Ann Thorac Surg 2004;77:1433-1434
© 2004 The Society of Thoracic Surgeons
Case report
Minimally invasive direct coronary artery bypass in a cardiac transplant recipient with allograft vasculopathy
Ivan Aleksic, MD, PhDa*,
Jarowit A. Piotrowski, MDa,
Markus Kamler, MDa,
Ulf Herold, MDa,
Heinz G. Jakob, MD, PhDa
a Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Essen, Germany
Accepted for publication May 21, 2003.
* Address reprint requests to Dr Aleksic, Department of Thoracic and Cardiovascular Surgery, University Hospital Essen, Hufelandstr 55, 45122 Essen, Germany
e-mail: ivan.aleksic{at}uni-essen.de
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Abstract
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Coronary bypass operation with cardiopulmonary bypass has provided disappointing results for the treatment of cardiac allograft vasculopathy (CAV). We describe a 61-year-old man who underwent heart transplantation for secondary dilated cardiomyopathy in 1995. Consecutively, CAV developed with clinically silent left anterior descending occlusion. After angiographic diagnosis in 1998 he successfully underwent a minimally invasive direct coronary artery bypass procedure. Annual coronary angiography showed a patent left internal mammary to left anterior descending bypass graft more than 4 years after operation. In select cases, minimally invasive direct coronary artery bypass is a therapeutic option for the treatment of CAV.
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Introduction
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Cardiac allograft vasculopathy (CAV) remains the single most important cause of death during long-term follow-up after heart transplantation (HTX) [1]. The experience with conventional bypass operation with cardiopulmonary bypass graft for the treatment of CAV is limited. Results from 36 bypass graft operations are available [2–6]. The reasons for the scarcity of bypass graft procedures in this setting are the high prevalence of diffusely diseased distal coronary arteries and the high overall perioperative mortality of 35% [2–5]. Pethig and colleagues [6] were the first to report 7 patients without any perioperative mortality after bypass graft operation for CAV. Still, they restrict bypass graft operation and retransplantation to selected patients.
Advantages of minimally invasive direct coronary artery bypass (MIDCAB) grafting include avoidance of cardiopulmonary bypass graft, great vessel manipulation, and re-sternotomy and have facilitated its use in patients undergoing reoperative coronary bypass grafting. Doty and colleagues [7] reported freedom from angina in 90% of patients after reoperative MIDCAB grafting. Stamou and coworkers [8] reported an actuarial survival of 83% with a mean ± SD follow-up of 2.5 ± 1 years and an operative mortality of 2% after redo MIDCAB procedures.
We describe the case of a 61-year-old man with secondary dilated cardiomyopathy: 3 years after HTX he was diagnosed with left anterior descending (LAD) occlusion and underwent MIDCAB grafting. This is the first case of beating heart revascularization for CAV.
A 61-year-old man underwent orthotopic HTX for secondary dilated cardiomyopathy in 1995 after aortic valve replacement for aortic insufficiency in 1984 and redo aortic valve replacement because of a paravalvular leak in 1989. The donor was a 25-year-old male victim of a motor vehicle accident without any history of hypertension, smoking, or drug abuse.
The recipient's postoperative course was uneventful except for several rejection episodes, which were treated by intravenous steroids. Routine coronary angiography was performed annually and showed beginning CAV within 2 years after transplantation. In October 1998 another follow-up angiogram demonstrated clinically silent proximal LAD occlusion. The occlusion was not amenable to any cardiologic intervention. Coronary flow reserve in the circumflex artery (CX) had decreased from 4.0 the year before to 2.3, indicating progression of CAV. Coronary flow reserve in the right coronary artery was 4.3. Scintigraphy revealed viable myocardium in the septum and the apex.
Faced with a third conventional reoperation, we decided to perform a MIDCAB procedure by way of a small anterior approach through the left fourth intercostal space. The LAD had a thickened wall, and the left internal mammary artery was anastomosed to the LAD with a 7-0 running suture. The patient's postoperative course was unremarkable, and he was discharged home on postoperative day 6.
Annual angiographic studies were continued and showed progression of his CAV in the CX. The latest angiogram, from January 2003 (Fig 1),
showed a patent left internal mammary artery–LAD bypass graft without any anastomotic stenosis. A circumscript lesion in segment 13 of the CX was treated with a sirolimus-eluting stent, and coronary flow reserve again increased from 1.9 to 2.5.
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Fig 1. Left internal mammary artery–left anterior descending (LAD) bypass graft more than 4 years after minimally invasive direct coronary artery bypass (left anterior oblique projection), indicating no anastomotic stenosis but diffuse irregularities of the native LAD.
