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Ann Thorac Surg 1997;63:405-407
© 1997 The Society of Thoracic Surgeons

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Original Article: Cardiovascular

Reoperative Coronary Bypass Grafting Without Cardiopulmonary Bypass Through a Small Thoracotomy

Thoraxcenter, University Hospital of Groningen, Groningen, the Netherlands

Accepted for publication August 12, 1996.

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Background. The danger of coronary reoperations is mainly hidden in the reopening of the sternum and in the manipulation of the heart and the old grafts. Therefore, the minimally invasive direct coronary artery bypass procedure seems an ideal technique for coronary reoperations if only the left anterior descending coronary artery needs to be revascularized and the left internal mammary artery has not been used previously.

Method. From January 1995 until May 1996 we performed 81 minimally invasive direct coronary artery bypass procedures through a small anterolateral thoracotomy in the fifth intercostal space, anastomosing the left internal mammary artery to the left anterior descending coronary artery. Six of these 81 were reoperative minimally invasive direct coronary artery bypass procedures on patients who had previously undergone coronary grafting through a median sternotomy with a vein graft to the left anterior descending coronary artery.

Results. Mean operation time was 85.8 ± 22.2 minutes. Mean length of the mammary pedicles was 13 ± 2 cm. Mean coronary occlusion time was 9.2 ± 3.2 minutes. Mean postoperative hospital stay was 5.7 ± 1.2 days (range, 5 to 8 days). No mortality and no cardiac-related morbidity were recorded.

Conclusions. These results suggest that the technique is safe and promising in selected cases of reoperative coronary operation.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Mortality and morbidity rates of reoperative coronary artery bypass grafting (CABG) are higher than in primary CABG [1]. Several independent determinants of operative mortality for reoperative CABG have been identified [2], but the danger of the reoperative CABG is mainly hidden in the reopening of the sternum and in the manipulation of the heart and the old grafts [3]. Therefore, minimally invasive direct CABG (MIDCABG) seems an ideal technique for reoperative CABG operations if only the left anterior descending artery (LAD) needs to be revascularized and the left internal mammary artery has not been used previously. The procedure can be performed through an anterolateral small access through the fifth intercostal space; resternotomy and cardiopulmonary bypass are not required [4].

In this report we describe 6 patients undergoing reoperative MIDCABG who had previously undergone CABG through a median sternotomy with a vein graft to the LAD.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Patients
From January 1995 until May 1996, 1,248 total CABGs were performed in our Institute: 1,192 were first operations and 56 were reoperations (4.5%). In the same period we performed 75 first MIDCABGs and 6 reoperative MIDCABGs (5 men/1 woman; mean age, 65.7 ± 6.7 years) (Table 1).

Method
The method that we used in reoperative MIDCABG was the same one used in primary MIDCABG [4]. A double-lumen endotracheal tube was used to collapse the left lung during the procedure. A small left anterolateral thoracotomy was made through the fifth intercostal space. The left internal mammary artery was harvested by direct vision (without video-assisted thoracoscopy) and with the aid of a specially adapted wound spreader. The LAD and its graft were easily identified after the pleura and the pericardium were opened. To reduce the heart rate during the procedure, we used intravenous esmolol in 2 patients. To test the tolerance to local coronary ischemia, we briefly occluded the LAD with two 5-0 looping polypropylene sutures after heparinization (150 IU/kg; activated clotting time, >200 seconds). If no electrocardiographic or hemodynamic changes occurred, the LAD was opened distally to the site of the old venous anastomosis. The mammary-to-coronary artery anastomosis was made with a running 7-0 polypropylene suture. Two or more single polypropylene stitches were used to fix the mammary pedicle to avoid kinking. No protamine was given afterward. The wound was closed in layers and one pleural drain was left in place.

Aspirin (80 mg/d) was given for 3 months. To enable the patient to be discharged in good condition within 5 days after the operation, mobilization was performed according to a special training scheme especially developed for MIDCABG procedures.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Mean operation time was 85.8 ± 22.2 minutes (see Table 1). Mean length of the mammary pedicles after the harvesting was 13 ± 2 cm. Mean coronary occlusion time was 9.2 ± 3.2 minutes. All patients were extubated within 6 hours of admission to the intensive care unit. Mean postoperative hospital stay was 5.7 ± 1.2 days (range, 5 to 8 days). Patient 4 had a prolonged hospital stay because of an atonic bladder requiring a urethral catheter.

