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Ann Thorac Surg 2002;73:505-510
© 2002 The Society of Thoracic Surgeons

Original article: cardiovascular

Minimally invasive single-vessel coronary artery bypass with the internal thoracic artery and early postoperative angiography: midterm results of a prospective study in 120 consecutive patients

Sérgio A. Oliveira, MD*a, Luiz Augusto F. Lisboa, MDa, Luís Alberto O. Dallan, MDa, Salomon O. Rojas, MDa, Luiz F. Poli de Figueiredo, MD, PhDa

a Division of Cardiac Surgery, Department of Cardiopneumology, Heart Institute (InCor), University of São Paulo Medical School, São Paulo, Brazil

Accepted for publication September 25, 2001.

* Address reprint requests to Dr Oliveira, Av. Higienópolis, 370 Ap. 19o, São Paulo, SP, 01238-001, Brazil
e-mail: dcioliveira{at}incor.usp.br


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 References
 
Background. This prospective study was undertaken to determine the role of the minimally invasive direct coronary artery bypass with early postoperative angiography and midterm follow-up in 120 consecutive patients with single-vessel coronary artery disease.

Methods. Minimal access (6 to 10 cm), without complete sternotomy and no cardiopulmonary bypass, was used. The lesions were located at the proximal left anterior descending coronary artery in 95% of the patients. Routine coronary angiography was performed before discharge.

Results. Postoperative angiography was performed in 104 (90.4%) of those 115 patients who had coronary revascularization concluded by the mini-access method. The internal thoracic artery patency rate was 98.1% (95.2% grade A). Two (1.7%) patients presented with perioperative myocardial infarction, which led to the single in-hospital death (0.8%). Of the remaining 119 patients, 113 (95.0%) were asymptomatic. The event-free probability was 94.9% and the actuarial survival was 98.3% with 42 months of follow-up.

Conclusions. For selected patients with single-vessel coronary artery disease and no major myocardial dysfunction, minimally invasive direct coronary artery bypass is a safe operation and a less invasive alternative to conventional coronary artery bypass grafting.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 References
 
Conventional bypass grafting for single-vessel coronary artery disease, using the internal thoracic artery (ITA), is a safe operation with low morbidity and excellent long-term results [1, 2]. Since 1995, minimally invasive direct coronary artery bypass (MIDCAB), through a small thoracotomy and without cardiopulmonary bypass, has been proposed as an alternative to conventional coronary artery bypass (CABG) [3, 4]. However, concerns have been raised regarding the accuracy of the coronary anastomosis performed through a limited access on a beating heart, and the consequences of an incomplete revascularization using this technique in patients with multiple vessel disease [5–7].

There are a few studies in which an early postoperative angiography was systematically used for assessment of the anastomosis after MIDCAB [8–12]. Moreover, the majority of these studies includes patients with multiple-vessel disease and variable left ventricle function, which markedly impacts outcome [13, 14]. To determine the role of the MIDCAB in a homogenous group, a prospective study was performed with early postoperative angiography and midterm follow-up in patients with single-vessel coronary artery disease and no significant ventricular dysfunction.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 References
 
This study was approved by the University of São Paulo School of Medicine Scientific and Ethics Committee. All patients gave informed consent to undergo MIDCAB and early routine postoperative angiography. From November 1995 to December 1998, 120 consecutive patients with single-vessel coronary artery disease with normal ventricular function or mild dysfunction (ejection fraction between 0.35 and 0.55) were prospectively selected to undergo MIDCAB. All patients presented symptomatic single-vessel coronary artery disease, with at least 70% diameter stenosis in the left anterior descending coronary artery (LAD) before the first diagonal branch, or in the proximal segment of the right coronary artery (RCA). Coronary lesions were considered unsuitable for coronary artery angioplasty because of a type C stenosis (American College of Cardiology/American Heart Association classification) [15], completely occluded artery in 6 patients (5.0%), and restenosis after a previous angioplasty in 11 patients (9.1%). Patients with multiple-vessel coronary artery disease or severe ventricular dysfunction were not included in this study.

Patient population
The patient population consisted of 120 consecutive patients, 97 men (80.8%) and 23 women (19.2%). The ages ranged from 30 to 81 years, with a mean age of 57.2 ± 11.4 years. The main clinical manifestation of coronary artery disease was unstable angina in 80 patients (66.7%), stable angina in 32 (26.7%), and acute myocardial infarction in 8 patients (6.6%). Preoperative angiography showed that the single-vessel disease was located in the proximal LAD in 114 patients (95.0%) and in the proximal RCA in 6 patients (5.0%). Left ventricular function was normal in 100 (83.3%) and mildly compromised in 20 patients (16.7%). Patient demographics are shown in Table 1.


