Ann Thorac Surg 2005;80:1336-1339
© 2005 The Society of Thoracic Surgeons
Original article: Cardiovascular
Redo Minimally Invasive Direct Coronary Artery Bypass Grafting
Stephan Jacobs, MD
*
,
David Holzhey, MD,
Thomas Walther, MD, PhD,
Volkmar Falk, MD, PhD,
Friedrich W. Mohr, MD, PhD
Department of Cardiac Surgery, Heartcenter, University of Leipzig, Germany
Accepted for publication March 16, 2005.
* Address reprint requests to Dr Jacobs, Klinik für Herzchirurgie, Universität Leipzig Herzzentrum, Strümpelstrasse 39, 04289 Leipzig, Germany (Email: stjacobs{at}aol.com).
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Abstract
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BACKGROUND: Conventional redo coronary artery bypass grafting is associated with an increased risk of mortality and morbidity as a result of manipulation of patent grafts, mediastinitis, and the presence of pericardial adhesions. Minimally invasive direct coronary artery bypass grafting may be an alternative approach in selected patients.
METHODS: From January 1997 to October 2003, 46 patients (mean age, 66 ± 7.4 years) underwent minimally invasive direct coronary artery bypass grafting using the left internal thoracic artery to the left anterior descending artery on the beating heart as a reoperation. Patients after previous cardiac operation by means of median sternotomy without use of the left internal thoracic artery presenting with a significant left anterior descending artery stenosis ("culprit lesion") were included. Predicted mortality was 13.6% (range, 2.4% to 72.8%) as calculated by the logistic Euroscore; ejection fraction was 0.531 (range, 0.14 to 0.81). Surgical results were analyzed for mortality, morbidity, duration of the procedure, hospital stay, and event-free survival.
RESULTS: Mean operating time was 103 ± 34 minutes. There were two in-hospital deaths (4.6%), one for malignant ventricular arrhythmia (Euroscore, 60.9%) and the second as a result of severe gastrointestinal bleeding (Euroscore, 29.2%). One patient (2.3%) was successfully reoperated on because of perianastomotic hematoma using the same approach after 6 days. Patients were discharged after 9.4 ± 2.6 days. There were no other serious adverse events, no stroke, and no myocardial infarction. During follow-up (37 ± 21 months, complete in 92.1%), 1 patient experienced angina and 6 patients died. The actuarial 4-year survival is 74.8% (95% confidence interval, 51% to 92%), and the actuarial 4-year event-free survival including freedom from angina, major adverse cardiac events, and reintervention is 81% (95% confidence interval, 54% to 97%).
CONCLUSIONS: Minimally invasive direct coronary artery bypass grafting can be considered as an alternative approach for redo coronary artery bypass grafting in selected patients.
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Introduction
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Minimally invasive direct coronary artery bypass grafting (MIDCAB) is an accepted treatment option for single-vessel coronary artery disease. Compared with conventional coronary artery bypass grafting (CABG), it is less traumatic while yielding similar patency results [1–4]. Despite improvement in cardiac anesthesia and increased surgical experience, redo CABG procedures are still associated with an increased mortality and morbidity [5, 6]. Reopening of the sternum, aortic clamping, manipulation of the heart, incomplete myocardial protection, and old patent grafts that serve as a source for emboli may affect surgical mortality and morbidity [7]. Performing a MIDCAB procedure using the left internal thoracic artery (LITA) without requiring a sternotomy and avoiding cardiopulmonary bypass as well as extensive dissection of the heart may present a valuable treatment alternative in selected patients who require redo CABG of the anterior wall.
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Patients and Methods
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Patients
From January 1997 to October 2003, 46 patients underwent reoperative MIDCAB using the LITA to graft the left anterior descending coronary artery (LAD) on the beating heart. Included were patients who had a previous cardiac operation through a sternotomy without the use of the LITA and a stenosis of an LAD that was regarded as the major target vessel ("culprit lesion") for revascularization.
Patient age was 66 ± 7.4 years. There were 40 male and 6 female patients. Forty-three patients underwent their first and 3 their second reoperation for myocardial revascularization. In addition, 13 patients had had one or more coronary angioplasty procedures. One patient had previous mitral valve replacement, 1 had double-valve replacement, 2 had a combination of aortic valve replacement and myocardial revascularization, 1 had resection of an ascending aortic aneurysm with bypass grafting, and 1 had closure of an atrial septal defect. The mean interval between the first operation and reoperation was 9.4 ± 3.5 years. Ten of the patients presented with multivessel coronary artery disease; revascularization of the other vessels was not feasible because of severe and diffuse atherosclerotic coronary artery disease. Results were analyzed for mortality, morbidity, operation time, hospital stay, and event-free survival.
Predicted mortality in this group of patients was 13.6% (range, 2.4% to 72.8%) as calculated by the logistic Euroscore. Two patients had a medical history of ventricular arrhythmia and an ejection fraction of less than 0.15. Preoperative demographics are summarized in Table 1.
Surgical Procedure
Patients were placed in a supine position with the left side elevated 30 degrees. Single right lung ventilation was performed. The fourth or fifth intercostal space was exposed through a 6- to 8-cm muscle-sparing anterolateral incision. The LITA was harvested under direct vision. Limited dissection of pericardial adhesions was performed only. The target vessel was easily identified mostly by the presence of an old vein graft. Local coronary artery occlusion was achieved when necessary by widely placing a felt-pledgeted 4-0 Prolene (Ethicon, Somerville, NJ) suture proximal to the site of the anastomosis. The LITA to LAD anastomosis was performed using a running 8-0 Prolene suture after local immobilization with a reusable stabilizer. Intraoperative graft flow was measured in 24 patients using transit-time Doppler (21 ± 8 mL). All patients were admitted to the intensive care unit and received 500 mg of intravenous aspirin immediately postoperatively.
