Bilateral minimally invasive direct coronary artery bypass grafting with the use of two arterial grafts

A novel internal thoracic artery harvesting technique via subxiphoid approach--for the least invasive coronary artery bypass grafting

We have performed 12 cases of robotically assisted coronary artery bypass grafting (CABG) to accomplish less invasive revascularization. In this report, we describe a new method of robotically assisted internal thoracic artery (ITA) harvesting via subxiphoid approach, using the da Vinci surgical system. A 22-year-old man with three-vessel coronary artery disease due to Kawasaki disease was referred to our institution for coronary artery revascularization. A small subxiphoid incision was made, and the xiphoid process at the lower end of the sternum was excised. A U-shaped hook was inserted into the retrosternal space, and the lower sternum was lifted. A 30 degrees angle-up camera was inserted under the U-shaped hook, bilateral ITAs were harvested in a totally skeletonized fashion endoscopically. The required time for right ITA harvesting was 50 min, and that for the left was 20 min. After bilateral ITAs were harvested, composite grafts were made, and then the distal anastomoses were made. The patient was discharged six days after the operation. We performed a new robotically assisted bilateral ITA harvesting technique via sub-xiphoid safely and with excellent results. This method might be an evolutionary step of minimally invasive direct coronary artery bypass (MIDCAB) using the da Vinci surgical system.

Endoscopic radial artery harvesting: patient satisfaction and complications

Endoscopic radial artery harvesting was recently introduced to reduce the morbidity associated with conventional open harvesting and improve cosmetic outcomes. From January 2004 through December 2006, 25 radial arteries were harvested endoscopically from 25 patients using the VasoView endoscopic system. Bilateral radial arteries were harvested from 6 patients by both the endoscopic and open techniques, and postoperative patient satisfaction was assessed using a visual analogue scale. Mean harvesting time was 61.9 +/- 16.0 min (range, 44-105 min), and mean harvested conduit length was 16.8 +/- 2.0 cm (range, 15-19 cm). Objective dorsal thenar numbness remained in 2 patients (8%); none complained of forearm numbness. All patients expressed marked satisfaction with the endoscopic technique and the small incision. Patient satisfaction was significantly higher with the endoscopic technique than with the open technique (visual analogue scale of 9 vs 5). Postoperative angiography revealed occlusion of a graft that had been anastomosed to a small diagonal branch. The overall graft patency was 96.6%. Endoscopic radial artery harvesting can be performed safely with infrequent complications. This method results in excellent patient satisfaction, particularly regarding the cosmetic outcome.

Coronary artery bypass grafting for patients with an atherosclerotic ascending aorta

OBJECTIVES

We review the outcome of coronary artery bypass grafting in patients with a severe atherosclerotic ascending aorta.

METHODS

Subjects were 31 patients averaging 69.4 +/- 6.9 years old studied from 1990 through 1998. Ascending aortic lesions were assessed using epiaortic echo and 2 types of aortic nonclamping techniques applied. In 29 patients operated on in the early years, bypass grafting was conducted on the hypothermic fibrillated heart in 22 and on the beating heart in 7. The remaining 2 underwent off-pump coronary artery bypass grafting more recently. For cases with multivessel disease, we used composite grafting.

RESULTS

Three patients developed mild stroke and 5 died within 30 days of surgery--4 from multiple emboli (1 accompanied by a stroke) and 1 from perioperative myocardial infarction. One hospital death occurred due to brain damage and multiorgan failure following unexpected rupture of a saphenous vein graft. No cardiac deaths occurred in the late stage of our series. Actuarial survival was 73.0% for 3 years and 68.0% for 5 years. Freedom from cardiac events was favorable in the remaining 25 survivors.

CONCLUSIONS

Outcome was suboptimal for the risks involved. Recent technical advances, including coronary surgery on the beating heart with or without cardiopulmonary bypass using variable in-situ or free arterial grafts, associated with adequate evaluation of systemic atherosclerosis, should improve this outcome.

