The Dresden approach for complete multivessel revascularization

Left thoracotomy approach for off-pump coronary artery bypass grafting surgery: 15 years of experience in 2500 consecutive patients

OBJECTIVES

Our goal was to describe the experience at 2 centres with off-pump coronary artery bypass grafting using a left thoracotomy.

METHODS

From January 2002 to December 2017, a total of 2528 consecutive patients (578 women, mean age 62.3 ± 9.1 years) were operated on using this technique. Data were collected prospectively and analysed retrospectively.

RESULTS

There were no conversions to median sternotomy and 6 patients (0.2%) were converted to on-pump CABG. The mean number of grafts per patient was 2.8 ± 0. 9. The 30-day mortality rate was 1.0% (25 patients). Most patients were extubated in the operating theatre (97.3%), and 47 patients (1.9%) needed re-exploration for bleeding. Seven patients (0.3%) experienced a cerebrovascular event; 4 (0.3%) had a postoperative myocardial infarction; and 84 (3.4%) had new-onset atrial fibrillation. A total of 1510 patients (61.1%) were discharged from the hospital in the first 48 h after surgery. Long-term survival rates were 98.8%, 93.6% and 69.1% at 1, 5 and 10 years, respectively (central image). During the follow-up period, 60 patients (2.9%) were re-examined for recurrence of angina with a new coronary angiogram; of those, 24 (1.2%) required percutaneous coronary intervention and 11 (0.5%) had redo surgery.

CONCLUSIONS

A left thoracotomy is a safe alternative to a median sternotomy for coronary artery bypass grafting on the beating heart, with low early complications and good mid- and long-term results.

Minimally invasive and robotic coronary artery bypass grafting-a 25-year review

During the mid-1990s cardiac surgery started exploring minimally invasive methods for coronary artery bypass grafting (CABG) and has over a 25-year period developed highly differentiated and less traumatic operations. Instead of the traditional sternotomy mini-incisions on the chest or ports are placed, surgery on the beating heart is applied, sophisticated remote access heart lung machine systems as well as videoscopic units are available, and robotic technology enables completely endoscopic approaches. This review describes these methods, reports on the cumulative intra- and postoperative outcome of these procedures, and gives an integrated view on what less invasive coronary bypass surgery can achieve. A total of 74 patient series published on the topic between 1996 and 2019 were reviewed. Six main versions of minimal access and robotically assisted CABG were applied in 11,135 patients. On average 1.3±0.6 grafts were placed and the operative time was 3 hours 42 min ± 1 hour 15 min. The procedures were carried out with a hospital mortality of 1.0% and a stroke rate of 0.6%. The revision rate for bleeding was 2.5% and a renal failure rate of 0.9% was noted. Wound infections occurred at a rate of 1.2% and postoperative hospital stay was 5.6±2.2 days. It can be concluded that less invasive and robotically assisted versions of coronary bypass grafting are carried out with an adequate safety level while surgical trauma is significantly reduced.

Multivessel Arterial Revascularization via Left Anterior Thoracotomy

To present the technique and to evaluate the outcomes of the multivessel minimally invasive coronary revascularization through the left anterior thoracotomy. From July 2017 to March 2019 in 229 consecutive patients with isolated multivessel coronary artery disease we performed complete coronary revascularization through the left anterior minithoracotomy (6-8 cm skin incision). In 47 of them we performed multiarterial revascularization using left internal mammary artery and T-shunt with left radial artery or right internal mammary artery. Cardiopulmonary bypass (CPB), Chitwood clamp and blood cardioplegia were used in all patients. Heart strings, encircling tapes and Chitwood clamp were used to reduce the distance from skin to coronary targets. Usual coronary instruments were used. The perioperative outcomes of multiarterial graft strategy group were compared with uniarterial graft strategy group. There were no mortality, no perioperative myocardial infarcts, and no conversion to sternotomy with either graft strategy groups. The mean number of distal anastomoses, CPB time, and total hospital stay were not different between the groups. Aortic cross-clamp time ((83.8 ± 17.4 (45;121) vs 67.8 ± 17.4 (35;146), P < 0.0001) and total operation time (283.5 ± 45 (205;495) vs 254.3 ± 48.6 (175;590), P = 0.0003) were longer in patients with multiarterial revascularization compared to uniarterial revascularization using left internal mammary artery and veins. Multivessel coronary bypass grafting using CPB and cardioplegia can be routinely performed minimally invasively through the left anterior thoracotomy. In selected patients multiarterial revascularization could be done with excellent procedural outcomes.

Complete Coronary Revascularization via Left Anterior Thoracotomy

OBJECTIVE

Our aim was to develop the minimally invasive coronary artery bypass grafting (CABG) technique, which is equally effective and safe compared with conventional coronary grafting technique, is reproducible, and can be applied in the vast majority of patients with isolated coronary artery disease.

