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Ann Thorac Surg 1998;66:1022-1025
© 1998 The Society of Thoracic Surgeons

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Supplement

Minimally invasive coronary artery bypass grafting without cardiopulmonary bypass: early experience and follow-up

^a Clinic of Cardiac Surgery, Heartcenter, University of Leipzig, Leipzig, Germany

Address reprint requests to Dr Diegeler, Clinic of Heart Surgery, Heartcenter, University of Leipzig, Russenstr 19, D 04289 Leipzig, Germany
e-mail: (diea{at}server3.medizin.uni-leipzig.de)

Presented at "Facts and Myths of Minimally Invasive Cardiac Surgery: Current Trends in Thoracic Surgery IV," New Orleans, LA, Jan 24, 1998.

Abstract

Background. There is renewed interest in coronary artery bypass grafting without cardiopulmonary bypass using the anterolateral minithoracotomy approach. We evaluated 209 patients who underwent minimally invasive direct coronary artery bypass grafting using an anterolateral minithoracotomy. The anastomosis was performed under direct vision on the beating heart without using cardiopulmonary bypass.

Methods. The procedure was performed using a 6- to 9-cm left (or right) anterolateral thoracotomy for internal thoracic artery graft harvesting and anastomosis. Different devices were used for local immobilization. In 195 patients a single internal thoracic artery to left anterior descending coronary artery bypass was performed, in 3 patients a single right internal thoracic artery to right coronary artery bypass, and in 11 patients the radial artery was used together with the internal thoracic artery as a T-graft.

Results. Conversion to sternotomy or cardiopulmonary bypass was necessary in 10 (4.7%) patients. Intraoperative myocardial infarction was observed in 4 patients (1.9%). Early postoperative redo operation was necessary in 5 patients (2.4%). Mortality was 0.47%. Postoperatively, 191 patients (91.3%) underwent angiography for graft patency control. The overall patency rate was 97.3%. Minor stenosis of the internal thoracic artery graft was observed in 18 patients (9.4%); moderate stenosis was observed in 5 patients (2.6%). Midterm angiographic follow-up after 6 months was performed in 58 patients. The patency rate was 98.2%. One patient with severe symptomatic stenosis (1.7%) underwent reoperation.

Conclusions. With the help of the local immobilization systems off-pump coronary artery bypass grafting was safely performed through a minithoracotomy. The incidence of intraoperative and postoperative complications was low and follow-up showed good results. Thus, minimally invasive direct coronary artery bypass grafting is an excellent technique for arterial revascularization in patients having symptomatic left anterior descending coronary artery disease.

Currently there is renewed interest for coronary artery bypass graft operations (CABG) without using cardiopulmonary bypass (CPB). First reported by Kolessov [1] in 1967, the off-pump technique has been mainly abandoned since CPB became the standard for CABG. Nevertheless several groups continued to perform CABG without CPB in selected patients [2–4]. During the past 2 years a combination of the off-pump technique and an anterolateral minithoracotomy was standardized and has now gained acceptance worldwide [5, 6]. The aim of less invasive CABG is to avoid any negative impact of CPB. This is thought to improve the outcome for the individual patient to achieve early recovery and additionally to decrease costs. Minimally invasive direct CABG has been facilitated by the development of specially designed instruments for an atraumatic harvesting of the internal thoracic artery (ITA) under direct vision using a left or right minithoracotomy. Nevertheless, some surgeons prefer endoscopic technique for ITA harvesting [7, 8]. The quality of the anastomosis of the graft on the beating heart is crucial for the surgical outcome. The local immobilization of the anastomotic site provided by specially designed devices increased both the ability and the safety of the graft–anastomosis performed on the beating heart. Several different devices for local immobilization of the beating heart at the site of the anastomosis have become available. Most of these devices were used in our study and are consecutively evaluated.

Material and methods

Patients
Between November 1996 and December 1997, 209 patients underwent coronary artery revascularization without using CPB. A limited left (or right) anterolateral access through the fourth intercostal space was used. Indications for CABG was isolated proximal stenosis of the left anterior descending coronary artery (LAD) or right coronary artery, respectively. Selected patients with an additional stenosis of a major diagonal or intermediate branch were also included and received radial artery T-grafts.

All patients received anesthesia under a standardized protocol, including a Swan-Ganz catheter in all patients. Changes in ST segment were monitored using a on-line three-channel electrocardiogram (ECG, precordial lead II, V₅, and aVL). Temporary single-lung ventilation could be performed with a double-lumen tracheal tube. The lateral body of the patients was covered by a warm airflow sheet (WarmTouch Malincroth, Hennef, Germany) to prevent a drop of body temperature during the procedure. To decrease postoperative pain bupivacaine hydrochloride, 10 to 15 mL 0.25%, was applied by means of an intercostal catheter every 4 hours.

