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Ann Thorac Surg 1999;68:94-99
© 1999 The Society of Thoracic Surgeons

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Original Articles

Off-pump revascularization of the circumflex artery: technical aspect and short-term results

^a Department of Surgery, Montreal Heart Institute, Montreal, Quebec, Canada
^b Department of Anesthesia, Montreal Heart Institute, Montreal, Quebec, Canada

Address reprint requests to Dr Cartier, Research Center, Montreal Heart Institute, 5000 Belanger St East, Montreal, PQ, H1T 1C8, Canada;
e-mail: cartierr{at}icm.umontreal.ca

	Abstract

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Background. Beating heart surgery is a technique currently used for revascularization of the anterior and inferior territory. However, revascularization of the circumflex artery is more problematic. With a specific apparatus and surgical technique, we have extended the use of beating heart surgery to more than 90% of patients with multivessel disease, including those necessitating circumflex artery revascularization.

Methods. Between October 1996 and November 1997, 140 patients underwent beating heart surgery by the same surgeon (R.C.). Among these patients, 111 required reconstruction of the circumflex artery territory and were followed up prospectively. They represent the cohort of patients presented in this study. There were 90 men and 21 women averaging 64 ± 9.9 years of age. Mean left ventricular ejection fraction was 55% ± 13.7%, and a significant left main coronary artery disease was present in 27% of the patients. Five patients had prior coronary revascularization.

Results. An average of 3.1 ± 0.1 grafts/patient were performed. Complete revascularization was achieved in 95%. Only 1 patient needed conversion to cardiopulmonary bypass because of spontaneous ascending aortic dissection. Perioperative and postoperative bleeding were 446 ± 245 mL and 644 ± 442 mL, respectively. Homologous transfusions were required in 40% of the patients. Myocardial infarction occurred in 2.7% and operative mortality in 0.7% (1 patient). Average hospital stay was 6.6 ± 3.1 days, and no patient exhibited early recurrence of angina. Early coronary angiograms (first 8 patients) demonstrated a 100% patency with 95% freedom from significant stenosis.

Conclusions. Complete coronary artery revascularization is feasible on the beating heart without the assistance of cardiopulmonary bypass with a low morbidity and mortality and excellent early angiographic results. Long-term follow-ups are needed to substantiate the potential long-term benefits of this technique.

	Introduction

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Less invasive cardiac surgical procedures are gaining large acceptance among the cardiovascular community [1–3]. Performing coronary artery bypass grafting without cardiopulmonary bypass decreases the perioperative morbidity generally related to cardiac surgery [4]. Although minithoracotomy and ministernotomy allow direct revascularization of the left anterior descending and right coronary arteries (RCA), it does not provide a comfortable access to the circumflex (CX) territory [5]. Few reports have addressed this difficult issue. Benetti and colleagues [6] have reported extensive experience with multiple vessel revascularization through standard sternotomy without mechanical stabilization, although limited description was given on the surgical technique used to access the CX artery. Moshkovitz and colleagues [7] have proposed an extension of the midline incision through the fifth intercostal space to facilitate access to the CX artery in patients with impaired left ventricular function that inevitably increases morbidity. Since October 1996, at the Montreal Heart Institute, we have developed a surgical technique and apparatus that allow easy access to the entire CX territory. Previous reports have presented excellent angiographic results with this technique [8, 9]. We present the technical aspect of this procedure along with the early clinical results.

	Material and methods

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During the period from October 1996 to November 1997, 142 patients underwent coronary artery revascularization without cardiopulmonary bypass by the same surgeon (R.C.) at the Montreal Heart Institute. This represents 66% of all the revascularizations performed during this same period by the same surgeon, and 90% of revascularizations undertaken between March and November 1997. Among the patients operated on without cardiopulmonary bypass, 111 had a multivessel disease requiring revascularization of the CX artery. They represent the cohort of patients reported here.

Patient selection
Initially, patients whose operation was performed without extracorporeal circulation were selected according to certain anatomic criteria, such as the presence of double- or triple-vessel disease with no intramyocardial, diffused atheromatous coronary vessels or left main disease. Patients presenting a calcified ascending aorta were selected for the procedure, but patients requiring more than one bypass on the CX artery territory were rejected. However, with time and experience (last 100 patients), indications were extended to most cases of coronary revascularization. Only patients with very deep intramyocardial left anterior descending artery (1 patient) or patients with unstable hemodynamics during anesthesia induction were excluded from the procedure.

