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Ann Thorac Surg 2007;83:108-114
© 2007 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Seven-Year Follow-up After Minimally Invasive Direct Coronary Artery Bypass: Experience With More Than 1300 Patients

David M. Holzhey, MDa,*, Stephan Jacobs, MDa, Michael Mochalski, MDa, Thomas Walther, MD, PhDa, Holger Thiele, MD, PhDb, Friedrich W. Mohr, MD, PhDa, Volkmar Falk, MD, PhDa

a Department of Cardiac Surgery, Heart Center Leipzig, Leipzig, Germany
b Department of Cardiology, Heart Center Leipzig, Leipzig, Germany

Accepted for publication August 14, 2006.

* Address correspondence to Dr Holzhey, Herzzentrum Leipzig, Strümpellstrasse 39, 04289 Leipzig, Germany (Email: dholzhey{at}web.de).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
BACKGROUND: Minimally invasive direct coronary artery bypass (MIDCAB) for revascularization of the left anterior descending artery has become a routine operation. Here we present the experience after more than 1300 MIDCAB procedures with up to 7 years of follow-up.

METHODS: All patients undergoing standard MIDCAB between 1996 and 2004 were included. Long-term follow-up information about health status, major cardiac and cerebral adverse events, and freedom of angina was collected annually by a questionnaire or personal contact. Preoperative, intraoperative, and postoperative data could be completed for all 1347 patients. Five-year follow-up was available for 450 patients and 7-year follow-up for 194 patients.

RESULTS: Mean age was 63.2 years (range, 25 to 92 years) and mean ejection fraction was 0.61 ± 0.14. In 23 patients (1.7%), intraoperative conversion to sternotomy or CPB, or both, was necessary. Early postoperative mortality was 0.8% (n = 11), and 0.4% (n = 5) had a perioperative stroke. A routine postoperative angiogram in 709 patients showed 95.6% early graft patency. Short-term target vessel reintervention was needed 55 patients (4.1%): 10 had percutaneous transluminal coronary angioplasty/stent and 45 had reoperation. A repeat angiogram at the 6-month follow-up was available in 350 patients and demonstrated 94.3% graft patency. Kaplan-Meier analysis revealed a 5-year survival of 91.9% (95% confidence interval [CI], 90.1% to 93.8%) and a 7-year survival of 89.4% (95% CI, 86.7% to 92.1%). The freedom of major adverse events and angina was 89.5% (95% CI, 87.4% to 91.5%) after 5 years and 83.3% (95% CI, 79.0% to 87.5%) after 7 years.

CONCLUSIONS: MIDCAB can be safely performed with low postoperative mortality and morbidity. The excellent short-term and long-term survival as well as freedom from major adverse cardiac and cerebral events and angina compare favorably with stenting and conventional surgery.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Minimally invasive direct coronary artery bypass (MIDCAB) has gained widespread acceptance and is the preferred method of surgical revascularization for isolated coronary artery disease of the anterior wall at some centers. In addition, MIDCAB is performed in selected high-risk patients with multivessel disease who have extensive comorbidity or are at high risk for sternotomy. Yet, the operation remains challenging, and alternative procedures such as stenting of the left anterior descending artery (LAD) or off-pump coronary artery bypass grafting (OBCAP) are available. This study presents the preoperative, intraoperative, and postoperative data of all MIDCAB patients with at least 1-year follow-up operated on at a single center during an 8-year period.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
From 1996 to 2004, 1347 patients underwent standard MIDCAB through a 5-cm to 6-cm anterolateral muscle-sparing minithoracotomy. Take-down of the left internal thoracic artery was performed under direct vision. The activated clotting time was kept at 300 seconds throughout the operation and was neutralized incompletely with a half dose of protamine after completion of the anastomosis. A standard reusable pressure stabilizer was used. Proximal LAD occlusion was performed using a 4-0 felt-pledgeted suture. Preconditioning was not applied. Distal occlusion was avoided whenever possible. No intracoronary shunts were used. A mister-blower was used in all cases. Antiplatelet therapy using 100 mg of aspirin was started the day of operation.

There were 378 women (28%) and 969 men (72%). The mean age was 63.2 ± 10.7 years (range, 25 to 92 years), and 65 patients were older than 80 years. Elective revascularization was scheduled in 1287 patients (95.6%); the procedure was urgent in 46 (3.4%) and emergent in 14 (1%).

