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Ann Thorac Surg 2000;70:1371-1377
© 2000 The Society of Thoracic Surgeons

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Original articles: cardiovascular

Coronary revascularization of the circumflex

^a Section of Cardiac Surgery, Department of Surgery, Washington Hospital Center, and MedStar Research Institute, Washington, DC, USA

Address reprint requests to Dr Corso, Division of Cardiac Surgery, Washington Hospital Center, 106 Irving St NW, Suite 316 South Tower, Washington, DC 20010
e-mail: pjc1{at}mhg.edu

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. Minimally invasive direct coronary artery bypass, without cardiopulmonary bypass, through a left lateral thoracotomy approach (lateral MIDCAB), is a safe alternative to coronary artery bypass surgery using cardiopulmonary bypass (on-pump CABG) of the circumflex system via median sternotomy. However, it is unknown whether lateral MIDCAB may yield an improved long-term outcome over the conventional on-pump median sternotomy approach.

Methods. We compared the perioperative outcomes of patients undergoing lateral MIDCAB (n = 34) versus conventional on-pump CABG of the circumflex system (n = 16) from June 1996 to July 1999. The two groups were similar with respect to baseline characteristics and risk stratification. Patients who required only one or two grafts for complete revascularization were included.

Results. Lateral MIDCAB patients had a lower need than on-pump CABG patients for intraoperative (12% MIDCAB vs 43% on-pump CABG, p = 0.03) and postoperative transfusions (29% vs 69%, p = 0.01), had fewer neuropsychologic changes (0% vs 19%, p = 0.03), and had a lower rate of postoperative atrial fibrillation (12% vs 44%, p = 0.02). Lateral MIDCAB was also associated with a significantly lower postoperative length of stay (5 ± 2 vs 7 ± 3 days, p = 0.02). Actuarial survival at a mean period of follow-up of 19 ± 11 months was 97% for the lateral MIDCAB versus 88% for the on-pump CABG group (p = 0.6). Event-free survival was 88% for lateral MIDCAB versus 81% for on-pump CABG (p = 0.1).

Conclusions. Lateral MIDCAB may safely be performed in patients with isolated coronary artery disease of the circumflex system with improved early morbidity and an abbreviated hospital stay compared with conventional median sternotomy on-pump CABG.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Minimally invasive direct coronary artery bypass grafting (MIDCAB) has gained wide acceptance as an alternative to median sternotomy with cardiopulmonary bypass [1–3]. Encouraging early clinical reports of minimally invasive coronary artery bypass surgery demonstrating excellent early patency rates, low morbidity and mortality, and shortened hospital stay have stimulated worldwide interest in these techniques [4, 5]. Anterior MIDCAB has been described as a minimal access approach for revascularization of the left anterior descending artery. Lateral MIDCAB (through a left lateral thoracotomy approach) has been shown to be a safe alternative to coronary artery bypass surgery on cardiopulmonary bypass (on-pump CABG) of the circumflex system via median sternotomy, especially in reoperated patients [6–9]. However, it is largely unknown whether lateral MIDCAB may offer a better long-term outcome than the conventional on-pump median sternotomy approach.

The purpose of this study was to compare the early and late outcomes of patients after lateral MIDCAB versus conventional on-pump CABG for revascularization of the circumflex system.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Patients
The computerized database of the Division of Cardiac Surgery of the Washington Hospital Center was queried to identify all patients who underwent revascularization of the circumflex system between June 1996 and July 1999. Only patients who received one or two grafts were included (n = 50). Of these, conventional on-pump CABG was performed in 16 (32%) and lateral MIDCAB was performed in 34 (68%) patients. These 34 MIDCAB patients represented 4% of the total number of patients (n = 808) who had off-pump CABG during the period of study. Clinical events were source documented. Baseline demographics, procedural data, and perioperative outcomes were recorded on standardized data-entry forms.

Definitions
Preoperative variables
Diabetes mellitus was defined as a history of diabetes mellitus, regardless of duration of the disease or need for oral agents or insulin. Chronic obstructive pulmonary disease (COPD) was defined as forced expiratory volume in 1 second (FEV₁) < 75% of predicted and/or chronic use of bronchodilators. Chronic renal insufficiency was defined as serum creatinine value 2.0 mg/dL or greater.

Postoperative variables
Low-output syndrome was defined as the postoperative use of inotropic support for more than 24 hours for the purpose of generating an adequate cardiac output. Prolonged ventilatory support was defined as pulmonary insufficiency requiring ventilatory support for more than 24 hours. Postoperative neuropsychologic changes were defined as the appearance of confusion, agitation, delirium, memory deficits, seizures, stupor, or stroke.