Operative technique for the limited left or right anterolateral access
The left or right anterolateral minithoracotomy was performed through the fourth intercostal space without resecting or dissecting any part of the ribs. A specially designed ITA access retractor (CTS ITA Access Retractor, CardioThoracic Systems Inc, Cupertino, CA; or ThoraLift, US Surgical Corp, Norwalk, CT) was used for ITA harvesting under direct vision. An initial 100 IU/kg of heparin was applied before interruption of the internal artery. For rib retraction and immobilization of the myocardial surface a second device was used. After opening of the pericardial sac the target coronary artery was dissected from surrounding tissue and held by two 4-0 polypropylene sutures at a short distance proximal and distal to the anastomosis that were snared over a piece of pericardium for temporary interruption of blood flow. In all patients with nonocclusive LAD disease, ischemic preconditioning of 5 minutes followed by another 5 minutes of reperfusion was performed to exclude myocardial dysfunction or severe arrhythmia during ischemia and to increase the tolerance to ischemia. Regardless of ST-segment changes during temporary occlusion of the coronary artery, the anastomosis was performed without CPB when myocardial function remained stable and no ventricular arrhythmia occurred. Local immobilization at the anastomosis was achieved with the different stabilizers (CTS, US Surgical, Origin, Menlo Park, CA; OmniTract, Minneapolis, MN; and Medtronic Octopus, Minneapolis, MN). Anastomosis of the graft was performed using one running 8-0 polypropylene suture, starting at the heel of the anastomosis. In case of an additional radial artery T graft the anastomosis between the radial artery and the ITA graft was performed first at a distance of about 3 cm from the distal end of the ITA in a perpendicular angle using one running 8-0 polypropylene suture. Next, the anastomosis between the radial artery and the diagonal or intermediate branch was performed. Finally, the distal anastomosis between the ITA graft and the LAD was performed.

Protamine was applied to neutralize 80% of the heparin dosage. In every patient only one drain was positioned in the corresponding pleural cavity. An intercostal catheter was inserted under direct vision, dorsal to the incision and close to the endothoracic fascia, for postoperative pain control. The fourth and fifth rib were approximated and wounds were closed.

Results

Demographics of all patients are shown in Table 1. Different procedures that were performed with a limited access are listed in Table 2. The intraoperative and perioperative course is described in Table 2 as well. Intraoperative hemodynamics were unchanged in 193 (92.3%) patients. In 2 patients a conversion to CPB was necessary because of a severe drop in cardiac output and ventricular arrhythmia during temporary ischemia caused by LAD occlusion. In the remaining 14 patients hemodynamic depression could be balanced by temporary application of low-dose adrenergic drugs. Perioperative complications are listed in Table 3. Most of these complications occurred during the initial learning period. The total rate of early redo operations was 2.4% (5 of 209). Postoperative angiography was performed in 191 (91.3%) patients. Although 8.7% of the patients did not consent, they had an uneventful postoperative course and were in New York Heart Association functional class I at discharge. Grafts were patent in 97.3%. The results of a midterm follow-up of the first 58 patients at 6 months revealed angina classification according to the Canadian Cardiovascular Society (CCS) classification as class I, 80.7%; class II, 17.6%; and class III, 1.7%. Patency rate was 98.3%; the patient who was in CCS class III had graft occlusion and underwent reoperation. One moderate stenosis and three minor stenoses at the anastomosis were observed. One early moderate stenosis disappeared at the 6-month follow-up. All patients were symptom free. Further early follow-up data are listed in Table 4.

Different surgical techniques were developed recently to perform MIDCAB on the beating heart without CPB to reduce the surgical trauma for CABG. Some authors combine endovascular CPB with a limited access [9, 10]; others apply the off-pump technique either with limited access or with the sternotomy approach [11]. The anastomoses of the grafts are still performed under direct vision. Full endoscopic techniques are being developed but have not been introduced in the clinical routine so far. Thus "less invasive" would be the best term at present for this kind of surgery.

Less invasive CABG was standardized since the first specially designed devices (CTS-CardioThoracic Systems, Inc) became available for ITA graft harvesting and for local immobilization of the coronary anastomosis. Minimally invasive direct CABG is now routinely performed without using CPB. For ITA harvesting we still recommend avoiding any steal phenomena or kinking of the graft. An excellent approach to the ITA can be achieved by using the CTS ITA Access Retractor or the US Surgical ThoraLift.

