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Ann Thorac Surg 1998;66:1076-1081
© 1998 The Society of Thoracic Surgeons

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Supplement

Beating heart operations including hybrid revascularization: initial experiences

^a Department of Cardiac Surgery, Hamburg, Germany
^c Department of Cardiology, Albertinen-Krankenhaus, Hamburg, Germany
^b Center of Cardiology, Hamburg-Othmarschen, Hamburg, Germany

Address reprint requests to Dr Riess, Albertinen-Krankenhaus Abt für Herzchirurgie, Suentelstrasse 11 a, 22457 Hamburg, 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. The outcome of patients (n = 45) with coronary one- to three-vessel disease undergoing beating heart operations using a recently developed stabilizing device was investigated.

Methods. Left internal mammary artery-to-left anterior descending coronary artery (LIMA-to-LAD) revascularization was carried out alone (n = 31) or as hybrid procedure in combination with a balloon angioplasty (n = 14).

Results. All 45 patients underwent a successful LIMA-to-LAD procedure without intraoperative complication during a 21 ± 8-minute (range, 10 to 53 minutes) LAD occlusion time. In 14 hybrid procedures a total of 19 stenoses including 3 left main stenoses were treated successfully by percutaneous transluminal coronary angioplasty and stenting. The postoperative courses were uneventful with the exception of two surgical reexplorations necessitated by bleeding. No worsening of renal, neurologic, or respiratory functions occurred in any patient. In the group having a single LIMA-to-LAD procedure, early postoperative coronary angiograms (22 of 31) showed a patent LIMA graft and excellent anastomosis; this was also true in 4 patients 12 months after operation as shown in angiograms. All patients undergoing hybrid revascularization demonstrated a patent LIMA-to-LAD anastomosis; in 1 patient there was a dissection in the midlevel of the LIMA, which was stented successfully. The 6-month follow-up angiograms in 7 of 14 patients revealed open LIMA bypass grafts in all patients except 1, who was stented because of dissection.

Conclusions. These data indicate that a beating heart operation including hybrid revascularization is safe and effective in selected patients with coronary one- to three-vessel disease including left main stenosis. This approach may be especially advantageous in comparison with conventional coronary artery bypass grafting in patients with severe concomitant disease.

Minimally invasive coronary artery bypass grafting has recently been introduced into the realm of cardiac surgery and has been proved to be an important technique for the cardiovascular patient [1–4]. Obvious advantages of the minimally invasive approach are less tissue traumatization and better preserved stability of the sternum, resulting in less postoperative pain, better wound healing, and a superior cosmetic result. The most important advantage of minimally invasive procedures, however, is that cardiopulmonary bypass (CPB) with its multiple side effects [5] in virtually every organ system, including heart, kidneys, lungs, and central nervous system, can be avoided. Furthermore CPB-related activation of the complement, coagulation, and fibrinolysis systems and damage of red blood cells, leukocytes, and platelets, which may result in bleeding and thromboembolic complications, can be avoided as well. B cell and T cell depletion may increase the risk of infections and could accelerate the progression of malignant diseases.

The CPB apparatus itself is another source of complications such as cannulation-related injuries and gas and particulate embolism [6], which may result in cerebrovascular events. Strokes occur with a considerable frequency [7], especially in elderly patients undergoing CPB, because of aortic atheromas liberated by the perfusion system, or hypoperfusion during CPB of cerebral vascular beds as a result of significant proximal stenotic vascular lesions in the carotid, vertebral, or intracranial arteries. Moreover, CPB seems to be responsible for a considerable number of neuropsychiatric abnormalities including depression, confusion, memory loss, decreased cognition, and incoordination [8], which are not observed in patients undergoing minimally invasive coronary artery bypass grafting (CABG). Furthermore, the high-dose heparin regimen during CPB may increase the risk of perioperative bleeding. Summarizing, the minimally invasive left internal mammary artery-to-left anterior descending coronary artery (LIMA-to-LAD) procedure may result in a better outcome for patients and probably a reduction in cost [9–11]. Therefore, in this study we investigated whether hybrid revascularization is a valid alternative to conventional CABG in patients with coronary multivessel disease.

