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Ann Thorac Surg 1999;67:1677-1681
© 1999 The Society of Thoracic Surgeons

Original Articles

Minimally invasive direct coronary artery bypass for redo patients

Kagami Miyaji, MDa, Randall K. Wolf, MDa, John B. Flege, Jr, MDa

a Department of Cardiac Surgery, The Christ and Jewish Hospital, University of Cincinnati, Cincinnati, Ohio, USA

Accepted for publication December 15, 1998.

Address reprint requests to Dr Wolf, Cardiovascular and Thoracic Surgeons, Inc., 2123 Auburn Ave, Suite 401, Cincinnati, OH 45219


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. The minimally invasive direct coronary artery bypass (MIDCAB) procedure, using a small anterolateral thoracotomy without cardiopulmonary bypass, has been recommended for high-risk patients because it is less traumatic than conventional coronary artery bypass grafting. For redo patients who have patent grafts and pericardial adhesions, the MIDCAB may be preferable to the conventional operation because manipulation of the graft and dissection of adhesions may be minimized.

Methods. Since November 1995, 120 patients underwent the MIDCAB procedure in our institution. Among these patients, there were 25 redo cases (20.8%). We reviewed these redo cases and studied their surgical results (mortality, morbidity, hospital stay, operation time, and postoperative inotropic support). To clarify the usefulness of this procedure, we compared the results of redo operations with those of the first-time operations.

Results. For redo MIDCAB, there was one operative death (4%) because of intestinal infarction. The mean hospital stay was 4.3 days and the number of patients who needed postoperative positive inotropic agents was 3 (12%). There was no significant differences between redo and first-time operation patients in mortality, morbidity, hospital stay, operation time, and postoperative inotropic support.

Conclusions. Results of the MIDCAB procedure for redo patients were comparable to those for primary MIDCAB operations.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
The minimally invasive direct coronary artery bypass (MIDCAB) procedure, performed with a small anterior lateral thoracotomy and without cardiopulmonary bypass, is becoming more and more widely performed [1–9]. The MIDCAB procedure, which is less invasive than conventional coronary artery bypass grafting (CABG), has been used for patients who are at high risk because of poor left ventricular function [10] and have suitable coronary anatomy. Recently, reoperative CABG without the use of cardiopulmonary bypass has been reported with favorable results [11]. The main features that affect surgical mortality and morbidity in redo CABG are reopening of the sternum, aortic clamping, and manipulation of the heart and the old patent grafts. Performing MIDCAB without sternotomy, cardiopulmonary bypass, aortic cross-clamping, and extensive dissection of the heart can avoid these problems in patients with suitable coronary anatomy needing reoperative CABG.

In this article, we reviewed patients who underwent MIDCAB procedures for redo CABG in our institution and compared them with those who had MIDCAB as a first operation.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
Since November 1995, of 120 patients who underwent MIDCAB procedures in our institution, there were 25 redo patients (20.8%) (Table 1). Their ages ranged from 40 to 87 years (mean, 66.2 ± 13.5 years). Four patients (16%) were older than 80 years. There were 19 male patients and 6 female patients. There were 6 second redo cases and 1 third redo case. Target sites were left anterior descending coronary artery (LAD), 15; posterior descending artery, 7; and right main coronary artery, 3.


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  		Table 1. Patient Data

 
Procedures performed
Procedures performed included single bypass with left internal mammary artery (LIMA) to LAD, 9; gastroepiploic artery to posterior descending artery or LAD, 8; saphenous vein graft (SVG) to LAD or right main coronary artery, 5; and right internal mammary artery to old SVG, 3. Among 9 LIMA to LAD procedures, there were one H-graft and one T-graft procedures. The patient with the H-graft procedure had complete symphysis of the left chest cavity procluding the thoracoscopic internal mammary artery (IMA) harvest, and underwent H-graft MIDCAB using a short SVG [12, 13]. In the patient who underwent a T-graft procedure, his LIMA had been used at the previous CABG, and there was a tight stenosis in the distal anastomotic site. A T-graft procedure (from the proximal LIMA to LAD) using a radial artery graft was selected.

