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Ann Thorac Surg 2000;70:79-83
© 2000 The Society of Thoracic Surgeons
a Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
Address reprint requests to Dr Wiklund, Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, S-413 45 Göteborg, Sweden
e-mail: lars.wiklund{at}medfak.gu.se
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Abstract |
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Methods. One hundred thirty consecutive patients were studied. Median sternotomy was performed in 77 patients and anterior minithoracotomy in 53 patients.
Results. There were no differences in early clinical data or persistent postoperative pain between the groups. Early graft patency was 88% in the thoracotomy group and 96% in the sternotomy group (p = 0.3). Five of 7 patients who presented with a significant stenosis at the first coronary angiography had a normal angiogram at the reangiography. None of the patients with nonsignificant stenosis at the early coronary angiography had any clinical signs of ischemia or chest pain.
Conclusions. In our experience, anterior minithoracotomy and median sternotomy are different and distinguishable regarding early outcome and early graft patency. Most of the stenoses visualized at the early coronary angiography had vanished at a later coronary angiography, which makes the interpretation of the angiogram hazardous as a tool for the decision for redo procedure in the early postoperative period.
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Introduction |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Recently, new technology has been developed for safe coronary surgery on a beating heart [6, 7]. This technique has been applied via a small anterior thoracotomy [8–11] or a median sternotomy [6, 7]. A common opinion is that a minithoracotomy is technically more demanding than is sternotomy, which can jeopardize the safe takedown of ITA and the anastomosing procedure [12–14]. It has been discussed whether a small anterior thoracotomy causes less morbidity than sternotomy. It has been claimed that besides a better cosmetic result and a shorter hospital stay to reduce costs, an anterior minithoracotomy would cause less pain than median sternotomy [15, 16]. The aim of this report is to present our retrospective experience with the off-pump CABG procedure via either anterior minithoracotomy or median sternotomy in patients with single LAD disease regarding clinical outcome, early graft patency, and wound-related problems.
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Material and methods |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Postoperative angiography
A selective coronary angiography of ITA and LAD was performed in the first 50 consecutive patients (out of the total 130 patients) during the first postoperative period (1 to 5 days), including 24 patients from the thoracotomy group and 26 from the sternotomy group. Angiography was performed before and after administration of intracoronary nitroglycerin to relieve spasm. All the anastomoses were reviewed and classified as described by FitzGibbon and associates [17]. However, we further divided grade B into two subgroups as described: grade A, excellent graft with unimpaired run-off; grade B1, stenosis reducing caliber of anastomosis, and LAD or ITA to less than 50% of the grafted coronary artery; grade B2, stenosis reducing caliber of anastomosis, and LAD or ITA to more than 50% of the grafted coronary artery; and grade O, occlusion.
Postoperative follow-up of patients with stenosis in their early postoperative coronary angiogram
All patients (n = 9) with a stenosis grade B1 were examined with an exercise test (12-lead electrocardiogram [ECG] on an exercise bicycle) measuring the appearance of chest pain according to the New York Heart Association. All patients (n = 8) with a stenosis grade B2 were examined with an additional coronary angiography at times that varied between 3 and 18 months postoperatively.
Postoperative follow-up of wound problems
The first 74 patients (out of the total 130 patients) who underwent CABG with ITA to LAD with either anterior minithoracotomy (25 patients) or median sternotomy (49 patients) were presented with a questionnaire that included questions regarding postoperative wound problems such as infection and pain. The severity of pain was estimated using a scale where 0 was no pain and 10 was the worst pain imaginable.
Statistical methods
Clinical data are reported as mean ± SEM. Patency rates and the frequency of postoperative chest pain between groups was compared with the 
2 test and the Fisher’s exact probability test. Univariable and multivariable logistic regression analyses were used to compare a variety of demographic and clinical factors between groups.
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Results |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Early graft patency
According to the first postoperative coronary angiogram, patency was 88% in the thoracotomy group and 96% in the sternotomy group (Table 2). The postoperative coronary angiogram showed occlusion of ITA in 3 patients in the thoracotomy group and in 1 patient in the sternotomy group. Two of these patients were regrafted using CPB, 1 with a vein graft and 1 with a reimplantation of the ITA. In 1 patient, who had had three previous percutaneous transluminal coronary angioplasty (PTCA) procedures performed in the LAD, the vessel was found to be too heavily calcified for further grafting. The only patient in the sternotomy group who had graft occlusion was an old man who was judged to be beyond further attempts for surgery.
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Postoperative follow-up of patients with stenosis grade B2
Of a total of 8 patients, 1 patient with a stenosis grade B2 due to a kink on ITA was regrafted with a vein using CPB (Table 3). Five out of the remaining 7 patients (71%) showed no sign of stenosis in a repeat angiography. One patient with remaining stenosis underwent successful PTCA and 1 patient has no chest pain and is doing well in spite of a persisting stenosis.