Material and methods

Since January 1997 a total of 45 patients (39 men/6 women) with coronary artery disease (one-vessel, n = 15; two-vessel, n = 12; three-vessel, n = 18) were treated with a beating heart operation including hybrid revascularization in the Department of Cardiac Surgery and Department of Cardiology of the Albertinen-Krankenhaus Hamburg and the Center of Cardiology, Hamburg-Othmarschen. Thirty-nine LADs showed a high-grade proximal lesion; six LADs were proximally occluded. Fourteen patients had a history of previous percutaneous transluminal coronary angioplasty (PTCA)/stenting. The mean age of the patients was 63 ± 9 years (range, 37 to 86 years); weight, 77.6 ± 10.4 kg (range, 59 to 101 kg); and left ventricular ejection fraction, 0.58 ± 0.09 (range, 0.35 to 0.84). A sinus rhythm was found in 43 patients and a chronic supraventricular arrhythmia in 2 patients. In 19 of 45 patients concomitant diseases were present: renal dysfunction (including need for dialysis), 7 patients; malignant diseases, 7; diabetes mellitus (treated with insulin), 7; chronic obstructive pulmonary disease, 4; Bechterew’s disease, 2; stenoses of the carotid artery, 2; brain atrophy, 2; previous stroke, severe calcification of the ascending aorta, amyloidosis, and chronic pancreatitis, 1 patient each. One additional patient with coronary two-vessel disease had previously lost both legs as a result of an accident.

Anesthesia was maintained with a continuous intravenous infusion of propofol and sufentanyl or remifentanyl and a single bolus injection of pancuronium bromide. Standard monitoring of cardiac operation was performed including automatic ST-segment analysis and Swan Ganz catheter monitoring in patients with a left ventricular ejection fraction of less than 0.45. The LIMA was harvested up to the second intercostal space under direct vision after an inverted L-shaped ministernotomy up to the left third intercostal space and maximal vasodilation was achieved by injection of papaverine. After administration of heparin (10,000 IU/per patient) the LAD was snared twice in the midlevel using silicone loops with a blunt needle. After 5 minutes of LAD occlusion followed by another 5 minutes of reperfusion, the LAD was occluded again and anastomosis between the LIMA and the LAD was performed with a running 8-0 monofilament suture on the beating heart without the use of CPB. For the local stabilization of the heart we have developed a device for LAD occlusion and stabilization (MidCOAST, minimally invasive direct coronary occlusion and stabilizing technique; AESCULAP, Tuttlingen, Germany). No pharmacologically induced decrease of heart frequency was used. In the case of retrograde flow through the arteriotomy field, blood was displaced by a CO₂ blower device. Preconditioning was used only in 1 patient. After a test occlusion of 5 minutes followed by 5 minutes of reperfusion, an additional 5 minutes of occlusion and reperfusion was performed. When the anastomosis had been completed, the silicone loops were removed, the mammary pedicle was fixed with fibrin glue to avoid kinking of the mammary artery, and the pericardium was closed. A retrosternal drain as well as a drain into the left pleural cavity were inserted. The ministernotomy was refixed with wires and the wound was closed.

In a subgroup of 14 patients with two-vessel (n = 5) and three-vessel (n = 9) coronary disease a hybrid revascularization was performed within a clinical study (Table 1 ). Stenoses of the right coronary artery and the circumflex artery or the left main stem were treated by interventional cardiologic techniques after the LIMA-to-LAD procedure. Coronary angiograms were performed 6 and 12 months after operation to document the quality of the anastomosis, especially restenosis in the coronary vessel, which had been treated by PTCA and stenting. Furthermore, we looked for radiologic signs of potential endothelial injuries to the LAD in the area of snaring.

All operations were performed without intraoperative complications. The period of coronary occlusion of 21 ± 8 minutes (range, 10 to 53 minutes) was well tolerated by all patients, even by patients with severe three-vessel coronary disease or with low left ventricular ejection fraction (<0.40, n = 6). All patients remained hemodynamically stable without pharmacologic support. No arrhythmias occurred during LAD occlusion in any patient. Only slight ST-segment elevations (0.8 ± 0.7 mV [range, 0.2 to 2.0 mV]) were present in 11 of the 45 study patients. In the other 34 patients, the electrocardiograms remained completely unchanged during LAD occlusion. Only 2 of 18 patients with a three-vessel disease showed ST-segment elevations during LAD occlusion. After declamping of the LIMA-to-LAD bypass graft, protamine chloride (5,589 ± 532 IU [range, 2,000 to 8,000 IU]) was administered to 36 of 45 patients to reverse the anticoagulatory effect of heparin. Operating time was 150 ± 20 minutes (range, 110 to 235 minutes).