There were 5 patients who underwent MIDCAB procedure using an SVG [14]. In 4 patients (no. 22, 23, 24, and 25), the IMA graft was used in the previous operation and there was no available arterial graft for the target vessel. In one patient (no. 21), the decision to use an SVG was made after the LIMA had been mobilized and found to have poor blood flow. The target sites included LAD, 2; old SVG, 2; and right main coronary artery, 1. Proximal anastomosis was performed in carotid artery, 3; and axillary artery, 2.

The incisions used were small left anterior thoracotomy, 12; partial sternotomy and median laparotomy, 7; small right anterior thoracotomy, 2; small right anterior thoracotomy + partial sternotomy, 2; and small left anterior thoracotomy + partial sternotomy and median laparotomy, 2.

The video-assisted minimally invasive direct coronary artery bypass (VADCAB) procedure [15–17], which is defined as a combination of the video thoracoscopic IMA harvest and direct coronary artery bypass grafting via minithoracotomy (small incision 5 to 8 cm in length) without cardiopulmonary bypass, has been introduced since November 1995 for patients who needed MIDCAB procedure using IMA. Operative procedure of video-assisted MIDCAB is the following. After achieving satisfactory general endotracheal anesthesia with a double-lumen tube, the patient was placed in a 20 to 30-degree right or left lateral decubitus position. Three small incision were made: the highest two (about 5 mm in length), for the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) and an endoscopic Kitner dissector (Ethicon Endo-Surgery), were in the third and fourth intercostal spaces on the midaxillary line, and the lowest one (about 10 mm in length) for the rigid 30-degree scope was in the fifth or sixth intercostal space in the anterior axillary line. With low-flow CO2 insufflation and the Harmonic Scalpel, the left or right IMA was dissected from its bed from the superior border of the first to the fifth or sixth rib. All branches of the IMA were controlled with the Harmonic Scalpel. An anterior thoracotomy was made in the fourth intercostal space. The ribs were spread without resection, and the remainder of the IMA harvest was completed. The pericardium was opened, and adhesion between the pericardium and left ventricle was dissected in as small an area as required at the site where the target vessel is supposed to be located because these adhesions work as a kind of stabilizer. The reusable DiamondGrip stabilizer (Genzyme Surgical Products, Cambridge, MA) was placed. After 10,000 U of heparin was given, the target vessel was encircled with two 3-0 Goretex (W.L. Gore & Assoc, Flagstaff, AZ) sutures proximally and distally. One suture was tightened for 5 minutes for an ischemic test, monitoring the electrocardiogram and the arterial blood pressure, and then released. If there were no manifestations of ischemia, both sutures were tightened and an arteriotomy was made. The IMA graft was anastomosed to the LAD or old SVG end-to-side using running suture of 7-0 Prolene (Ethicon, Somerville, NJ).

This video-assisted MIDCAB procedure was performed in 9 patients, including 6 LIMA to LAD and 3 right IMA to old SVG. These stabilization of myocardial surface and temporary occlusion techniques were used in all other 16 patients.

Risk factors
There were 12 patients (48%) with significant risk factors, including 4 patients with chronic obstructive pulmonary disease, 4 older than 80 years, 3 with low left ventricular ejection fraction (less than 30%), 1 with a recent myocardial infarction, 1 with renal failure, 1 with a recent cerebral infarction, and 1 with lung cancer in whom a left upper lobectomy and MIDCAB procedure were performed simultaneously through left thoracotomy. This patient’s LIMA had been previously used and was occluded, and a catheter-based intervention was not deemed possible.

Study protocol
We reviewed surgical results (mortality, morbidity, postoperative cardiac support, and hospital stay) and short-term follow-up graft patency of these redo patients (group R). Mortality, morbidity, postoperative cardiac support, operation time, and hospital stay for group R were compared with those of 95 patients who underwent the MIDCAB procedure as the first coronary revascularization (group C).

Statistical analysis
The Student’s t test was used for comparison of hospital stay. The Fisher’s exact probability test was used for comparison of mortality, morbidity, and postoperative cardiac support between these two groups. Differences were regarded as statistically significant if less than 0.05 (p < 0.05).


