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Ann Thorac Surg 1998;65:413-419
© 1998 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Port-Access Coronary Artery Bypass Grafting With the Use of Cardiopulmonary Bypass and Cardioplegic Arrest

Cardiovascular Institute, University Hospital "Carl Gustav Carus," Dresden, Germany

Accepted for publication August 3, 1997.

Prof Reichenspurner, Department of Cardiac Surgery, University Hospital Munich-Grosshadern, Marchioninistrasse 15, D-81377 Munich, Germany.

	Abstract

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Background. To reduce surgical trauma, we performed minimally invasive Port-Access (Heartport Inc, Redwood City, CA) coronary artery bypass grafting with cardiopulmonary bypass and cardioplegic arrest.

Methods. Thirty-six men and 6 women with a median age of 59 years (range, 31 to 75 years) and isolated lesions of the left anterior descending branch of the coronary artery underwent Port-Access coronary artery bypass grafting. A small (6- to 9-cm) incision was made parasternally on top of the fourth rib. The left internal thoracic (mammary) artery was dissected and taken down through the minithoracotomy either alone or using an additional thoracoscopic approach. Cardiopulmonary bypass was instituted through femoral cannulation, and an additional endoarterial balloon catheter (Heartport Inc) was introduced into the ascending aorta for aortic occlusion, aortic root venting, and the delivery of cold antegrade crystalloid cardioplegia. After cardioplegic arrest, the left internal mammary artery was anastomosed to the left anterior descending artery under direct vision.

Results. The median left internal mammary artery takedown time was 49.5 ± 21.9 minutes, the duration of cardiopulmonary bypass was 59.5 ± 32.8 minutes, the aortic occlusion time was 28.5 ± 7.9 minutes, the intensive care unit stay was 1.0 ± 3.2 days, and the total hospital stay was 5.0 ± 2.5 days. Intraoperative angiograms were done in the first 10 patients and showed patent left internal mammary artery grafts without anastomotic complications in all cases. Two arterial dissections, including one aortic dissection, were observed in patients with preexisting peripheral vascular disease. The other complications were minor. All but 1 patient recovered well, with no major limitations in their daily activities.

Conclusions. Using this minimally invasive method, sternotomy-related complications can be avoided, the hospital stay can be reduced, and a safe coronary artery bypass grafting procedure can be performed with the advantage of cardiopulmonary bypass and cardioplegic arrest as are used routinely in conventional coronary artery operations.

	Introduction

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Minimally invasive surgical procedures using endoscopic access and special instruments have become routine in many surgical specialties, such as gynecology, orthopedics, and abdominal surgery. Thoracoscopic surgical techniques also have been used widely and routinely in many centers for thoracic operations. In the field of cardiac surgery, clinical interest in minimally invasive surgical techniques has been aroused by reports of thoracoscopic ligation of patent ductus arteriosus, ligation and division of vascular rings, insertion of pericardial drains, and ligation of the thoracic duct [1].

To perform minimally invasive cardiac operations using cardiopulmonary bypass (CPB) and cardioplegic arrest, a project was started at Stanford University a few years ago focusing on coronary artery bypass grafting using a minimally invasive surgical approach in connection with an endovascular CPB system [2]. This system uses femoral arterial and venous access for CPB and a transfemoral endoaortic occlusion catheter (Endoaortic Clamp; Heartport Inc, Redwood City, CA). Using these devices, endoscopic preparation of the left internal thoracic (mammary) artery (LIMA) was performed in dogs with consecutive Port-Access bypass grafting of the LIMA to the coronary arteries. After extensive animal studies, a phase I Food and Drug Administration trial was performed at the Stanford University School of Medicine [3]. In March 1996, a clinical program of Port-Access coronary artery bypass grafting using the endovascular CPB system was begun at our institution.

