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Ann Thorac Surg 2000;69:1787-1791
© 2000 The Society of Thoracic Surgeons

Original articles: Cardiovascular

Minimally invasive coronary artery revascularization on the beating heart

Jochen T. Cremer, MDa, Thorsten Wittwer, MDa, Andreas Böning, MDa, Marcel B. Anssar, MDa, Theo Kofidis, MDa, Andreas Mügge, MDb, Axel Haverich, MDa

a Department of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
b Department of Cardiology, Hannover Medical School, Hannover, Germany

Address reprint requests to Dr Cremer, Department of Cardiac and Vascular Surgery, Christian-Albrechts-University, Arnold-Heller-Str 7, 24105 Kiel, Germany
e-mail: jcremer{at}kielheart.uni-kiel.de


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. The quality of surgical beating heart revascularization is frequently questioned, especially when the surgical access is limited. Nevertheless, the number of off-pump coronary procedures is expanding worldwide.

Methods. Since getting started with minimally invasive direct coronary artery bypass to anterior myocardial vessels in June 1996, 306 patients received left internal mammary artery grafting through an anterior minithoracotomy. Risk increasing comorbidities were present in 168 of them. Particular attention was paid to early postoperative angiographic results and complications.

Results. The 30-day mortality summed up at 1.0% and was limited to patients with additional risks for conventional bypass grafting. Early postoperative control angiographies in 232 patients confirmed a global patency rate of 97.8%, revealing in addition four unexpected malinsertions to diagonal branches. In surviving patients major complications like myocardial infarction, stroke, or multiorgan failure were completely absent.

Conclusions. Minimally invasive direct coronary artery bypass grafting appears to allow for a safe and effective revascularization of the left anterior descending artery by use of the left internal mammary artery. Especially patients with risk increasing comorbidities should benefit from this approach, provided the surgical indication based on a dominating left anterior descending artery lesion. Angiographic minimally invasive direct coronary artery bypass results seem to fulfill the expectations generated by results obtained in conventional left internal mammary artery grafting and appear to be superior to interventional means.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
During the past few years different minimally invasive techniques have been developed and further advanced for coronary revascularization. The particular approaches claim to reduce the surgical trauma, that means, be minimally invasive with respect to smaller chest incisions, avoidance of extracorporeal circulation, and preserved chest stability [1–5]. Among these the MIDCAB technique (minimally invasive direct coronary artery bypass) combines the advantages of all these aspects but is restricted in its applicability to anterior myocardial vessels [6, 7]. Nevertheless, MIDCAB grafting of the left anterior descending artery (LAD) by use of the left internal mammary artery (LIMA) represents meanwhile the most frequently performed minimally invasive procedure in heart surgery.

Therefore most groups prefer open beating heart techniques under mechanical stabilization through a minithoracotomy with the eventual aid of videotechnology. While establishing the MIDCAB approach, major concerns focused on the quality of the anastomosis, the creation of de novo LAD lesions due to occlusion devices, and the myocardial tolerance of the temporary ischemia required for sewing the anastomosis. Beyond this, the application of MIDCAB–LIMA–LAD grafting for multivessel disease has been severely doubted regarding the completeness of myocardial revascularization in general. Trying to address these aspects at least in part we present our results in more than 300 patients obtained in a 2-year period with a standardized MIDCAB approach.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
Cardiac findings
After getting started with minimally invasive heart surgery in June 1996, 306 patients underwent MIDCAB grafting to the LAD or diagonal branches until August 1998 at the Hannover Medical School. The majority of these patients (Table 1) presented with one-vessel disease (n = 174). There were also numerous patients with two- (n = 86) or three-vessel disease (n = 46). The indication for a MIDCAB approach in these 132 patients with multivessel disease was derived from the individual cardiac findings or the extent and severity of comorbidity. Thus, the accompanying lesions were not significant in 22 patients and 30 patients had preexisting extensive myocardial scars not requiring revascularization or diffusely calcified vessels smaller than 1 mm (n = 8). In 44 patients with a complex proximal LAD stenosis (type C) a hybrid procedure was primarily intended to achieve additional revascularization of a second vessel. The remaining 28 patients with a leading LAD problem were multimorbid patients with combined comorbidities increasing the risk for conventional on-bypass revascularization immensely, whereas complete multivessel beating heart revascularization appeared technically not achievable. In parallel to the MIDCAB program techniques for off-pump multivessel grafting through a midline sternotomy were introduced and patients were carefully selected to either procedure.


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  		Table 1. Preoperative Cardiac Findings in 306 Patients With MIDCAB Grafting

 
Comorbidities
Meaningful comorbidities (Table 2) of the whole group present in 168 patients included predominantly diseases resulting in organ dysfunction or insufficiency followed by vascular diseases. In addition, some rarely occurring diseases may imply particular aspects and risks when applying conventional heart procedure with extracorporeal circulation. Thus, active malignancies, chronic immunosuppression, and previous osteomyelitis appeared worth mentioning.


