypass (4). No incomplete revascularization was attempted, and arteries needing an additional bypass graft were approached through a sternotomy: proximal right coronary artery (2), diagonal (1), and circumflex (1). All anastomoses were performed on a beating heart. A postoperative angiogram was done in all patients.

Fourteen patients (56%) were in the hospital preoperatively with class III or IV angina. No patient was turned down on the basis of small size of the target vessel on angiography, as this is often misleading and vessels less than 1.5 mm were successfully grafted (Figs 1A, 1BGoGo).



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  		Fig 1. . (A, B) Bypass grafts carried out to vessels less than 1.5 mm. (C) Postoperative angiogram. (D) Minimally invasive direct coronary artery bypass graft with "waisting" seen beyond the distal anastomosis.

 
Patient monitoring included electrocardiography, intraarterial blood pressure, bladder temperature and neuromuscular blockade assessment. Pulmonary artery catheterization for cardiac output monitoring was done in all patients, most with both continuous cardiac output and continuous mixed-venous oxygen saturation capabilities (Edwards Swan-Ganz Continuous Cardiac Output Catheter with SvO2 model 744H7.5F; Baxter Healthcare Corporation, Irvine, CA). External defibrillator patches were placed on all patients before surgical preparation. Most patients also had a transesophageal pacemaker (Tapscope; Arzco Medical Systems, Inc) positioned to augment heart rate and cardiac output after completion of the surgical anastomosis (Fig 2Go). A warming blanket (40°C) was used to keep the patients warm as the first few patients cooled down to 32°C intraoperatively. Cardiopulmonary bypass without priming was kept on standby in all cases.



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  		Fig 2. . External defibrillator patches and transesophageal pacemaker in position in a patient undergoing minimally invasive direct coronary artery bypass grafting.

 
Generally, anesthesia was induced with propofol or midazolam and then was maintained with isoflurane, sufentanil, midazolam (with or without ketamine), and nondepolarizing muscle relaxants as required. Although a few early patients had double-lumen endotracheal tubes placed, a standard orotracheal tube is now used. Both optimal preoperative ß-blockade and intraoperative intravenous esmolol were used to maintain a slow heart rate (40 to 70 beats/min). Intermittent boluses of intravenous adenosine have lately been used to produce 10- to 12-second brief episodes of cardiac standstill for crucial stitches to the heel and toe of the anastomosis.

For patients undergoing a minithoracotomy an 8- to 10-cm skin incision medial to the nipple was made, a portion of the fourth intercostal cartilage was excised, and the pleural space was opened. Occasionally the third rib was divided medially, then rewired to the sternum to facilitate access to the proximal internal thoracic artery (ITA) and subsequently rewired to the sternum. The rib cage was elevated using a scapular retractor (Fig 3Go) and the ITA was dissected up to the second intercostal space proximally with the patient in slight Trendelenburg position. After 10,000 IU of heparin was given, the ITA was divided distally under the fifth rib.



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  		Fig 3. . Stabilization is achieved with "peanut" forceps, and a scapular retractor is used for rib cage elevation.

 
The pericardium was incised in T-fashion and opened vertically to the pulmonary artery bifurcation to avoid kinking of the ITA at the pericardial reflection. The LAD was examined and snared both proximally and distally at the chosen anastomotic site, with 4-0 Prolene (Ethicon, Somerville, NJ). A 100-mg intravenous bolus of lidocaine was given before the LAD was snared, and ischemic preconditioning was done for 5 to 10 minutes. Stabilization was achieved using either the assistant's index and middle fingers or a "peanut" on a Kelly forceps (see Fig 3Go). The anastomosis was carried out using a continuous 8-0 Prolene suture using the double-suture technique.

After completion of the anastomosis, the graft flows for the last 8 patients were checked with a transit-time ultrasonic flow probe (Transonic Systems, Ithaca, NY). A small chest tube was then put in the left pleural space, an intercostal block with 0.5% bupivicaine was done, and the wound was closed in layers.

The patients were taken to the intensive care unit and within 4 to 6 hours had a postoperative angiogram (Fig 1CGo). After discharge they were seen at our outpatient clinic at 2 weeks, and by their respective cardiologists at 6 weeks and 3 months. The follow-up is 100% complete, and ranges from 15 days to 11 months.


   Results
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 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Clinical results are summarized in Table 2Go.The conduits used were left ITA (24), right ITA (3), and saphenous vein graft (2). Endarterectomy of a right coronary artery on a beating heart was carried out in 1 patient.


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  		Table 2. . Clinical Results
 
Three patients needing more than one coronary artery bypass graft underwent a median sternotomy and 3 patients with isolated LAD disease because the LAD was thought to be intramyocardial or was diffusely diseased perhaps requiring an endarterectomy also underwent a median sternotomy (6/25; 24%). There was no difference in outcomes between the sternotomy and thoracotomy group.