	Patients and Methods

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Forty-two patients with isolated significant lesions of the left anterior descending coronary artery (LAD) were evaluated for port-access coronary artery bypass grafting. Thirty-five patients (83.3%) had proximal LAD stenosis, ranging from 65% to 95% (median, 80%). Seven patients (16.7%) showed an occluded LAD on angiography. Eight patients (19%) previously had undergone percutaneous transluminal coronary angioplasty and 3 (7.1%) had had stents placed in the LAD. Twenty-eight patients (66.7%) showed no other major coronary artery lesions and 14 (33.3%) showed higher-grade stenosis on very small diagonal or marginal branches that were not amenable to surgical repair. Thus, all patients were referred for single-vessel revascularization of the LAD. They ranged in age from 31 to 75 years (median, 59 ± 11.2 years). Thirty-six of the patients were men and 6 were women. The preoperative left ventricular ejection fraction ranged from 0.38 to 0.88 (median, 0.71 ± 0.21). Before operation, 5.1% of the patients were in CCS stage 1, 69.2% were in stage 2, and 25.6% were in stage 3; 5.1% were in New York Heart Association class I, 85.4% were in class II, and 9.5% were in class III.

All the patients underwent preoperative assessment of the abdominal aortic iliac, and femoral arteries using Doppler sonography. In addition, transesophageal echocardiography was performed in all the patients to evaluate the condition of the ascending and descending aorta and to exclude major aortic valve incompetence. Renal function was studied in all the patients, with measurement of serum creatinine and creatinine clearance, to exclude those with preoperative renal insufficiency. Before the initiation of this program, approval of the hospital institutional review board was obtained and informed consent was given by all the patients.

The endovascular CPB system used consisted of a Y-shaped femoral arterial return cannula, a femoral venous cannula for drainage of the right atrium, an endopulmonary vent catheter inserted through the right internal jugular vein, and an endoaortic balloon occlusion catheter (Endoclamp; Heartport Inc).

After the induction of anesthesia, the patients were intubated with a double-lumen endotracheal tube to allow right single lung ventilation. The right internal jugular vein was punctured using a 9F introduction system for later insertion of the endopulmonary vent catheter. The right radial artery was used for invasive blood pressure monitoring.

The patient was placed in a supine position with the left shoulder elevated about 30 degrees. The left arm was attached to the body dorsally to the posterior axillary line. The patient was prepared and draped in such a way that the whole left chest was accessible as well as the whole sternum, in case the operation had to be converted to a conventional procedure with sternotomy. Both groins were prepared for surgical access.

A small (6- to 8-cm; median, 7.2 cm) incision was made parasternally on top of the fourth rib. During dissection and removal of the cartilaginous part of the fourth rib, care was taken not to injure the internal thoracic vessels. Thereafter, the LIMA was dissected distally down to below the sixth rib, with careful preparation of a pedicle and division and ligation of the side branches. Next, the LIMA was dissected proximally up to the first rib, with preparation, ligation, and division of all the side branches, including the second intercostal branch in all patients (100%) and the first intercostal branch in 10 patients (23.8%). In 5 patients (11.9%), disarticulation of the cartilaginous portion of the third rib was necessary to allow adequate exposure. In 5 patients (11.9%), during the early phase of our program, complete visualization of the LIMA was not possible through the minithoracotomy alone, so thoracoscopic preparation of the LIMA was accomplished through three small lateral chest ports.

As the LIMA was being prepared, the femoral vessels were dissected through a small incision (2 to 4 cm) made on the right side in 34 patients (82.9%) and on the left side in 7 patients (17.1%). The vessels were dissected and surrounded by umbilical tapes. The Y-shaped femoral arterial return cannula (23F) was placed into the femoral artery. A long (100-mm) guidewire was used to ensure correct placement of the arterial cannula. The positions of the guidewire and the cannula were verified by fluoroscopy before the arterial cannula was connected to the arterial line. Thereafter, the 21F venous cannula was inserted into the femoral vein and positioned into the right atrium using transesophageal echocardiography.

Before the initiation of CPB, the endoaortic clamp was positioned using a guidewire through the other opening of the Y-shaped arterial cannula. The guidewire and the occlusion catheter then were forwarded into the ascending aorta using fluoroscopy and transesophageal echocardiography. During the insertion of the endovascular bypass system, an endopulmonary vent catheter was placed by the anesthesiologist through the right internal jugular vein over a Swan-Ganz catheter using pressure control and, when necessary, fluoroscopy.

