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Ann Thorac Surg 1997;64:1648-1653
© 1997 The Society of Thoracic Surgeons
Department of Surgery, Lenox Hill Hospital, New York, New York
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Abstract |
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Methods. From April 1994 through December 1996, 199 patients (age, 36 to 93 years) underwent minimally invasive coronary artery bypass grafting through minithoracotomy, subxiphoid, and lateral thoracotomy incisions, with internal mammary artery, gastroepiploic artery, and composite grafts placed using local coronary artery occlusion.
Results. The conversion rate to sternotomy was 7% (14/199). Preoperative risk factors included unstable angina (n = 83), reoperative coronary artery bypass grafting (n = 54), low ejection fraction (n = 53), congestive heart failure (n = 44), renal insufficiency (n = 25), chronic obstructive pulmonary disease (n = 36), cerebrovascular accident (n = 22), and diffuse vascular disease (n = 47). Morbidity included wound infections (n = 5), reoperation for management of bleeding (n = 6) and acute graft occlusion (n = 2), perioperative stroke (n = 1), atrial fibrillation (n = 14), and perioperative myocardial infarction (n = 7). The operative mortality was 3.8% (7/185). The number of grafts placed in 185 patients was as follows: single, 156; double, 28; and triple, 1. Early (less than 36 hours) angiography and Doppler flow assessment of the coronary anastomoses in 85% of the patients showed that 92% were patent. Routine use of mechanical stabilization of the coronary artery since April 1996 was found to be associated with an increase in the patency rate of the left internal mammary artery–left anterior descending coronary artery anastomosis to 97%, versus 89% (p = 0.055) associated with conventional immobilization techniques. Of the 148 patients followed up beyond 1 month (range, 1 to 32 months; mean, 9.2 ± 7.4 months) postoperatively, 3 have died (3 to 7 months), and of the 145 survivors the cardiac-related event (percutaneous transluminal coronary angioplasty, reoperation, readmission for recurrent angina, and congestive heart failure)–free interval was 93%.
Conclusions. The minimally invasive coronary artery bypass grafting operation is safe and effective. Regional cardiac wall mechanical immobilization enhances the early graft patency and must be considered an essential part of this operation.
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Introduction |
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Because of the competitive status of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery stenting, interest has recently been stimulated in developing minimally invasive direct coronary artery bypass grafting (MIDCABG) [1–3]. The evolution of MIDCABG techniques and our clinical experience between April 1994 through December 1996 form the basis of this report.
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Patients and Methods |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Surgical Technique
Standard cardiac anesthetic techniques are used, with infrequent application of single-lung ventilation. During local coronary artery occlusion the depth of anesthesia is increased to decrease the contractility of the left ventricle, lower blood pressure, and slow the heart rate. Before April 1996 when we began to use regional cardiac wall mechanical stabilization, pharmacologically induced bradycardia, accomplished with esmolol, diltiazem, or verapamil, and intermittent cardiac standstill, accomplished with bolus intravenous infusions of adenosine, were used to facilitate the coronary artery anastomosis. Transesophageal echocardiographic evaluation of the left ventricular wall motion, continuous ST-segment mapping, and determination of the mixed venous oxygen saturation were routinely performed.
INCISIONS FOR MIDCABG.
As shown in Figure 1, an anterior incision is made over the fourth intercostal space to expose the LAD, diagonal artery, and mid-RCA. A 7.5-cm subxiphoid incision with release of the costal attachment of the diaphragm is made to expose the distal RCA and posterior descending arteries; the right gastroepiploic artery is used as a graft. A midlateral incision in the third or fourth intercostal space between the midclavicular and midaxillary line in front of the scapula with the patient in the anterolateral position is used for composite left internal mammary artery (LIMA)–radial artery grafting of the OM and proximal LAD. A 7.5-cm-long, lateral thoracotomy incision over the sixth interspace from the tip of the scapula to the spine in the back is used to expose the circumflex OM-1 or OM-2. The radial artery and saphenous vein graft from the descending thoracic aorta are used as grafts.
