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Ann Thorac Surg 2001;71:196-200
© 2001 The Society of Thoracic Surgeons

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Original article: cardiovascular

Reoperative CABG using left thoracotomy: a tailored strategy

^a Division of Cardiac Surgery, Brigham and Women’s Hospital, Boston, Massachusetts, USA

Accepted for publication July 10, 2000.

Address reprint requests to Dr Byrne, Division of Cardiac Surgery, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115
e-mail: jgbyrne{at}bics.bwh.harvard.edu

	Abstract

Top Abstract Introduction Material and methods Results Comment References

 
Background. Reoperative coronary artery bypass grafting (CABG) through a left thoracotomy is a challenging operation with no one dominant approach. We developed a tailored strategy for this difficult group of patients, integrating the currently available newer technologies for each patient indication.

Methods. Between October 1991 and October 1999, 50 consecutive patients underwent reoperative CABG through a left thoracotomy. Age was 65 ± 9 years, 40 (80%) were men, and preoperative ejection fraction was 40 ± 13. In 36 patients (72%) the left internal mammary artery had been placed to the left anterior descending coronary artery during the primary CABG and in 25 of 36 patients (70%) this left internal mammary artery–left anterior descending coronary artery graft was patent. The mean duration from previous CABG was 8.0 ± 4.8 years. Three approaches were used: (1) conventional cardiopulmonary bypass using fibrillatory or circulatory arrest (n = 33, 66%); (2) Heartport endoaortic balloon occlusion (n = 4, 8%); and (3) off-pump beating heart techniques (n = 13, 26%).

Results. The off-pump CABG technique was used in the majority of recent patients and 1 (7.7%) had to be converted to cardiopulmonary bypass due to hemodynamic instability. When cardiopulmonary bypass was used its duration was 122 ± 59 minutes and mean temperature on bypass was 24° ± 6°C. In the 4 patients in whom the Heartport system was used, the median endo-aortic occlusion duration was 49 minutes. Patients received an average of 1.4 grafts/patient. In 60 of 70 patients (89%) distal anastomoses were performed to an anterolateral coronary target. There were 3 of 50 (6%) operative deaths, 2 in the conventional group and 1 in the endo-aortic balloon occlusion group. The mean length of stay in the 47 survivors was 7.8 ± 3.9 days (median, 7 days).

Conclusions. Reoperative CABG by left thoracotomy remains a challenging operation. Several techniques, including off-pump CABG, conventional cardiopulmonary bypass, circulatory arrest, and endoaortic balloon occlusion, should be in the surgeon’s armamentarium to allow a tailored approach for each operation based on patient indications.

	Introduction

Top Abstract Introduction Material and methods Results Comment References

 
The left thoracotomy approach for reoperation of coronary artery bypass grafting (CABG) has been described for many years but few reports document the results of a large series. The entire literature contains only about 170 patients reported [1–21] and the largest series contains only 23 patients [17] (Table 1). Most studies include sporadic case reports and our own group reported a study of 5 patients in 1987 [6]. With the introduction of techniques for off-pump CABG (OP-CABG) as well as endoaortic balloon occlusion, several alternatives to conventional cardiopulmonary bypass (CPB) are now available. Although several recent reports have included patients in whom off-pump techniques were used [13, 15–17, 19–21], few document selection criteria by which a particular method was chosen. Thus, no one approach has become dominant. In this report, we develop a tailored approach in which we use each technology when it is most ideally suited. We document the results of 50 patients—the largest series reported—with an emphasis on the selection criteria by which the currently available technologies were chosen.

	Material and methods

Top Abstract Introduction Material and methods Results Comment References

Operative techniques
Reoperation CABG through the left thoracotomy was approached in one of three ways: (1) conventional CPB using fibrillatory or circulatory arrest (n = 33, 66%); (2) Heartport endoaortic balloon occlusion (Heartport, Redwood City, CA) techniques (n = 4, 8%); and (3) off-pump beating heart techniques (n = 13, 26%). Whichever approach was selected, the operation was a two-stage procedure. The patient was first positioned supine for right femoral cannulation, harvesting of the saphenous vein graft or radial artery conduit and for placement of a left femoral intraaortic balloon pump (IABP) or arterial line for IABP backup if deemed necessary. While supine, a pulmonary artery catheter was placed and a transesophageal echocardiographic probe was inserted to assess the descending thoracic aorta for atheromatous changes, overall cardiac function, and to assess for aortic valvar insufficiency. After cannulation of the right femoral vessels, the cannulas were draped off in a sterile fashion and the patient was positioned for a left full lateral thoracotomy. An external defibrillator (R2 Stat Padz, Zoll, Inc, Burlington, MA) was placed on the patient before draping for subsequent defibrillation, as necessary. A double lumen endotracheal tube was used to deflate the left lung. The left chest was entered through the fourth intercostal space and the fourth rib was shingled. The inferior pulmonary ligament was divided and the lung was dissected off the pericardium, preserving the left phrenic nerve. The pericardium was entered with a knife away from the phrenic nerve and the intrapericardial space was dissected enough for venting of the left ventricular apex or pulmonary veins should CPB and venting before systemic cooling be necessary. Dissection was limited to that which was required to safely perform the CABG, and provide venting options if CPB was used, especially in the setting of mild aortic insufficiency.