After the LIMA was harvested, the pericardium was opened longitudinally above the right ventricular outflow tract. The LAD was examined with regard to blood flow and evidence of stenosis and the length of the LIMA was checked before proceeding with the procedure. Thereafter, intravenous heparin was administered and the LIMA was ligated distally; the pedicle was placed in a papaverine-soaked sponge. A soft tissue retractor (Heartport Inc) was inserted to enable better exposure through the small thoracotomy (Fig 1).

View larger version (143K): [in this window] [in a new window]   Anterior minithoracotomy for Port-Access coronary artery bypass grafting. In 37 patients, the left internal mammary artery was dissected through this incision. In 5 patients, an additional thoracoscopic approach using three small lateral chest ports was used to take down the left internal mammary artery.

View larger version (70K): [in this window] [in a new window]   (A) Fluoroscopic image of the endoaortic balloon catheter used for occlusion of the ascending aorta and administration of cold antegrade cardioplegia. (B) Transesophageal echocardiographic control of the endoaortic balloon catheter. (The balloon is marked by an arrow.)

The total operative time, LIMA harvesting time, duration of CPB, and duration of cardioplegic arrest were monitored. After transferral to the intensive care unit, the duration of ventilation, length of intensive care unit stay, and total hospital stay also were recorded. The patients had complete follow-up, including a physical examination, 12-lead electrocardiogram, and chest roentgenogram 2 days, 14 days, 6 weeks, and 12 weeks after operation. In addition, cardiac enzymes (creatine kinase and creatine kinase-myocardial band) were measured 6 hours and then 2 days after operation. Intraoperative angiograms of the LIMA graft to the LAD were obtained in the first 10 patients as part of the study protocol. A postoperative angiogram was obtained 3 months after operation in the first 29 patients (70.7%). The last 26 patients (63.4%) also underwent an electrocardiographic stress test 3 months after operation.

	Results

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Outcome
The revascularization procedure was accomplished without the need for sternotomy in all but 1 patient. In the 1 patient, the LIMA showed severe atherosclerotic disease with evidence of occlusion in the proximal portion and was not suitable for grafting. The procedure was converted to a sternotomy and a saphenous vein was used for the coronary artery bypass graft. In all other patients, the procedure was performed as planned. The LIMA was harvested through the minithoracotomy alone in 37 patients (88.1%) and with the additional use of thoracoscopy in 5 patients (11.9%). The median values for the operative time, LIMA takedown time, duration of CPB, duration of aortic occlusion, duration of reperfusion, period of postoperative ventilation, length of intensive care unit stay, and length of total hospital stay are listed in Table 1. All patients were weaned from CPB without any evidence of myocardial ischemia and without any inotropic support.

Follow-up was complete in all patients at 6 weeks and in 37 patients (90.2%) at 12 weeks. At the time of examination, 39 patients (95.1%) were completely free of angina pectoris. Two patients (4.9%) complained of minor angina-like symptoms during major exercise. One of these patients showed a new stenotic lesion in the LAD approximately 1 cm distal to the anastomosis and underwent uncomplicated percutaneous transluminal coronary angioplasty. The second patient had an uneventful angiographic study. Altogether, 29 patients (69%) underwent angiographic follow-up at 3 months; in addition to the abovementioned patient, one additional study revealed a diffuse stenotic LAD proximal and distal to the anastomosis. All the other studies showed patent anastomoses without any evidence of stenosis (Fig 3).

View larger version (152K): [in this window] [in a new window]   Angiogram of the left internal mammary artery demonstrating patency of the anastomosis to the left anterior descending artery.

View larger version (116K): [in this window] [in a new window]   Postoperative result after wound closure.

A major postoperative hemorrhage developed in 1 patient 6 hours after operation and the patient had to undergo a sternotomy for exploration of the bleeding source. At the time of reoperation, a LIMA side branch was found to be bleeding and was ligated. A postoperative hemothorax necessitating additional drainage developed in 2 patients. One patient had a transient hemiparesis for 24 hours, probably caused by an air embolism, followed by a complete recovery. All complications are listed in Table 2.