Thirty-two of 45 patients were extubated in the operating theater. The remaining 13 patients were extubated 4.5 ± 3.6 hours (range, 2 to 16 hours) after the end of the operation. The level of creatinine kinase (CK), measured 4 hours postoperatively, was 64 ± 36 IU/L (range, 27 to 218 IU/L). In our protocol the myocardial band of CK was only determined when the CK value exceeded 140 IU/L. This was the case in only 4 patients (CK = 142, 179, 200, and 218 IU/L), and the myocardial band CK values were determined to be 3, 5, 8, and 11 IU/L. The postoperative course was uneventful in all patients, except for a reexploration 3 hours after operation in 1 patient because of prolonged bleeding (>200 mL/h) through the thorax drainage tubes and in another patient on the first postoperative day as a result of a hematoma in the left pleural cavity. During reexploration in the first patient, bleeding from the sternum was found and coagulated by means of diathermia. In the second patient the hematoma was removed. No transfusion was necessary in any of the 45 patients, and the mean hemoglobin value on discharge was 11.7 ± 1.2 mg/dL (range, 8.2 to 15.7 mg/dL). No respiratory insufficiency and no diaphragm dysfunction occurred. In none of the patients was a worsening of preexistent organ dysfunction observed. All patients could be mobilized on the first day postoperatively, including the one with bilateral leg amputation. No instability of the sternum occurred in any patient. All patients were free of angina pectoris postoperatively, and a patent LIMA-to-LAD anastomosis could be demonstrated in all coronary angiograms performed in 36 of 45 patients. Postoperative coronary angiogram revealed a dissection in the midlevel of the LIMA graft in 1 patient from the hybrid revascularization group. The dissection could be treated successfully by stenting and open LIMA graft, shown to be patent on an angiogram 6 weeks later. However, at the 6-month follow-up angiographic control, the LIMA graft was occluded. Two patients refused postoperative coronary angiography, and in 7 patients with impaired renal function we did not perform angiographic control of the LIMA-to-LAD bypass graft to avoid the application of contrast medium.

Postoperative echocardiography revealed no pathologic finding in any patient. During the postoperative course no new episode of supraventricular arrhythmia occurred. No cerebrovascular events and no neuropsychiatric abnormalities were observed. Patients were discharged 5.5 ± 1.8 days (range, 3 to 12 days) after operation in a good condition. As of 12-month follow-up coronary angiograms were performed in 5 of the 45 patients, which showed open LIMA-to-LAD grafts with a widely open anastomosis. Twelve months after LIMA-to-LAD bypass, angina pectoris and progression of the left main stenosis (80%) on coronary angiogram developed in 1 patient with middle grade (50%) main stenosis and additional LAD and small circumflex artery branches. This patient was treated successfully by PTCA and stenting of the left main stem. All other patients were free of angina pectoris.

In 14 patients with multivessel coronary disease a hybrid revascularization was performed (Tables 1, 2). In addition to the LIMA-to-LAD procedure, further coronary stenoses of the right coronary artery and circumflex artery or the left main stem were treated successfully by interventional cardiologic techniques. Twelve patients received outpatient PTCA/stenting procedures on postoperative days 3.5 ± 1.2 (range, 2 to 7). In 1 additional patient an outpatient PTCA including stenting was performed 21 days before the LIMA-to-LAD procedure and in another patient 26 days after beating heart operation. A total of 19 significant stenoses including three left main stenoses were treated by interventional cardiologic techniques in 14 patients. In all patients the hybrid revascularization was successful and patients were free of angina pectoris. Exercise electrocardiographic test revealed no signs of myocardial ischemia. All coronary angiograms performed in patients undergoing hybrid revascularization early postoperatively (14 of 14 patients) and 6 months later (8 of 14 patients) revealed an open LIMA-to-LAD anastomosis except in 1 patient with LIMA graft occlusion after dissection and no signs of stenoses in coronary vessels, treated by PTCA/stenting procedures.

The LIMA-to-LAD procedures were performed in a heterogeneous group of selected patients with one- to three-vessel coronary disease. Three groups of patients can be identified: (1) patients with a significant proximal LAD stenosis not suitable for coronary balloon angioplasty, (2) patients with one- to three-vessel coronary disease and severe concomitant diseases, and (3) patients with coronary multivessel disease including significant stenoses in the circumflex artery and the right coronary artery or the left main stem treatable by balloon angioplasty but a significant proximal LAD lesion not suitable for PTCA. In all of these patients the LIMA-to-LAD procedure proved to be a safe and effective approach. In all patients the anastomosis could be created successfully with the MidCOAST device for local cardiac stabilization and occlusion of the LAD, which provided excellent stabilization of the area of anastomosis and proved to have no negative side effects on hemodynamics. Even in patients with decreased left ventricular ejection fraction (<0.40), the operation could be carried out successfully without the use of catecholamines. We used a CO₂ blower device, which proved to be a very useful tool in patients with retrograde coronary flow through the arteriotomy field. In contrast to the experiences of other investigators, no ventricular arrhythmias during coronary occlusion could be observed in our patients [8]. Preconditioning was used only in 1 patient with a severe three-vessel coronary disease and stenoses of the LAD, circumflex artery, and occlusion of the right coronary artery who demonstrated ST-segment elevations of 2.0 mV during the period of test occlusion [12]. In spite of a mean LAD occlusion period of 21 ± 8 minutes, no sign of significant myocardial damage was observed, documented by CK or by the myocardial band of CK [13, 14].