CPB with cold fibrillatory arrest
Although femoral cannulation was common, descending thoracic aortic cannulation was also used but this was undertaken only after direct epiaortic echocardiogrphy had confirmed limited descending thoracic aortic disease. In a few patients neither the femoral artery nor the descending thoracic aorta was satisfactory and the axillary artery, which is usually free of disease [22], was cannulated and proximal saphenous vein graft anastomoses were taken off the descending thoracic aorta on circulatory arrest. On CPB, the patient was cooled to 20°C to 25°C. Patients with a patent LIMA–LAD graft were routinely cooled to 20°C and no attempts were made to limit LIMA flow. Once the heart fibrillated, the pulmonary artery pressures and transesophageal echocardiographic scans were monitored for signs of left ventricular distention and, if detected, the left ventricle was vented through the left ventricular apex or pulmonary veins. Low CPB flows (1 L/min) were occasionally necessary for adequate visualization of the distal coronary anastomoses. When left ventricular venting was occasionally needed to avoid left ventricular distention and subsequent subendocardial ischemia, careful deairing procedures were required. The patients were placed in Trendelenberg and maintained in that position throughout the operation until all the air was evacuated as documented by transesophageal echocardiography. Then, during rewarming, on full CPB flows, the heart was deaired by applying suction on the vent in the left ventricular apex and then temporarily decreasing the flows on CPB and ventilating the lungs. The left ventricular vent was maintained on controlled suction until off bypass. Once off bypass, the CPB pump was used to keep up with the volume loss from the vent site until all air was evacuated as documented by transesophageal echocardiography. Had the heart not defibrillated spontaneously, then the previously placed external defibrillator pads were used to obtain a rhythm.

Endoaortic balloon occlusion
In some patients in whom aortic insufficiency was present and in whom CPB was deemed necessary, the Heartport (Redwood City, CA) endoaortic balloon occluder with antegrade and percutaneous transjugular retrograde cardioplegia was used. The techniques for cannulation and endoaortic balloon positioning have been described in detail elsewhere [23]. In patients in whom a patent LIMA–LAD graft is present, no attempt to occlude the LIMA graft was made and the patient was systemically cooled to 20°C for additional myocardial protection, understanding there would be some cardioplegia "washout" effect. In the unusual situation where electrical activity resumed, additional cardioplegia was administered.

OP-CABG
A full CPB dose of heparin was administered, and backup 21F percutaneous cannulation of the right femoral vein was performed to allow rapid institution of CPB if necessary. The patient was turned to the side and a left thoracotomy was performed as described above. We used a variety of stabilizers, including the Octupus I and II (Medtronic, Minneapolis, MN) as well as the CTS Ultima (Guidant, Cupertino, CA) apparatus with intracoronary shunts (Flo-coil; Guidant) and the mister-blower (Guidant). The proximal anastomoses were performed first to improve the lie of the conduit as well as to provide immediate revascularization after the distal anastomosis was performed. After successful OP-CAB, the right percutaneous femoral vein was decannulated from underneath the drapes and the heparin reversed. Had OP-CAB been unsuccessful, the descending thoracic aorta was readily available for cannulation and conventional CPB techniques could be used.

Conduct of coronary artery bypass grafts
Whichever method is selected, the choice of which distal targets to graft was based on standard indications. The proximal anastomoses were performed to the descending thoracic aorta, the left subclavian artery, or a previously patent graft. The proximal anastomoses were performed to the descending thoracic aorta using a side biting clamp or, if the aorta was heavily diseased, as documented by epiaortic echocardiography, then during a brief period of circulatory arrest. In patients in whom inflow was obtained from the left subclavian artery, and in whom a patent LIMA–LAD graft was present, ischemic changes in the LAD distribution were monitored.