All patients with anterolateral thoracotomy experienced less wound pain than those who underwent reoperative grafting with the conventional midsternotomy wound, according to the standard scale of pain. Moreover, patients generally felt that they recovered much faster from the MIDCABG procedure than from their first operation, which was performed through a midsternotomy and with cardiopulmonary bypass. All patients have had a cardiac event-free follow-up (mean follow-up, 10 ± 5 months; range, 4 to 16 months), and there have been no cases of recurrent angina or positive exercise test.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Previously, the left thoracotomy has been suggested to be an effective alternative approach, along with coronary operation without cardiopulmonary bypass, for patients having a second coronary operation [3, 5], although this point of view is still controversial [6].

In this report reoperative MIDCABG was used in a small group of patients with recurrent angina attributable to occlusion of a previous vein graft to the LAD. The main reasons for the small number of reoperative MIDCABGs performed were the decreasing use of the vein grafts to the LAD, the concomitant increase in the use of the left internal mammary artery at first coronary operation, and, moreover, the infrequent indication to revascularize one single coronary vessel in reoperations.

In this group a small anterolateral thoracotomy through the fifth intercostal space was used; the left internal mammary artery was harvested and anastomosed to the LAD without the use of cardiopulmonary bypass, according to the technique that we described previously [4]. Our preference for the fifth intercostal space is because of the more lateral site of skin incision that we use: the more lateral the incision, the more cranial will be the final access because of the anatomy of the ribs and intercostal spaces. This small group of 6 patients was part of a larger group of 81 patients that was operated on in our institute using this technique. No mortality and no cardiac-related morbidity was recorded, along with a less painful incision, a rapid recovery, and a short hospital stay. In addition the mean length of hospital stay was affected both by the prolonged stay of 1 patient with noncardiac-related (urinary tract) problems and by the fact that 4 of 5 remaining patients had had a long preoperative hospitalization in other hospitals, while waiting to be transferred to our institute. From the technical point of view we found that the identification of the LAD was facilitated by the presence of the old occluded vein graft and that the mammary-to-coronary artery anastomosis was facilitated by the reduced motion of the epicardial surface. In fact, in these cases the epicardium is firmly adherent to the pericardium and this consistently reduces the motion of the epicardium itself, when only the pericardium overlying the LAD is dissected free.

The results obtained in this group led us to conclude that the technique seems safe and promising in reoperative CABG, despite the small number of performed cases.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Address reprint requests to Dr Boonstra, Thoraxcenter, University Hospital of Groningen, Hanzeplein 1, 9713 EZ Groningen, the Netherlands.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Edwards FH, Clark RE, Schwartz M. Coronary artery bypass grafting: The Society of Thoracic Surgeons national database experience. Ann Thorac Surg 1994;57:12–9.[Abstract]
2. He GW, Acuff TE, Ryan WH, He YH, Mack MJ. Determinants of operative mortality in reoperative coronary artery bypass grafting. J Thorac Cardiovasc Surg 1995;110:971–8.[Abstract/Free Full Text]
3. Fanning WJ, Kakos GS, Williams TE Jr. Reoperative coro-nary bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1993;55:486–9.[Abstract]
4. Benetti FJ, Ballester C, Sani G, Boonstra PW, Grandjean JG.Video-assisted coronary bypass surgery. J Cardiol Surg 1995;10:620–5.
5. Kigawa I, Suma H, Nishimi M, Horii T, Fukuda S, Wanibuchi Y. The second coronary reoperation via the left thoracotomy without cardiopulmonary bypass. Nippon Kyobu Geka Gakkai Zasshi 1994;42:603–6.[Medline]
6. Cosgrove DM III. Is coronary reoperation without the pump an advantage? [Editorial]. Ann Thorac Surg 1993;55:329.[Medline]

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This Article Abstract 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): Piet W. Boonstra Massimo A. Mariani Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Boonstra, P. W. Articles by Mariani, M. A. Search for Related Content PubMed PubMed Citation Articles by Boonstra, P. W. Articles by Mariani, M. A.