Grafts for Left Main Trunk Lesion Using “MIDCAB Doughnut” on Beating Heart

Successful beating heart multiple bypass grafting to the left anterior descending and circumflex artery for a left main trunk lesion was performed in 5 patients through a left thoracotomy using the “MIDCAB doughnut” for immobilization and hemostasis. After completion of left internal thoracic artery-to-left anterior descending artery grafting, a radial artery or saphenous vein graft was anastomosed safely to the obtuse marginal branch, without hemodynamic deterioration. Extending the left anterior small thoracotomy 3 or 4 cm laterally, the obtuse marginal branch could be approached easily without rotating the beating heart. The device achieved a still and stable operative field even for circumflex grafting. An inflow of the graft to the circumflex was placed at the left axillary artery to prevent blood flow shortage to the left coronary system. Mean perioperative blood flow was 29.5 ± 7.1 mL·min−1 in the internal thoracic artery grafts and 43 ± 8 mL·min−1 in the circumflex grafts. Postoperative angiography revealed patency of all grafts. The technique may extend the surgical indications for beating heart bypass surgery without cardiopulmonary bypass.

Minimally Invasive Coronary Artery Bypass: Experience in 114 Patients

From February 1996 to May 1998, 114 patients underwent a small (6 to 8 cm) left anterior thoracotomy for single-vessel coronary artery bypass grafting on a beating heart. There were 85 men and 29 women with a mean age of 63.1 ± 9.4 years, ranging from 36 to 84 years, and a mean preoperative ejection fraction of 53.2% ± 6.9%. The left internal mammary artery was anastomosed to the left anterior descending coronary artery under direct vision without cardiopulmonary bypass. There was no mortality. Postoperative morbidity included superficial wound infection in 3 patients. The length of the left internal thoracic artery was insufficient in two patients and the radial artery was used as an extension. Sixty-five (57%) patients underwent repeat coronary angiography (49 early, 16 late) and all grafts were patent. On intraoperative transesophageal echocardio-graphy, no segmental wall motion was seen during local coronary occlusion. Mean operative time was 1.7 ± 0.3 hours. One hundred and three patients (90%) were discharged 2 to 4 days postoperatively. The mean follow-up was 21.7 months. Minimally invasive surgery for left anterior descending coronary artery revascu-larization was considered to be a simple and effective alternative to the standard operation or angioplasty in selected patients.

[Minimally invasive cardiac surgery: surgical techniques and anesthetic problems]

OBJECTIVE

To review current data on minimally invasive cardiac surgery.

DATA SOURCES

Search through the Medline data base of French or English articles.

DATA EXTRACTION

The articles were analysed to make a synthesis of the various techniques with their main indications and contra-indications.

DATA SYNTHESIS

Minimally invasive cardiac surgery includes various surgical procedures. The usual techniques are described, their major benefits and drawbacks are discussed. The main goals of anaesthetic management are preservation of ventricular function and systemic perfusion, detection and treatment of myocardial ischaemia, prevention of hypothermia in case of coronary artery bypass grafting on the beating heart via sternotomy, intermittent selective ventilation of the collapsed lung using CPAP in case of limited thoracotomy. Expertise in transoesophageal echocardiography is essential for insertion and checking the accurate positioning of the various catheters of the endovascular CPB Heartport system (pulmonary vent, endosinus catheter, venous cannula, endoaortic clamp) allowing coronary artery bypass grafting and mitral valve surgery through limited thoracotomy and finally, detection of retained intracardiac air and assessment of complete clearing of cardiac cavities after mitral valve surgery through limited thoracotomy and aortic valve surgery via ministernotomy. Short-acting anaesthetic agents allow rapid recovery from anaesthesia, early extubation and discharge to the surgical ward within 24 h, whereas overall time spent in the operating room is often longer than with conventional cardiac surgery.

