Ann Thorac Surg 1999;68:470-472
© 1999 The Society of Thoracic Surgeons
Original Articles
Coronary revascularization without cardiopulmonary bypass in patients with pectus excavatum
Peter Y. Kim, MDa,
Thorsten Wittwer, MDb,
Axel Haverich, MDb,
Jochen T. Cremer, MDb
a Department of Surgery, Medical College of Georgia, Augusta, Georgia, USA
b Department of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
Address reprint requests to Dr Kim, Department of Surgery, Medical College of Georgia, 1120 15th St, Augusta, GA 30912-4000;
e-mail: pkim{at}mail.mcg.edu
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Abstract
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Background. Coronary revascularization in patients with pectus excavatum is technically difficult through a median sternotomy secondary to the posterior displacement of the sternum and the asymmetric angulation that it produces. The role of minimally invasive coronary artery bypass grafting (MIDCABG) in this subset of patients was evaluated.
Methods. In 1998, four patients with pectus excavatum underwent revascularization of the left anterior descending artery without cardiopulmonary bypass through a left anterior minithoracotomy.
Results. All patients underwent the procedure without intraoperative complications and postoperative angiography demonstrated adequate graft patency.
Conclusions. The advantages of MIDCABG in patients with pectus excavatum is the superior exposure to the LAD and LIMA and avoidance of a median sternotomy and cardiopulmonary bypass. This procedure is deemed safe and effective in patients with such deformities of the chest wall.
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Introduction
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The most common congenital deformity of the chest wall is pectus excavatum, in which the body of the sternum is displaced posteriorly to produce a funnel-shaped depression [1]. The association of this sternal malformation in patient with coronary artery disease complicates a planned cardiac procedure by making a median sternotomy technically more difficult and by limiting the operative exposure [2]. An alternative surgical approach in a select group of patients is to use an anterior minithoracotomy for access. We used minimally invasive direct coronary artery bypass grafting techniques in patients with pectus excavatum.
A 57-year old man presented with a 3-month history of worsening angina despite medical therapy. Physical examination revealed a pectus excavatum, and cardiac auscultation demonstrated a systolic ejection murmur. Transthoracic echocardiography revealed pulmonary valve insufficiency with dilatation of the pulmonary artery (4.7 cm) in addition to right ventricular hypertrophy. The coronary angiogram demonstrated a significant proximal stenosis of the left anterior descending artery (LAD). A computed tomogram of the chest confirmed the displacement of the heart into the left hemithorax along with lateral rotation of the LAD secondary to the sternal deformity and associated pulmonary artery dilatation and right ventricular enlargement (Figs 1 and 2).
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Fig 1. Computed tomogram of chest demonstrating sternal displacement and angulation. Lateral rotation of the left anterior descending artery is also shown.
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Fig 2. Displacement of the heart and great vessels into the left chest. Pulmonary artery dilatation is evident.
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Because of the aforementioned physical and radiologic findings, an alternate route of access for bypass was agreed upon. Under cardiac anesthesia and application of single lung ventilation, the patient was placed in a 20-degree right lateral decubitus position. The fifth intercostal space was entered through an 8-cm left submammary incision. The left internal mammary artery (LIMA) was mobilized proximally to the first intercostal space and distally to the inferior border of the fifth rib with the aid of an IMA Retractor (Cardio-Thoracic Systems, Cupertino, CA) and Thora-Lift (Vascular Therapies, Norwalk, CT) for a length of 14 cm. The operative exposure was enhanced by exerting vertical traction to the IMA Retractor which further opened the retrosternal space. Systemic heparin, 100 U/kg, was administered, and the distal end of the LIMA pedicle clipped and transected. Papaverine hydrochloride was applied topically to the pedicle, and a soft vascular clamp was placed proximally after confirming adequate flow. Next, the pericardium was opened and the left ventricle inspected. The LAD was located extremely laterally, therefore, the pericardium was suspended by pledgetted traction sutures to rotate the heart anteriorly. Coronary artery immobilization was accomplished with a mechanical stabilizer (Cardio-Thoracic Systems, Cupertino, CA) and temporary, local LAD occlusion was done with two 4-0 polypropylene tourniquet sutures over silicone tubes, 2 cm apart. The LAD was prepared and an arteriotomy made 2 to 3 minutes after local occlusion did not demonstrate any electrocardiographic or hemodynamic changes. The coronary anastomosis was done with a single, continuous 8-0 polypropylene suture. A small thoracostomy tube was placed, the chest closed, and the patient returned to the intensive care unit. Postoperatively, the patient remained stable and graft patency was deemed to be adequate by control angiography (Fig 3). With preserved thoracic stability and uncomplicated wound healing the patient recovered without difficulty. Figure 4 is a photograph of the patient at a follow-up visit.
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Fig 4. Photograph on postoperative follow-up which shows the degree of pectus deformity and outlines the minithoracotomy site used for access.
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Three other patients with pectus excavatum and underlying coronary artery disease had similar operative repairs with good results as demonstrated by postoperative angiography and resolution of symptoms. The procedure time, hospital stay, and recovery time were similar to those of patients without sternal deformities who had minimally invasive coronary artery bypass grafting.
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Comment
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Coronary artery revascularization using minimally invasive coronary artery bypass grafting techniques is well described in the literature [3–5]. Early results have shown that it can be done safely and effectively.
The concomitant presence of pectus excavatum and coronary disease requiring intervention can render median sternotomy technically difficult. The posterior displacement of the sternum and the asymmetric angulation that it produces in addition to the displacement of the heart into the left hemithorax limits operative exposure [2]. The dissection and mobilization of the LIMA can also be more difficult in this setting. Additional techniques have been reported to improve the operative exposure. A left thoracotomy, median sternotomy with extension into the left second and sixth intercostal spaces, and bilateral eversion of the divided sternal edges have been described [6–8].
In our group of 4 patients with pectus excavatum, each presented with a severe chest wall deformity and underlying single coronary artery disease (type C lesion). The advantages of minimally invasive coronary artery bypass grafting in this subset of patients are the superior exposure to the LAD and LIMA, avoidance of a median sternotomy and the possibility of exacerbated postoperative pulmonary dysfunction, and avoidance of cardiopulmonary bypass. The operative exposure is enhanced further by exerting vertical traction on the IMA Retractor. The LIMA is also more readily accessible secondary to the angulation of the median chest wall, which provides a better presentation of the LIMA when approached from the lateral side. Overall, this procedure is deemed safe and effective in patients with such deformities of the chest wall.
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References
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Cremer J., Strüber M., Wittwer T., et al. Off-bypass coronary bypass grafting via minithoracotomy using mechanical epicardial stabilization. Ann Thorac Surg 1997;63:S79-S83.
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Accepted for publication February 25, 1999.
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Abstract
Introduction