	Results

Top Abstract Introduction Material and methods Results Comment References

 
In 13 patients (26%) CPB was not used (OP-CABG group). One OP-CABG patient had to be converted to an on-pump beating heart technique because of hemodynamic instability during clamping of the left subclavian artery for a proximal anastomosis in a patient with a patent LIMA–LAD graft.

Cardiopulmonary bypass was used in 37 patients (74%), 33 (66%) using conventional method and 4 (8%) using the Heartport system. In the 4 patients in whom the Heartport system was used, the mean endoaortic occlusion duration was 50 ± 25 minutes (median, 49 minutes). Arterial cannulation was peripheral (femoral or axillary) in 29 of 37 patients (78%). The descending thoracic aorta was cannulated in 8 of 37 patients (22%). Mean CPB duration was 122 ± 59 minutes (median, 130 minutes) and mean temperature on bypass was 24° ± 6°C (median, 25°C). There were 70 grafts (1.4 grafts/patient) as detailed in Table 2.

	Comment

Top Abstract Introduction Material and methods Results Comment References

 
The principle finding in this study is that, for reoperation CABG through the left thoracotomy, a variety of methods including conventional cardiopulmonary bypass, circulatory arrest, port-access with endoaortic balloon occlusion, and OP-CABG techniques should be in the surgeon’s armamentarium to allow a tailored approach to each operation based on patient indications.

Reoperative CABG through a left thoracotomy was developed primarily to avoid potential catastrophic sternal reentry injuries [24] especially in the setting of patent anterior CABG grafts, aortic aneurysms, or previous mediastinitis [6]. At present, with the majority of patients undergoing primary CABG receiving LIMA–LAD grafts, avoiding sternal reentry would be most beneficial, as injury to a patent LIMA–LAD graft is highly morbid [25].

Because symptomatic relief is the primary indication for most patients undergoing reoperative CABG by left thoracotomy, very careful patient selection is mandatory. Preoperative documentation of ischemia by noninvasive methods, such as technetium-99m sestamibi uptake or dobutamine stress echocardiography, in a graftable region accessible to left thoracotomy may be very helpful. We believe that, in the setting of a patent LIMA–LAD graft, this operation should be undertaken only when severe symptoms are unresponsive to maximum medical treatment and preoperative studies have documented ischemia.

Preoperative evaluation to assess aortic insufficiency is essential in these patients. Moderate to severe aortic insufficiency is a relative contraindication to left thoracotomy using cold fibrillation on CPB, unless endoaortic balloon occlusion is available. Venting in these circumstances will decompress the left ventricle but, if the return on the vent is significant, will also result in inadequate end-organ perfusion. In these circumstances endoaortic balloon occlusion of the ascending aorta with percutaneous transjugular retrograde cardioplegia may be a good alternative. Another option is on-pump beating heart CABG and we used this method in 1 patient in the conventional group.

The majority of the older literature contain reports of small series, mostly using CPB, fibrillatory arrest, moderate hypothermia, femoral or descending thoracic aortic cannulation, and proximal anastomoses taken off the descending thoracic aorta or subclavian artery with about 1 to 2 grafts/patient [1, 3–12] (Table 1). Most do so with the intent to avoid redo sternotomy, as we report here. Unusual approaches included the one reported by Ungerleider and colleagues [4] on their technique involving cannulation of the main pulmonary artery for venous return and the report by Suma and associates [14] on the use of circulatory arrest for distal anastomoses. Walker and Sang [5] reported on the use of a right or left lateral thoracotomy as an alternative approach to reoperation CABG and Sakakibara and colleagues [19] reported on the use of the right gastroepiploic artery and additional left thoracotomy for reoperation CABG.

More recently, with the development of off-pump techniques, several reports have documented the safety of OP-CABG for reoperation CABG [13, 15, 17, 19–21]. Moshkovitz and associates [13], in a study of 6 OP-CABG patients, are among the first to report on the use of OP-CABG techniques for reoperation CABG through the left thoracotomy. Subramanian [15] reported 18 patients in whom a 7-cm mini-left thoracotomy, right anterior thoracotomy, or subxiphoid incision was used. Allen and colleagues [17] compared perioperative outcomes of conventional (resternotomy) single-vessel reoperation CABG in 12 patients versus reoperation CABG done by a "minimally invasive" limited anterior thoracotomy OP-CABG technique in 23 patients. The minimally invasive group had significant reductions in atrial fibrillation, time to extubation, transfusions required, and length of cardiac recovery and hospital stay. However, none of these reports developed an integrated or tailored approach based on patient conditions as we describe here.

