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Ann Thorac Surg 1999;68:946-948
© 1999 The Society of Thoracic Surgeons

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Original Articles: Cardiovascular

Off-pump obtuse marginal grafting with local stabilization: thoracotomy approach in reoperations

^a St. Vincent Medical Center, Los Angeles, Califorinia, USA
^b Providence St. Joseph Medical Center, Burbank, California, USA
^c St. John’s Regional Medical Center, Oxnard, California, USA

Address reprint requests to Dr Baumgartner, Pacific Cardiothoracic Surgery Group, St. John’s Regional Medical Center, 1700 N Rose Ave, Suite 440, Oxnard, CA 93030

	Abstract

Top Abstract Introduction Patients and methods Comment References

 
Background. Redo coronary surgery in patients with patent internal mammary artery (IMA) grafts may be hazardous. A thoracotomy approach has been used to graft the circumflex branches to avoid injury from sternal re-entry. Combining this approach with off-pump revascularization techniques may be useful.

Methods. Seven consecutive patients who had undergone prior coronary revascularization developed symptoms attributable to lateral wall ischemia. Five of them had patent IMA grafts. These patients underwent off-pump obtuse marginal grafting using local immobilization techniques via a thoracotomy approach. Inflow was from the descending aorta in 6 patients and splenic artery in 1.

Results. Obtuse marginal grafting was successfully performed in all cases without need for cardiopulmonary bypass.

Conclusions. Off-pump obtuse marginal grafting via the thoracotomy route may be useful in redo coronary surgery, particularly in instances of patent IMA grafts.

	Introduction

Top Abstract Introduction Patients and methods Comment References

 
Injury to patent coronary conduits in reoperative cardiac surgery in a graft-dependent heart can be catastrophic. The patent left or right internal mammary artery (LIMA or RIMA) grafted onto the left anterior descending artery (LAD) is particularly vulnerable. A left thoracotomy is useful for redo coronary grafting of the circumflex branches of the lateral wall of the heart [1].

In recent years, off-pump coronary artery bypass grafting (CABG) in first time and redo cases has been accomplished through small anterior thoracotomies [2–4], primarily to graft the LAD and diagonal branches using the left internal mammary artery. This minimally invasive direct coronary artery bypass (MIDCAB) does not address circumflex disease, which is not easily accessible with a limited thoracotomy. Circumflex disease has been grafted in an off-pump manner in limited numbers using a sternotomy [5, 6]. It has also been done by posterior thoracotomy using the Octopus tissue stabilizer (Medtronic Inc, Grand Rapids, MI) in several cases [7]. We herein report 7 consecutive patients with prior CABG, including 5 with patent LIMA to LAD grafts, who underwent successful obtuse marginal grafting via a left posterolateral thoracotomy approach. All were done without cardiopulmonary bypass using local immobilization techniques.

	Patients and methods

Top Abstract Introduction Patients and methods Comment References

 
Seven consecutive patients who presented with recurrent angina and/or heart failure after prior CABG had significant disease in the circumflex distribution, for which prior obtuse marginal grafts were either not done or had been done and failed. The lesions in the circumflex system in all patients were either not amenable to, or failures of, angioplasty, and were refractory to medical management. Five of the 7 patients had patent LIMA to LAD grafts. Table 1 lists specific preoperative details. Surgical intervention was selected in these patients. These 7 patients are a subset of 180 patients who have undergone off-pump CABG procedures by us with 0% mortality (the vast majority multivessel bypass by median sternotomy).

View larger version (54K): [in this window] [in a new window]   Fig 1. Off-pump obtuse marginal grafting with local stabilization. Exposure is via a left posterolateral thoracotomy in this redo situation. Pericardiotomy is performed posterior to the phrenic nerve (PN). The stabilizer is straddling the distal anastomosis between the saphenous vein graft (SVG) to the obtuse marginal (OM). The proximal anastomosis of the SVG is to the descending aorta (A) below the inferior pulmonary vein (IPV) and mobilized inferior pulmonary ligament.

All 7 patients underwent successful revascularization of the obtuse marginal distribution, have done well, and have gone home. During a follow-up period ranging from 2–6 months, angina did not develop in any of the patients and no patients showed other symptomatic or electrocardiogram evidence of ischemia or infarction. Routine postoperative coronary angiography has not been done.

	Comment

Top Abstract Introduction Patients and methods Comment References

 
The patent RIMA-to-LAD graft, which crosses the midline, is in great jeopardy during redo median sternotomy. Although a LIMA grafted to the LAD is usually to the left of the midline, it may be exposed to injury if the intact pleura in an emphysematous patient displaces it to the midline. Furthermore, the IMA graft may become injured in subsequent dissection to approach the lateral wall of the heart. For these reasons, median sternotomy may not be the incision of choice in reoperative cardiac surgery requiring circumflex branch revascularization, and left thoracotomy may be preferable. The thoracotomy approach should also be considered in cases with prior mediastinitis or radiation treatment, calcification of the ascending (but not descending) aorta, and presence of a tracheostomy.