Minimally invasive direct coronary artery bypass for redo patients

BACKGROUND

The minimally invasive direct coronary artery bypass (MIDCAB) procedure, using a small anterolateral thoracotomy without cardiopulmonary bypass, has been recommended for high-risk patients because it is less traumatic than conventional coronary artery bypass grafting. For redo patients who have patent grafts and pericardial adhesions, the MIDCAB may be preferable to the conventional operation because manipulation of the graft and dissection of adhesions may be minimized.

METHODS

Since November 1995, 120 patients underwent the MIDCAB procedure in our institution. Among these patients, there were 25 redo cases (20.8%). We reviewed these redo cases and studied their surgical results (mortality, morbidity, hospital stay, operation time, and postoperative inotropic support). To clarify the usefulness of this procedure, we compared the results of redo operations with those of the first-time operations.

RESULTS

For redo MIDCAB, there was one operative death (4%) because of intestinal infarction. The mean hospital stay was 4.3 days and the number of patients who needed postoperative positive inotropic agents was 3 (12%). There was no significant differences between redo and first-time operation patients in mortality, morbidity, hospital stay, operation time, and postoperative inotropic support.

CONCLUSIONS

Results of the MIDCAB procedure for redo patients were comparable to those for primary MIDCAB operations.

On-line assessment of regional ventricular wall motion by transesophageal echocardiography with color kinesis during minimally invasive coronary artery bypass grafting

OBJECTIVE

Our objective was to determine the changes in regional ventricular wall motion during minimally invasive direct coronary artery bypass grafting by color kinesis using transesophageal echocardiography.

METHODS

Minimally invasive coronary artery bypass grafting was performed in 34 patients, during which transesophageal echocardiography was used. Thirteen patients had isolated disease of the left anterior descending artery. Regional ventricular wall motion was analyzed by color kinesis with the SONOS 2500 transesophageal echocardiograph (Hewlett-Packard Co, Andover, Mass). On-line assessment of regional wall motion was continued during the operation.

RESULTS

Wall motion abnormalities during ischemia were present in 4 cases, left ventricular mid-anterior hypokinesis in 3 cases, and left ventricular apical-lateral hypokinesis in 1 case. In all cases, wall motion was maintained after bypass. In patients with total coronary occlusion, changes in wall motion did not occur during anastomosis.

CONCLUSIONS

Color kinesis allowed us to evaluate the change in regional ventricular wall motion induced by myocardial ischemia during minimally invasive coronary artery bypass grafting both objectively and quantitatively.

Early experience with minimally invasive direct coronary artery bypass grafting with the internal thoracic artery

OBJECTIVE

Minimally invasive direct coronary artery bypass is performed under direct vision without sternotomy or cardiopulmonary bypass. The technique can be used in both primary and reoperative cases by employing the internal thoracic artery to perform arterial revascularization of the anterior surface of the heart.

METHODS

Patients were selected who had significant coronary artery disease limited to 1 or 2 coronary distributions on the anterior surface of the heart. Coronary target vessels were grafted with the internal thoracic artery through a small anterior thoracotomy. After partial heparinization the anastomosis was facilitated by local coronary occlusion and handheld stabilization.

RESULTS

Between August 1994 and July 1997, 162 patients underwent minimally invasive direct coronary artery bypass grafting with the internal thoracic artery. The left and right internal thoracic arteries were used for grafting of the left anterior descending artery in 142 patients (88%), the proximal right coronary artery in 7 patients (4%), existing saphenous vein grafts in 5 patients (3%), and diagonal branches in 2 patients (1%). Sequential grafting with the left internal thoracic artery was performed in 2 patients (1%) and bilateral internal thoracic artery grafting was performed in 4 patients (3%). Eight patients (4.9%) died within 30 days after the operation, 3 of cardiac causes. Seven additional patients died during the follow-up period. Nine patients (5.6%) required reintervention for graft stenosis or occlusion during follow-up. Of 141 patients seen 2 or more weeks after the operation, 135 (96%) had resolution of their anginal symptoms at a mean follow-up of 12 months (range 0-31 months).

