Ann Thorac Surg 1999;68:234-235
© 1999 The Society of Thoracic Surgeons
Case Reports
Minimally invasive direct coronary artery bypass using H graft for pleural symphysis
Kagami Miyaji, MDa,
Randall K. Wolf, MDa,
John B. Flege, Jr, MDa
a Department of Cardiac Surgery, The Christ Hospital and University of Cincinnati, Cincinnati, Ohio, USA
Address reprint requests to Dr Wolf, Cardiovascular and Thoracic Surgeons, Inc, 2123 Auburn Ave, Suite 401, Cincinnati, OH 45219
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Abstract
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In November 1995, video-assisted minimally invasive direct coronary artery bypass procedure, which is defined as a combination of the thoracoscopic internal mammary artery (IMA) harvest and direct coronary bypass grafting, was introduced for patients who need minimally invasive direct coronary artery bypass (MIDCAB) using IMA. In the thoracoscopic IMA harvest, the pleural adhesions or symphysis present an obstacle. We present a case where a redo patient who had complete pleural symphysis of left chest cavity precluded the thoracoscopic IMA harvest, and MIDCAB with the H graft procedure was performed.
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Introduction
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Since November 1995, we have performed 120 minimally invasive direct coronary artery bypass (MIDCAB) procedures. The video-assisted minimally invasive direct coronary artery bypass (VADCAB) procedure was especially introduced for patients who needed MIDCAB procedures using IMA. The VADCAB procedure is defined as a combination of the video thoracoscopic internal mammary artery (IMA) harvest and direct coronary bypass grafting via minithoracotomy (small incision 5–8 cm in length). In the thoracoscopic IMA harvest, extreme pleural adhesion or symphysis makes this difficult, if not impossible. Here, we report the case of an H graft [1] in a patient needing a MIDCAB procedure who had pleural symphysis of the left chest cavity precluding the thoracoscopic IMA harvest.
An 80-year-old woman with severe chronic obstructive pulmonary disease (COPD) and coronary insufficiency was referred to us for consideration of MIDCAB. She had had coronary artery bypass grafting using saphenous vein grafts to the left anterior descending (LAD), and circumflex marginal and posterior descending coronary arteries 15 years ago. Her coronary cineangiogram revealed a patent graft to the circumflex marginal artery and a patent graft to the LAD proximal to a significant stenotic lesion, and occlusion of the right coronary artery and a graft to it. The left ventricular ejection fraction was 0.5. The dobutamine thallium test showed a reversible perfusion defect correlating with the tight LAD stenosis. She had moderate mitral regurgitation demonstrated by transesophageal echocardiography. Because of multiple problems (age, redo, COPD, and mitral regurgitation), limited coronary revascularization by MIDCAB was recommended.
After a satisfactory general endotracheal anesthesia with a double-lumen tube, the patient was turned on the left side 20 degrees, abducting the left arm for sufficient exposure of the axilla. The rigid 30-degree thoracoscope was placed through the fifth intercostal space. Thoracoscopy demonstrated complete left pleural symphysis making the LIMA harvest guided by video thoracoscopy impractical, if not impossible. We elected to use the H graft procedure, considering it less traumatic than the LIMA harvest under direct vision. An anterior minithoracotomy, 8 cm in length, was made in the fourth intercostal space. A section of the cartilaginous portion of the fifth rib was removed, and LIMA and LAD were exposed. The LIMA was cleared over a distance of 5 cm and the hand-held Doppler test revealed excellent pulsatile signal. A segment of the left thigh saphenous vein 5 cm in length was harvested, and Heparin 10,000 U was given intravenously. After the reusable stabilizer was placed, the LAD was looped with two 3-0 Gore-Tex sutures proximally and distally. The proximal suture was tightened for 5 minutes for an ischemic test. There were no manifestations of ischemia and both sutures were tightened. A longitudinal arteriotomy was performed on the LAD, and the saphenous vein graft was anastomosed end to side to both the LIMA and the LAD (Fig 1). The mean blood flow through the saphenous vein graft measured by ultrasound transit time was 22 mL/min. The total operation time was 110 minutes and no blood product was used. The postoperative course was uneventful and the patient was discharged home on the fourth postoperative day.
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Fig 1. (A) Representative picture of H graft procedure. (B) The LAD is looped with two 3-0 Gore-Tex sutures proximally and distally. The LIMA is controlled with two fine clips. The short saphenous vein graft is placed between the LAD and LIMA in end-to-side fashion (H graft).
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Comment
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MIDCAB is gaining acceptance. In almost all MIDCAB procedures reported, internal mammary grafts have been used because a proximal anastomosis is not necessary and a 10-year patency rate of 90% is expected. Because it is less invasive and less traumatic than conventional CABG, the MIDCAB procedure has been recommended for high-risk patients. Favorable results of the MIDCAB procedure for redo CABG have been reported [2].
Since November 1995, among 120 MIDCAB cases in our institute, 80 patients (67%) had thoracoscopic-assisted internal mammary artery harvest using the harmonic scalpel [3], which pleural adhesions or symphysis may make difficult or impossible. The patient described here is the only case in which we have considered this technique not feasible.
The MIDCAB procedure using H graft seemed to us less traumatic than extensive mobilization of the LIMA under direct vision, as described by Cohn and associates [1]. There is the potential for diversion of LIMA flow to noncoronary vascular beds, the so-called "steal" phenomenon [4, 5]. Other authors claim that the persistence of intact proximal intercostal branches does not influence the blood flow of the distal LAD [1, 6]. The H graft technique leaves the IMA in continuity and its branches in place, and it remains to be shown whether this will detract from blood flow to the coronary artery. Nevertheless, the MIDCAB using H graft is a useful alternative procedure in the limited situation, such as a high-risk redo case with complete symphysis. As in this case, where we used a short saphenous vein as H graft instead of other short arterial grafts, the long-term follow-up is needed.
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References
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Cohn W.E., Suen H.C., Weintraub R.M., Johnson R.G. The "H" graft. J Thorac Cardiovasc Surg 1998;115:148-151.[Abstract/Free Full Text]
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Miyaji K., Wolf R.K., Flege J.B., Jr Minimally invasive direct coronary artery bypass for redo patients. Ann Thorac Surg 1999;67:1677-1681.[Abstract/Free Full Text]
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Ohtsuka T., Wolf R.K., Hiratzka L.F., Wurnig P., Flege J.B., Jr Thoracoscopic internal mammary artery harvest for MIDCABG using the harmonic scalpel. Ann Thorac Surg 1997;63(Suppl):S107-S109.
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Schmid C., Heublein B., Reicheli S., Borst H.G. Steal phenomenon caused by a parallel branch of the internal mammary artery. Ann Thorac Surg 1990;50:463-464.[Abstract/Free Full Text]
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Hartz R.S., Heuser R.R. Embolization of IMA side branch for post-CABG ischemia. Ann Thorac Surg 1997;63:1765-1766.[Abstract/Free Full Text]
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Luise R., Teodori G., Di Giammarco G., et al. Persistence of mammary artery branches and blood supply to the left anterior descending artery. Ann Thorac Surg 1997;63:1759-1764.[Abstract/Free Full Text]
Accepted for publication November 21, 1998.
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Minimally invasive direct coronary artery bypass controversy: the truly minimally invasive coronary artery bypass versus the "H" graft
Ann. Thorac. Surg.,
April 1, 2000;
69(4):
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Abstract
Introduction