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  		Table 1. Patient Demographics (n = 120)

 
Surgical technique
All patients were operated on by a single team of surgeons, and all coronary artery anastomoses were performed by the senior surgeon (SAO). External defibrillator patches were placed before anesthesia induction. In the first 48 patients, a double-lumen endotracheal tube and single-lung ventilation were used to facilitate ITA dissection and coronary anastomosis, which was subsequently considered unnecessary. The next 72 patients were then managed with a single-lumen endotracheal tube and conventional double-lung ventilation. The surgical approach, although always by means of a minimal access (6 to 10 cm) and without complete sternotomy, changed over time. A small left anterior thoracotomy was our initial and most commonly used access, performed in 59 patients (49.2%). More recently, our preference has been through an inferior ministernotomy, used in 27 patients (22.5%) (Fig 1).



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  		Fig 1. Site of minimal access incisions in 120 patients who underwent minimally invasive direct coronary artery bypass grafting.

 
The ITA was partially harvested under direct vision, between the second and sixth intercostal space, and "skeletonized" to gain more length. Distal division of the ITA was made after an intravenous injection of 1.5 mg/kg of heparin, to keep activated clotting time twice the baseline value. The pericardium was partially opened, close to the ITA, and traction sutures were placed laterally in the pericardium, to retract the heart forward, allowing stability of the beating heart, thereby facilitating coronary artery anastomosis.

Local coronary artery occlusion was achieved with a 5-0 Prolene (Ethicon, Inc, S.J. Campos, SP, Brazil) suture or with a silastic retractor tape (Quest Medical, Inc, Dallas, TX) placed proximally and distally to the site of the coronary arteriotomy. The suture was snared with a thin silicone tube and silastic bolsters to avoid coronary artery injury. Local myocardial ischemic preconditioning was routinely performed with 3 to 5 minutes of coronary occlusion, followed by 3 to 5 minutes of reperfusion. The distal snare was tightened only if required to obtain a bloodless field after the arteriotomy; distal retrograde flow was frequently minimal.

Two methods of coronary artery immobilization were used to perform the anastomosis. In the first 47 patients (39.2%), intravenous ß-blockers were used to produce bradycardia and global cardiac stabilization. Local coronary artery stability was achieved by gently pulling the Prolene sutures previously placed proximal and distal to the target site. After November 1996, two mechanical stabilizers (Cardio Thoracic Systems Inc, Cupertino, CA or Genzyme, Cambridge, MA) have been used to provide local cardiac compression and immobilization of the coronary anastomosis area.

Surgical procedure
Direct anastomosis of the left ITA to the LAD was performed in 103 (90.4%) of 114 patients with single proximal LAD stenosis. In 8 patients (7.0%) the left ITA was elongated with a small segment of the inferior epigastric artery (5 patients) or a small segment of the radial artery (3 patients). In another 3 patients, one with intramyocardial LAD and two with small LAD, the coronary artery revascularization was carried out at the diagonal branch. All 6 patients with a single proximal RCA stenosis had direct anastomosis of the right ITA to the RCA.

Local coronary occlusion was well tolerated in 115 patients (95.8%). In 5 patients (4.2%), alterations suggestive of myocardial ischemia were observed, arrhythmia in three, ST-segment change in one, and hemodynamic instability in another patient. For these patients, the alterations were overcome by the use of an intracoronary shunt. The coronary occlusion time ranged from 8 to 30 minutes (mean, 14 ± 3.8 minutes). Advances in mechanical stabilizers, new retractors, and the accumulated experience were responsible for the reduction in the duration of the operation from 3 to 4 hours to a typical 2-hour procedure time.

Postoperative course
All patients were admitted to the intensive care unit under mechanical ventilation and extubated after showing adequate respiratory effort, normal blood gases, and hemodynamic stability. Blood samples, electrocardiograms, and chest roentgenograms were obtained routinely. Perioperative myocardial infarction was defined by ST-segment change, small R waves progression, or the development of significant new Q waves on postoperative electrocardiograms, associated with elevation of the creatine kinase, MB fraction to greater than two times the upper limit of normal.

Postoperative angiography
The ITA patency was assessed by early angiography, always performed before discharge, between days 3 and 8, with a mean of 5.8 ± 1.8 days postoperatively. All angiograms were reviewed by an interventional cardiologist and by a cardiac surgeon, using the Fitzgibbon grading system [16] (A, excellent graft with unimpaired runoff; B, stenosis reducing the caliber of proximal or distal anastomosis or trunk to less than 50% of the grafted coronary artery, and O, occlusion).