CONCLUSIONS

Anterior minimally invasive direct coronary artery bypass grafting with the internal thoracic artery avoids the risks of repeated sternotomy, aortic manipulation, and cardiopulmonary bypass. There was a low rate of reintervention, and patients had excellent resolution of anginal symptoms. Postoperative length of stay was comparatively short, and continued follow-up will be essential to evaluate long-term graft patency and patient survival.

Surgical results of video-assisted minimally invasive direct coronary artery bypass

BACKGROUND

A video-assisted minimally invasive direct coronary artery bypass procedure is defined as a combination of video thoracoscopic internal mammary artery harvest and direct coronary bypass grafting through a minithoracotomy without cardiopulmonary bypass. We reviewed our experience with this procedure and examined its efficacy.

METHODS

Since November 1995, 110 patients have undergone a minimally invasive direct coronary artery bypass procedure in our institution. Seventy (64%) of them underwent a video-assisted minimally invasive operation (group 1). As a control group (group 2), we reviewed the results in 37 patients who underwent conventional single or double coronary artery bypass grafting using an internal mammary artery graft between 1993 and 1995 and could have been candidates for minimally invasive direct coronary artery bypass grafting.

RESULTS

There were two hospital deaths (2.9%) in group 1 and one hospital death (2.7%) in group 2. There were no significant differences in mortality or morbidity between the two groups. The number of patients who needed postoperative positive inotropic agents was significantly greater in group 2, and this group also had a significantly longer mean postoperative intubation time and mean hospital stay than group 1.

CONCLUSIONS

The surgical results of video-assisted direct coronary artery bypass procedures were better than those of conventional coronary artery bypass grafting in this review. A long-term follow-up for graft patency is needed.

Minimally invasive cardiac surgery: current status and perspective

Recently, the minimally invasive approach has become a growing aspect in the field of cardiac surgery with the goal of eliminating cardiopulmonary bypass (CPB) and/or median sternotomy. In coronary bypass surgery, the application of this approach is direct anastomosis, primarily of the left internal thoracic artery to the left descending coronary artery under a beating condition without the use of CPB through a small left thoracotomy minimally invasive direct coronary artery bypass (MIDCAB). In the repair of intracardiac lesions, CPB cannot be excluded, but a small right parasternal incision or small partial sternotomy (ministernotomy) has been applied for congenital defects and mitral and aortic valve lesions. With technological advances in CPB, these approaches may become more popular in the near future.

Bilateral thoracoscopic minimally invasive direct coronary artery bypass grafting using internal thoracic arteries

BACKGROUND

Single-vessel coronary artery bypass grafting of the left internal mammary artery (ITA) to the left anterior descending coronary artery using a minithoracotomy has been shown to produce excellent results with a very low mortality. However, this procedure cannot be used in patients with double- or triple-vessel disease. Our goal was to develop a minimally invasive direct coronary artery bypass grafting procedure without cardiopulmonary bypass for patients with multivessel disease.

METHODS

Both ITAs were thoracoscopically harvested using video imaging. Limited bilateral anterior thoracotomies were performed in the fourth intercostal spaces, thus exposing the right coronary artery and the left anterior descending coronary artery. The right ITA-right coronary artery and ITA-left anterior descending coronary artery anastomoses were performed without cardiopulmonary bypass using 8-0 polypropylene sutures.

RESULTS

This procedure was successfully performed in 3 patients. The patients were extubated in the operating room. Postoperative angiographic studies showed patent left ITA and right ITA grafts.

CONCLUSIONS

Bilateral thoracoscopic minimally invasive direct coronary artery bypass grafting can be used to treat patients with a proximally diseased left anterior descending coronary artery and right coronary artery. Bilateral thoracoscopic ITA harvesting is a less invasive surgical technique that may become an option for the management of multivessel coronary artery disease.