Ann Thorac Surg 2000;70:2017-2022
© 2000 The Society of Thoracic Surgeons
Original article: cardiovascular
Minimally invasive coronary artery revascularization: off-pump bypass grafting and the hybrid procedure
Tadashi Isomura, MDa,
Hisayoshi Suma, MDa,
Taiko Horii, MDa,
Toru Sato, MDa,
Teisei Kobashi, MDa,
Hideo Kanemitsu, MDa
a Cardiovascular Surgery, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
Accepted for publication April 27, 2000.
Address reprints requests to Dr Isomura, Cardiovascular Surgery, Hayama Heart Center, 1898 Shimoyamaguchi, Hayama, Kanagawa, Japan 240-0116
e-mail: isomura{at}hayamaheart.gr.jp
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Abstract
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Background. Coronary artery bypass grafting without cardiopulmonary bypass (off-pump-CAB; OPCAB) as a minimally invasive procedure has been used increasingly to treat coronary artery disease. The procedure makes multivessel revascularization possible, with new instruments and techniques, and hybrid therapy (combination of angioplasty and OPCAB) can be a new method of treating coronary disease. We present our experience using OPCAB and our strategy for coronary revascularization.
Methods. Of 216 patients treated with OPCAB, the lesion was single in 100 and multivessel in 116. Preoperative risks that could increase the mortality and morbidity rates were present in 127 patients, excluding 55 who were 75 years old or older.
Results. There were four hospital deaths, three of which were noncardiac, and five operative morbidities: transient cerebral ischemia in 3, perioperative myocardial infarction in 1, and congestive heart failure in 1. A postoperative angiogram was done in 157 patients (220 grafts), and with heart stabilization the patency rate without stenosis improved to 93.6%. For 116 patients with multivessel disease, technically complete revascularization was done in 84%, either with multivessel revascularization in 61 patients or the hybrid procedure in 37 patients. Among 20 patients with left main trunk lesion, five had the hybrid procedure. Angina recurred in 3, including 1 who died suddenly of infarction. The angiogram at recurrence showed restenosis of left main lesion and occlusion of the graft to the left anterior descending artery. Postoperative follow-up for 2 years showed 12 patients with recurrent angina and five late deaths from noncardiac-related events.
Conclusions. The heart stabilizer and new techniques for coronary revascularization with a beating heart have improved the anastomotic quality of grafts. The hybrid procedures were effective in selected patients but were considered contraindicated in patients with left main trunk lesion. OPCAB was safe, effective, and suitable especially in patients with high risks for coronary artery bypass grafting.
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Introduction
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Since Benetti and Ballester [1] reported coronary artery bypass grafting (CABG) through a left anterior small thoracotomy (LAST) without cardiopulmonary bypass (CPB) in 1994, CABG without sternotomy and CABG with no CPB have gained worldwide interest.
With the increase of CABG without CPB (off-pump CABG, OPCAB), new operative instruments have been developed. The heart stabilizer has improved the quality of anastomosis with a beating heart. We have been performing the LAST operation since 1996 and simultaneously performing OPCAB through a median sternotomy to complete multiple coronary artery revascularization.
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Patients and methods
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Between January 1996 and December 1999, 216 patients had CABG without CPB. There were 155 men and 61 women, and their ages ranged from 27 to 89 years (mean, 68 years). Preoperative angiogram showed single-vessel coronary artery disease in 100 patients and multivessel coronary artery disease in 116 patients, including 20 patients with a left main trunk (LMT) lesion (Table 1). Preoperative risks were seen in 127 patients (58.8%), excluding 55 patients (25.4%) who were 75 years old or older, and are given in Table 2. In 57 patients CPB was considered to be impossible or high risk because of calcified ascending aorta, bleeding tendency, severe cerebrovascular lesion, or a combination of those lesions. In the other 70 patients CPB was avoided because of increased operative morbidity from the effect of CPB on risks such as severe peripheral vascular lesion, renal failure, cancer, or chronic obstructive pulmonary disease (Table 2). The LAST operation was done in 87 patients, and median sternotomy was done in 121 patients, excluding three subxyphoid and five lower half-sternotomy. The patients with multivessel lesions including LAD lesion for CABG and who were free of calcification or chronic total occlusion in the other coronary arteries by angiographic assessment were considered candidates for hybrid therapy.
Selection of patients
Left anterior small thoracotomy operation
The patients who had failure of angioplasty or stenting and isolated left anterior descending (LAD) coronary artery disease were selected as candidates for small thoracotomy. The patients with reoperation, LAD lesion, and suitable angioplasty for concomitant coronary disease were also candidates for this procedure. Chronic obstructive pulmonary disease was a contraindication for this approach because of lung decompression during this procedure.