Surgical procedure
All surgical procedures were performed under general anesthesia maintained by continuous infusion of narcotics and benzodiazepines. Muscle relaxation was accomplished by intermittent administration of pancuronium. Coronary stabilization was achieved with a mechanical coronary stabilizer specially designed (patent pending) to be used as a pushing device as well as a pulling device depending on the location of the target artery (Figs 1, 2). Silicone elastomer rubber bands attached to a blunted needle ("retractotape," Canadian Cardiovascular; Quest, Allen, TX) were applied around the vessel to occlude blood flow proximally and distally to the arteriotomy. Heart beat was maintained less than 75 beats/min through intravenous bolus injection of metoprolol (1 to 5 mg) to facilitate the procedure and decrease myocardial oxygen consumption. With the coronary stabilizer, the target artery excursion during beating is maintained to a minimum. Vascular anastomoses were performed with the conventional technique, as previously reported [8]. All surgical procedures were performed through a median sternotomy. Electrocardiographic ST segment and hemodynamics were carefully monitored during the operation, with nitroglycerin, as well as phenylephrine infusion, used as needed to stabilize hemodynamics. A coronary cross-clamping test of 1 minute was always conducted before the arteriotomy to evaluate ischemic tolerance.

View larger version (73K): [in this window] [in a new window]   Fig 1. Push type stabilizer angulated at 100° and used for left anterior descending and diagonal and posterior descending arteries.

View larger version (94K): [in this window] [in a new window]   Fig 2. Pull type stabilizer angulated at 230° and used for obtuse marginal, right coronary, and posterolateral arteries.

View larger version (129K): [in this window] [in a new window]   Fig 3. Attachment of the stabilizer on the transverse arm of the retractor.

View larger version (49K): [in this window] [in a new window]   Fig 4. Fan-shaped distribution of the pericardial stay sutures.

View larger version (33K): [in this window] [in a new window]   Fig 5. Verticalized heart with second obtuse marginal artery stabilized with the pull type stabilizer.

Data
All data are expressed as mean ± standard deviation.

	Results

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Population mean age was 64.1 ± 9.9 years (range, 39 to 80 years), consisting of 90 men and 21 women. Surgical indications were unstable angina in 73 patients (67%), chronic angina in 37 patients (36%), and cardiogenic shock in 1 patient (1%). Preoperative left ventricular ejection fraction was 55% ± 13.7% (range, 18% to 87%). Preoperative risk factors are displayed in Table 1. An average of 3.09 ± 0.62 grafts/patient (range, 2 to 4 grafts/patient) were performed, which included 17 double, 67 triple, and 27 quadruple bypass grafts. As vascular conduits, internal thoracic arteries were used in 96% of patients, saphenous vein grafts in 93%, and radial arteries in 8%. Complete revascularization was achieved in 105 (95%) patients. Thirty patients (27%) presented significant (> 50% stenosis) left main coronary artery disease. Five patients had prior coronary operations. Double grafts to the CX were completed on seven occasions. Sequential bypasses were performed on three occasions (two with internal thoracic arteries and one with vein grafts), and coronary endarterectomy with or without vein angioplasty on eight occasions (left anterior descending coronary artery, 5; diagonal artery, 1; obtuse marginal artery, 1; RCA, 1). Graft distribution and regional coronary ischemic time according to the three main areas of the myocardium are presented in Table 2. Graft distribution according to the type of conduit used and the location of the coronary artery grafted is displayed in Table 3.

Perioperative and postoperative blood loss averaged 446 ± 245 mL (range, 100 to 1,200 mL) and 644 ± 442 mL (range, 0 to 2,225 mL), respectively. Forty percent of the patients required homologous transfusion. On average, 2.6 ± 0.4 units of blood (range, 1 to 14 units of blood) and a total of 5.3 ± 0.8 units of blood products (red cell packs, platelets, fresh-frozen plasma, and cryoprecipitate packs) (range, 1 to 62 units of blood products) were administered per patient who required homologous transfusions. Cardiac isoenzyme creatine kinase averaged 11.7 ± 11.0 IU the day of the operation, 20.1 ± 20.6 IU on postoperative day 1, and 15.3 ± 18.9 IU on postoperative day 2. Maximal arterial lactate counts were, respectively, 2.04 ± 0.83 mmol/L and 2.9 ± 1.06 mmol/L during the operation and early on (first 12 hours) after the operation. Mean operative time was 171 ± 45 minutes (range, 82 to 270 minutes) and mean postoperative hospital stay, 6.57 ± 3.06 days (range, 3 to 21 days). Only one patient had to be converted to cardiopulmonary bypass because of a type A dissection of the ascending aorta that occurred after partial cross-clamping of the ascending aorta. The ascending aorta was replaced, and the patient underwent an uneventful recovery. Histologic examination of the resected segment confirmed the presence of cystic medial necrosis.

Morbidity and mortality
Three patients (2.7%) sustained perioperative myocardial infarction, 1 transmural and 2 subendocardial Non-Q wave (cardiac isoenzyme creatine kinase > 100 IU), but none required prolonged inotropic assistance or aortic counterpulsation support. Atrial fibrillation occurred in 28% of the patients, reoperation for bleeding or sternal dehiscence in 8%, systemic or local infections (none requiring mediastinal exploration) in 7%, and respiratory insufficiency necessitating prolonged (> 48 hours) respiratory support in 3.5%. Transient ischemic accident occurred in 1% and no patient sustained a cerebrovascular accident. One patient (0.9%) died on day 10 of multiorgan failure subsequent to postoperative sternal bleeding. No patient exhibited early recurrence of angina, and no other diagnostic or therapeutic procedure has been performed.