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Postoperative wound-related problems
Ninety-two percent answered the questionnaire at a mean follow-up time of 10 months postoperatively (3 to 22 months), with no difference between patients that had undergone anterior minithoracotomy (n = 24) or median sternotomy (n = 41). Superficial wound infection requiring antibiotic treatment occurred in 8% of the cases in both groups. No mediastinitis occurred, but 1 patient who had undergone anterior minithoracotomy developed a deep wound infection. Thirty-two percent in the thoracotomy group reported postoperative pain compared with 23% in the sternotomy group at the time of follow-up (p = 0.4). The patients described the severity of pain at a mean of 3 (in a scale from 0 to 10) in both groups. In both groups, more than 75% were back to full activity at the time of investigation.
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Comment |
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TopAbstractIntroductionMaterial and methodsResultsCommentReferences |
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Interpretation of the coronary angiogram early after CABG is difficult. After the patient in whom a reoperation was performed because of a significant stenosis on the postoperative coronary angiogram, we became suspicious of the relevance of the angiographic findings. Even though there was a significant stenosis, there was a quick run-off of the injected contrast, indicating an acceptable surgical result. Furthermore, no patient with a significant stenosis had any clinical symptoms. After the experience with the reoperated patient, the subsequent 3 patients with significant stenoses were followed with a coronary angiogram 3 months later. Two of these patients now had a normal angiogram, confirming the clinical suspicion that the early postoperative coronary angiogram is difficult to interpret.
In our experience, most of the significant stenoses both in the ITA and in LAD turned out to be transient because they were not apparent at the late postoperative coronary angiography. Recently, this has also been described by Diegeler and associates and Mack and associates [19, 20]. It was also notable that none of the patients with nonsignificant stenosis at the early postoperative coronary angiography had signs of coronary ischemia at the time of follow-up. The stenoses, whether they were graded B1 or B2, were located at different levels, that is the ITA graft, the anastomotic site, or LAD (Table 3). One explanation for the ITA graft stenosis could be transient edema caused by the clamp used on the pedicle. In some cases, there was a stenosis distally of the anastomotic site, on the LAD, which could be due to hematoma caused by the occlusion sutures. Another explanation could be that some early stenoses seen in small vessels in cases performed off-pump are caused by platelet agglutination and therefore would not be seen in patients operated upon using cardiopulmonary bypass with its well-known effects on platelet function and other elements of the clotting cascade [21, 22]. With this thought in mind, we now try, if possible, to avoid the distal occlusion suture. It seems to be difficult to draw conclusions from angiographic findings in the early postoperative period. This is an important observation, as a significant stenosis at the early coronary angiography may result in an unnecessary reoperation. As a consequence, it may be a better alternative to measure the coronary blood flow intraoperatively with a transit Doppler flow meter or to have a coronary angiogram done on the operating table before any stenosis due to edema occurs, which, however, requires special equipment [23, 24]. If this equipment were not available, a more suitable time for coronary angiography would be well after the first postoperative period and after the healing process, for example, 6 months postoperatively if the patients have no signs of ischemia.
We believe that it is important to have strict selection criteria for choosing minithoracotomy so that the number of cases converted to sternotomy is limited. It should be kept in mind that it still remains to be proven that anterior minithoracotomy is superior in any respect to median sternotomy for grafting ITA to LAD. The questionnaire dealing with pain from the wound could not support the hypothesis that patients who underwent anterior minithoracotomy suffered less postoperative pain. Even though we did not resect cartilage in any case, the trauma to the costal cartilage may induce more intense pain than does median sternotomy [25]. It is known from the vast experience in coronary artery bypass grafting with median sternotomy that the pain from the wound is relatively limited. Patients with unclear LAD anatomy or an intramyocardial course of LAD are unsuitable for anterior minithoracotomy because these patients are more likely to need CPB.
One of the disappointing findings was that the length of hospital stay was similar to that of conventional CABG patients on CPB in our institution (unpublished data). This is in contrast to other authors, who have shown a significantly reduced hospital stay [6–11, 15]. Our findings can be explained by the fact that all patients were treated according to the same protocol in the ward as for conventional CABG patients on CPB. Furthermore, certain postoperative complications such as atrial fibrillation were not eliminated, albeit fewer. Whether or not there were any differences between patients who underwent thoracotomy or median sternotomy concerning the time that the patients were back to their ordinary activity is unknown to us.
A major limitation with this study is that it is not controlled and randomized. All patients were selected for anterior minithoracotomy or sternotomy, based on technical and medical reasons discussed above. The most important question is whether the long-term patency is comparable after thoracotomy and sternotomy. The only way to answer that is to do a randomized, prospective, controlled study, but as the patients suitable for minithoracotomy at each center are limited, the study has to be a multicenter trial.
In conclusion, this report shows that different and distinguishable early graft patency and clinical outcomes are seen with median sternotomy and minithoracotomy, respectively. There were more patients from the minithoracotomy group, where the angiogram showed significant stenosis early postoperatively. In addition, minithoracotomy causes more pain from the wound compared with sternotomy. The fact that most of the significant stenosis visualized at the early coronary angiogram could not be seen at the secondary angiogram makes the interpretation in the early postoperative period difficult. This may support other methods, such as intraoperative Doppler flow measurements, for determination of a satisfying surgical result, followed by an angiography after a time period of approximately 3 to 6 months to confirm patency.
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