Median sternotomy and off-pump coronary artery bypass
Patients who required multiple CABG and had preoperative risks that contraindicated CPB were considered candidates for complete multivessel revascularization or OPCAB plus percutaneous transluminal coronary angioplasty (PTCA) (hybrid therapy).
Combined off-pump coronary artery bypass and angioplasty
Angioplasty was done in the diseased vessels other than the LAD artery. If vessels were totally occluded, tortuous, or an extensive lesion was present, angioplasty was contraindicated.
Surgical technique
In LAST operations, a left submammary incision measuring 7 cm was made, and the chest was entered through the forth or fifth intercostal space. The left internal thoracic artery (LITA) was harvested between the second or first intercostal space and the fifth intercostal space under direct vision or by using a retractor (LIMA Lift; Cardio Thoracic System, Cupertino, CA). After 100 IU/kg of heparin was given and activating coagulation time was controlled at 250 to 300 seconds, the ITA was divided distally. After the LAD was exposed, the proximal and distal LAD was snared with elastic suture (Matsuda Ika Kogyo, Tokyo, Japan), and the anastomosis was constructed with continuous 7.5 Oval-M monofilament (Matsuda Ika Kogyo, Tokyo, Japan) using the double-parachute method. Coronary artery stabilization was obtained not pharmacologically but mechanically (Platform Access, Cardio Thoracic System, or Matsuda Ika), and a bloodless field was obtained with a carbon dioxide blower.
Median sternotomy was used in most patients who required multivessel OPCAB. After the full sternotomy, the LITA was mobilized from the sixth rib to the subclavian vessels in the usual fashion. After takedown of the LITA, the LITA-LAD anastomosis was completed as done in the LAST operation. To accomplish the revascularization of an obtuse marginal branch or posterodescending artery, two 1-cm stockinet gauzes (Heart holder tapes; Matsuda Ika Kogyo, Tokyo, Japan) were passed through the transverse sinus and behind the inferior vena cava, and the heart was rotated to a proper position by lifting the tapes with the patient in the Trendelenburg position. After exposure and stabilization, the obtuse marginal or posterodescending branch was revascularized with either saphenous vein or gastroepiploic artery. The hemostasis was secured and the incision was closed. Postoperative electrocardiogram, serum creatine kinase, and creatine kinase-MB levels were measured routinely in the intensive care unit. Postoperative angiogram was taken on the same postoperative day or 1 day before discharge within 1 week postoperatively in most patients to confirm the quality of anastomosis. In patients who received hybrid therapy, the PTCA or stenting was done simultaneously with the postoperative angiogram.
All patients were followed up postoperatively, and the longest follow-up time was 30 months. Recurrence of angina, myocardial infarction, repeated PTCA, redo surgery, or cardiac death was considered a cardiac-related event, and both cardiac and noncardiac deaths were surveyed.
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Results
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In LAST operations, single bypass of LITA to LAD was done in most patients. The number of distal anastomoses in patients with median sternotomy ranged from one to four, and the mean number was 1.6 per patient. Conversion to CPB did not occur, but conversion from the LAST operation to median sternotomy occurred in 3 patients, 2 because the LAD was deeply intramuscular and 1 because of failure of the exposure of the LITA. The LITA was injured during harvest through a left thoracotomy in 5 patients, and the inferior epigastric artery was anastomosed to the proximal LITA to repair the graft. All injuries occurred at the fourth or fifth intercostal space at the beginning of the harvest through a left thoracotomy. Ventricular fibrillation occurred in 1 patient when the heart was lifted and rotated to expose the marginal artery; electric shock was required.
Early death (within 30 days postoperatively) occurred in 3 patients (1.4%). In 2 of them ischemic intestinal necrosis developed 1 or 6 days postoperatively. One 82-year-old died of LMT lesion dissection resulting from PTCA trouble and emergent off-pump CABG of LITA to LAD. One patient died of perioperative cerebral infarction in the hospital more than 30 days after operation; the patient had cerebral infarction and renal failure at the time of preoperative coronary angiogram. After stabilization of the neurologic symptoms, OPCAB was done. During the operation systemic pressure was maintained at 100 to 120 mm Hg; however, the permanent stroke occurred postoperatively and multiorgan failure developed.
In the intensive care unit, transient cerebral ischemia occurred in 3 patients with severe cerebrovascular disease; however, all of them recovered without permanent neurologic symptoms. Perioperative myocardial infarction occurred in 1 patient 4 hours postoperatively, and emergent angiogram showed LAD thrombosis; PTCA and thrombolysis were successful. Congestive heart failure developed in 1 patient after the operation, and the angiogram showed residual severe mitral regurgitation and incorrect anastomosis of the LITA, not to the LAD but to the diagonal branch. The patient had a successful redo operation for mitral repair and revascularization of LAD with the use of CPB and median sternotomy 14 days after the initial LAST operation. No patient had ventricular tachycardia in the intensive care unit.