METHODS

From July 2017 to November 2018 a total of 170 nonselected consecutive patients underwent minimally invasive on-pump multivessel CABG through the left anterior minithoracotomy in the fourth intercostal space using a Chitwood clamp and blood cardioplegia. We named this technique total coronary revascularization via left anterior thoracotomy. The mean number of grafts was 3.1 ± 0.7. Left internal mammary artery was used in 159 (93.5%) patients, right internal mammary artery in 4 (2.4%) patients, radial artery in 25 (14.7%) patients, and veins in 148 (87%) patients.

RESULTS

We had no mortality, no postoperative myocardial infarcts, and no conversion to sternotomy. There were 2 postoperative strokes without residual neurological deficit and 2 revisions for postoperative bleeding. The total operation time was 258.8 ± 43.9 minutes, cardiopulmonary bypass time 135.8 ± 26.6 minutes, and aortic cross-clamp time 71.2 ± 19.4 minutes. The mean intensive care stay was 2.1 ± 0.56 days and mean total hospital stay 6.3 ± 1.3 days.

CONCLUSIONS

Complete coronary revascularization could be routinely performed using the above-mentioned technique. No patient selection, based on number of grafts, quality and location of coronary vessels, left ventricle function, age, gender, or body mass index, is required.

Minimally Invasive Coronary Bypass Using Internal Thoracic Arteries via a Left Minithoracotomy

Objective

Harvesting of the right internal thoracic artery (RITA) under direct vision, through a left minithoracotomy, without robotic or thoracoscopic assistance has never been done or described before. Bilateral internal thoracic arteries (BITAs) in coronary artery bypass grafting (CABG) have shown greater survival and freedom from reintervention. The aim was to develop a multivessel minimally invasive CABG technique in which the BITAs are harvested under direct vision and complete revascularization of the myocardium is done by the off-pump method, using only BITAs (left internal thoracic artery [LITA]–RITAY) through a 2-in left minithoracotomy, without robotic/thoracoscopic assistance—the “Nambiar Technique.”

Methods

From August 2011 to December 2012, a total of 150 patients underwent off-pump minimally invasive multivessel CABG using BITAs, through a 2-in left minithoracotomy incision. Both internal thoracic arteries were harvested directly under vision, and complete revascularization of the myocardium was done using the LITA-RITAY composite conduit, followed by flow study of the grafts. Coronary artery stabilization for anastomoses was done by using epicardial stabilizers introduced through the minithoracotomy.

Results

One hundred fifty patients had minimally invasive total arterial myocardial revascularization using BITAs (LITA-RITA Y composite conduit) via a left minithoracotomy. The mean number of grafts was 2.8. A total of 81.6% of the patients had three grafts. Ejection fraction was 34.5 ± 5.2. There was one mortality but no major morbidity. The RITA and LITA harvest times were 39.5 ± 11.2 and 35.2 ± 8.6 minutes, respectively. The total time in the operating room (including extubation) was 331.5 ± 42.5 minutes, and operating time was 240.8 ± 24.6 minutes. One hundred twenty-six patients (87.7%) were extubated on the table. The mean hospital stay was 3.1 days. One patient (0.6%) had an elective conversion to sternotomy because the flow in the LITA-RITA Y composite conduit was inadequate and had saphenous vein grafts. Coronary angiograms were done in 37 patients (25%); and computed tomographic angiograms, in 33 patients (22%), and the grafts were patent. Stress test was done in 80 patients (53%), which had normal findings.

Conclusions

The Nambiar Technique encompassed using a 2-in left minithoracotomy incision through which the BITAs were conveniently harvested in a skeletonized manner under direct vision without robotic or thoracoscopic assistance. Multivessel total arterial revascularization was then done using the LITA-RITA Y composite conduit by the off-pump methodology. The early outcomes have been excellent, and coronary angiograms showed widely patent grafts. This technique is reproducible and can be done on an empty beating heart to aid in training.

Robotic Assisted Multivessel Minimally Invasive Direct Coronary Artery Bypass With Port-Access Stabilization and Cardiac Positioning: Paving the Way for Outpatient Coronary Surgery?

BACKGROUND

Minimimal access multivessel coronary artery bypass grafting with same day hospital discharge remains the ultimate goal. We evaluated the feasibility for achieving multivessel coronary bypass through minimal access.

METHODS

From January to July 2003, 30 patients under went off-pump minimally invasive multivessel coronary bypass. Internal mammary arteries were harvested with robotic telemanipulation with three ports. A 2-inch to 3-inch incision with soft tissue retractor was used to perform coronary anastomosis. Robotic ports were used to introduce stabilization and cardiac positioning devices. Endoscopic harvesting of radial artery was done when necessary.