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) (IMA Retractor; CardioThoracic Systems, Cupertino, CA) during this period that affords excellent exposure of the LIMA, thus facilitating the mobilization of the LIMA up to its origin. Distally the LIMA is dissected to the inferior border of the fifth rib. A similar technique is used for right IMA (RIMA) mobilization for MIDCABG to the mid-RCA.
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After the LIMA has been prepared, the IMA retractor spreader is replaced by another spreader (Access Platform; CardioThoracic Systems), which carries the coronary artery stabilizer (Fig 3) (Stabilizer; CardioThoracic Systems). The pericardium is incised 1 cm lateral to the IMA pedicle parallel to the midline. The left ventricle is inspected, the LAD is located, and the pericardium is suspended by traction sutures. The sutures placed laterally for the pericardium are pulled upward toward the suprasternal notch, which cradles and rotates the heart anteriorly to bring it up closer to the surface.
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Local coronary artery occlusion has been done either by widely placing double-looped 5-0 Prolene (Ethicon, Somerville, NJ) sutures proximal and distal to the site of anastomosis, with the coronary artery protected underneath the looped sutures through the use of silicone elastomer bolsters, or by placing silicone elastomer retractor tape (our practice since April 1996; Quest Medical Inc, Dallas, TX). Since January 1995, routine ischemic preconditioning has been done with 5 minutes of occlusion followed by 4 to 5 minutes of reperfusion and then completed by occlusion for coronary artery anastomosis.
We have used two methods of coronary artery immobilization. The first, which is the conventional one and the one we used before April 1996, involved the liberal use of ß-blockers and calcium-channel blockers and intermittent transient cardiac standstill accomplished with 5- to 10-mg bolus intravenous infusions of adenosine. The second one, which we have used since April 1996, involved the use of the regional cardiac wall mechanical immobilization platform (see Fig 3
). The coronary anastomosis is performed with single, continuous 8-0 Prolene sutures. Since April 1995, two 8-0 Prolene sutures have been used, one placed at the toe and one at the heel, with three throws made at each end. After this the IMA graft is parachuted down to the coronary artery and the anastomosis on both sides is finished. In patients receiving sequential and composite multiple grafts to the diagonal and circumflex arteries, the LIMA–LAD anastomosis is done as a last step.
Heparin is not routinely neutralized with protamine. An intercostal block with bupivacaine is used to control incisional pain. A small pleural tube is placed, the wound closed, and the patient returned to the intensive care unit. The postoperative care in the patients described here was routine, with early extubation (less than 2 hours postoperatively) and the discontinuation of all invasive lines in the first 6 hours. Patients are transferred to the floor after removal of the pleural drainage catheter (less than 24 hours postoperatively). Graft patency is routinely assessed immediately postoperatively by echocardiographic Doppler flow assessment of the IMA and other arterial grafts and by angiography performed less than 36 hours postoperatively. Most patients are discharged in 36 hours. Follow-up stress testing with thallium is performed at 1 to 6 months postoperatively in patients who consented to this.
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Results |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Postoperative complications occurred in 35 of the 185 patients (18.9%). Two patients underwent an urgent postoperative (less than 24 hours) LIMA-LAD graft revision through a standard sternotomy with cardiopulmonary bypass because of an acute LIMA–LAD graft occlusion with recurring rest angina and ischemic electrocardiographic changes. One of these 2 patients was a 71-year-old man who was found to have an intramyocardial LAD at the time of MIDCABG; the second was a 62-year-old man who suffered severe chest pain with acute ST-segment elevation in the anterolateral lead within 6 hours of LIMA–LAD MIDCABG. Immediate angiography revealed an occlusion of the LIMA–LAD anastomosis, which was successfully dilated using PTCA. He was reoperated on for postoperative bleeding. At reoperation, in addition to anastomotic bleeding, the anastomosis was found to be partially occluded with thrombus. Successful revision of this graft was done through a sternotomy. Both patients are clinically well at 1 year and 5 months. In only the second patient did a Q-wave anterolateral myocardial infarction develop. In 6 patients who underwent reexploration for postoperative bleeding, bleeding was originating from the intercostal branches in 4 and a branch of the LIMA in 1 and was due to avulsion of a short LIMA from the anastomotic site in a 64-year-old man, which occurred on the third postoperative day. This patient underwent emergency successful grafting of a saphenous vein graft to the LAD through a sternotomy.
