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Ann Thorac Surg 1997;64:1835-1839
© 1997 The Society of Thoracic Surgeons
Interventional Centre and Departments of Surgery A, Radiology, Anesthesiology, and Medicine B, Rikshospitalet, Oslo, Norway
Accepted for publication June 23, 1997.
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Abstract |
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 TopFootnotes Abstract IntroductionMinimally Invasive Direct...PatientsResultsCommentReferences |
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Introduction |
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TopFootnotesAbstractIntroductionMinimally Invasive Direct...PatientsResultsCommentReferences |
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The long-term patency of successful left internal mammary artery (LIMA) grafting to coronary arteries is well recognized, and follow-up studies of open coronary artery bypass grafting have shown that the most important factor for freedom from symptoms and eventless survival is the anastomosis between the LIMA and the left anterior descending coronary artery (LAD) [1, 2]. To justify LIMA-to-LAD bypass grafting performed as a minimally invasive direct coronary artery bypass grafting (MIDCABG) procedure without cardiopulmonary bypass, the results must be as good as those achieved by conventional coronary artery bypass grafting. In a specially designed surgical-radiologic suite we have performed MIDCABG procedures as well as integrated hybrid procedures, that combine LIMA-to-LAD MIDCABG and percutaneous transluminal coronary angioplasty and stenting of other stenosed vessels in one session.
A surgical-radiologic suite at the newly erected Interventional Centre, Rikshospitalet, Oslo, with a cross-disciplinary organization, greatly facilitates safe MIDCABG as well as the integrated hybrid approach to treatment of coronary artery disease (Fig 1
) [3].
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Minimally Invasive Direct Coronary Artery Bypass Grafting and Integrated Hybrid Procedures |
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TopFootnotesAbstractIntroductionMinimally Invasive Direct...PatientsResultsCommentReferences |
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The patient was in supine position with 20-degree elevation of the left shoulder and the arm positioned over the head. During right single-lung ventilation thoracoscopic (Scharakawa Olympus Co Ltd, Tokyo, Japan) dissection of the LIMA was performed by electrocautery or by Harmonic Scalpel (Ultracision Inc, Smithfield, RI) through small (2-cm) incisions in the third and fifth intercostal spaces. Subsequently, a limited (8- to 10-cm) anterior thoracotomy without rib resection was performed in the fourth intercostal spaces. The pericardium was incised over the course of the LAD and the edges were fixed by stay sutures to stabilize the heart. Tourniquets by pledget-reinforced sutures of 3-0 Gore-Tex (W.L. Gore & Assoc, Flagstaff, AZ) were placed deep to the LAD, proximal and distal to the chosen site for the arterial incision. Under continuous monitoring by transesophageal echocardiography (VingMed Sound AS) and measurement of cardiac output and mixed venous oxygen saturation (Dräger Cicero EM, Lübeck, Germany), ischemic preconditioning was performed for 5 minutes by tightening of the proximal tourniquet followed by 5 minutes of reperfusion. During the preconditioning the LIMA was divided and papaverine (2 mg/mL) was instilled. Subsequently, the LAD was incised and the tourniquets were gently tightened. The heart rate was controlled by continuous infusion of esmolol (50 to 300 µg • kg-1 • min-1), and the effect of bleeding in the anastomotic region was reduced by a surgical site visualization wand (VisuFlo, Midvale, UT). Anastomosis was performed with one continuous, double-armed Prolene 7-0 (Ethicon GmbH & Co KG, Norderstedt, Germany) suture.
After the completion of the anastomosis, flow in the LIMA graft was measured by transit-time flowmetry (CardioMed Flowmeter model CM CM4008; Medi-Stim AS, Oslo, Norway), and subsequently angiography was performed on the operating table, which has integrated x-ray equipment (DLX LC Advantx; GE, Milwaukee, WI), to assess anastomosis and graft patency and quality. Nonfunctional or suboptimal anastomoses were immediately taken down and revised by following the same sequence of steps as described above.
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Patients |
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TopFootnotesAbstractIntroductionMinimally Invasive Direct...PatientsResultsCommentReferences |
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Results |
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TopFootnotesAbstractIntroductionMinimally Invasive Direct...PatientsResultsCommentReferences |
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). In 1 patient with an occluded LAD that had not been angiographically visualized preoperatively, anastomosis was attempted but had to be abandoned due to a nongraftable periphery of the artery.