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
Surgical results
There was one hospital death (4%) in redo cases because of intestinal infarction and 3 major postoperative complications (12%) (hemothorax, arrhythmia, and prolonged air leakage after lobectomy) (Table 2). The number of patients who needed postoperative positive inotropic agents was 3 (12%). Postoperatively, the mean intensive care unit stay was 28.0 ± 14.9 hours. Twelve patients (48%) were extubated in the operating room. The post-operative intubation time was 3.1 ± 4.3 hours. The duration of hospital stay was 4.3 ± 2.3 days (range, 2 to 11 days).


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  		Table 2. Surgical Results of MIDCAB for Redo Cases

 
Graft assessment
Intraoperative handheld Doppler test was performed and revealed satisfactory results in all cases. Intraoperative transit time ultrasound assessment for IMA graft was performed in 7 patients (28%). The mean blood flow of the IMA grafts measured by ultrasound transit time was 24.3 ± 12.4 mL/min (range, 13 to 50 mL/min). In one patient, after a side-to-side gastroepiploic artery to posterior descending artery anastomosis, intraoperative retrograde angiography through the distal end of the conduit was performed. Portable x-ray units were used. This provided clear visualization of the conduit and anastomosis. The postoperative ultrasound Doppler assessment (22 patients) and angiography (1 patient) before discharge from hospital was performed in the 24 surviving patients, and showed that all grafts were patent. The mean follow-up period was 18.2 months. For 12 patients, 3- to 6-month follow-up Doppler assessment or angiography showed all grafts were patent (100%).

Comparison with the first operation patients
There were 2 hospital deaths (2.1%) in group C; one from extension of preoperative recent cerebral infarction, and the other from cardiac arrhythmias (Table 3). There were no significant differences between the redo group (4%) and group C (p = 0.51). There were 11 major postoperative complications (11.6%) in group C (arrhythmia, 5; wound infection, 2; pneumonia, 2; extension of preoperative recent cerebral infarction, 1; and bleeding, 1). There were no significant differences between the redo group (12%) and group C (p = 0.59). The number of patients who needed postoperative positive inotropic agents was 19 (20%) in group C. There were no significant differences between the redo group (12%) and control group (p = 0.27). The mean operation time in redo cases was 229.6 ± 52.1 minutes, whereas that of group C was 219.2 ± 57.5 minutes. There were no significant differences between the redo group and control group (p = 0.44). The mean duration of hospital stay of patients in group C was 4.4 ± 2.1 days (range, 2 to 11 days). There were no significant differences between the redo group (4.3 ± 2.3 days) and control group (p = 0.79).


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  		Table 3. Comparison Between Redo and First Operation Casesa

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
Minimally invasive direct coronary artery bypass is gaining acceptance [1–9]. Because it is less invasive than conventional CABG, the MIDCAB procedure has been recommended for high-risk patients, particularly those needing reoperations, who have suitable anatomy [10]. For redo patients, the MIDCAB procedure avoids manipulation of patent grafts and mobilization of adhesions from previous operation. Favorable results of the MIDCAB procedure for redo CABG, in a small series limited to revascularization of the LAD using the LIMA, have been reported [11]. Since November 1995, 120 patients underwent the MIDCAB procedure in our institution. We reviewed 25 redo cases and their surgical results to clarify the usefulness of this procedure.

The surgical results of MIDCAB procedure for redo patients (mortality, morbidity, postoperative cardiac support, and hospital stay) were acceptable. The mortality, morbidity, postoperative cardiac support, operation time, and hospital stay were compared with those of patients who underwent the MIDCAB procedures as the first coronary revascularization, and there were no significant differences between these two groups.

In the MIDCAB procedure, coronary artery anastomosis is performed on the beating heart, and stabilization of the heart is of great importance. In almost all redo patients, there are adhesions between the left ventricle and pericardium and these adhesions work as a kind of stabilizer.

In almost all MIDCAB procedures reported, arterial grafts such as LIMA, right internal mammary artery, or gastroepiploic artery have been used. Some patients needing reoperation, particularly those of advanced age, may have no available arterial grafts because the IMAs have been used in the previous operation or arterial grafts (IMA, gastroepiploic artery, or radial artery) are not suitable because of atherosclerotic changes. In our series, there were 5 patients (20%) in whom arterial grafts were not available. In 4 patients, the IMA graft had been used in a previous operation and there was no available arterial graft for the target vessel, and 1 patient had an unsuitable LIMA because of poor blood flow. The SVG was used in these 5 patients and proved quite satisfactory as an alternative bypass conduit in redo MIDCAB patients with no available arterial conduit.

