"Keyhole" coronary artery bypass surgery

Distal anastomotic patency of the Cardica C-PORT(R) xA system versus the hand-sewn technique: a prospective randomized controlled study in patients undergoing coronary artery bypass grafting

OBJECTIVES

The C-Port® Distal Anastomosis Systems (Cardica, Inc., Redwood City, CA, USA) demonstrated favourable results in feasibility trials. However, distal vein anastomoses created with the C-Port® or C-Port xA® system have never been compared with hand-sewn distal vein anastomoses. The objective of this study was to compare distal end-to-side anastomoses facilitated with the C-Port xA® System with the traditional hand-sewn method.

METHODS

This single-centre prospective randomized controlled study comprised 71 patients (device group n = 35, control group n = 36) who underwent primary elective coronary artery bypass grafting between June 2008 and April 2011. The primary study end-point was 12-month distal anastomotic patency, which was assessed with prospective ECG-gated 256-multislice computed tomographic coronary angiography using a step-and-shoot scanning protocol. For the primary end-point, a per-protocol analysis was used.

RESULTS

In the device group, four (11%) anastomoses were converted to hand-sewn anastomoses, and additional stitches to achieve haemostasis were necessary in 22 (76%) patients. There was no hospital mortality in either group. During the 12-month follow-up, a single death occurred in the Device group and was unrelated to the device. Twenty-nine patients in the device group and 32 in the control group completed 12-month CT coronary angiography. The overall patency of 160 studied distal vein graft anastomoses was 93%. Comparison of the end-to-side target anastomosis showed 12-month patencies of 86 and 88% in the device group and the control group, respectively.

CONCLUSIONS

According to these preliminary results and despite the limited number of patients, the use of the C-Port xA® System is safe enough to perform distal end-to-side vein graft anastomosis, with respect to 12-month end-to-side distal venous anastomotic patency. Although there are some technical challenges with this device, the incidence of complications is comparable to the traditional hand-sewn technique.

Hybrid revascularization feasibility in minimally invasive direct coronary artery bypass grafting combined with percutaneous transluminal coronary angioplasty in patients with acute coronary syndrome and multivessel disease

OBJECTIVES

We reviewed early and midterm outcome of 11 multivessel-disease acute coronary syndrome patients treated by hybrid revascularization, i.e., initial coronary angioplasty followed by minimally invasive direct coronary artery bypass grafting. We evaluated procedural efficacy and applicability.

METHODS

Beginning in August 1997, hybrid revascularization was conducted in 11 multivessel-disease acute coronary syndrome patients--9 men and 2 women with a mean age of 70.3 +/- 9.3 years. Occlusion or stenosis of the target coronary artery was treated by interventional cardiologic techniques and minimally invasive direct coronary artery bypass grafting, and the early and midterm outcome evaluated. Coronary angiography was conducted in all cases at 2 weeks, 6 months, 1 and 3 years postoperatively to evaluate anastomosis and restenosis in treated coronary vessels.

RESULTS

Initial intervention succeeded in patients with minimal residual stenosis. Subsequent minimally invasive direct coronary artery bypass grafting involved no complications. Coronary angiography early postoperatively, 6 months, 1 and 3 years later showed grafts patent without stenosis. Percutaneous transluminal coronary angioplasty was reconducted on restenotic lesions in 3 patients, 1 of whom required 3 procedures.

CONCLUSIONS

Hybrid revascularization appears safe and effective in coronary revascularization, at least over the short term. Several patients underwent angioplasty for restenosis within 3 years after initial procedure. Overall acceptance of this hybrid method depends on long-term functional success of the 2 procedures. Its major limitation is restenosis of angioplasty sites and the need for repeat procedures.

Clinical results with left axillary to left anterior descending coronary artery bypass

BACKGROUND

The minimally invasive direct coronary artery bypass procedure is not feasible if the left internal mammary artery has been used or has inadequate flow. We have applied a modified minimally invasive direct coronary artery bypass procedure, which uses a graft from the left axillary artery to the left anterior descending coronary artery in such situations.

METHODS

The graft is anastomosed to the left axillary artery adjacent to the clavicle and tunneled underneath the vein, where it enters the thorax through the first interspace and courses to the left anterior descending coronary artery along the mediastinum.