Selection criteria
The principal indications for lateral MIDCAB were bypass regrafting of the circumflex system in patients who were considered high risk for on-pump CABG due to medical comorbidities, such as previous CABG or previous sternotomy, renal failure, diffuse cerebrovascular and peripheral vascular disease, aortic atherosclerosis, or religious convictions that precluded blood transfusions [10–12].

Risk stratification
Parsonnet [13] and Cleveland clinic [14] risk-stratification models were used to control for potential between-group imbalances in preoperative variables that could influence perioperative outcomes.

Surgical techniques
For on-pump CABG, standard anesthesia and surgical techniques, extracorporeal circulation, and myocardial protection methods were used [15]. For lateral MIDCAB, the patient was positioned in the left lateral decubitus position, after the conduits (radial artery or saphenous vein graft) had been harvested. The harvested arteries were treated with papaverine. A left lateral thoracotomy approach was used and the fifth intercostal space was entered without removing the rib. The left lung was collapsed and the patient was ventilated through the right lung using a double-lumen endotracheal tube. The pericardium was then opened posterior to the phrenic nerve, and adhesions were lysed as needed. The patient was then heparinized (10,000 IU, bolus, IV). After the diseased artery was located, a silastic suture bolstered with a pledget encircling the entire artery, epicardial fat, and veins was placed proximally to the anastomotic site to achieve temporary coronary artery occlusion. No ischemic preconditioning was used for myocardial protection. A compression stabilizer (CardioThoracic Systems Inc, Cupertino, CA; or Medtronic stabilizer, Medtronic, Minneapolis, MN) was used to stabilize the coronary artery (Fig 1). The anastomosis was performed using continuous 7-0 Prolene sutures, in an antegrade fashion. A blower device (Aries CO₂ Blower; CardioThoracic Systems Inc) was used to keep the field clear of blood and the incised edges of the coronary artery separated during the anastomosis. The proximal anastomosis was usually placed on the descending thoracic aorta with this approach (Fig 2). The subclavian artery was used as an alternative when atherosclerosis precluded anastomosis to the descending thoracic aorta.

View larger version (136K): [in this window] [in a new window]   Fig 1. MIDCAB from left circumflex coronary artery to the descending thoracic aorta using a vein conduit and epicardial stabilization.

View larger version (137K): [in this window] [in a new window]   Fig 2. Completion of anastomosis between the graft and the descending thoracic aorta.

Pain management protocol
Intercostal blocks with bupivacaine (0.5%) one intercostal space above, one below, as well as at the intercostal space of the incision were used for early pain control after lateral MIDCAB. Postoperative pain control was achieved with intravenous doses of morphine (2 mg), as needed, and 5 mg every 6 hours of oxycodeine, per os (after morphine was discontinued). During the course of the study, epidural analgesia (continuous infusion of bupivacaine 0.125% and fentanyl 2 to 5 µg/mL at a rate of 6 to 10 mL/h) has been increasingly employed.

Follow-up
After Institutional Review Board approval, follow-up information was obtained from the patients or their referring physicians. Events documented were hospitalized myocardial infarction, hospitalized stroke, coronary angiogram, and subsequent need for a revascularization procedure (percutaneous transcatheter intervention or reoperated CABG), since the initial procedure (lateral MIDCAB or on-pump CABG) and death (cardiac plus noncardiac). Target vessel reintervention was defined as any revascularization procedure to the conduit graft or the grafted artery.

Statistical analysis
Primary comparisons were performed between the lateral MIDCAB and on-pump CABG groups. Data were expressed as numbers (percentages) or as means ± standard deviation. Categorical variables were compared using two-tailed Fisher’s exact test. Continuous variables were compared using a two-tailed, unpaired Student’s t test for variables with normal distributions and a two-tailed Mann-Whitney U test for variables with nonnormal distributions. Actuarial and event-free Kaplan-Meier survival curves were created for patients of the two groups and comparisons were performed with the log-rank test. Event-free survival was defined as freedom from hospitalized myocardial infarction, hospitalized stroke, death, and target vessel reinterventions (percutaneous transcatheter interventions or reoperated CABG), whichever occurred first. p values less than or equal to 0.05 were considered statistically significant. All statistical analyses were performed using SPSS 9.0 for Windows 95 (SPSS Inc, Chicago, IL).