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  		Table 2. Comorbidities in 168/306 Patients With MIDCAB Grafting

 
Surgical technique
Since introducing MIDCAB grafting into our surgical program as previously described [8], a few things have been changed or modified. We still use an anterior minithoracotomy entering the fourth or fifth intercostal space without division or resection of ribs. Applying a reusable very efficient retractor system (ThoraLIFT, Vascular Therapies, Norwalk, CT) to create a vertical tunnel we usually prepare the LIMA more proximally gaining an average length 12 to 14 cm. But it is not a principal condition to divide all side branches and to prepare the IMA origin. Under mechanical stabilization (CTS, Cupertino, CA) the LAD becomes exposed and two 4-0 polypropylene sutures are stitched around the LAD (one each loop) grasping a significant amount of tissue. To reduce the risk of vascular wall injury very soft silicone tubes serve as tourniquets just for gentle LAD occlusion avoiding any additional tension on snares for a better presentation or immobilization of the LAD. For an improved visualization of the vascular structures a blowing device (Medtronic DLP, Grand Rapids, MI) is principally available. After a test occlusion of 2 minutes, the LAD is incised and the anastomosis is performed with a single 8-0 polypropylene running suture starting at the contralateral heel. Esmolol is reserved only for hypercontractile or tachycardic hearts.

Follow-up
A complete 30-day follow-up was obtained for every patient. For precise evaluation of revascularization results, an early postoperative control angiography was generally recommended, except for octogenarians or patients with compensated renal insufficiency being at risk for further deterioration of the renal function along with the administration of contrast medium. In a group of patients, release of creatine kinase and its myocardial isoform (creatine kinase [CK] and CK-MB three samples within 24 hours) and troponin T (preischemic, 8 hours, 14 hours) was investigated to evaluate the generation of intraoperative ischemia associated with the temporary occlusion of the LAD.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
Primarily all patients left the surgical theatre in stable hemodynamic conditions. None of them received intraaortic balloon counterpulsation. The surgical technique was converted to a conventional approach (sternotomy, extracorporeal circulation) in only 3 patients due to proximal IMA injury in 2 patients and unexpected occlusion of the left IMA in another patient after thoracic operation in his youth.

Four patients died in relation to the MIDCAB procedure, but only in 2 patients due to cardiac reasons. One of them was a 64-year-old woman suffering from one-vessel disease and additional sclerosis of the ascending aorta presenting with small anterior (<= 1 mm) vessels coursing deep in the epicardial fat. After sequential LIMA grafting to the LAD and the diagonal branch she developed ventricular fibrillation 5 hours later on the intensive care unit. Although some residual IMA flow was present during open inspection of the anastomosis an immediate surgical regrafting with venous grafts in conventional technique was performed but remained finally unsuccessful (graft unrespected regarding patency). Another 72-year-old female patient with a complex cardiac situation (left main stem stenosis, unstable angina, reduced left ventricular ejection fraction < 30%) and combined comorbidities (circular calcification of the ascending aorta, iliofemoral and peripheral arterial occlusive disease, insulin-dependent diabetes mellitus, renal insufficiency) appeared not amenable for interventional therapy or conventional cardiosurgical revascularization. In a desperate situation she was finally accepted for a MIDCAB procedure. After an uneventful primary course she developed a lethal posterolateral myocardial infarction on postoperative day 12, whereas the patency of the LIMA anastomosis was confirmed later by autopsy. Two other patients with significant comorbidities died of multiorgan failure (postoperative day 28) or due to respiratory insufficiency (postoperative day 52).

No other patient developed a postoperative myocardial infarction, and significant inotropic support (dopamine, >= 3 mg · kg-1 · min-1 or epinephrine) became rarely necessary (5.2%). After a liberal heparin regimen the average postoperative bleeding amounted to 384 ± 361 mL per 24 hours without need for rethoracotomies in any of these patients within the first few days. Blood substitutes were given only in 3.9%. However, a secondary hemothorax was seen twice and required revision by sternotomy or repeat thoracotomy. Temporary atrial fibrillation occurred in 18 patients (5.9%). Postoperative strokes were completely absent. Wound healing was impaired in 6 patients (2%): three dehiscences, two superficial, and one deep infection. Despite the fact that the pericardium was left open when closing the chest, pericardial effusions were observed in 14 patients (4.6%), and became secondarily drained in four of them by interventional means.

In a group of 32 patients analyzed for intraoperative ischemia all troponin T levels ranged below a critical value of 0.1 ng/mL (preischemic: 0.021 ± 0.014 ng/mL; 8 hours: 0.041 ± 0.051 ng/mL; 14 hours: 0.03 ± 0.027 ng/mL) and maximal CK-MB averaged at 6.9 ± 2.8 IU/L representing 2.7% of total CK. Thus, the temporary LAD occlusion appeared not to be associated with a significant myocardial damage.