Most of the patients had single-vessel coronary artery disease of the LAD (n = 855), 313 had formal two-vessel disease, and 171 had formal three-vessel disease. Those patients were scheduled for MIDCAB when the stenoses of the other vessels were insignificant, the coronary arteries were graded too small (<1 mm) for surgical revascularization or were severely calcified distally, or both, or the corresponding myocardial territories were scarred, nonvital, or aneurysmatic. However, 152 patients had multivessel disease with an indication for additional therapy of other coronary vessels. Thus, a hybrid procedure was completed in which preoperative (n = 35), intraoperative (n = 4) or postoperative (n = 41) non-LAD stenting was done.

Incomplete revascularization was accepted in 72 patients because of high risk for sternotomy or extensive comorbidity, or both. The risk profile is given in Table 1. The mean ejection fraction was 0.607 ± 0.141, the preoperatively calculated additive European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 2.5 (range, 0 to 16) with a corresponding expected perioperative mortality of 3.6% (range, 0.9% to 72.8%).


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  		Table 1. Preoperative Comorbidity and Risk Factors
 
All patients gave their written consent to anonymous data storage and analysis, and the local Ethics Committee approved the study.

Intraoperative data, perioperative complications, and angiographic findings were collected from written and electronic files of all patients. During the first years, when MIDCAB was still a relatively new procedure under investigation, 709 patients received a routine coronary angiogram postoperatively to evaluate graft patency, and 351 patients had a repeated study at 6 months. Later on, a postoperative angiogram was only performed when graft problems were suspected by clinical symptoms, electrocardiogram findings or elevated enzymes, or the patient participated in a clinical trial. A summary of the number of patients per quarter undergoing a routine postoperative angiography is given in Figure 1.


Figure 1
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  		Fig 1. Number of patients per quarter and postoperative coronary angiograms (MIDCAB = minimally invasive direct coronary artery bypass).

 
From 2003 on, follow-up information was gathered routinely by postal questionnaires and telephone calls to the patient or the treating general physician. Data were collected on survival, general condition, freedom from a major cardiac and cerebral adverse event (MACCE), including myocardial infarction, target vessel reintervention, cardiac death, and stroke; and freedom of angina. The closing interval for follow-up for this report was August to November 2005. Five-year follow-up was completed for 450 patients (55% of possible follow-up) and 7-year follow-up for 194 patients (40% of possible follow-up).


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Intraoperative Course
Mean operation time was 106 ± 14 minutes, 60 patients received a second bypass graft to the diagonal or intermediate branch using an additional venous graft, the left radial artery, or the left internal mammary artery (LIMA) sequentially. Target vessel occlusion caused temporary ST elevation or depression in 73 patients (5.4%), which reversed immediately upon reperfusion in all cases. Ventricular fibrillation occurred in 8 patients, and a severe drop of blood pressure occurred in 5 patients. In most of the cases, these complications were overcome by external defibrillation and temporary inotropic support. In 23 patients (1.7%), the operation could not be completed as planned. Median sternotomy became necessary in 15 patients (1.1%), and 10 needed cardiopulmonary bypass (0.7%). Details of all conversions are summarized in Table 2.


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  		Table 2. Intraoperative Conversion
 
Postoperative Angiography and Reintervention
An elective routine predischarge angiogram in 709 patients (57.7%) showed a patency rate of 95.6% (n = 678), where 613 patients (86.5%) were graded FitzGibbon A, and 22 grafts (3.1%) were completely occluded. After the practice of routine control angiography was stopped, a coronary angiography was performed solely on the presence of postoperative ST elevations or increased cardiac enzymes indicating myocardial ischemia. Symptom-based angiography was performed in additional 68 patients (5.0%). Of these patients, 55 (80.9%) had patent grafts (FitzGibbon A in 41, 60.3%), and nine grafts (13.2%) were occluded.

Short-term reintervention of the target vessel was performed in 55 patients (4.1%), in most cases due to stenosis of the anastomosis, stenosis of the LAD distal to the anastomosis, or narrowing or kinking of the LIMA. These problems were managed by percutaneous transluminal coronary angioplasty/stent implantation in 10, reanastomosis through the primary minithoracotomy in 18, and 12 patients with difficult anatomic conditions had beating-heart reanastomosis through a median sternotomy. Reoperation by conventional bypass grafting with median sternotomy and cardiopulmonary bypass became necessary in 15 patients, most often because of severe calcification of the LAD (n = 5), severe circulatory depression on occlusion of the LAD (n = 3), or emergency reoperation (n = 2).