In 30 patients with two- to three-vessel coronary disease the LIMA-to-LAD procedure was performed either alone (n = 16) or in combination with postoperative coronary angioplasty of additional coronary stenoses (n = 14). In all 30 patients LAD was the dominant vessel. The other coronary vessels were either small or diffuse calcified (n = 8), stenosed by less than 70% (n = 8) or significantly stenosed (>70%); these patients were treated with angioplasty postoperatively (n = 14). In 3 patients undergoing hybrid revascularization a left main stenosis was treated successfully by PTCA and stenting after a minimally invasive LIMA-to-LAD procedure. By this approach the risk of PTCA of a left main stenosis may significantly be reduced [15]. Anastomotic patency rates after a minimally invasive LIMA-to-LAD procedure are reported to be about 90% [16, 17]. In our group, all early postoperative angiograms showed a patent LIMA-to-LAD anastomosis, except for 1 patient with a dissection of the LIMA graft. In this patient we used a different approach; we used a ministernotomy up to the fourth instead of the third intercostal space. This may be the reason for increased tension to the LIMA vessel during preparation, which may have resulted in dissection.

Because of the excellent stabilization of the MidCOAST device, sewing of the LIMA-to-LAD anastomosis was easy, and the quality of the anastomosis appeared to be the same as the one achieved in conventional coronary bypass techniques (Fig 1 ). Patients were free of angina pectoris and did not show signs of ischemia on the electrocardiogram. Although routine postoperative angiograms are invasive and expensive, and Subramanian [17] found that echocardiography correlates well with angiography and switched to the less invasive Doppler echocardiography, we preferred a systematic angiographic follow-up of all patients undergoing minimally invasive LIMA-to-LAD procedures to document the quality of the anastomosis and to detect potential clot formations in the LIMA-to-LAD anastomosis or endothelial injury of the LAD in the area of snaring [18]. In our clinical experience we have no hint that the snaring of the LAD by vessel loops causes any endothelial injuries [19]. A reason for this might be that snaring of the LAD is combined with the stabilizing platform of the MidCOAST system minimizing tension on the LAD. Up to date all coronary angiogram performed 12 months after operation showed a widely patent LIMA-to-LAD anastomosis of excellent quality. No endothelial dissections or stenoses were observed in the area of snaring.

View larger version (124K): [in this window] [in a new window]   Fig 1. Angiogram of the left internal mammary artery-to-left anterior descending coronary artery bypass graft 6 months postoperatively.

The decreased traumatization of tissue and avoidance of the high-dose heparinization and hemodilution of standard CPB are further benefits of the minimally invasive LIMA-to-LAD procedure, resulting in a decreased amount of postoperative bleeding and less demand for transfusion [9]. In our group, no blood transfusion was required in any patient. Interestingly, we observed only one new postoperative episode of supraventricular arrhythmia in 1 of the 45 study patients, which is in contrast to the findings of other investigators [8, 13, 14].

Respiratory insufficiency and diaphragm dysfunction could not be observed in any patient. In contrast, diaphragm dysfunction occurred in 10% to 80% of patients undergoing conventional CABG [10].

Because we had only limited experience with the postoperative recovery of patients having undergone this minimally invasive approach, the mean postoperative hospital stay in our group was 5.5 ± 1.8 days, which will be certainly reduced in the future [9].

In conclusion, in patients with a single significant proximal LAD lesion, minimally invasive LIMA-to-LAD bypass grafting seems to be an attractive alternative to conventional CABG as well as balloon angioplasty, because this method is less invasive than common CPB operations and it can be assumed that the results are comparable with those of conventional bypass grafting techniques. Furthermore, the minimally invasive LIMA-to-LAD procedure, in contrast to the conventional bypass technique, may reduce the length of stay and perioperative morbidity [20].

The second group, high-risk patients with one- to three-vessel coronary disease and severe concomitant diseases, were treated by the concept of the "culprit lesion" or by a hybrid revascularization. In our opinion, these patients especially benefit from this approach, because the preexisting organ dysfunctions were not worsened by the trauma of CPB. This probably results in a better patient outcome and a reduction of costs.

Further studies are currently underway to investigate whether patients with two- and three-vessel disease and no severe concomitant disease (third group) will also profit from this approach. Our early experience with these patients is that they can be treated safely and effectively. However, the number of patients is small and long-term results are available only in some patients. Therefore, randomized studies are necessary to clarify which approach—conventional CABG versus hybrid procedure—provides better results.

Acknowledgments

We are grateful to Petra Schlizio for her skillful secretarial assistance.

References

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