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Because of repeated rejection events, the patient's immunosuppression regimen was switched to tacrolimus and mycophenolate mofetil. In addition, secondary prevention by lipid-decreasing therapy and antihypertensive drugs was pursued aggressively.
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Comment
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In the past, retransplantation was regarded as the only surgical option for treatment of CAV. In view of the persistent organ shortage and the possible recurrence of CAV, retransplantation has not gained widespread acceptance.
Experience with the management of CAV by means of conventional bypass operation is limited. Most studies [2–5] have reported discouraging perioperative mortality—up to 43%—because of a high proportion of patients with diffuse distal disease [3]. In addition, long-term results after all palliative revascularization procedures, including angioplasty, coronary atherectomy, and bypass operation, have been disappointing. Therefore, Pethig and associates [6], among others, have recommended stenting guided by intravascular ultrasound as the method of choice for interventional therapy of CAV. This is despite the fact that this group was the first to report on 7 patients who underwent bypass operation after HTX without any perioperative mortality.
Musci and associates [3] have recommended intravascular ultrasound and coronary flow reserve measurements for assessing the severity of distal obliterative disease before any intervention. In our patient, such measurements were performed routinely. When the proximal LAD occlusion was diagnosed, coronary flow reserve of the CX had decreased to 2.3 from 4.0 the year before, indicating progression of CAV.
In our patient, a proximal LAD occlusion right behind its origin was diagnosed. Our cardiologists considered a catheter-based intervention too dangerous. Because there was evidence of viable myocardium on the one hand and progressive CAV, as evidenced by decreased coronary flow reserve, on the other hand, surgical intervention became necessary.
All MIDCAB procedures share common advantages, such as avoidance of re-sternotomy, aortic manipulation, and cardiopulmonary bypass graft [7]. These features have made these procedures attractive for redo cases. Good results regarding clinical freedom from angina and probability of operative death, as well as actuarial survival after redo MIDCAB procedures, have been published by Doty and associates [7] and Stamou and colleagues [8], respectively.
The patient described in this report faced his third reoperation. On the basis of the angiographic findings, a limited access by way of a small anterior thoracotomy was preferred. The midterm success of MIDCAB, as evidenced by annual angiographic follow-up, supports our concept of beating heart revascularization in this patient.
MIDCAB grafting for CAV has to be reserved for patients with good coronary targets and a moderately reduced coronary flow reserve. This approach should be considered if no catheter-based intervention is possible and if coronary flow reserve measurements have been performed to assess the overall severity of CAV. In selected patients, MIDCAB grafting represents a useful therapeutic option for the treatment of CAV after cardiac transplantation.
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References
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- Hosenpud J.D., Novick R.J., Bennett L.E., Keck B.M., Fiol B., Daily P. The Registry of the International Society for Heart and Lung Transplantation: thirteenth official report—1996. J Heart Lung Transplant 1996;15:655-674.[Medline]
- Halle A.A., DiSciascio G., Massin E.K., et al. Coronary angioplasty, atherectomy and bypass surgery in cardiac transplant recipients. J Am Coll Cardiol 1995;26:120-128.[Abstract]
- Musci M., Pasic M., Meyer R., et al. Coronary artery bypass grafting after orthotopic heart transplantation. Eur J Cardiothorac Surg 1999;16:163-168.[Abstract/Free Full Text]
- Patel V.S., Radovancevic B., Springer W., et al. Revascularization procedures in patients with transplant coronary artery disease. Eur J Cardiothorac Surg 1997;11:895-901.[Abstract]
- Parry A., Roberts M., Parameshwar J., Wallwork J., Schofield P., Large S. The management of post cardiac transplantation coronary artery disease. Eur J Cardiothorac Surg 1996;10:528-532.[Abstract]
- Pethig K.M., Heublein B., Haverich A. Cardiac allograft vasculopathy–coronary interventions and surgical options. Z Kardiol 2000;89(Suppl 9):IX/66-69.
- Doty J.R., Salazar J.D., Fonger J.D., Walinsky P.L., Sussman M.S., Salomon N.W. Reoperative MIDCAB grafting: 3-year clinical experience. Eur J Cardiothorac Surg 1998;13:641-649.
- Stamou S.C., Pfister A.J., Dullum M.K.C., et al. Late outcome of reoperative coronary revascularization on the beating heart. Heart Surg Forum 2001;4:69-73.[Medline]
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Abstract
Introduction