Postoperative angiograms were done for 220 grafts (157 patients) (Fig 1). Early in this series, no stabilization was used, and the graft patency was 83.7%, excluding 12.5% of stenosis of the anastomotic site. After the use of heart stabilization, the patency rate without stenosis improved to 93.6%. The ITA was used in 193 grafts, the saphenous vein in 54, gastroepiploic artery in 23, and radial artery in seven (Table 3). The inferior epigastric artery was used to repair the injured ITA or extension of the arterial graft. For redo CABG, the proximal site of the free radial artery or saphenous vein was anastomosed to the left subclavian artery (Fig 2) in 6 patients to avoid reentry of the median sternotomy and to enter through a left thoracotomy.
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Fig 1. Off-pump coronary artery bypass grafting with the use of a heart stabilizer in a 56-year-old patient with cerebrovascular disease. The left internal thoracic artery (LITA) was anastomosed to the left anterior descending artery (LAD) and the right gastroepiploic artery (GEA) to the posterodescending branch (PD). Postoperative angiograms were taken on the sixth postoperative day, and in both grafts, flow completely filled the coronary arteries.
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Fig 2. For a patient with redo coronary artery bypass grafting and requiring single left anterior descending artery (LAD) revascularization, the left subclavian artery, which was rarely sclerotic, was selected as the site of proximal anastomosis. The left radial artery (RA) was anastomosed to the left subclavian artery proximally and LAD distally in a 63-year-old patient who had previous coronary artery bypass grafting and occluded left internal thoracic artery-to-LAD graft. With the LAST procedure, operative morbidity was low because adhesion was minimal.
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In 116 patients with multivessel disease, hybrid therapy (OPCAB and PTCA) was done in 37 patients, and 40 vessels were treated at the time of postoperative angiogram. Technically complete revascularization for the multivessel lesions was done in 57 patients, excluding transmyocardial laser revascularization in 4 patients with small target vessels (Table 4). In 5 patients with LMT lesion, hybrid therapy was done during our early series. Angioplasty to the LMT lesion was successful within 7 days after a LAST operation of LITA to LAD; however, angina recurred in 3 patients within 3 months after treatment, including one death from acute myocardial infarction. Those patients had restenosis of the LMT lesion in addition to occlusion of the LITA to LAD or string of the LITA graft that had been fully patent at the time of the first early postoperative angiogram (Fig 3). The remaining 18 patients who did not receive complete OPCAB or hybrid procedures had single revascularization of the LAD. Nine of them had calcified aorta or preoperative severe cerebrovascular lesion. Four patients had no operative risks and they had double-vessel lesions, LAD lesion and lesions in small right coronary artery, or circumflex artery. One patient had redo CABG and 2 required repeat PTCA after discharge because of angina. There were no late deaths among those 18 patients.
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Table 4. Multivessel Lesion and Therapeutic Method in 116 Patients Who Had Off-Pump Angioplasty-Bypass Combination Therapy
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Fig 3. The left main trunk (LMT) lesion was treated by hybrid procedures in 5 patients. The anastomosis of the left internal thoracic artery (LITA) to the left anterior descending artery (LAD) was patent in the early postoperative period (A) and the LMT lesion was treated successfully with angioplasty simultaneously (B). However, angina recurred 3 months after the procedures, and angiogram showed occluded left LITA graft and restenosis of the LMT lesion (A, B). The LMT lesion is now considered a contraindication for hybrid therapy. (p/OP = postoperative; PTCA = percutaneous transluminal coronary angioplasty.)
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All 212 operative survivors were followed up, and 5 patients died after discharge. Causes of death included noncardiac events such as cerebrovascular disease, liver disease, and cancer. Twelve patients had recurrent angina, including 3 with LMT lesion. All 12 patients had a repeat angiogram; the LITA had become stenotic or occluded in 4 patients, and the lesion of the nonbypassed vessel was treated by angioplasty or medication. The longest survival in this series was 30 months, and 207 patients currently survive, with 90.1% of them without angina.
