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Ann Thorac Surg 1998;66:1073-1075
© 1998 The Society of Thoracic Surgeons
a Clinic for Cardiovascular Surgery, Rotenburg, Germany
Address reprint requests to Dr Oster, Clinic for Cardiovascular Surgery, Panoramastraße 100, D-36199 Rotenburg, Germany
Presented at "Facts and Myths of Minimally Invasive Cardiac Surgery: Current Trends in Thoracic Surgery IV," New Orleans, LA, Jan 24, 1998.
Abstract
Background. Internal mammary artery to left anterior descending coronary artery anastomosis can be done without extracorporeal circulation on the beating heart. This method seems to have particular advantages for elderly patients, those 70 years old or older.
Methods. From January 1, 1997, to October 31, 1997, 27 patients have been operated on with a minimally invasive approach through a left-sided minithoracotomy. Twelve patients had up to four previous percutaneous interventions with percutaneous transluminal coronary angioplasty (3) or percutaneous transluminal coronary angioplasty and stent implantation (9). The remainder showed stenosis not suitable for percutaneous transluminal coronary angioplasty or an occluded vessel. In all patients the internal mammary artery was anastomosed with the left anterior descending coronary artery, and in 2 patients additionally with the first diagonal. In 1 patient the operation had to be converted to a sternotomy because it was impossible to identify the left anterior descending coronary artery.
Results. All patients survived the operation. There was no perioperative infarction. All patients were extubated within 4 hours. Mean stay in the intensive care unit was 20.3 hours; postoperative stay was 7.4 days. Nine patients had elective repeat angiography within 10 days postoperatively and all showed a patent graft.
Conclusions. We believe that minimally invasive coronary revascularization of the anterior wall can be done in elderly patients with low risk and good results.
The internal mammary artery (IMA) is the standard conduit for revascularization of the left anterior descending coronary artery (LAD). Numerous investigations showed that the IMA has a higher patency and this is related to longer symptom-free survival and less postoperative myocardial infarction [1–3].
Because of the close anatomic relationship between the IMA and the LAD this operation can be done through a left-sided anterolateral thoracotomy on the beating heart [4–6]. Avoidance of extracorporeal circulation (ECC) reduces the operative stress for the patient and allows more rapid recovery. Therefore this seems to be a real minimally invasive surgical procedure [7]. We have adopted this method especially for the elderly patient, because patients older than 70 years have an increased risk during operation with ECC [8].
Methods
From January 1, 1997, to October 31, 1997, 27 patients (9 women, 18 men) with a mean age of 75.5 years (70 to 85 years) have been operated on at our institution with a minimally invasive approach. All patients had stable angina pectoris and a normal ejection fraction. Twelve patients have had up to four previous percutaneous interventions, either a percutaneous transluminal coronary angioplasty (3) or a percutaneous transluminal coronary angioplasty and stent implantation (9). The remainder showed either a stenosis not suitable for percutaneous transluminal coronary angioplasty (10) or an occlusion of the LAD, which could not be recanalized (2).
After standard induction of anesthesia the patient was intubated with a double-lumen tube to allow single-lung ventilation.
An anterolateral incision 8 to 12 cm long was made and the pectoralis muscle was divided. After opening of the pleural cavity in the fourth intercostal space the CTS retractor (CardioThoracic Systems, Cupertino, CA) was installed and dissection of the IMA was started, going cranially above the first rib and caudally to the fifth intercostal space. The patient was heparinized (1 mg/kg), and the IMA was divided after ligation of the distal stump. After checking the free flow the IMA was occluded with a small bulldog clamp.
The pericardium was opened longitudinally and the LAD was identified. After insertion of the CTS stabilizer the LAD was proximally occluded by passing a 5-0 Prolene (Ethicon, Somerville, NJ) suture underneath the vessel and gently pulling it up. Distal occlusion was achieved by the heel of the CTS stabilizer. The vessel was then opened approximately 5 mm and the IMA was anastomosed with an 8-0 Prolene running suture after proper shaping. After completion of the anastomosis the stabilizer and the occluding suture were removed, and after checking for bleeding the edges of pericardium were approximated and a chest drain was placed. The chest was closed in routine manner.