Follow-up
After discharge, all patients were followed in our outpatient clinic or by their respective cardiologists. The follow-up was completed in 100% of the patients, ranging from 6 to 42 months (mean, 24.9 months). During the follow-up period, a prospective evaluation of the occurrence of new cardiac events, such as refractory angina requiring redo CABG or angioplasty, acute myocardial infarction, or cardiac death, was conducted. Late coronary angiography was carried out selectively for persistent or recurrent ischemic events.

Statistical analysis
Data are reported as mean value ± standard deviation. Discrete variables in the surgical technique were compared by the Fisher’s exact test. A probability value of less than 0.05 was considered significant. Survival and event-free probability were estimated by the Kaplan-Meier method. Statistical analyses were performed by the Statistical Analysis System (SAS Institute, Inc, Cary, NC).


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 References
 
In 115 (95.8%) patients, the operation was conducted with the minimal access approach on a beating heart; in 5 patients (4.2%) the MIDCAB was converted to a median sternotomy. In 4 of these patients, the conversion resulted from an insufficient length of the ITA or different coronary artery anatomy, including intramyocardial artery or a lateralized coronary artery. One patient had urgent conversion because of a small right ventricular rupture, during the LAD snare. All 5 patients had uneventful postoperative recoveries. The conversion was more frequent (p = 0.0020) in RCA revascularization (2 of 6 patients, 33.3%) than in LAD revascularization (3 of 114 patients, 2.6%). There was a trend (p = 0.076) toward a lower conversion rate with the use of mechanical stabilizer (1 of 73 patients, 1.4%) than without it (4 of 47 patients, 8.5%).

Early postoperative data
One hundred eighteen (98.3%) patients were extubated during the first 6 postoperative hours and 113 (94.2%) patients had discharged from intensive care less than 24 hours after admission. The creatine kinase MB fraction levels were increased more than two times the upper limit of normal in 4 patients (3.3%); however, in only 2 patients (1.7%) it was associated with electrocardiographic changes suggestive of myocardial infarction. There was no intraoperative death. One patient (0.8%), who had a perioperative anterior myocardial infarction, died on the third postoperative day. Postoperative data are shown in Table 2.


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  		Table 2. Postoperative Data in 120 Patients

 
Early angiographic study
Postoperative angiography was performed in 104 (90.4%) of 115 patients who had the coronary revascularization by means of the limited access. Six patients (5.2%) did not have postoperative angiography because of preexisting renal disease or major postoperative complications. In addition, 5 patients (4.4%) with excellent outcomes did not accept to have postoperative angiography. The ITA patency rate was 98.1% (102 of 104 patients). In 2 patients (1.9%), anastomotic occlusions were observed; 1 patient underwent a conventional CABG with the right ITA to the LAD, and the other patient was treated with LAD angioplasty. Both patients had uneventful outcomes. Three patients (2.9%) with asymptomatic grade B ITA anastomoses were evaluated by myocardial scintigraphies, which were negative for ischemia; two of them underwent late angiography, showing spontaneous regression to a grade A ITA anastomosis. There was no difference in ITA patency before (38 of 38, 100%) and after (64 of 66 patients, 97.0%) the systematic use of mechanical stabilizers. Table 3 displays the findings of the early angiography, according to the Fitzgibbon grading system [16].


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  		Table 3. Early Postoperative Angiography (n = 104)

 
Midterm follow-up
From the remaining 119 patients, 113 (95.0%) were asymptomatic, with no other surgical or interventional procedure performed during a postoperative follow-up period ranging from 6 to 42 months (mean, 24.9 months). Four patients (3.3%) had recurrent angina and 2 (1.7%) had acute myocardial infarction, 3 and 14 months postoperatively. These 6 patients with ischemic events underwent a second postoperative angiographic study; the ITA was occluded in 4 and patent in 2 patients. Of the 2 patients with patent ITA, one had angina owing to progression of circumflex coronary arteriosclerosis, treated by angioplasty, and the other became symptomatic during a high rate atrial fibrillation, with resolution after sinus rhythm. Of the 4 patients with occluded ITA (two had ITA elongation with a segment of the inferior epigastric artery), 3 underwent conventional CABG, 2, 3, and 14 months postoperatively, and 1 patient was managed clinically. One patient was in cardiogenic shock after an acute myocardial infarction, and died on the third postoperative day after an emergency reoperation. The event-free probability (defined as refractory angina requiring redo CABG or percutaneous transluminal coronary angioplasty, acute myocardial infarction, or cardiac death) was 94.9% in a follow-up period up to 42 months, and the actuarial survival was 98.3% (Fig 2 and Table 4).



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  		Fig 2. Survival (dotted line) and event-free probability (solid line) at 42 months after minimally invasive direct coronary artery bypass grafting (Kaplan-Meier method). Event-free from refractory angina requiring redo coronary artery bypass grafting or percutaneous transluminal coronary angioplasty, acute myocardial infarction or cardiac death.