Graft patency
Early graft patency was angiographically established in the first 8 patients and from the autopsy of the ninth patient subsequent to a multiple organ failure mortality. Results are expressed in Table 4 according to the classification of Fitzgibbon and colleagues [10].

	Comment

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Although Borst and coworkers [14] reported a combined cumulative experience exceeding 3,000 beating heart surgeries, only 13% of these patients had triple-vessel disease, and on average only 1.4 grafts/patient were performed. These figures do not reflect the current surgical practice in coronary artery revascularization, as nearly 65% of the surgical referrals have triple-vessel disease. Although off-pump procedures are quite attractive for the obvious advantages of avoiding cardiopulmonary bypass-related complications, the basic principles of complete revascularization should not be compromised when it comes to the management of coronary artery insufficiency. The beneficial effects of complete revascularization on event-free survival have been shown by Buda and associates [15] in the early 1980s and confirmed by others later on [16, 17].

Bell and colleagues [16] from the Mayo Clinic, who retrospectively reviewed 3,372 nonrandomized surgical patients from the Coronary Artery Surgery Study Registry with triple-vessel coronary disease, demonstrated that patients with severe angina (New York Heart Association class III and IV) or left ventricular dysfunction (ejection fraction < 35%) had a better 6-year survival and event-free survival when grafts to three or more vessels were completed. Interestingly, a similar conclusion was reached with the use of coronary artery angioplasty in triple-vessel disease [18–20].

Obviously, the main challenge in off-pump coronary procedures remains the access to the CX. Benetti and colleagues [6], who have reported 1,420 off-pump procedures, probably have the most extensive experience with this type of procedure. These authors describe a technique in which deeply placed, large pericardial silk stay sutures are used to help rotate the apex while relying on the gentle retraction of the apex by the assistant, who pulls the heart up and down slowly with every stitch to preserve hemodynamics. This method allowed Benetti and coworkers [6] to revascularize up to 80% of their patients. Experimentally, Grundeman and associates [21], and Jansen and colleagues [22] have reported the feasibility of immobilizing the posterolateral cardiac wall with the straight Octopus paddles fixed directly on the ventricle. The apex was progressively raised anteriorly during a 2-minute period by pulling on the left ventricle. The heart "dislocation" caused a 20% drop in the cardiac output, which spontaneously resumed its initial value after restoration of the heart to the normal position. They also recorded a 44% drop in left ventricular stroke volume that could be completely compensated by the Trendelenburg maneuver. Contrary to this technique, the method we described to access the CX territory does not rely on heart dislocation. The fan-shaped distribution of the pericardial stay sutures implanted well below the phrenic nerve line allows reorientation of the apex without manual mobilization of the heart, thereby avoiding distortion of the left ventricle’s geometry. With the apex pointing toward the ceiling, the surgeon has access to the entire posterior wall and can mechanically stabilize any of the obtuse marginal arteries without affecting left ventricular hemodynamics. The use of the open pull type stabilizer makes this maneuver easy for the operator, and no manipulation by the assistant is required. Even deep intramyocardial obtuse marginal arteries can be dissected out and grafted with small internal thoracic artery conduits. Early on in our experience, we recognized the hemodynamic benefit of the Trendelenburg position during the verticalization of the heart. By increasing the hydrostatic pressure, the Trendelenburg position increases the venous blood return to the right ventricle. We found this position remarkably well tolerated. Lately, we have presented data on the hemodynamics during mobilization and demonstrated that the verticalization was as well tolerated as the anterior stabilization [23]. Curiously, in our experience, stabilization of the diagonal arteries was frequently a cause of hemodynamic disturbances, probably because of direct compression on the left ventricular outflow tract.

In the current series of 111 revascularizations of the CX artery, the surgical technique previously described was successful in all cases and no necessity conversions occurred during the procedure because of poor stabilization or unstable hemodynamics. Complete revascularization was achieved in 95% of the cases, with no patient experiencing early recurrent angina. The aortic dissection that occurred on the 101st patient occurred on an already preaneurysmal aorta (4.5 cm diameter) on which histopathologic examination revealed cystic medial necrosis disease. As a result, we strongly believe these enlarged aortas should not be side-clamped. Instead, revascularization should be done without aortic manipulation using internal thoracic arteries and Y grafts. Nevertheless, since this incident, we now apply the side-clamp on the ascending aorta only when the systemic pressure is less than 110 mm Hg to minimize vascular trauma.

In conclusion, our results confirm that complete multivessel revascularization can be achieved with good early clinical and angiographic results in a majority of patients with appropriate positioning of the heart and adequate mechanical stabilization. However, long-term studies are needed to substantiate these early good results and confirm the efficacy of this technique.

	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): Raymond Cartier Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Cartier, R. Articles by Blain, R. Search for Related Content PubMed PubMed Citation Articles by Cartier, R. Articles by Blain, R.