In this report we present a tailored approach whereby most of the available technologies should be available to modify each patient’s operation to their specific needs (Fig 1). Our methods have evolved as the technologies have developed. With the introduction of OP-CABG technologies our current strategy is to first attempt OP-CABG and the 13 patients in whom this method was used generally represent the more recent patients in the series. The OP-CABG technique avoids arterial cannulation and the effects of CPB and is usually quite feasible because there is natural stability of the myocardium due to scarring. Modern stabilizers have allowed safe and meticulous anastomotic technique. Because conversion to an on-pump method may be necessary, we have placed a backup 21F right percutaneous femoral venous cannula, after heparinization using a full CPB dose, while the patient was supine and then secured it and draped it off in a sterile fashion before turning the patient to the side. The right side was preferred because advancement of a left femoral venous cannula over the pelvic brim when the patient is in the lateral decubitus position can be very difficult. A 0-silk figure eight suture was placed around the cannula entry site in the skin for subsequent ligation after removal of the cannula. This figure eight suture serves to tamponade the vein entry site. We have not had any problems with groin hematomas or deep vein thrombosis using this technique. In 1 patient OP-CABG was unsuccessful due to hemodynamic instability. Rapid conversion to CPB was facilitated by direct cannulation of the descending thoracic aorta with venous drainage provided by the previously placed right 21F percutaneous femoral cannula. We have preferred this approach over relying on cannulation of the main pulmonary artery for venous drainage because the pulmonary artery may be encased in scar and difficult to access in an emergency. Relative contraindications to OP-CABG are small targets, intramyocardial vessel, need for endarterectomy, inadequate stabilization, and surgeon preference. In these circumstances, beating heart CABG on CPB can be performed using the stabilizers as for OP-CABG. If this is not possible, for reasons including those outlined for OP-CABG, then conversion to cold fibrillation on CPB, or endoaortic balloon occlusion with cardioplegia, will be necessary. Endoaortic balloon occlusion may be most beneficial in the setting of significant aortic insufficiency. Using this strategy, we developed an algorithm to guide the overall management of this challenging group of patients whereby the simplest methods are used first with conversion to more complex technologies as patient indications warrant (Fig 1).

View larger version (24K): [in this window] [in a new window]   Fig 1. Off-pump coronary artery bypass graft (OP-CABG), with percutaneous 21F right femoral venous cannulation backup, is our preferred initial approach to patients with symptomatic coronary artery disease (CAD) in whom ischemia has been documented in a graftable region accessible by left thoracotomy. If OP-CABG cannot be performed because of small targets, intramyocardial vessel, need for endarterectomy, inadequate stabilization, or surgeon preference, then conversion to cardiopulmonary bypass (CPB) is easily facilitated by direct cannulation of the descending thoracic aorta. Beating heart CABG on CPB can then be performed using stabilizers as for OP-CABG. If this is not possible for reasons including those outlined for OP-CABG, then conversion to cold fibrillation with or without left ventricular (LV) venting on CPB or endoaortic balloon occlusion with cardioplegia and venting will be necessary. Endoaortic balloon occlusion is used primarily in the setting of significant aortic insufficiency. The algorithm suggests starting with the simplest methods first and conversion to more complex technologies as patient indications warrant.

From this experience, we conclude that a tailored approach to reoperation CABG by left thoracotomy, using a variety of methods including conventional CPB, circulatory arrest, port access with endoaortic balloon occlusion, and OP-CABG techniques is a safe and effective strategy for this challenging group of patients.

	References

Top Abstract Introduction Material and methods Results Comment References

 