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Preoperative patient characteristics are summarized in Table 1. Patients were well matched with respect to baseline characteristics and risk stratification. The only exception was that significantly more patients in the lateral MIDCAB group had reoperated CABG compared with conventional on-pump CABG patients. No patient in the MIDCAB group needed a conversion to conventional on-pump procedure or median sternotomy off-pump. Arterial conduits were used in 16 (47%) lateral MIDCAB patients versus 8 (50%) on-pump CABG patients (Table 2). In the former, the radial artery was mostly used as an arterial conduit, while in the on-pump CABG group, the internal mammary artery (IMA) was the preferred arterial conduit (IMA, 6 of 8 patients [75%]; radial artery, 2 of 8 patients [25%]). Concurrent transmyocardial revascularization and CABG was performed in 2 (6%) patients after lateral MIDCAB and in 4 (25%) after on-pump CABG (p = NS). The Heart Laser (PLC Systems, Inc, Milford, MA) was used in 4 of these 6 patients (on-pump CABG, n = 4; lateral MIDCAB, n = 2), and the Eclipse TMR 2000 Holmium Laser System (Eclipse Surgical Technologies, Inc, Sunnyvale, CA) was used in 2 patients who had on-pump CABG. All of these patients had transmyocardial revascularization in areas adjacent to the grafted territories.

Postoperative length of stay was significantly longer after on-pump CABG versus lateral MIDCAB. The median postoperative stay for on-pump CABG was 7 days versus 4 days for the lateral MIDCAB group.

Although one death occurred in the on-pump CABG group, this difference was not statistically significant due to the small number of patients in our study. The death occurred in a patient with depressed ejection fraction who had reoperated on-pump CABG; this patient died on the first postoperative day as a result of myocardial failure.

Late clinical outcome
Actuarial survival at a mean period of follow-up of 19 ± 11 months was 97% for lateral MIDCAB versus 88% for the on-pump CABG (p = 0.6) (Fig 3, Table 4). Late stroke occurred in 0% after lateral MIDCAB versus 6% of patients after on-pump CABG (n = 1) (p = 0.3), while late myocardial infarction occurred in 6% (n = 2) and 0%, respectively (p = 0.5). Of the 2 patients who had myocardial infarction after lateral MIDCAB, 1 had a subsequent angiogram in which the radial artery graft could not be visualized and this was presumed to be the cause of his myocardial infarction, while the other expired as a result of the myocardial infarction, 63 days after the procedure. Repeated angiogram for recurrent angina was needed in 9% of patients (n = 3) after lateral MIDCAB versus 0% of patients after on-pump CABG (p = 0.5). Of the 3 patients who had repeated angiogram after lateral MIDCAB, target-vessel percutaneous transcatheter intervention was needed in 2 patients (6%), due to graft occlusion (60 days post-MIDCAB, case 22) and distal graft stenosis (55 days post-MIDCAB, case 33), respectively, while patent anastomosis (FitzGibbons grade A [16]) was demonstrated in the third patient. No patient in our series needed reoperated CABG. Event-free survival (freedom from death, myocardial infarction, stroke, or target vessel reintervention) was 81% for on-pump CABG versus 88% for lateral MIDCAB (p = 0.2) (Fig 4).

View larger version (13K): [in this window] [in a new window]   Fig 3. Actuarial survival curve of patients after lateral MIDCAB and on-pump CABG with the hospital mortality included. (solid line = lateral MIDCAB; dotted line = on-pump CABG.)

View larger version (15K): [in this window] [in a new window]   Fig 4. Event-free survival curves (freedom from death, myocardial infarction, stroke, or target vessel reintervention) of patients after lateral MIDCAB and on-pump coronary artery bypass surgery (solid line = lateral MIDCAB; dotted line = on-pump CABG).

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

Reoperated patients and lateral MIDCAB
In our series, lateral MIDCAB was preferred for reoperated high-risk patients in an effort to avoid the hazards of repeat sternotomy [8] and to access the circumflex artery and its branches through a left lateral aspect of the pericardium, which is relatively free of adhesions compared with the anterior surface of the heart [6]. Further, adhesions from previous sternotomies, in addition to the use of epicardial stabilizer, may have a local stabilizing effect, reducing the motion of the heart and thereby facilitating arteriotomy and anastomosis [6, 17]. Moreover, avoidance of cardiac cannulation and dissection of adhesions, as required by a sternotomy approach, may eliminate the repeated lifting and manipulation of the heart that has been related to increased risk of embolization of the native coronary arteries by the dislodging of atherosclerotic debris from the old but still patent grafts [18].

Additionally, the use of pericardial stay sutures implanted below the phrenic nerve allowed reorientation without manual mobilization of the heart and thereby avoiding distortion of left ventricular hemodynamics. In a swine model, displacement of the heart was associated with hemodynamic changes with the use of straight Octopus paddles fixed directly on the ventricle. A possible explanation might be the reduction of stroke volume [19] and coronary blood flow [20] due to right ventricular dysfunction, as a result of mechanical interference with diastolic expansion without valvular incompetence [20]. In contrast, in our series, we used deeply seated pericardial sutures to preserve systemic hemodynamics as described by Benetti and associates [21] and Cartier and Blain [22].