RESULTS

Twenty-three patients (77%) had anterior throracotomy approach and 7 (23%) had transabdominal approach. Average number of bypass grafts was 2.6 (range 2-4). There was no mortality in hospital or on 30-day follow-up. Twenty-nine patients (97%) were extubated on the operating table. Two patients required reoperation for bleeding and 1 of those patients needed conversion to sternotomy for additional bypass grafting. Within 24 hours of surgery 50% of patients (n = 15) were discharged, 10% (n = 3) were discharged in 24 to 36 hours, 17% (n = 5) were discharged in 36 to 48 hours, 17% (n = 5) were discharged in 48 to 72 hours, and 2 patients stayed more than 3 days in the hospital. Two patients needed readmission to hospital within 30 days; 1 for pleural effusion and 1 for wound infection.

CONCLUSIONS

Robotic harvesting of internal mammary arteries and port access stabilization and cardiac positioning allows multivessel coronary bypass to be performed through a small incision. Currently, the majority of the patients can be safely discharged within 36 hours of operation.

Port access video-assisted proximal anastomosis with the symmetry aortic connector in MIDCABG procedure

We present an alternative way to create a video-assisted port access proximal anastomosis in the ascending aorta with the Symmetry Bypass System Aortic Connector (St. Jude Medical ATG, St. Paul, MN). This technique was successfully used in a patient undergoing urgent minimally invasive direct coronary artery bypass grafting (MIDCABG), in whom the left internal mammary artery was not harvested owing to subtotal occlusion of the left subclavian artery. Port access use of mechanical anastomotic devices may increase the indications for minimally invasive coronary artery surgery.

Video-assisted multivessel revascularization through a left anterior small thoracotomy approach with the Symmetry Aortic Connector System

OBJECTIVE

We sought to demonstrate the applicability of video-assisted multivessel revascularization through a left anterior small thoracotomy approach with the use of the Symmetry Aortic Connector System (St Jude Medical Anastomotic Technology Group, Inc, St Paul, Minn) as an alternative to the standard median sternotomy approach and to evaluate predischarge angiographically documented graft patency.

METHODS

From October 2001 through February 2002, a total of 15 patients with triple-vessel disease were operated on through a left anterior small thoracotomy approach with video-assisted port-access construction of proximal aorta-to-saphenous vein anastomoses with the Symmetry Aortic Connector System and cardiopulmonary bypass with femoral cannulation and without cardioplegic arrest. There were 9 male and 6 female subjects with a mean age of 68.3 +/- 3.6 years and an average ejection fraction of 55.8% +/- 19.6%. Subject inclusion criteria consisted of female sex (initially but not throughout the study), coronary artery reoperations, and sternal bone disease. Subject exclusion criteria consisted of an age younger than 65 years, extensive atheromatous plaques in the ascending aorta, and aortoiliac occlusive disease. All but 1 patient underwent angiographic patency evaluation before discharge.

RESULTS

Fifteen operations were performed successfully without any deaths. Twenty-nine sutureless proximal anastomoses were performed, with an average of 3.13 +/- 0.62 distal anastomoses per patient. Eleven (73%) patients underwent a fast track protocol with extubation in the operating room. We did not observe any instances of low cardiac output syndrome, stroke, renal insufficiency, wound complication, or perioperative myocardial infarction. A single episode of atrial fibrillation occurred in this group. Angiographic assessment of 44 bypass grafts and target arteries was performed, and 86% of those examined were widely patent (FitzGibbon score A).

CONCLUSIONS

We have demonstrated a potential advantage of the sutureless Symmetry Aortic Connector System as a suitable approach that affords minimal access. Video-assisted multivessel revascularization through a left anterior small thoracotomy approach with an automated mechanical anastomosis device is particularly useful in patients undergoing coronary artery bypass reoperations or those at risk of poor sternal healing or infection. This approach seems to be a safe alternative to standard median sternotomy.

How safe is the port access technique in minimally invasive coronary artery bypass grafting?

BACKGROUND

This study compares conventional coronary artery bypass grafting (CABG) with port access CABG via a left anterior small thoracotomy in patients requiring surgical multivessel revascularization. Clinical, neuropsychological, and angiographic outcomes were studied, as well as parameters of myocardial and cerebral protection. Pathogenicity of cardiopulmonary bypass (CPB) was further evaluated by measuring parameters of peripheral limb ischemia and inflammatory whole-body response.

METHODS

In a prospective randomized study, 40 patients who required multivessel CABG were assigned to either conventional CABG via complete median sternotomy (group A) or port access CABG via minithoracotomy (group B). Control angiograms were performed in group B only. In addition, patients underwent neuropsychological testing after the operation. CK, CK-MB, and Troponin T levels were documented. S-100B protein and neuron-specific enolase (NSE) served to quantify cerebral injury. The terminal complement complex (C5b-9) and myeloperoxidase concentrations were determined to analyze inflammatory whole-body response after CPB.