	Comment

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

The use of the LIMA as a coronary artery bypass graft to the LAD has been associated with excellent long-term results in regard to patient survival and graft patency [6]. Single vessel coronary artery bypass grafting of the LIMA to the LAD has been studied extensively and demonstrated to produce excellent long-term results with almost no mortality [7]. Despite these results, the current treatment of choice for patients with isolated proximal LAD lesions remains the use of percutaneous transluminal coronary angioplasty, most likely because of its less invasive nature [8]. However, percutaneous transluminal coronary angioplasty is associated with a high rate of restenosis, commonly necessitating reintervention.

Coronary artery bypass grafting is a more invasive procedure, but it produces excellent graft patency rates, particularly with LIMA grafts to the LAD. The aim of this study was to decrease the surgical trauma by using a less invasive, smaller access route to the heart. At the same time, the standards of conventional cardiac operations, such as the use of CPB and cardioplegic arrest, were maintained. All major studies of coronary artery bypass grafting have evaluated conventional surgical procedures, including the use of CPB and cardioplegic arrest. The use of cardioplegia has enabled surgeons to perform coronary anastomosis on an arrested heart, which increases the safety and accuracy of the anastomosis.

A few years ago, a cardiac surgical team at Stanford University worked on an experimental model, performing coronary artery bypass grafting through small intrathoracic port incisions using a thoracoscope in combination with an intraoperative microscope [2]. The precondition for this surgical approach was the use of "endovascular CPB system." Using this system, CPB is initiated through femoral arterial and venous cannulation and an endoaortic balloon occlusion catheter is inserted through the femoral arterial cannula into the ascending aorta, which then allows internal occlusion of the ascending aorta in combination with proximal administration of cardioplegic solution.

After the completion of extensive experimental studies, a Food and Drug Administration study was begun at Stanford University using the same surgical approach in patients with single LAD stenosis. After the initial cases, the incision for the intraoperative microscope was extended to an anterior thoracotomy through which the coronary anastomosis was performed [3].

After completion of the phase I study at Stanford, the use of Port-Access coronary artery bypass grafting was initiated at our institution in 1996. Forty-two patients with isolated proximal stenosis of the LAD were operated on through a small left anterior thoracotomy with the use of the femoral endovascular CPB system. Partial rib resection was done in the described patients; however, this type of resection has been discontinued in our current practice. The femoral arterial cannula is Y-shaped, allowing insertion of the endoaortic occlusion catheter through the same access site.

Preparation of the LIMA up to at least the second intercostal space was accomplished directly through the anterior minithoracotomy in all but 5 patients; an additional thoracoscopic approach through three small lateral chest ports was necessary in these 5 patients, allowing high proximal dissection of the LIMA. Ligation of the first intercostal branch is not always feasible; however, the necessity of this procedure never has been documented clearly.

After the initiation of CPB, the endoaortic occlusion catheter was forwarded into the ascending aorta using fluoroscopy and transesophageal echocardiography. After aortic occlusion, cardioplegic solution was administered and the coronary anastomosis was performed on an arrested heart with venting of the aortic root.

The intraoperative data show an extended operative time, including a relatively long time for LIMA preparation resulting from accurate proximal dissection of the LIMA. However, there is a learning curve involved, and the times for LIMA preparation have decreased significantly in the last 20 patients. To ensure the accuracy of the surgical technique, intraoperative angiography was done in our first 10 patients and showed complete patency of all grafts and anastomoses in all cases. The duration of postoperative ventilation and length of stay in the intensive care unit are comparable to those of patients who undergo conventional coronary artery bypass grafting. However, patients who underwent Port-Access coronary artery bypass grafting were mobilized faster and discharged from the hospital after a median of 5 days, compared with 8 days after conventional coronary artery bypass grafting. Thus, the length of the hospital stay comes close to that of patients who undergo percutaneous transluminal coronary angioplasty (2 to 3 days on average).