The MIDCAB procedure was performed in 25 redo patients and provided acceptable and satisfactory surgical results compared with the MIDCAB as the first operation.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Cooley D.A. Limited access myocardial revascularization. A preliminary report. Tex Heart Inst J 1996;23:81-84.[Medline]
  2. Calafiore A.M., Giammarco G.D., Teorori G., et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1663.[Abstract/Free Full Text]
  3. Zenati M., Domit T.M., Saul M., et al. Resource utilization for minimally invasive direct and standard coronary artery bypass grafting. Ann Thorac Surg 1997;63:S84-S87.
  4. Watanabe G., Misaki T., Kotoh K., Abe Y., Yamashita A., Ueyama K. Bilateral minimally invasive direct coronary artery bypass grafting with the use of two arterial grafts. J Thorac Cardiovasc Surg 1997;113:949-951.[Free Full Text]
  5. Cremer J., Struber M., Wittwer T., et al. Off-bypass coronary bypass grafting via minithoracotomy using mechanical epicardial stabilization. Ann Thorac Surg 1997;63:S79-S83.
  6. Mack M.J., Acuff T.E., Casimir-Ahn H., Lonn U.J., Jansen E.W. Video-assisted coronary bypass grafting on the beating heart. Ann Thorac Surg 1997;63:S100-S103.
  7. Mariani M.A., Boonstra P.W., Grandjean J.G., van der Schans C., Dusseljee S., van Weer E. Minimally invasive coronary artery bypass grafting without cardiopulmonary bypass. Eur J Cardiothorac Surg 1997;11:881-887.[Abstract]
  8. Mishra Y.K., Mehta Y., Juneja R., Kasliwal R.R., Mittal S., Trehan N. Mammary-coronary artery anastomosis without cardiopulmonary bypass through a minithoracotomy. Ann Thorac Surg 1997;63:S114-S118.
  9. Arom K.V., Emery R.W., Nicoloff D.M., Flavin T.F., Emery A.M. Minimally invasive direct coronary artery bypass grafting: experimental and clinical experiences. Ann Thorac Surg 1997;63:S48-S52.
  10. Moshkovitz Y., Sternik L., Paz Y., et al. Primary coronary artery bypass grafting without cardiopulmonary bypass in impaired left ventricular function. Ann Thorac Surg 1997;63:S44-S47.
  11. Boonstra P.W., Grandjean J.G., Mariani M.A. Reoperative coronary bypass grafting without cardiopulmonary bypass through a small thoracotomy. Ann Thorac Surg 1997;63:405-407.[Abstract/Free Full Text]
  12. Cohen W.E., Suen H.C., Weintraub R.M., Johnson R.G. The "H" graft: an alternative approach for performing minimally invasive direct coronary artery bypass. J Thorac Cardiovasc Surg 1998;115:148-151.[Abstract/Free Full Text]
  13. Miyaji K, Wolf RK, Flege JB Jr. Minimally invasive direct coronary artery bypass using H-graft for pleural symphysis. Ann Thorac Surg 1999 (in press).
  14. Wolf R.K., Miyaji K., Flege J.B., Jr Saphenous vein as an alternative graft in minimally invasive direct coronary artery bypass. J Thorac Cardiovasc Surg 1999;117:822.
  15. Ohtsuka T., Wolf R.K., Hiratzka L.F., Wurnig P., Flege J.B., Jr Thoracoscopic internal mammary artery harvest for MIDCAB using the harmonic scalpel. Ann Thorac Surg 1997;63:S107-S109.
  16. Wolf R.K., Ohtsuka T., Hiratzka L.F., Wurnig P., Flege J.B., Jr Early results of thoracoscopic internal mammary artery harvest. Eur J Cardiothorac Surg 1998;14(Suppl 1):S54-S57.[Abstract/Free Full Text]
  17. Miyaji K., Wolf R.K., Flege J.B., Jr Surgical results of video-assisted minimally invasive direct coronary artery bypass. Ann Thorac Surg 1999;67:1018-1021.[Abstract/Free Full Text]



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