In-hospital outcome
In the present study, lateral MIDCAB was associated with a significantly lower need for intraoperative and postoperative transfusions and shorter procedural time than conventional on-pump CABG. Neuropsychological changes were similarly lower after lateral MIDCAB. Cerebral microemboli generated during on-pump CABG might be implicated in postoperative neurologic impairment [23–25]. BhaskerRao and associates [23] documented in a prospective study that cerebral function improved after off-pump in comparison with on-pump CABG.

In addition, the rate of new-onset atrial fibrillation was almost four times lower after lateral MIDCAB than after on-pump CABG. This may be explained by the effects of systemic hypothermia, manipulation of the atria, and greater surgical trauma in patients undergoing on-pump CABG [12, 26, 27]. There was a significantly lower rate of low output syndrome after lateral MIDCAB than after on-pump CABG, as reported by previous authors [13, 16]. Postoperative development of acute renal failure, and need for prolonged ventilatory and intraaortic balloon pump support, were lower after lateral MIDCAB than after on-pump CABG, but these differences were not statistically significant, most probably due to a type II statistical error created by the small sample size.

Interestingly, lateral MIDCAB was associated with a shorter length of stay compared with on-pump CABG, emphasizing the uneventful recovery of this subset of patients. However, postoperative pain was found to be an important issue after MIDCAB, possibly due to damage of the corresponding intercostal nerves, as suggested by Stanbridge and associates [4]. An intense postoperative pain management protocol was used in our series to minimize patient discomfort and facilitate early ambulation.

A patient expired as a result of myocardial failure the first postoperative day after on-pump CABG, while no patient died in-hospital after lateral MIDCAB (Parsonnet estimated mortality: 9% for lateral MIDCAB vs 7% for on-pump CABG, p = 0.2).

Late clinical outcome
A trend towards a higher repeated target-vessel percutaneous transcatheter intervention rate was documented in the lateral MIDCAB versus the on-pump CABG group; this difference was not statistically significant, most probably due to the small sample size. The learning curve of this technically demanding novel approach may account for the 6% graft failure rate recorded in our series. Two patients in the lateral MIDCAB group were readmitted to the hospital due to a myocardial infarction, while 1 patient in the on-pump CABG group was readmitted due to a stroke. Late mortality was lower in the lateral MIDCAB than on-pump CABG group. A trend to improved event-free survival (freedom from repeated revascularization procedures, stroke, myocardial infarction, and death) was documented in the lateral MIDCAB versus the on-pump CABG group.

Limitations
The limitations of our study include the small size of each group and the drawbacks inherent in any retrospective nonrandomized analysis. However, chart review, data entry, and event adjudication were independently performed according to prespecified criteria. Large, prospective randomized studies are needed to set the indications and contraindications of beating heart approaches.

Implications from the study
In our initial experience, application of MIDCAB through a left lateral thoracotomy approach was possible only for isolated coronary artery disease of the circumflex system. The technical aspects limit the wide application of the described technique in patients who need multiple revascularization. Lateral MIDCAB should be attempted by surgeons familiarized with off-pump revascularization. However, the learning curve is not as steep as that of anterior MIDCAB or median sternotomy off-pump CABG. Moreover, patients should be able to tolerate single lung ventilation, and careful screening and patient selection (FEV₁ > 60% of normal) must be employed. During the course of this study, it was found helpful to perform the anastomoses in a distal to proximal sequence, proceeding from the third to the first obtuse margin, in patients who needed more than one graft. Potential kinking of the graft after completion of the anastomosis may be avoided by running the graft under the inferior pulmonary ligament.

Lateral MIDCAB approach may allow treatment of the "culprit" lesion of the circumflex coronary artery in high-risk patients with multivessel coronary artery disease, probably as a hybrid procedure, ie, combined with transcatheter intervention. There is also a learning curve associated with this technique, which accounted for a 6% early graft failure rate in our series.

In conclusion, lateral MIDCAB may be safely performed in patients with isolated coronary artery disease of the circumflex system with lower early and late morbidity than the conventional on-pump median sternotomy approach. Early and late mortality were similarly low and comparable with the respective values after on-pump CABG. However, future prospective randomized studies are needed to validate and confirm the results of the present study.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
We are indebted to Ellen Shair, MA, Research Writer/Editor, MedStar Research Institute, for her editorial contribution to this manuscript. We also acknowledge the invaluable contribution of Tracie Lomax, RA, Research Coordinator, Medstar Research Institute, in the preparation of this manuscript.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments 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): Sotiris C. Stamou Ammar S. Bafi Steven W. Boyce Albert J. Pfister Mercedes K.C. Dullum Jorge M. Garcia Paul J. Corso Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Stamou, S. C. Articles by Corso, P. J. Search for Related Content PubMed PubMed Citation Articles by Stamou, S. C. Articles by Corso, P. J.