Clinically significant atrial fibrillation requiring full digitalization and the intravenous administration of procainamide or a calcium-channel blocker drip for 24 hours was seen in 14 of the 185 patients. A perioperative myocardial infarction occurred in 7 patients, 6 with an anterior wall (3 patients with an LIMA-LAD graft occlusion) and 1 with an inferior wall myocardial infarction. Neurologic complications were infrequent (1/185). Five obese women with large breasts had a superficial wound infection at the lateral end of the submammary incision.
Seventy-five percent of the patients were extubated within the first 2 hours postoperatively. Early (less than 36 hours) routine angiographic and transthoracic pulse Doppler flow assessment of the coronary artery anastomosis (189/220, 85%) showed that 92% (174/189) were patent, with total occlusion in 9 patients and stenosis of more than 20% in 6. An early patency study performed in 143 of 152 patients with LIMA–LAD anastomoses (111 by angiography, 32 by Doppler echocardiography only) showed an overall patency rate of 93% (133/143); angiography showed patency in 91% (101/111).
The routine use (since April 1996) of regional cardiac wall mechanical immobilization of the coronary artery target site in 72 consecutive LIMA–LAD anastomoses resulted in an early overall patency rate of 97% (70/72), which is significantly (p = 0.055) (Table 4) higher than the 89% (63/71) achieved with the conventional immobilization technique (six occlusions and two anastomotic stenoses). If one considers only the angiographically shown patency, the patency rate in the patients in whom the conventional immobilization technique was used was 84% (38/44), which is significantly less (p = 0.028) than the 97% (65/67) in the patients in whom the regional cardiac wall mechanical immobilization technique was used. Of the eight anastomotic occlusions and two anastomotic stenoses that occurred in the LIMA-LAD group, 2 patients underwent urgent reoperation. Four of the remaining 6 patients underwent emergency PTCA of both the LAD and LIMA grafts and only 1 underwent PTCA of the LAD graft; the remaining patient was treated with medical therapy. Simple passage of a guidewire through the totally occluded LIMA graft resulted in immediate opening of the graft.
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Comment |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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years. The conversion rate from minithoracotomy to sternotomy with cardiopulmonary bypass in our experience was 7%. This is probably a result of the learning curve. Of the most recent 100 patients, only 3 patients have had to be converted for technical reasons (i.e., fatty heart, extensively calcified LAD, and difficult intramyocardial LAD). The fact that only 1 of the 199 patients had to be converted because of hemodynamic deterioration confirms our impression that local coronary artery occlusion, at least of the LAD, is well tolerated. The high rate of conversion to sternotomy (5/19, 26%) in patients undergoing RIMA–RCA MIDCABG (because of diffuseness of the disease and the difficulty immobilizing the mid-RCA), in combination with the low early patency rate of RIMA–RCA grafts (3/15, 20% occlusion), leads us to believe that this operation should be performed only in rare instances when the RCA is of good caliber and quality in a thin patient with a short anteroposterior diameter of the chest. However, the higher patency rate (8/9, 89%) in patients with a right gastroepiploic–distal RCA or posterior descending artery anastomosis, combined with lack of conversion to sternotomy, suggests that an inferior MIDCABG may be a better approach to RCA grafting.