Most patients remained intubated until after postoperative angiography, accounting for some delay in extubation and discharge from the intensive care unit. The hospital stay for the last 5 patients was 2.5 days. There were neither deaths nor perioperative myocardial infarctions; 3 patients (12%) had documented postoperative atrial arrhythmias lasting more than 30 minutes. Postoperative complications were as follows:

Only 1 patient was transfused blood: she was a poor surgical risk in whom dilutional anaemia developed as a result of intraoperative crystalloid infusion, and subsequently had a transfusion reaction complicated by acute renal dysfunction, congestive heart failure, and atrial fibrillation. There were no reopenings for bleeding.

Two patients had reoperations purely on the basis of angiographic stenosis. In both instances there was Thrombolysis in Myocardial Infarction 3 flow in the ITA-LAD graft, and 1 patient had a 25 mL/min flow measured with the transit-time ultrasound flow probe. Flows greater than 10 mL/min are generally considered acceptable. Both patients had their ITAs reused at reoperation. Both patients had good-sized LADs measuring 2.0 mm in diameter, and the stenosis was seen just above the heel of the anastomosis, probably as a result of an adventitial band or pursestringing at the time of suture tying on a beating heart. No clear cause could be documented at the time of reoperation. Since then we have adopted the double-suture technique. One left ITA was found to be damaged at the time of postoperative angiography in the early part of our experience. This patient underwent a stent placement, but returned 3 months later with angina. He was reoperated on and the right ITA was used to bypass the LAD distal to the previous anastomosis under conventional cardiopulmonary bypass. All other patients remain well and are symptom free.

The patency of the 29 grafts was 28/29 (96.7%). All the anastomoses were reviewed and graded as described by FitzGibbon and associates [10]:

All grades relate to the worst appearance in multiplane angiographic views. One right ITA could not be selectively cannulated, and one left ITA anastomosis was inadequately visualized; these cases were excluded from the analysis. Thus of the 26 anastomoses assessed, 21 (81%) were grade A and 5 (19%) were grade B.

These results were then compared with the first 25 consecutive ITA-LAD anastomoses constructed primarily under conventional cardioplegic arrest by the same surgeon (I.S.G.). These were assessed angiographically at the National Defence Medical Centre, Ottawa, within 30 days after the operation. All left ITA-to-LAD anastomoses were grade A (24/25, 96%), and one right ITA anastomosis to LAD was occluded, grade "O" (1/25; 4%; p = 0.175).


   Comment
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 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
A patent left ITA–LAD graft is the single most important determinant of long-term and event-free survival [11, 12]. Notwithstanding the benefits of smaller incisions, shortened hospital stays, and reduced operative morbidity, in the ultimate analysis, the maximum benefit for the patient is dependent on and will be judged by the technical perfection of the ITA-LAD anastomosis.

Imperfect grafts have a poorer long-term outcome. This has future implications for the patient and the health care system. Our previously reported 1-year occlusion rate for grade B venous grafts was 24% compared with 6% for grade A grafts and was prognostically significant [10]. The grades assigned by four experienced cardiologists have been reproducible [13]. There are studies, however, in which early graft stenosis did not predict late occlusion [14, 15]. In the experience of Lytle and associates [16], two stenotic ITA grafts restudied after a mean of 88 months did not show any change. However, we have no reason to believe that early distal anastomotic defects in venous or arterial grafts are prognostically different. Our reported analysis of 456 ITA grafts showed a decrease in grade B grafts from 10% early to 3% at 5 years with a coincident increase in grade O grafts from 5% to 20%, which would suggest that this view is correct [17].

Postoperative angiography is essential for assessing graft patency. Current noninvasive tests cannot quantitate graft patency and remain to be validated. In our limited experience (8 cases) with the Transonic flow probe there has been one instance of a false positive result where the graft flow was satisfactory (25 mL/min) but the postoperative angiogram showed a significant stenosis. In another case the graft flow remained less than 8 mL/min in spite of attempts to dilate the distal coronary bed maximally with adenosine, yet the postoperative angiogram was satisfactory. The major objective of our MIDCABG study, therefore, was to accomplish 100% early angiographic follow-up to determine patency and, specifically, to assess the quality of the anastomoses constructed on a beating heart. We elected to carry this out within the first 4 to 6 hours, usually with the patients still intubated, so that necessary revisions could be carried out expeditiously before permanent myocardial damage occurred.

We have demonstrated a 97% early patency for all anastomoses. There have been no anastomotic occlusions, although damage to one ITA precluded flow to the distal LAD. On qualitative analysis of the anastomoses that could be assessed 21/26 (81%) were excellent or grade A and 5/26 were imperfect or grade B. This compares well with our total experience of 456 internal thoracic artery grafts that were examined early (<6 months) postoperatively. The overall patency was 95%, and 386 (85%) of the anastomoses were graded A, 45 (10%) were B, and 25 (5%) were occluded (grade O) [17].