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Comment
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In 1967 Kolessov [2] reported CABG without CPB; however, the use of CPB has been the gold standard for complete revascularization for CABG. After some challenging reports [1, 3, 4] of CABG through a small left thoracotomy (LAST operation) or lower-half sternotomy [5] without pump, CABG without CPB became increasingly popular as an alternative to CABG. Since 1996, we have been using the LAST operation and have been interested in OPCAB through both left thoracotomy and median sternotomy. In this study, we presented operative results of OPCAB and the hybrid procedure. The main reason for the LAST operation was patient driven; it enables faster recovery and an earlier return to work because it does not require sternotomy, although the surgical benefit was obtained by this technique in redo CABG. In contrast, the OPCAB through a median sternotomy was surgically driven in most patients, to decrease surgical morbidity after use of CPB. In our series, 58.8% of the patients had preoperative risks for CABG. The hospital mortality rate was 1.9%, including 1.4% from noncardiac deaths. Despite a high-risk patient group, other operative morbidity with OPCAB was low [6]. The disadvantages of OPCAB were difficulty of LITA mobilization through thoracotomy that used an unfamiliar approach and performing anastomotic stenosis or graft occlusion procedures with a beating heart. Many instruments were different from those used in conventional CABG, such as LITA harvesting kits and several kinds of heart stabilizers [6, 7]. When we compared our early graft patency results without heart stabilizer to those with stabilizer by postoperative angiogram, the patency rate improved from 83.7% to 93.6%. For harvesting LITA, careful attention was required while opening the fourth or fifth intracostal space. However, when we used full or lower-half median sternotomy the procedure of LITA dissection was similar to that routinely used. The second disadvantage of the LAST procedure was that the technique did not allow complete revascularization through a left thoracotomy. To solve this problem, we combined the LAST operation with PTCA as the hybrid procedure reported by others [8–10]. The candidates for the hybrid procedure were limited by the suitability of lesions for PTCA; they were carefully followed up for restenosis after the angioplasty. Therefore, selection of candidates was very important for this procedure. In our series, the hybrid procedure was used in 32% of the patients with multivessel lesions. Among them, this procedure was attempted in 5 with LMT lesion to minimize the invasiveness of the treatment. The PTCA to treat the LMT lesion after the LAD revascularization with LAST was successful in all 5 patients; however, angina recurred in 3 patients, including 1 who had acute myocardial infarction and cardiac death because of restenosis of the LMT lesion and LITA failure from incompetent flow of the LAD after treatment of the LMT lesion. Although Liekweg and Misra [11] reported a case of successful treatment of LMT lesion with the hybrid procedure, we believe that the hybrid procedure for LMT lesion is not ideal because of sudden onset of LMT restenosis and LITA collapse. The increased interest in OPCAB has resulted in complete revascularization without CPB by applying several techniques and instruments, such as rotation of the table, lifting the heart to facilitate marginal or inferior wall grafting, pericardial mobilization, and local heart-stabilization instruments. The multivessel CABG was performed by median sternotomy and results were similar to or better than those obtained by ordinary CABG with CPB. In our series, most patients who had median sternotomy had preoperative risks for surgery; however, mortality and morbidity rates were low and the results were good at 2 years of follow-up.
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References
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Benetti F.J., Ballester C. Use of thoracoscopy and a minimal thoracotomy, in mammary-coronary bypass to left anterior descending artery, without extracorporeal circulation. Experience in 2 cases. J Cardiovasc Surg (Torino) 1995;36:159-161.[Medline]
-
Kolessov V.I. Mammary artery-coronary artery anastomosis as method of treatment for angina pectoris. J Thorac Cardiovasc Surg 1967;54:535-544.[Medline]
-
Calafiore A.M., Di Giammarco G., Teodori G., et al. Left anterior descending coronary artery grafting through left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1665.[Abstract/Free Full Text]
-
Sabramanian V.A. Less invasive arterial CABG on a beating heart. Ann Thorac Surg 1997;63:S68-S71.
-
Doty D.B., Dirusso G.B., Doty J.R. Full-spectrum cardiac surgery through a minimal incision: ministernotomy (lower half) technique. Ann Thorac Surg 1998;65:573-577.[Abstract/Free Full Text]
-
Spooner T.H., Hart J.C., Pym J. A two-year, three institution experience with the Medtronic octopus: systematic off-pump surgery. Ann Thorac Surg 1999;68:1478-1481.[Abstract/Free Full Text]
-
Calafiore A.M., Giuseppe V., Mazzei V., et al. The LAST operation. Techniques and results before and after the stabilization era. Ann Thorac Surg 1998;66:998-1001.[Abstract/Free Full Text]
-
Angelini G., Wilde P., Salerno T., Bosco G., Calafiore A. Integrated left anterior small thoracotomy and angioplasty for multivessel coronary revascularization. Lancet 1996;347:757-758.[Medline]
-
Friedrich G., Bonatti J., Dapunt O. Preliminary experience with minimally invasive coronary artery bypass surgery combined with coronary angioplasty. N Engl J Med 1997;336:1454-1455.[Free Full Text]
-
Lloyd C.T., Calafiore A.M., Wilde P., et al. Integrated left anterior small thoracotomy and angioplasty for coronary artery revascularization. Ann Thorac Surg 1999;68:908-912.[Abstract/Free Full Text]
-
Liekweg W.G., Misra R. Minimally invasive direct coronary artery bypass, percutaneous transluminal coronary angioplasty, and stent placement for left main stenosis. J Thorac Cardiovasc Surg 1997;113:411-412.[Free Full Text]
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Abstract
Introduction