Angiographic results
Of 232 early control angiographies (Fig 1) performed after a mean of 21.6 ± 32.8 days a global patency rate of 97.8% (five left IMA occlusions) was obtained. However, in 4 patients malinsertions to diagonal branches were assessed. Looking for potential reasons for IMA graft occlusion we found a small LAD diameter (<= 1 mm) in 2 patients. Another two LADs were proximally occluded and diffusely diseased. Significant stenoses (> 50%) of the left IMA, the anastomosis, or the distal LAD (de novo) were present in 8 patients (2.6%). Subsequently no other surgical revascularizations were performed. Except for scheduled hybrid procedures, three percutaneous transluminal coronary angioplasties were required in 2 patients with malinsertion and one with LIMA occlusion. The other patients with restricted revascularization were treated with medication. More specific angiographic results of the majority of examined patients with more attention to anomalies and irregular findings have meanwhile been published by our group [9]. Such angiographic anomalies were not subjected to scheduled repeat investigations.



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  		Fig 1. Regular angiographic findings after successful MIDCAB grafting of the left anterior descending artery (LAD) revealing a tension-free internal mammary artery (IMA) course with sufficient function of the anastomosis.

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
Subsequently to the pioneering introduction of the MIDCAB-procedure by Benetti [1], Calafiore [6], and Subramanian [7] and their colleagues, a continuous development and refinement of instrumentation and surgical steps took place. Thus, major advances have been gained with mechanical stabilization of the myocardial surface by means working with local pressure or suction [2, 10]. Besides, the surgical trauma could be further reduced with especially designed thoracic retractors allowing access without division or resection of ribs and allowing a better presentation of the proximal IMA. Meanwhile, several studies have assessed that the avoidance of extracorporeal circulation results in less activation of systemic inflammatory processes [11, 12], which still exert their detrimental effects in conventional heart operations on bypass [13].

With this background and regarding the increased surgical risk in a major number of our MIDCAB patients due to more complex cardiac findings (unstable angina, cardiothoracic reoperations, severely depressed left ventricular function) and due to significant comorbidities, the obtained perioperative results appeared encouraging. This is not only reflected by the 30-day mortality rate of 1.0%, but also by the low incidence of perioperative infarctions and other major complications.

The key issue, however, needs to be answered, whether the results of revascularization are comparable or superior to commonly applied techniques for the invasive treatment of LAD lesions. This is especially important as the results of grafting through a small incision on the beating heart with impaired visualization are frequently doubted [14–16]. To sufficiently discuss this matter, control angiographies appear absolutely required. Although the principal proof of patency may be obtained by thermal imaging or transthoracic Doppler sonographies, details regarding stenosis at any level of the revascularization, the LIMA course, or de novo vascular lesions of the LAD would be missed. No prospective studies have been published so far trying to compare MIDCAB results to conventional coronary operations. Considering angiographic results of LIMA–LAD grafting through a sternotomy on bypass, the meta-analysis of Mack and colleagues [17] gives a basic survey. Therein early LIMA patency rates range between 94.0% and 98.8%, being in part evidently different from patency rates between 99% and 100%, which are frequently anticipated. In addition, many of the historic studies have the inherent disadvantage of relatively low proportions of patients being angiographically investigated. A more actual and detailed information extracted from a multicenter study reported by Berger and associates [18], assessed a LIMA–LAD patency rate of 98.8% in 645 patients. In addition, they describe impaired bypass function with stenoses >=50% in 7.8%.

Adversely, current results of interventional myocardial revascularization as represented by the Belgium Netherlands Stent Trial (BENESTENT) confirm immediate success rates (residual stenoses <= 50%) of 91.1% without stent and 92.7% with stent implantation [19]. Procedural occlusion rates vary between 2.7% and 3.5% and these data do not imply the problem of restenosis [19, 20]. Even in the stent era with new antiplatelet concepts [21], target vessel revascularization within 6 months is required between 15.7% and 26.8%. Furthermore, when comparing MIDCAB results with interventional therapy, the proportion of proximal LAD occlusions has to be adequately respected as such lesions are less effectively treated by interventional means [22]. Of course, it must be admitted that such comparisons are of limited value and more substantial information can only be derived from prospective trials comparing MIDCAB grafting and interventional revascularization.

Nevertheless, we regard MIDCAB grafting as a very attractive surgical option for the treatment of dominant LAD lesions in coronary artery disease. The currently available instruments allow for standardized and safe procedures with low conversion and complication rates and satisfying angiographic results.