 

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  		Table 4. Number of Patients at Risk

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
References
 
We performed MIDCAB using ITA in 120 consecutive patients with symptomatic, isolated stenosis in the LAD or RCA and no major ventricular dysfunction. Our results support the concept that MIDCAB is a safe operation, and could be an alternative to conventional CABG, with similar graft patency and midterm results.

Concerns regarding anastomosis accuracy after MIDCAB led some surgeons, including us, to routinely evaluate, with angiography, ITA patency and the aspect of coronary artery anastomosis. In our study, postoperative angiograms were done on all except 10 surviving patients. The early ITA patency rate of 98.1% (95.2% grade A) was similar to the largest series using MIDCAB, ranging between 87% and 99% [8–12] and to the conventional CABG series, using routine early angiography (range, 94% to 99%) [17]. Although our report is confirmatory, there are a few studies providing routine early angiography and our data may be useful to support comparisons between stenting and other surgical approaches of LAD lesions. All ITAs were harvested partially, and no significant flow steal was detected during early postoperative angiograms.

In this study, there was no intraoperative mortality or neurologic complication. Our in-hospital cardiac events and mortality rate were also comparable to the published series of both MIDCAB [8, 11] and conventional CABG [1, 2]. There were two (1.7%) postoperative myocardial infarctions, one of them leading to the only in-hospital death (0.8%). This patient had sudden death at the third postoperative day, probably from an arrhythmia that could be related to an acute graft occlusion. Autopsy was not performed. The other patient presented electrocardiographic signs of anterior ischemia and elevation of creatine kinase, MB fraction. Because a patent ITA was detected in the postoperative angiogram of this patient, his infarction was likely the result of temporary ischemia during the coronary occlusion time to perform the anastomosis.

During a mean follow-up of 24.9 months, 113 patients (95%) remained asymptomatic and the actuarial survival was 98.3%, in a follow-up period up to 42 months. In our previous Medicine, Angioplasty or Surgery Study (MASS) [18], with a follow-up period of 3 years, patients with single vessel LAD disease had 97% event-free probability (refractory angina requiring revascularization, acute myocardial infarction, or cardiac death) with conventional left ITA to LAD operation, which was higher than the 94.9% event-free probability in the present study. However, when compared to our data from the MASS study [18], medical treatment alone or angioplasty (event-free probability of 83% and 74%, respectively), our current results with MIDCAB are superior.

Three patients required reoperation 2, 3, and 14 months postoperatively, because of early left ITA graft occlusion. Our experience with late left ITA patency in conventional CABG observed in the MASS study was 98.6% [19]. Because two of three occlusions occurred in patients in whom the left ITA was elongated with a segment of the inferior epigastric artery, we believe that these composite grafts may have compromised our results. These technical problems were observed early in our experience. These occlusions became clinically apparent as new onset angina in 1 patient and as acute myocardial infarctions in the other 2 patients. One of them died after a conventional CABG, performed during the acute event, 3 months after MIDCAB. With the availability of new retractors, allowing a more complete left ITA harvesting, composite grafts have not been required.

The widely accepted primary indication for MIDCAB is unstable angina and isolated LAD disease, which were also our main indications, as only 5% of our patients had isolated RCA disease. We performed MIDCAB to the RCA in type C lesions or ostial disease unsuitable for angioplasty. Those patients undergoing MIDCAB with the right ITA to the RCA had higher conversion rates to median sternotomy, related to technical difficulties to immobilize the RCA or arrhythmias induced by transient RCA occlusion. More recently, we have performed MIDCAB to RCA with the use of an intracoronary shunt or performed the anastomosis in the posterior descending coronary artery, with the right ITA or with the right gastroepiploic artery.

Our initial approach to MIDCAB was through a left anterior small thoracotomy, as reported by Calafiore and colleagues [4]. However, in our study, this approach was associated with significant postoperative incisional pain. An inferior ministernotomy was made and became our choice because of improved exposure, effectiveness, and painless recovery.

We did not perform intraoperative flow measurements. Our graft patency was established by intraoperative observation. Coronary anastomosis patency and quality, evaluated by invasive, expensive, and not risk-free arteriography, will be soon replaced by noninvasive techniques such as ultrasonography and magnetic resonance. Our study was prospective but not comparative. The definitive role of MIDCAB will be established by carefully designed, randomized, prospective studies with cost-benefit analysis and long-term follow-up. On the basis of our results, we conclude that, for selected patients with single-vessel coronary artery disease, MIDCAB is a safe operation and an excellent, less invasive, and more attractive, alternative to conventional CABG.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 References
 

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