1. Borst H.G. Left-sided thoracotomy for coronary artery reoperation. Thoraxchir Vask Chir 1978;26:95-97.[Medline]
2. Cheung D., Flemma R.J., Mullen D.C., Lepey D. An alternative approach to isolated circumflex coronary bypass reoperation. Ann Thorac Surg 1982;33:302.[Medline]
3. Faro R.S., Javid H., Najafi H., Serry C. Left thoracotomy for reoperation for coronary revascularization. J Thorac Cardiovasc Surg 1982;84:453-455.[Medline]
4. Ungerleider R.M., Mills N.L., Wechsler A.S. Left thoracotomy for reoperative coronary artery bypass procedures. Ann Thorac Surg 1985;40:11-15.[Abstract]
5. Walker W.S., Sang C.T. Avoidance of patent anterior grafts at revisional coronary artery surgery: use of a lateral thoracotomy approach. Thorax 1986;41:692-695.[Abstract/Free Full Text]
6. Knight J.L., Cohn L.H. Left thoracotomy and femoro-femoral bypass for reoperative revascularization of the posterior coronary circulation. J Card Surg 1987;2:343-349.[Medline]
7. Burlingame M.W., Bonchek L.I., Vazales B.E. Left thoracotomy for reoperative coronary bypass. J Thorac Cardiovasc Surg 1988;95:508-510.[Abstract]
8. Gandjbakhch I., Acar C., Cabrol C. Left thoracotomy approach for coronary artery bypass grafting in patients with pericardial adhesions. Ann Thorac Surg 1989;48:871-873.[Abstract]
9. Grosner G., Lajos T.Z., Schimert G., Bergsland J. Left thoracotomy reoperation for coronary artery disease. J Card Surg 1990;5:304-308.[Medline]
10. Watanabe G., Haverich A., Speier R. Third-time coronary artery revascularization. Thorac Cardiovasc Surg 1993;41:163-166.[Medline]
11. Fanning W.J., Kakos G.S., Williams T.E., Jr Reoperative coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1993;55:486-489.[Abstract]
12. Uppal R., Mills N.L., Wechsler A.S., Smith P.K. 1985: left thoracotomy for reoperative coronary artery bypass procedures. 1993 update. Ann Thorac Surg 1993;55:1275-1276.[Abstract]
13. Moshkovitz Y., Sternik L., Mohr R. Coronary bypass reoperations without cardiopulmonary bypass: the Israeli experience. J Cardiovasc Surg (Torino) 1994;35:59-62.[Medline]
14. Suma H, Kigawa I, Horii T, et al. Coronary artery reoperation through the left thoracotomy with hypothermic circulatory arrest. 1995;60:1063–6.
15. Subramanian V.A. Clinical experience with minimally invasive reoperative coronary bypass surgery. Eur J Cardiothorac Surg 1996;10:1058-1062.[Abstract]
16. Calafiore A.M., Suma H. Radial artery from left subclavian artery in redo coronary artery bypass grafting. Ann Thorac Surg 1996;62:901-902.[Abstract/Free Full Text]
17. Allen K.B., Matheny R.G., Robison R.J., et al. Minimally invasive versus conventional reoperative coronary artery bypass. Ann Thorac Surg 1997;64:616-622.[Abstract/Free Full Text]
18. Randolph Bolton J.W. Left thoracotomy for reoperative revascularization of the posterior coronary circulation. J Cardiovasc Surg (Torino) 1997;38:407-410.[Medline]
19. Sakakibara Y., Yoshimura Y., Mihara W., et al. Reoperation of coronary artery bypass with right gastroepiploic artery on a beating heart. Thorac Cardiovasc Surg 1997;45:88-89.[Medline]
20. Boonstra P.W., Grandjean J.G., Mariani M.A. Reoperative coronary bypass grafting without cardiopulmonary bypass through a small thoracotomy. Ann Thorac Surg 1997;63:405-407.[Abstract/Free Full Text]
21. Coulson A.S., Bakhshay S.A., Sloan T.J. Minimally invasive reoperation through a lateral thoracotomy for circumflex coronary artery bypass. Tex Heart Inst J 1998;25:170-174.[Medline]
22. Bichell D.P., Balaguer J.M., Aranki S.F., et al. Axilloaxillary cardiopulmonary bypass: a practical alternative to femorofemoral bypass. Ann Thorac Surg 1997;64:702-705.[Abstract/Free Full Text]
23. Galloway A.C., Shemin R.J., Glower D.D., et al. First report of the Port Access International Registry. Ann Thorac Surg 1999;67:51-58.[Abstract/Free Full Text]
24. Follis F.M., Pett S.B., Jr, Miller K.B., et al. Catastrophic hemorrhage on sternal reentry: still a dreaded complication?. Ann Thorac Surg 1999;68:2215-2219.[Abstract/Free Full Text]
25. Gillinov A.M., Casselman F.P., Lytle B.W., et al. Injury to a patent left internal thoracic artery graft at coronary reoperation. Ann Thorac Surg 1999;67:382-386.[Abstract/Free Full Text]

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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): John G. Byrne Lishan Aklog David H. Adams Lawrence H. Cohn Sary F. Aranki Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Byrne, J. G. Articles by Aranki, S. F. Search for Related Content PubMed PubMed Citation Articles by Byrne, J. G. Articles by Aranki, S. F. Related Collections Coronary disease Minimally invasive surgery