   Acknowledgments
 
We gratefully appreciate the professional expertise of Bärbel Bornholdt-Dudler in preparing the manuscript and coordinating publication issues.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

  1. Benetti F.J., Ballester C., Sani G., Boonstra P., Grandjean J. Video assisted coronary artery bypass surgery. Ann Thorac Surg 1996;61:1658-1665.[Abstract/Free Full Text]
  2. Boonstra P.W., Grandjean J.G., Mariani M.A. Improved method for direct coronary grafting without CPB via anterolateral small thoracotomy. Ann Thorac Surg 1997;63:567-569.[Abstract/Free Full Text]
  3. Gulielmos V., Knaut M., Wagner F.M., Schüler S. Minimally invasive surgical technique for the treatment of multivessel coronary artery disease. Ann Thorac Surg 1998;65:1331-1334.[Abstract/Free Full Text]
  4. Reichenspurner H., Gulielmos V., Wunderlich J., et al. Port-access coronary artery bypass grafting with the use of cardiopulmonary bypass and cardioplegic arrest. Ann Thorac Surg 1998;65:413-419.[Abstract/Free Full Text]
  5. Jansen E.W.L., Borst C., Lahpor J.R., et al. Coronary artery bypass grafting without cardiopulmonary bypass using the Octopus method. J Thorac Cardiovasc Surg 1998;116:60-67.[Abstract/Free Full Text]
  6. Calafiore A.M., Di Giammarco G., Teodori G., et al. Midterm results after minimally invasive coronary surgery (LAST operation). Eur J Thorac Cardiovasc Surg 1998;115:763-771.
  7. Subramanian V.A., McCabe J.C., Geller C.M. Minimally invasive direct coronary artery bypass grafting. Ann Thorac Surg 1997;64:1648-1653.[Abstract/Free Full Text]
  8. 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.
  9. Cremer J., Mügge A., Wittwer T., et al. Early angiographic results after revascularization by minimally invasive direct coronary artery bypass (MIDCAB). Eur J Thorac Cardiovasc Surg 1999;15:383-388.
  10. Borst C., Jansen E.W., Tulleken C.A., et al. Coronary artery bypass grafting without cardiopulmonary bypass and without interruption of native coronary flow using a novel anastomosis site restraining device ("Octopus"). J Am Coll Cardiol 1996;27:1356-1364.[Abstract]
  11. Gu Y.J., Mariani M.A., van Oeveren W., Grandjean J.G., Boonstra P.W. Reduction of the inflammatory response in patients undergoing minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1998;65:420-424.[Abstract/Free Full Text]
  12. Strüber M., Cremer J., Gohrbandt B., et al. Inflammatory response after coronary bypass grafting (CABG) versus minimal invasive surgery. Intensive Care Med 1997;23(Suppl 1):71.[Medline]
  13. Cremer J., Martin M., Redl H., et al. Systemic inflammatory response syndrome after cardiac operations. Ann Thorac Surg 1996;61:1714-1720.[Abstract/Free Full Text]
  14. Possati G., Gaudino M., Allessandrini F., Zimarino M., Glieca F., Luciani N. Systematic clinical and angiographic follow-up of patients undergoing minimally invasive coronary artery bypass. J Thorac Cardiovasc Surg 1998;115:785-790.[Abstract/Free Full Text]
  15. Izzat M.B., Yim A.P.C. Didn’t they do well?. Ann Thorac Surg 1997;64:1-2.[Free Full Text]
  16. Bonchek L.I., Ullyot D.J. Minimally invasive coronary bypass. Circulation 1998;98:495-497.[Free Full Text]
  17. Mack M.J., Osborne J.A., Shennib H. Arterial graft patency in coronary artery bypass grafting. Ann Thorac Surg 1998;66:1055-1059.[Abstract/Free Full Text]
  18. Berger P.B., Alderman E.L., Schaff H.V. Frequency of early occlusion and stenosis in the left internal mammary artery among patients undergoing CABG through a median sternotomy on conventional bypass. J Am Coll Cardiol 1997;30(Suppl 1):681.
  19. Serruys P.W., de Jaegere P., Kiemenej F., et al. A comparison of balloon-expandable-stent implantation with balloon angioplasty in patients with coronary artery disease. N Engl J Med 1994;331:489-495.[Abstract/Free Full Text]
  20. Serruys P., van Hout B., Bonnier H., et al. Randomised comparison of implantation of heparin-coated stents with balloon angioplasty in selected patients with coronary artery disease (Benestent II). Lancet 1998;352:673-681.[Medline]
  21. Topol E.J., Serruys P.W. Frontiers in interventional cardiology. Circulation 1998;98:1802-1820.[Free Full Text]
  22. Vogt A., Bonzel T., Harmjanz D., et al. PTCA registry of German community hospitals. Eur Heart J 1997;18:1110-1114.[Abstract/Free Full Text]
Accepted for publication November 29, 1999.




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