The main reason to reduce the invasiveness of CABG is to perform the procedure without CPB. It is important to have optimal local immobilization of the myocardial surface at the site of the target coronary artery. Different devices were compared, and the best immobilization could be achieved with the CTS, Origin, and Medtronic Octopus devices. In patients operated on with anterolateral minithoracotomy the LAD was accessible for a beating heart anastomosis in more than 90%. An intramyocardially running LAD necessitated conversion to sternotomy and CPB in 5 patients (2.4%). In another 15 patients the LAD was difficult to expose for anastomosis and postoperative graft failure occurred in 5 of these patients. Technical difficulties in exposing the LAD and performing the anastomosis increase the risk of graft failure. Therefore a liberal policy for early conversion is recommended. The mean duration of temporary LAD occlusion was 19.4 ± 3.2 minutes. This was well tolerated in all but 6 patients. In 2 of these patients conversion to CPB was necessary; in the remaining 4 completion of the anastomosis was possible without conversion and intraoperative myocardial damage did not occur according to normal postoperative enzymes and ECG. In all of these, LAD stenosis was less than 80%. Slight ST-segment elevation during temporary LAD occlusion was observed in 34 (16.2%) patients, all with nonocclusive LAD disease. Although the physiologic benefit of 5 minutes of ischemic preconditioning is not confirmed [12], we prefer this technique. At least it provides some safety, as a nontolerated occlusion of the coronary blood flow should become obvious during this period. Intraoperatively, a restriction of myocardial function and occurrence of ventricular arrhythmia rather than the elevation of ST segment have to be carefully monitored. If myocardial function remains stable and no ventricular arrhythmia occurs, the anastomosis can be performed irrespective of ST-segment elevation. Electrocardiographic changes during temporary occlusion of the LAD should return to normal within a few minutes after reperfusion. Based on our data, we believe the risk of intraoperative myocardial infarction is low (1.9%). In 2 of the 4 patients myocardial infarction was caused by a failure of the anastomosis rather than temporary occlusion of the LAD. In general we are concerned about complications if the LAD stenosis is less than 80%, the time after onset of symptoms is short, and only a few collaterals are seen on the angiogram. In these circumstances, the myocardium may not be well adapted to ischemia and sudden interruption of the remaining coronary blood flow may not be tolerated. For these patients the sternotomy approach and off-pump grafting is recommended because occlusion time to perform the anastomosis was much shorter (9.2 ± 2.3 minutes in our experience), and going on CPB is easily possible if it becomes necessary.

For intraoperative quality control, flow measurements of the graft using transit time Doppler is recommended, but this is not perfect in terms of various aspects. Based on our experience, we believe that neither the quantitative flow measurement nor the flow configuration are reflective of the true quality of the anastomosis [13]. For measurement of the distal flow, the LAD should still be snared proximally. An intraoperative angiogram provides information about the run-off through the graft, but it is not reflective of the quality of the stenosis. Recently we have developed endoscopic thermal coronary angiography for intraoperative graft patency control, but again, this technique provides only information about the patency and not the quality of the anastomosis [14].

The intraoperative and postoperative course was uneventful in most patients and recovery was excellent. Despite the smaller incision, the anterolateral thoracotomy is a rather painful access as noted during the first 3 postoperative days. Therefore postoperative pain management is crucial to performing an early extubation. An intercostal catheter is advantageous in the first postoperative days. Bupivacaine hydrochloride was applied every 6 hours in the first 3 postoperative days and continued on demand.

In general we recommend a postoperative angiographic control study in the catheter laboratory before discharge. A minor stenosis (50%) at the anastomotic site, usually a short distance proximal to the heel, was observed in 18 patients (9.4%). In addition, in 5 patients (2.6%) a stenosis of about 75% was observed. In these patients a postoperative exercise test was performed before discharge from the hospital. Because there was no pathologic ECG during exercise the patients were discharged without further intervention but follow-up is scheduled for shorter periods. Most patients had an uneventful recovery; thus, early discharge is safe. Because the performance of anastomosis on the beating heart is technically more demanding, we controlled the midterm patency rate by an additional angiogram after 6 months in this study. Our results from 58 patients showed an excellent patency rate of 98.3%, 1 moderate, and only 3 minor stenoses. All 4 patients confirmed a symptom-free follow-up, and exercise test was adequate without ischemic reactions. Interestingly, one of the moderate early stenoses disappeared after 6 months; thus, early postoperative spasm could be the reason for the narrowing at the heel of this anastomosis. Postoperative stenoses at the site of snaring or clamping of the coronary artery could not be observed in the early angiograms, nor could any de novo stenoses caused by intimal hyperplasia at the site of snaring after 6 months.

Less invasive CABG without CPB through a small anterolateral thoracotomy is technically more demanding but can be safely performed. It is now the routine technique for single-graft revascularization to the LAD or right coronary artery. The perioperative course is usually uneventful, and early recovery and discharge from the hospital can be anticipated. Short and midterm results are good. The long-term quality of the stenosis and the natural history of minor and moderate stenoses at the anastomosis have to be investigated by further follow-up.

References

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This Article Abstract Full Text (PDF) 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): Anno Diegeler Volkmar Falk Roberto Battellini Thomas Walther Friedrich W. Mohr Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Diegeler, A. Articles by Mohr, F. W. Search for Related Content PubMed PubMed Citation Articles by Diegeler, A. Articles by Mohr, F. W.