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Results
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On the basis of intention to treat, 46 patients were included in the study. Forty-three patients successfully received the MIDCAB procedure. In 3 patients, the MIDCAB procedure was not completed for the following reasons. In 1 patient with a large anterior wall aneurysm the LAD was completely occluded. An endarterectomy was not considered feasible (not an access-related problem), and no bypass graft was performed. This patient received a transplantation successfully 13 months later. In another patient, as a result of excessive cardiomyopathy with an ejection fraction of only 0.10 and no tolerance for single-lung ventilation, harvesting of the LITA through a minithoracotomy was not possible. This patient underwent a sternotomy and off-pump single bypass grafting. The third patient had massive pleural adhesions, rendering an operation through a minithoracotomy rather difficult. These 3 patients were excluded from further analysis (Fig 1).
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Fig 1. Analysis of 46 patients showing intraoperative dropouts, completed minimally invasive direct coronary artery bypass grafting (MIDCAB), events perioperative (periop.) and postoperative, and follow-up (n = patients). (MACE = major adverse cardiac event.)
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In-hospital mortality was 2 of 43 patients (4.7%). One experienced sustained ventricular fibrillation despite a patent graft and preoperative atrial implantable cardiac defibrillator implantation. He was in low cardiac output preoperatively, was not a candidate for either heart transplant or assist device therapy, and had a Euroscore of 60.9%, and MIDCAB was considered the last-option therapy. Another patient died of an acute massive upper gastrointestinal bleed from a previously undiagnosed gastric ulcer. Thus, the observed perioperative mortality was 4.7% and compared favorably to the predicted mortality of 13.6% as calculated by the logistic Euroscore. Mean operating time was 103 ± 34 minutes. Patients were extubated after a mean of 9.9 ± 2.6 hours. Postoperative atrial fibrillation occurred in 1 patient and was treated by single cardioversion. No myocardial infarction or neurologic event occurred. Forty-one patients were discharged after 9.4 ± 2.6 days. Twenty-three patients underwent postoperative angiography, which demonstrated Fitzgibbon type A graft patency in all patients. In 1 patient, however, routine angiography on postoperative day 6 demonstrated a small anastomotic leakage. The patient was reoperated on through the same access, giving a reoperation rate of 2.3%.
During the follow-up period of 37 ± 21 months, 1 patient experienced angina and 1 patient had to be reoperated on because of a progressive aneurysm of an old venous graft; the LITA graft was patent. Postoperatively this patient had multiorgan failure and died. Five other patients died during follow-up. One patient died of sudden cardiac death, 1 because of a stroke, 1 because of pneumonia, and 2 patients died of cancer. The actuarial 4-year survival is 74.8% (95% confidence interval, 51% to 92%; Fig 2), and the actuarial 4-year event-free survival, including freedom from angina, major cardiac events (noncardiac death excluded), and reintervention, is 81% (95% confidence interval, 54% to 97%; Fig 3).
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Fig 2. Actuarial 4-year survival (solid line) is 74.8% (95% confidence interval [dashed lines], 51% to 92%).
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Fig 3. Actuarial 4-year event-free survival (solid line) is 81% (95% confidence interval [dashed lines], 54% to 97%).
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Comment
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Minimally invasive direct coronary artery bypass grafting has become an accepted treatment for single-vessel disease with an excellent surgical outcome [8, 9]. Patients who require redo CABG have different demographic features compared with patients who undergo first-time surgical revascularization. They are older and suffer significant comorbidities such as cerebrovascular disease, renal failure, peripheral vascular disease, and chronic obstructive pulmonary disease. Avoidance of resternotomy, extensive dissection of the heart, aortic clamping, and incomplete myocardial protection are anticipated to be beneficial for patients undergoing coronary reoperation in terms of surgical mortality and morbidity. Redo off-pump CABG through sternotomy carries an incidence of in-hospital death from 1% to 4.3%. Perioperative myocardial infarction rate for redo off-pump CABG procedures has been reported between 2.9% and 9% and the stroke rate between 0.7% and 4.3% [10–13]. In comparison we observed neither myocardial infarction nor neurologic event in our series. In-hospital mortality was acceptably low, was not procedure-related, and compared well with the Euroscore predicted mortality of 13.6%.
During the follow-up period of 37 ± 21 months, recurrence of angina was low despite incomplete revascularization in 10 patients. The actuarial 4-year survival (74.8%) and event free-survival (81%) are comparable to midterm results of conventional redo CABG procedures [14, 15].
Other approaches may be of similar value for different territories. For isolated redo procedures of the circumflex artery, a posterior minithoracotomy using a radial artery or saphenous vein graft to the descending aorta may be performed. This approach may be especially helpful in patients with a patent LITA graft in whom damage of the graft is associated with a high mortality [16]. For revascularization of the right coronary artery, a transabdominal approach may be used for a sternum-sparing reoperation using the gastroepiploic artery [16].
A limitation of this study is the small number of patients. During the study period, a total of 1,410 MIDCABs was performed at this institution, of which only 46 were reoperations (performed by 4 surgeons). Another limitation is the lack of a comparison with either conventional redo or off-pump sternotomy redo procedures.
From the results presented here, MIDCAB can be considered as a valuable alternative for redo CABG in selected patients, especially for high-risk patients or when complete revascularization is not indicated.
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Abstract
Introduction