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Patient 1 was a 50-year-old man with a history of a previous myocardial infarction and angina pectoris (NYHA functional class II to III) of 1 year's duration. The patient had two-vessel disease, an occluded LAD with angiographic retrograde filling of the periphery, and a 90% stenosed circumflex artery. The ejection fraction was 0.60.
Patient 2 was a 76-year-old man with post-myocardial infarction angina pectoris (NYHA functional class III) of 6 months' duration. The patient had an occluded LAD with angiographic retrograde filling of the periphery and a 75% stenosed right coronary artery. The ejection fraction was 0.61.
In both patients, the angioplasty procedure and MIDCABG were performed according to protocol. However, in patient 1 the intraoperative angiogram showed anastomosis failure (Fig 2). Take-down and inspection of the anastomosis revealed a small plaque dissection in the "toe" of the anastomosis. The anastomosis was immediately revised using the same technique, with excellent angiographic result (Fig 3). In patient 2, mean flow in the LIMA graft was assessed to be 16 mL/min by intraoperative transit time flowmetry, after the anastomosis had already been revised once due to inadequate flow assumed to result from anastomosis failure. The follow-up angiogram, however, revealed an occlusion in the upper-mid portion of the LIMA graft (Fig 4). Because examination of the graft revealed a dissection at the site of occlusion, probably caused by a coronary clamp, the operation was converted to standard open coronary artery bypass grafting, with a reversed vein graft to the LAD. Interestingly, in neither case was deterioration of the left ventricular function recorded by transesophageal echocardiography. Both patients had an uneventful postoperative course. No evidence of myocardial infarction was recorded in either patient, and they were discharged from our unit on the third postoperative day. Postoperative data for all patients are given in Table 3.
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). Angiographic follow-up revealed a 50% to 75% stenosis of the anastomotic region of the LIMA graft in 1 patient. All of the other anastomoses and the angioplasty results were satisfactory. There were no serious adverse events in any patient. However, 3 patients had experienced left pleural effusion that required drainage, and 1 patient had recurrent pleural effusion at the time of follow-up. None of the patients complained of chest wall pain, but 1 patient with a nonunion of the fourth rib felt discomfort during physical exercise. Another 2 patients had a nonunion of the fourth rib that did not cause any discomfort.
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Comment |
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TopFootnotesAbstractIntroductionMinimally Invasive Direct...PatientsResultsCommentReferences |
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The MIDCABG procedure is technically difficult, and an increased graft patency failure may be expected. In a 6-year follow-up study in 197 patients [4], coronary artery bypass grafts performed on a beating heart with conventional open technique showed disturbingly lower patency rates when compared with results achieved by procedures on a cardioplegically arrested heart. When MIDCABG is performed with anastomosis of the LIMA to an occluded LAD, anastomosis failure may result in little or no immediate symptoms or signs. Also, in patient 2, intraoperative transit time flow measurement did not reveal the damage on the LIMA likely to have been caused during surgical dissection. Interestingly, the mean flow value was 16 mL/min, which is within the interval of 49.8 ± 32.9 mL/min (mean ± standard deviation) for flow in LIMA-to-LAD grafts described by Walpoth and associates [5]. In addition to direct flow measurements, thermal imaging has been suggested for intraoperative evaluation of graft patency in MIDCABG procedures [6]. However, at present no alternative methods provide the same information about the conduit and the anastomosis as angiography.
Minimally invasive direct coronary artery bypass grafting may become the method of choice for treating LAD stenoses or occlusions, if the patency rates compare with those achieved with conventional coronary artery bypass grafting. The integrated hybrid procedure developed in our hospital allows a more complete or optimal myocardial revascularization in selected patients in one session. Percutaneous transluminal coronary angioplasty and stenting have become established methods, and patency rates may compete with patency rates of reversed-vein bypass grafting [7]. Thus, the most critical part of an integrated hybrid procedure is a successful LIMA-to-LAD anastomosis. We have demonstrated the value of intraoperative angiography in MIDCABG and integrated hybrid procedures, because it allows a reliable diagnosis of an anastomosis failure and prompt and reliable correction. This approach may well decrease patient morbidity and possibly mortality, and most likely it will reduce the need for later interventions or operations.
The relief of angina pectoris and freedom from cardiac events are related to the patency of the vascular reconstruction, and the gold standard is the excellent results achieved by conventional techniques concerning short-term and long-term patency and eventless survival [1]. The concept of the interventional center as a common turf of surgeons, cardiologists, and radiologists [3] might thus be of particular value in MIDCABG and integrated hybrid procedures.
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References |
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