A left main dissection occurred in 1 patient during angiography, which necessitated bypass grafting to the circumflex artery (LIMA-LAD bypass patent), and 1 patient with posterior myocardial infarction due to acute stent thrombosis required urgent revascularization of the right coronary artery. Three patients who were originally planned as hybrid procedures and had occlusion of the LAD bypass received conventional multivessel bypass grafting.

Perioperative Mortality and Complications
Early postoperative mortality was 0.8% (11 patients with a mean predicted mortality of 18.6%) and compared favorably with the preoperatively calculated predicted mortality of 3.6%. One patient died of perforated duodenal ulcer, 2 from pulmonary embolism, 2 from acute respiratory failure with electromechanical decoupling, and 6 died of cardiac causes.

Perioperative permanent stroke occurred in 5 patients (0.4%). Rethoracotomy was necessary in 46 patients (3.4%) due to hematothorax or hemorrhage; in all these patients, the source was identified and fixed though the original thoracotomy. Other severe complications that impaired recovery and prolonged hospital stay were perioperative myocardial infarction in 8 patients (0.6%), necessity for use of intraaortic balloon pump/extracorporeal membrane oxygenation in 12 (0.8%), acute renal failure in 11 (0.8%), respiratory failure/pneumonia with prolonged artificial respiration in 24 (1.8%), and sepsis in 1 (0.1%). A summary of the postoperative complications is given in Table 3.


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  		Table 3. Postoperative Complications
 
Follow-Up and Long-Term Survival
Follow-up coronary angiograms at 6 months were available from 350 patients and demonstrated a patency rate of 94.3% (n = 330): 307 patients (87.7%) were graded FitzGibbon A, 23 patients (6.6%) were FitzGibbon B, and 10 patients (2.9%) had total occlusion of the graft.

Table 4 summarizes the number of completed follow-ups at present. We recorded 75 deaths: 23 for cardiac, 20 for noncardiac, and 32 for unknown reasons. Furthermore, 21 patients had a stroke, 11 had myocardial infarction, 43 needed reintervention of the target vessel (LAD), and 8 patients underwent redo surgery. At the time of the last follow-up, 49 patients complained of recurrent angina. Three patients were readmitted for pleural hernia of the minithoracotomy and were treated with reoperation, and 3 others were admitted for purulent wound infection and were treated with IV antibiotics and secondary wound healing without further problems.


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  		Table 4. Follow-Up Patients
 
Altogether, the actuarial 5-year survival, as calculated with Kaplan-Meier-analysis (Fig 2), was 91.9% (95% confidence interval [CI], 90.1% to 93.8%) and the 7-year survival was 89.4% (95% CI, 86.7% to 92.1%). The freedom from MACCE and angina was 89.5% (95% CI, 87.4% to 91.5%) after 5 years and 83.3% (95% CI, 79.0% to 87.5%) after 7 years, with a distinct decline after about 6.5 years (Fig 3).


Figure 2
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  		Fig 2. Kaplan-Meier survival (solid line). Dotted lines represent the 95% confidence interval.

 

Figure 3
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  		Fig 3. Freedom of major cardiac and cerebral events and angina (solid line). Dotted lines represent the 95% confidence interval.

 
Study Limitations
The major limitation of this study is its retrospective nature. The loss of patients to follow-up is a major drawback, partly explained by a lack of cooperation and because many patients were external referrals.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Consistent with former studies [1–5] it can be concluded that MIDCAB is a safe and efficient procedure for patients with single-vessel disease and selected patients with multi-vessel disease. MIDCAB is associated with an acceptable conversion rate, a low complication rate, and good long-term results. The perioperative mortality of 0.8% compares favorably with the 1.4% mortality for off-pump and 3.6% mortality for on-pump single bypass grafting as reported in the registry of the German Society for Thoracic and Cardiovascular Surgery in 2004 [6]. A comparison with the results of single vessel on-pump or off-pump revascularization of the LAD is not useful for our center, because very few such operations have been performed since the introduction of MIDCAB. Historic data of single-vessel LIMA–LAD grafting performed on-pump reveal a mortality of 0.0% to 1.8% [7, 8].

In a comprehensive review of the perioperative outcome and mid-term results of MIDCAB grafting, Kettering and colleagues [5] summarized the results of 16 studies. The results of this study are in line with the reported results of other groups reporting complication rates of early mortality (0% to 4.9%), perioperative infarction rates (0% to 3.9%), conversion rate to sternotomy/CPB (0% to 6.2%), short-term reintervention on target vessel (up to 8.9%), and overall perioperative complication rate (1.6% to 40%). Postoperative angiographic patency rates between 94% and 99% are also concordant with our results.