Two major intraoperative complications occurred. During the institution of retrograde CPB, a complete type A aortic dissection occurred in 1 patient, necessitating replacement of the ascending aorta. Dissection of the right iliac artery developed during the same procedure in a second patient, requiring femorofemoral crossover bypass because of poor flow through the right femoral artery. Both patients had evidence of peripheral vascular disease on preoperative Doppler examinations. These complications are known to occur after the use of retrograde CPB in patients with peripheral vascular disease. The degree to which this risk is increased by the additional manipulation associated with the insertion and placement of the intraaortic balloon catheter needs to be evaluated. The current incidence of arterial dissection in patients undergoing Port-Access cardiac operations is about 2%. Therefore, we believe that the use of retrograde endovascular CPB is contraindicated in patients with significant peripheral vascular disease. Major postoperative bleeding developed in 1 patient, necessitating reoperation through a sternotomy for hemostasis, but the patient recovered quickly from this repeated intervention. One patient had postoperative signs of a transient hemiparesis for 24 hours, possibly related to an air embolism. No other major complications occurred.

Within a follow-up period of 3 months, all but 1 patient recovered quickly and well after Port-Access coronary artery bypass grafting, with no major limitations in their daily activities. On further follow-up, only 1 patient had signs of angina pectoris and underwent reevaluation 3 months after revascularization. The angiogram showed a new stenotic lesion within the LAD about 1 cm distal to the anastomosis. The patient underwent an uncomplicated percutaneous transluminal coronary angioplasty. In addition, 28 patients underwent a 3-month control angiogram, with no evidence of an anastomotic stenosis or kinking.

This technique of minimally invasive coronary artery bypass grafting stands in contrast to other minimally invasive techniques that avoid the use of cardioplegic arrest or CPB. In the so-called minimally invasive direct coronary artery bypass procedure, the surgeon performs the graft anastomosis on the beating heart without CPB. Several centers have reported good reslts using this approach with and without stabilization of the coronary artery [9] [10] [11]. The advantage of this technique is its avoidance of CPB and insertion through femoral cannulation. However, the anastomosis is not performed on an arrested heart. Long-term follow-up and postoperative angiographic studies will have to compare the quality of the anastomoses performed on the beating heart to those performed on the arrested heart. We have performed postoperative angiographic studies on most of our patients who underwent Port-Access coronary artery bypass grafting and have shown patency rates comparable to those obtained with conventional coronary artery bypass grafting.

The described technique of Port-Access coronary artery bypass grafting using CPB and cardioplegic arrest was performed safely in all patients who had no evidence of peripheral vascular disease. Patients who are at risk for sternal complications particularly might benefit from this procedure. Evidence of major peripheral vascular disease represents a contraindication to the use of the endovascular CPB system. The use of this surgical technique allows extension of its application to patients with multivessel coronary artery disease, valvular heart disease, and congenital heart defects. In patients with mitral valve disease, Port-Access mitral valve repair or replacement has been performed successfully at our institution as well as in several other centers using a small right thoracotomy in combination with the endovascular CPB [12] [13] [14].

	Footnotes

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 
Doctors Reichenspurner, Gulielmos, Pompili, and Stevens are clinical consultants for Heartport Inc, Redwood City, CA. Neither the institution nor any of the authors received financial compensation from Heartport Inc.

	References

Top Footnotes Abstract Introduction Patients and Methods Results Comment References

 

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3. St. Goar FG, Siegel LC, Stevens JH, et al. Catheter based cardioplegic arrest facilitates Port-Access cardiac surgery. Circulation 1996;94(Suppl 1):52.[Abstract/Free Full Text]
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6. Boylan MJ, Lytle BW, Loop FD, et al. Surgical treatment of isolated left anterior descending coronary stenosis. J Thorac Cardiovasc Surg 1994;107:657-662.[Abstract/Free Full Text]
7. 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.[Abstract]
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10. Calafiore AM, Giammarco G, Teodori G, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1665.[Abstract/Free Full Text]
11. Cremer J, Strüber M, Wittwer T, et al. Off-bypass coronary bypass grafting via minithoracotomy using mechanical epicardial stabilization. Ann Thorac Surg 1997;63:S79-S83.
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