The LIMA–LAD grafting procedure is the most important operation that has been advanced by the MIDCABG technique. It is technically easier to perform it through a minithoracotomy than through a midline sternotomy because of the intactness of the mediastinal and pericardial attachment to the undersurface of the sternum, which brings the LAD close to the surface, and because this places the LAD directly underneath the pericardial opening made by this submammary incision. The surgical invasiveness is also minimal, and the patient's comfort level is high. Use of the IMA access retractor system has eliminated the routine need to excise the costal cartilage, with the result that postoperative pain is lessened.
Angiography was used routinely for early graft studies, until April 1995, when the echocardiographic Doppler technique began to be relied on solely for this purpose. However, an unanticipated asymptomatic LIMA–LAD graft total occlusion detected during a routine study on the third postoperative day in a 64-year-old man who had a technically perfect LIMA–LAD anastomosis to an LAD with a diameter of more than 2 mm prompted its return to using angiography as the routine means of studying early graft patency in January 1996. This was also prompted by a lack of data regarding the early status of the LIMA–LAD graft performed using even the conventional CABG technique.
A prerequisite for the broad application of this beating-heart technique without cardiopulmonary bypass is an optimal immobilization of the anastomotic site and a bloodless field, and we also believe the MIDCABG operation should be performed in such a way that it closely mimics the conventional sternotomy CABG, except for cardiopulmonary bypass and sternotomy. Our technique of isolating the entire length of the LIMA using the IMA access retractor system and regional cardiac wall mechanical immobilization of coronary artery target sites throughout the performance of the coronary artery anastomosis with the coronary artery stabilizer fulfills these prerequisites.
The conventional immobilization techniques (ie, pharmacologically induced bradycardia) does not completely eliminate the vertical as well as the transverse movement of the LAD during anastomosis, thus predisposing to the formation of multiple intimal tears with an unpredictable occurrence of thrombus at the site of the anastomosis leading to total occlusion or anastomotic stenosis. The fact that most of the total occlusions could be opened up immediately by the passage of a guidewire led us to believe that the anastomotic occlusion that occurs in this operation is largely due to thrombus that forms as a result of intimal damage during the operation when the target sites are moving. This is supported by the fact that the patency rate was greatly improved in patients in whom the mechanical immobilization method was used. The two occlusions that occurred in patients in whom this technique was used were attributable to poor graft quality as well as to extreme disease at the target site. The other possible cause of the total graft occlusion could be injury to the graft that occurs during mobilization of the IMA. Once again this part of the operation is greatly facilitated by the use of the retractor system, which makes possible good visualization and easy mobilization of the LIMA up to its origin. Preliminary application of the regional cardiac wall mechanical immobilization concept in inferior and lateral MIDCABG has begun to yield improved results in terms of patency.
The excellent exposure obtained in a small series of 5 patients by a midlateral MIDCABG incision opens a novel way of approaching both the circumflex artery and the LAD in patients with left main artery stenosis. It is necessary to gain further experience with this access technique for double grafting of the left coronary arterial system with both mammary arteries as grafts.
Although the postoperative follow-up period in our patients is still short, the remarkably high cardiac-related event–free rate (93%) indicates that important LIMA–LAD MIDCABG may be of substantial benefit in many of these high-risk patients, even though they have multivessel disease.
In conclusion, MIDCABG in patients undergoing primary, elective, urgent, or reoperative CABG is a safe and effective procedure that is associated with good early clinical results. Regional cardiac wall mechanical immobilization is an important concept and must become an essential part of this operative technique. Critical evaluation of the immediate as well as long-term angiographic results of this operation is important. We believe that in the future this operation will assume a place among the myocardial revascularization techniques.
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Footnotes |
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TopFootnotesAbstractIntroductionPatients and MethodsResultsCommentReferences |
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Address reprint requests to Dr Subramanian, Department of Surgery, Lenox Hill Hospital, 130 E 77th St, New York, NY 10021.
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