Although cardiopulmonary bypass and cardioplegic arrest are for the most part well tolerated, certain subgroups have a high incidence of significant pathophysiologic derangements, including systemic inflammatory and coagulopathic changes as well as end-organ sequelae. Such subgroups include the elderly, patients with severe cardiac, renal or pulmonary dysfunction, and those with prior stroke or confusion. It is in these patients, in particular, that off-pump procedures would be expected to have less morbidity than their on-pump counterparts. Technical issues have been a concern with off-pump CABG [8]. However, the ability to perform off-pump coronary grafting is substantially enhanced, at least for the LAD, with stabilization methods to limit regional wall motion at the point of anastomosis [3]. Nonetheless, the long-term patency rate of off-pump CABG is not yet proven to be equivalent to that on-pump.

The technique of off-pump obtuse marginal revascularization was successfully combined with the thoracotomy route for reoperative CABG surgery in our 7 patients. Since a thoracotomy is a more potent pulmonary stressor than sternotomy, preoperative lung function determination to ensure that the patient can tolerate a thoracotomy is worthwhile. A more distinct disadvantage of the approach is the technical difficulty of beating heart anastomoses, which should not be trivialized despite helpful local immobilization techniques. Off-pump thoracotomy grafting of the obtuse marginal targets is technically more difficult than MIDCAB grafting of the LAD. This relates to the relative proximity of the anterior heart vessels to the anterior chest wall compared to the distance of lateral heart vessels from the lateral chest wall. The result is a "deeper hole" for the surgeon to maneuver within, as well as a somewhat less steady stabilization by the immobilizer foot plate. It is thus important to maintain exposure of the left groin, or to even expose the femoral vessels in an anticipatory manner should emergency cannulation be required. Anesthesia support must be precise, diligent, and proactive rather than reactive.

A possible problem is calcification of the descending thoracic aorta, which may make a proximal anastomosis in this area difficult and may require alternative inflow possibilities, including the splenic (used in one of our patients) or subclavian arteries. Computed tomographic scanning of the chest preoperatively to assess for this may be advisable prior to such anticipated procedures. Furthermore, the use of arterial conduits, such as the radial artery, could conceivably lessen the chance of ultimate graft occlusion requiring re-thoracotomy as might be predicted with vein grafts.

Despite perceived disadvantages, the method was reliable and successful in our 7 patients. If done safely and efficiently, off-pump obtuse marginal grafting via the thoracotomy approach is a useful adjunct for redo-CABG patients, particularly those with patent IMA grafts.

	References

Top Abstract Introduction Patients and methods Comment References

 

1. Burlingame M., Bonchek L., Vazales B. Left thoracotomy for reoperative coronary bypass. J Thorac Cardiovasc Surg 1988;95:508-510.[Abstract]
2. Subramanian V., Stelzer P. Clinical experience with minimally invasive coronary artery bypass grafting (CABG). Eur J Thorac Cardiovasc Surg 1996;10:1058-1063.
3. Calafiore A.M., Di Giammarco G., Teodori G., et al. Midterm results after minimally invasive coronary surgery (LAST operation). J Thorac Cardiovasc Surg 1998;115:763-771.[Abstract/Free Full Text]
4. Buffolo E., de Andrade J.C.S., Branco J.N.R., Teles C.A., Aguilar L.F.A., Gomes W.J. Coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg 1996;61:63-66.[Abstract/Free Full Text]
5. Benetti F.J., Naselli G., Wood M., Geffner L. Direct myocardial revascularization without extracorporeal circulation. Chest 1991;100:312-316.[Abstract/Free Full Text]
6. Tasdemir O., Vural K.M., Karagoz H., Bayazit K. Coronary artery bypass grafting on the beating heart without the use of the extracorporeal circulation. J Thorac Cardiovasc Surg 1998;116:68-73.[Abstract/Free Full Text]
7. Jansen E.W.L., Borst C., Lahpor J.R., et al. Coronary bypass grafting without cardiopulmonary bypass using the Octopus method. J Thorac Cardiovasc Surg 1998;116:60-67.[Abstract/Free Full Text]
8. Gundry S.R., Romano M.A., Shattuck O.H., Razzouk A.J., Bailey L.L. Seven-year follow-up of coronary artery bypass performed with and without cardiopulmonary bypass. J Thorac Cardiovasc Surg 1998;115:1273-1278.[Abstract/Free Full Text]

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