RESULTS

There was no mortality. One patient suffered a retrograde aortic dissection immediately after onset of CPB, but had an uneventful postoperative course after surgical repair. Troponin T and CK-MB showed no difference between groups. CK and myoglobin were significantly higher in the minimally invasive cohort. Changes in complement activation (C5b-9) and myeloperoxidase during CPB markers of the whole-body inflammatory response were similar in both groups. S-100B concentrations in the port access group were significantly higher, whereas NSE levels were similar in both groups. Both groups did not display any significant difference in neuropsychological testing.

CONCLUSIONS

Minimally invasive multivessel CABG via minithoracotomy using port access technology is feasible and safe. Though prolonged operating and CPB times with significantly higher S-100B concentrations were observed in group B, equivalent myocardial and cerebral protection and similar whole-body inflammatory response were documented.

Totally robotic technique in multivessel coronary disease--is it possible?

Robotic techniques in coronary surgery have been established for a few years. The preparation of the internal mammary arteries is now a well-described procedure, as is anastomosis to the anterior wall vessels under cardiopulmonary bypass. To achieve totally robotic complete revascularization of the heart, there are still some problems to be solved. Potential solutions are discussed. Current techniques using telemanipulation systems in cardiac surgery are described and explained. Totally endoscopic off-pump complete revascularization of the heart might be achieved by a combination of techniques already developed by different teams around the world.

Closed chest totally endoscopic coronary artery bypass surgery: fantasy or reality?

With the introduction of the da Vinci robotic surgical system (Intuitive Surgical, Mountain View, CA) into minimally invasive cardiac surgery, the outlook of performing coronary artery bypass operations "closed chest" became a reality. Between May 1999 and July 2000 this wrist-enhanced instrumentation was used in 143 patients (107 men, 36 women, median age 63 10.3 y). Thirteen patients suffering from coronary artery disease (CAD) were treated as totally endoscopic coronary artery bypass (TECAB), 79 patients underwent a minimally invasive direct coronary artery bypass procedure, and 35 patients were treated using the robotic-enhanced Dresden Technique. Preoperative survival was 100%. All patients in the TECAB group were operated upon via a three- or four-point stab incision using the da Vinci robot for internal mammary artery takedown and for performance of anastomoses. These new robotic-enhanced surgical techniques promote an optimistic way of thinking about the further development of these procedures and its application in patients suffering from CAD.

Wrist-enhanced instrumentation: moving toward totally endoscopic coronary artery bypass grafting

BACKGROUND

With the introduction of the da Vinci robotic surgical system (Intuitive Surgical, Mountain View, CA) into minimally invasive cardiac operations the outlook for performing coronary artery bypass operations "closed chest" became a reality.

METHODS

Between May 1999 and December 1999 this new wrist-enhanced instrumentation was used in 61 patients. Six patients suffering from single-vessel coronary artery disease and one female patient with double-vessel disease underwent totally endoscopic coronary artery bypass. Thirty-seven patients with single-vessel disease underwent a minimally invasive direct coronary artery bypass procedure. Seventeen patients with double-vessel disease were treated using the robotic-enhanced Dresden technique.

RESULTS

Perioperative survival was 100%. In all patients the internal mammary arteries were safely harvested endoscopically and had excellent quality. In both totally endoscopic coronary artery bypass groups all patients were operated on through three stab incisions.

CONCLUSIONS

Our preliminary experience with this new surgical technique using robotic-enhanced minimally invasive methods for coronary artery disease promotes optimism regarding further development of these procedures and application in patients with coronary artery disease.

Robotic-enhanced arterial revascularization for multivessel coronary artery disease

BACKGROUND

A tendency to reduce operative trauma is determining the evolution of cardiac surgical techniques lately. The introduction of robotic-enhanced endoscopic systems enables surgeons to perform arterial revascularization for multivessel disease without sternotomy.

METHODS

From May 1999,17 (4 women, 13 men; median age 63+/-7.4 years) patients with multivessel coronary artery disease were treated surgically using arterial revascularization by means of bilateral internal mammary arteries. Both arteries were harvested endoscopically using the da Vinci system (Intuitive Surgical, Mountain View, CA). These vessels were anastomosed using the "Dresden technique."

RESULTS

Survival was 100%. Mean duration of the operation was 255+/-40.4 minutes. Bilateral internal mammary artery harvesting took 88.5+/-15.9 minutes; cross-clamp time was 36+/-8.7 minutes. An average of 2.06 anastomoses were performed per operation. Postoperatively, patients remained in the intensive care unit for 21+/-13 hours. One patient (5.8%) needed reexploration due to bleeding.

CONCLUSIONS

The robotic surgical system introduces a new treatment of coronary artery disease to surgical practice, and enables arterial revascularization with distinctly reduced surgical trauma.