Several recent publications focus on mid-term and long-term results. Al-Ruzzeh and colleagues [9] reported excellent mid-term general health perception and quality of life—even compared with an age-matched group of healthy British individuals—and great satisfaction with the procedure. In a comparison of MIDCAB with OPCAB LIMA–LAD bypass grafting, Vicol and colleagues [10] found a slightly lower rate of mid-term adverse cardiac events in the OPCAB group and concluded that MIDCAB should only be performed by experienced surgeons. This is in accordance with our experience. Further long-term surveillances of MIDCAB patients came to similar conclusions and results as in our study: Zimarino and colleagues [11] describe a 5-year adverse event rate of 12%, and Fraund and colleagues [12] found a long-term mortality of 6.8% and a MACCE rate of 9.7% in an average follow-up of 3.4 ± 0.7 years.

The MIDCAB operation remains more challenging than conventional CABG and is more costly than bare metal stenting [13]. Despite the long-term availability of bare metal stenting of the LAD, long-term data are sparse [11, 14] and rarely exceed the first postinterventional year. In addition to low periprocedural mortality, infarction, and complication rates, most of the current studies outline the problem of early stent stenosis and, thus, a high reintervention rate during the first 6 months that equals the initial cost-savings of the procedure [15]. Patency rates at 6 months are reported as 71%, with only few further stenoses of the target vessel after that time.

In a 5-year follow-up of a prospective trial, Goy and colleagues [16] report a higher rate of myocardial infarction (15% versus 4%; p = 0.0001), additional revascularization (38% versus 9%, p = 0.0001), and lower freedom of events (62% versus 91% p = 0.0001) in the percutaneous transluminal coronary angioplasty group compared with the conventional on-pump LIMA–LAD bypass surgery group. Results of another 5-year follow-up of a randomized trial with stenting versus bypass operation for multivessel disease reported a significantly lower reintervention rate in the bypass group, with no significant differences in mortality or other MACCE [17, 18].

Previous studies came to the same conclusion for patients after MIDCAB compared with stenting of the LAD, mainly because of early in-stent restenosis [9, 19], particularly in diabetic patients [20]. This benefit is most likely less prominent with the development of drug-eluting stents, but the perioperative risks of the surgical procedure remain [21, 22]. The long-term superiority of these stents remains still to be proven, however, and compared with surgical revascularization, will be lesion-dependent.