In the closest feasible comparative analysis of the current data the first 25 consecutive patients having ITA-LAD grafts previously fashioned by the same surgeon (I.S.G.) under conventional cardioplegic arrest and who underwent postoperative angiography within 30 days were reviewed; a 96% patency was demonstrated and all LITA-LAD anastomoses were graded A. The difference did not reach statistical significance when compared with the MIDCABG experience because of the small numbers (p = 0.185). However, it should be kept in mind that the 4-week interval in these patients might have allowed vessel wall edema, hematoma, or spasm to resolve. Our late follow-up angiography will reveal whether this indeed will take place and whether some of the grade B anastomoses will progress to grade A. In the present series we did not find any obvious cause for the angiographic stenosis in the 2 patients having reoperations. We have also noticed a "waisting" just beyond the distal anastomosis in some postoperative angiograms (Fig 1DGo). Whether this is a result of snaring of the LAD and is a temporary phenomenon or a harbinger of more permanent damage awaits follow-up studies.

The size of the recipient vessel has been well known to influence graft patency. Graft occlusion rates of 37.5% at 1 year with vessels measuring 1.5 mm or less and 18.5% with vessels measuring 1.5 mm or more have been reported [18]. These data, however, pertain only to venous grafts. The patency of arterial conduits when grafted to vessels of small caliber is not well established. We successfully grafted four vessels of less than 1.5 mm with excellent symptomatic relief and good early angiographic results. Again, late follow-up will reveal eventual outcome.

Our early results suggest that MIDCABG can be carried out effectively and safely in a select group of patients. The development of sophisticated stabilizing devices [19] and the evolution of instrumentation and pharmacologic adjuncts should hopefully further improve results.


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   Footnotes
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Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 
Address reprint requests to Dr Gill, 1053 Carling Ave, Ottawa, ON K1Y 4E9, Canada.


   References
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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  6. Calafiore AM, Di Giammarco G, Teodori G, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658–65.[Abstract/Free Full Text]
  7. Westaby S, Benetti FJ. Less invasive coronary surgery: consensus from the Oxford Meeting. Ann Thorac Surg 1996;62:924–31.[Free Full Text]
  8. Ullyot DJ. Look Ma, no hands! [Editorial]. Ann Thorac Surg 1996;61:10–1.[Free Full Text]
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  10. FitzGibbon GM, Burton JR, Leach AJ. Coronary bypass graft fate. Angiographic grading of 1,400 consecutive grafts early after operation and of 1,132 after one year. Circulation 1978;57:1070–4.[Abstract/Free Full Text]
  11. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal mammary artery graft on 10 year survival and other cardiac events. N Engl J Med 1986;314:1–6.[Medline]
  12. Cameron A, Davis KB, Green G, et al. Coronary bypass surgery with internal thoracic artery grafts—effects on survival over a 15 year period. N Engl J Med 1996;334:216–9.[Medline]
  13. FitzGibbon GM, Leach AJ, Keon WJ, et al. Coronary bypass graft fate. Angiographic study of 1,179 vein grafts early, one year, and 5 years after operation. J Thorac Cardiovasc Surg 1986;91:773–8.[Abstract]
  14. Campeau L, Enjalbert M, Lespérance J, et al. Athero-sclerosis and late closure of aorto-coronary saphenous vein grafts. Sequential angiographic studies at 2 weeks, 1 year, 5 to 7 years and 10 to 12 years after surgery. Circulation 1983;68(Suppl 2):1–7.
  15. Frey RR, Bruschke AVG, Vermeulen FEE. Serial angiographic evaluation 1 year and 9 years after aorto-coronary bypass. A study of 55 patients chosen at random. J Thorac Cardiovasc Surg 1984;87:167–74.[Abstract]
  16. Lytle BW, Loop FD, Cosgrove DM, et al. Long-term (5–12 years) serial studies of internal mammary artery and saphenous vein coronary bypass grafts. J Thorac Cardiovasc Surg 1985;89:248–58.[Abstract]
  17. FitzGibbon GM, Kafka HP, Leach AJ, et al. Coronary bypass graft fate and patient outcome: angiographic follow-up of 5,065 grafts related to survival and re-operation in 1,388 patients during 25 years. J Am Coll Cardiol 1996;28:616–26.[Medline]
  18. Grondin CM, Castonguay YR, Lesperance J, et al. Attrition rate of aorta-to-coronary saphenous vein grafts after 1 year. A study in a consecutive series of 96 patients. Ann Thorac Surg 1972;14:223–31.[Abstract/Free Full Text]
  19. Borst C, Jansen EWL, Tulleken LAF, et al. Coronary artery bypass grafting without cardiopulmonary bypass and without interruption of native coronary flow using a novel anastomosis site restraining device ("Octopus"). J Am Coll Cardiol 1996;27:1356–64.[Medline]



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