During dissection of the IMA and anastomosis the left lung was not ventilated to achieve a better view of the operating field.
Results
All patients survived the operation without major complications and are free of symptoms since. There were no perioperative myocardial infarctions; however, 12 patients showed ST-segment elevation up to 0.3 mV during anastomosis, which resolved completely after completion of the anastomosis. There were also no rhythm disturbances during the time of anastomosis.
Takedown of the IMA took a mean time of 18.2 minutes (12 to 35 minutes). This is twice as long as in standard procedures when dissecting the IMA through a sternotomy.
Time of anastomosis was 11 minutes (6 to 18 minutes) and total operation time was 68.2 minutes (50 to 100 minutes), which is only slightly less than a conventional operation using ECC.
In all patients the IMA was connected to the LAD, and in 2 patients additionally to the first diagonal branch. In 1 patient the operation had to be converted to a sternotomy because it was impossible to identify the LAD, which was running in the subepicardial tissue.
Postoperatively all patients were extubated within 4 hours. Mean stay in the intensive care unit was 20.3 hours (16 to 28 hours) and postoperative hospitalization was 7.4 days (5 to 12 days). Nine patients had elective repeat angiography within 10 days postoperatively and all showed a patent graft with unrestricted flow and anastomosis (Figs 1, 2).
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Comment
These results show that minimally invasive revascularization can be done with low risk and good results comparable to those of conventional surgical procedures; however, only the long-term results will demonstrate whether this method is as reliable as the conventional procedure using ECC. However, if a technically correct anastomosis is able to be constructed, long-term results should be comparable because they are only dependent on the progression of the arteriosclerotic disease [1, 3]. These primary results are encouraging and justify further evaluation of this technique.
A major advantage of this method is the avoidance of ECC. Extracorporeal circulation is a splendid tool and necessary for most cardiac surgical procedures. However it contributes much to the operative morbidity of patients. Use of ECC is responsible for decreases in renal and respiratory function [9], and also the number of cerebral vascular insufficiencies is significantly increased as compared with operations without ECC [9]. Therefore, avoidance of ECC leads to a more rapid recovery of patients, reducing postoperative hospitalization and costs [7, 10].
Problems with this method are related to the small operative site and coronary artery anatomy because it is difficult to identify the coronary artery in the small operative field. In cases in which the coronary arteries are running under subepicardial tissue or even intramyocardially, it can be impossible to find them and perform an anastomosis of a good quality. In these cases the operation has to be converted to a sternotomy because this approach offers a significantly better view of the heart and the coronary artery anatomy.
There must be a thorough indication for every surgical procedure and especially when a surgical technique is introduced. At this point we see the indication for minimally invasive procedures in symptomatic patients in whom other interventional procedures have failed or are associated with excessive risk. These are very proximal stenoses and occluded vessels that cannot be recanalized. Patients with significant comorbidity who have an increased risk for operation with ECC also represent an indication. In these patients a minimally invasive revascularization of the anterior wall could be combined with interventional procedures for other coronary lesions [4, 10]. However, these factors need further investigation to clarify this strategy.
References
This article has been cited by other articles:
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  R. W Emery, K. V Arom, and A. M Emery Complete revascularization on cardiopulmonary bypass: a closer look at existing technology Eur. J. Cardiothorac. Surg., September 1, 1999; 16(suppl_1): S66 - S68. [Full Text] [PDF]
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 M. S. Ghotbi and J. G. Ramsay Minimally Invasive Cardiac Surgery: Impact on Resource Usage, Costs, Length of Stay, and Return to Function Seminars in Cardiothoracic and Vascular Anesthesia, July 1, 1999; 3(2): 126 - 135. [Abstract] [PDF]
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