In the light of these considerations, we stress that the quality of the MIDCAB procedure can only remain high when it is performed in centers with a caseload that is adequate to allow surgeons to continuously sustain their skill level [10, 23]. In these circumstances, MIDCAB is a true alternative to conventional surgery. Even if the equability of stenting in the long-term outcome turns out to be true, there are still a number of indications, such as repeated in-stent stenosis, complete occlusion of the LAD, or lesions not suitable for stenting for anatomic reasons (complex type C stenosis or small vessels), where the MIDCAB operation will remain a good alternative.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Biglioli P, Antona C, Alamanni F, et al. Minimaily invasive direct coronary artery bypass grafting: midterm results and quality of life Ann Thorac Surg 2000;70:456-460.[Abstract/Free Full Text]
  2. Calafiore AM, Di Giammarco G, Teodori G, et al. Midterm results after minimally invasive coronary surgery (LAST operation) J Thorac Cardiovasc Surg 1998;154:763-771.
  3. Diegeler A, Matin M, Kayser S, et al. Angiographic results after minimally invasive coronary bypass grafting using the minimally invasive direct coronary bypass grafting (MIDCAB) Approach Eur J Cardiothorac Surg 1999;15:680-684.[Abstract/Free Full Text]
  4. Mehran R, Darigas G, Stamou SC, Pfister AJ, Dullum MKC, Leon MB. One-year clinical outcome after minimally invasive direct coronary artery bypass Circulation 2000;102:2799-2802.[Abstract/Free Full Text]
  5. Kettering K, Dapunt O, Baer FM. Minimally invasive direct coronary artery bypass grafting: a systematic review J Cardiovasc Surg 2004;45:255-264.[Medline]
  6. Gummert JF, Funkat A, Krian A. Cardiac surgery in Germany during 2004: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery Thorac Cardiovasc Surg 2005;53:391-399.[Medline]
  7. O’Keefe JH, Kreamer TR, Jones PG, et al. Isolated left anterior descending coronary artery disease: percutaneous transluminal coronary angioplasty versus stenting versus left internal mammary artery bypass grafting Circulation 1999;100:114-118.
  8. Goy JJ, Eeckhout E, Burnand B, et al. Coronary angioplasty versus left internal mammary artery grafting for isolated proximal left anterior descending artery stenosis Lancet 1994;343:1449-1453.[Medline]
  9. Al-Ruzzeh S, Mazrani W, Wray J, et al. The clinical outcome and quality of life following minimally invasive direct coronary artery bypass surgery J Card Surg 2004;19:12-16.[Medline]
  10. Vicol C, Nollert G, Mair H, et al. Midterm results of beating heart surgery in 1-vessel disease: minimally invasive direct coronary artery bypass versus off-pump coronary artery bypass with full sternotomy Heart Surg Forum 2003;6:341-344.[Medline]
  11. Zimarino M, Gallina S, Di Fulvio M, et al. Intraoperative ischemia and long-term events after minimally invasive coronary surgery Ann Thorac Surg 2004;78:135-141.[Abstract/Free Full Text]
  12. Fraund S, Herrmann G, Witzke A, et al. Midterm follow-up after minimally invasive direct coronary artery bypass grafting versus percutaneous coronary intervention techniques Ann Thorac Surg 2005;79:1225-1231.[Abstract/Free Full Text]
  13. Magovern JA, Benckart DH, Landreneau RJ, Sakert T, Magovern Jr GJ. Morbidity, cost, and six-month outcome of minimally invasive direct coronary artery bypass grafting Ann Thorac Surg 1998;66:1224-1229.[Abstract/Free Full Text]
  14. Sellke FW, Di Maio JM, Caplan LR, et al. Comparing on-pump and off-pump coronary artery bypass grafting: numerous studies but few conclusions: a scientific statement from the American Heart Association council on cardiovascular surgery and anesthesia in collaboration with the interdisciplinary working group on quality of care and outcomes research Circulation 2005;111:2858-2864.[Abstract/Free Full Text]
  15. Thiele H, Oettel S, Jacobs S, et al. Comparison of bare-metal stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery a 5-year follow-up Circulation 2005;112:3445-3450.[Abstract/Free Full Text]
  16. Goy JJ, Eeckhout E, Moret C, et al. Five-year outcome in patients with isolated proximal left anterior descending coronary artery stenosis treated by angioplasty or left internal mammary artery graftingA prospective trial. Circulation 1999;99:3255-3259.[Abstract/Free Full Text]
  17. Serruys PW, Ong AT, van Herwerden LA, et al. Five-year outcomes after coronary stenting versus bypass surgery for the treatment of multivessel disease: the final analysis of the Arterial Revascularization Therapies Study (ARTS) randomized trial J Am Coll Cardiol 2005;46:575-581.[Abstract/Free Full Text]
  18. Aoki J, Ong AT, Hoye A, et al. Five year clinical effect of coronary stenting and coronary artery bypass grafting in renal insufficient patients with multivessel coronary artery disease: insights from ARTS trial Eur Heart J 2005;26:1488-1493.[Abstract/Free Full Text]
  19. Diegeler A, Thiele H, Falk V, et al. Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery N Engl J Med 2002;347:561-566.[Abstract/Free Full Text]
  20. Shirai K, Lansky AJ, Mehran R, et al. Minimally invasive coronary artery bypass grafting versus stenting for patients with proximal left anterior descending coronary artery disease Am J Cardiol 2004;93:959-962.[Medline]
  21. Brambilla N, Repetto A, Bramucci E, et al. Directional coronary atherectomy plus stent implantation vs. left internal mammary artery bypass grafting for isolated proximal stenosis of the left anterior descending coronary artery Catheter Cardiovasc Interv 2005;64:45-52.[Medline]
  22. Hravnak M, Hoffman LA, Saul MI, et al. Atrial fibrillation: prevalence after minimally invasive direct and standard coronary artery bypass Ann Thorac Surg 2001;71:1491-1495.[Abstract/Free Full Text]
  23. Okawa Y, Baba H, Hashimoto M, et al. Comparison of standard coronary artery bypass grafting and minimary invasive direct coronary artery bypass graftingEarly and mid-term result. Jpn J Thorac Cardiovasc Surg 2000;48:725-729.[Medline]



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