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Ann Thorac Surg 1998;65:1513-1515
© 1998 The Society of Thoracic Surgeons

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Correspondence

Hybrid MIDCABG and Balloon Angioplasty for Multivessel Coronary Artery Disease

^a Division of Cardiothoracic Surgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, NT, Hong Kong

e-mail: izzat{at}mailserv.cuhk.edu.hk

To the Editor

The report by Dr Mack and colleagues [1] highlights the effectiveness and safety of combining minimally invasive coronary artery bypass grafting (MIDCABG) with catheter interventions in treating high-risk patients with multivessel disease. We would like to share our early experience with adopting a similar approach for the management of selected patients who suffer from significant comorbidities.

Between June and October 1996, 4 patients (all men; mean age, 68 ± 2 years) with multivessel coronary artery disease were selected for the combined MIDCABG plus angioplasty (PTCA) approach. All patients were symptomatic despite maximum medical therapy; 2 patients were in angina class III and 2 were in angina class IV. The decision to adopt the hybrid approach as opposed to a conventional operation was based on the presumed increased risk of cardiopulmonary bypass because of severe extensive arteriopathy (bilateral significant carotid stenoses plus atheromatous ascending aorta) in 1 patient, severe chronic obstructive airways disease (forced expiratory volume in 1 second < 1 L) in 1, cancer in 1, and severely impaired left ventricular function (ejection fraction <0.20) in 1 patient. In each patient, the left anterior descending artery was suitable for MIDCABG and the other coronary lesions were considered amenable to PTCA; however, none were considered suitable for a primary coronary angioplasty approach because of unfavorable coronary artery anatomy.

The surgical procedure was performed through a 6-cm left anterior minithoracotomy in the fourth intercostal space, with excision of the fourth costal cartilage. The left internal mammary artery was harvested with video assistance [2], and was anastomosed to the stabilized left anterior descending artery with running 7-0 Prolene (Ethicon, Somerville, NJ) sutures [3]. All patients were extubated in the operating room, and there were no surgical complications. Follow-up PTCA was performed during the same hospital admission. Each procedure commenced by performing left internal mammary artery graft angiography, which documented the presence of widely patent anastomoses in all patients, with no left internal mammary artery graft abnormalities. With this graft providing protection to the left coronary system, it was possible to achieve complete revascularization with PTCA and stenting in 3 patients; the fourth patient had PTCA to his circumflex coronary artery, whereas reopening his completely occluded right coronary artery was not possible. The mean hospital stay was 5.9 ± 0.9 days (range, 4 to 7 days). Only the last patient remains on oral nitrates treatment; he is now in angina class I (compared with angina class IV preoperatively). None of the other patients receive any antiangina treatment, and all are free of symptoms at a follow-up period of 12 to 16 months.

From this preliminary experience, we believe that combined MIDCABG and PTCA is a safe and effective approach from which selected high-risk patients with multivessel disease may benefit. Although simultaneous MIDCABG and PTCA was originally proposed [4], early experience has demonstrated certain drawbacks such as the uneconomical use of the interventional cardiology facilities and the potential conflict in the anticoagulation requirements. The staged approach presented here has the disadvantage that only partial revascularization is achieved after the first stage. Nevertheless, experience to date has not revealed any associated untoward complications [5, 6].

Even though our experience with the hybrid approach has been favorable, further work is needed to clarify patient selection and the long-term outcome of this approach. We agree entirely with Mack and associates’ conclusion that, at present, this approach should only be used selectively. Certainly, conventional coronary artery bypass grafting continues to be our standard approach for the management of patients with multivessel disease.

References

1. Mack M., Brown D.L., Sankaran A. Minimally invasive coronary bypass for protected left main coronary stenosis angioplasty. Ann Thorac Surg 1997;64:545-546.[Abstract/Free Full Text]
2. Izzat M.B., Yim A.P.C. Video-assisted internal mammary artery mobilisation for minimally invasive coronary artery bypass. Eur J Cardiothorac Surg 1997;12:811-812.[Abstract]
3. Izzat M.B., Yim A.P.C. Cardiac stabilizer for minimally invasive direct coronary artery bypass. Ann Thorac Surg 1997;64:570-571.[Abstract/Free Full Text]
4. Angelini G.D., Wilde P., Salerno T.A., Bosco G., Calafiore A.M. Integrated left small thoracotomy and angioplasty for multivessel coronary artery revascularisation. Lancet 1996;347:757-758.[Medline]
5. Izzat M.B., Yim A.P.C., Mehta D., et al. Staged minimally invasive direct coronary artery bypass and percutaneous angioplasty for multivessel coronary artery disease. Int J Cardiol 1997;62(Suppl 1):105-109.
6. Izzat M.B., Yim A.P.C. Minimally invasive LAD revascularization in high-risk patients with three-vessel coronary artery disease. Int J Cardiol 1997;62(Suppl 1):101-104.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Mohammad Bashar Izzat Anthony P.C. Yim Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Izzat, M. B. Articles by El-Zufari, M. H. Search for Related Content PubMed Articles by Izzat, M. B. Articles by El-Zufari, M. H.