RESULTS

Since 1997 we have used this operation in 22 patients with a mean age of 70 years (range, 52 to 83 years). All patients were high-risk candidates because of advanced age (70 +/- 7 years), depressed left ventricular function (mean left ventricular ejection fraction, 38% +/- 6%), or previous heart operation (20 of 22, 91%). Conduits for the graft were saphenous vein (n = 18) or radial artery (n = 4). Ten patients were extubated in the operating room, and the mean duration of mechanical ventilation was 5.8 +/- 6 hours. There was one operative death (1 of 22, 4.5%). The mean length of intensive care unit and hospital stay was 1.5 days (range, 1 to 6 days) and 6 days (range, 2 to 15 days), respectively. At a mean follow-up of 6 months, all discharged patients are alive and functionally improved. None have required surgical or catheter-based revascularization of the left anterior descending coronary artery.

CONCLUSIONS

The left axillary artery to left anterior descending coronary artery graft should be considered for high-risk patients in whom a minimally invasive direct coronary artery bypass procedure is not possible.

Evaluation of graft patency during minimally invasive coronary artery bypass grafting with Doppler flow analysis

BACKGROUND

An objective method for determining intraoperative graft patency is an essential part of minimally invasive direct coronary artery bypass. This study compares angiography and Doppler methods for graft analysis during minimally invasive direct coronary artery bypass and presents long-term outcome in a cohort of patients.

METHODS

Between March and October 1997, 35 patients had elective minimally invasive direct coronary artery bypass procedures in which the left internal mammary artery was anastomosed to the left anterior descending coronary artery. Immediate graft patency was determined with intraoperative angiography using selective injection of the left internal mammary artery from a femoral approach and with Doppler flow analysis using a 1-mm, 20-MHz Doppler probe placed directly on the graft.

RESULTS

There was immediate perfect patency with brisk flow in 91% of patients (32 of 35). A normal Doppler study, defined as a diastolic predominant pattern with a diastolic flow velocity of greater than 15 cm/second, was found in all patients with normal angiograms. All patients with abnormal angiograms also had abnormal Doppler flow. Thus, Doppler analysis was 100% accurate for confirming graft patency and for detecting failed grafts. All abnormal grafts were successfully revised, which allowed 100% early patency. Operative mortality was 2.8% (1 of 35) and there have been no late deaths at a follow-up of more than 2 years. One patient required angioplasty of the anastomosis (1 of 34, 2.9%), but none have required subsequent surgical intervention.

CONCLUSIONS

Objective analysis of graft flow in the operating room is necessary to achieve 100% early graft patency with minimally invasive direct coronary artery bypass operations. Doppler analysis is the preferred initial method, because it is safe, accurate, and rapid.

Short- and long-term follow-up after coronary bypass grafting for single-vessel coronary artery disease

Short-term outcome and 10-year clinical outcome were reviewed in 114 consecutive patients after coronary artery bypass grafting (CABG) for single-vessel coronary artery disease (CAD). Gated equilibrium radionuclide cineangiography was performed soon after CABG in all cases, and revealed very good early graft patency rates. There was no perioperative mortality, and very low morbidity. During follow-up there were seven late deaths, two from cardiac disease and five from non-cardiac causes. Cumulative survival at 10 years was 93%. Cumulative freedom from additional cardiac invasive procedures was 96%, 93% and 80% at 1, 5, and 10 years, respectively, and cumulative freedom from angina was 93%, 80% and 73%. Conventional single-vessel CABG thus can be safely performed, with minimal postoperative morbidity and no mortality, providing good long-term relief of angina and circumventing need for additional invasive procedures.

Same-day combined coronary angioplasty and minimally invasive coronary surgery

Integrated myocardial revascularization combines the advantages of angioplasty, stenting, and minimally invasive surgery to revascularize patients with multivessel coronary artery disease without cardiopulmonary bypass. This pilot study showed that a new same-day management strategy, consisting of percutaneous coronary intervention followed immediately by minimally invasive surgery, was feasible and provided complete all-arterial revascularization with minimal surgical trauma, short hospital stay, and excellent early therapeutic result in 14 patients with multivessel coronary disease.

Vascular clamp for hemostasis and stabilization during minimally invasive direct coronary artery bypass

A soft vascular clamp was used for hemostasis and stabilization of the operative field during minimally invasive direct coronary artery bypass (MIDCAB). The instrument was gently applied so that it clamps the coronary artery by grasping the adjacent myocardium. The method offered dry and stable operative field without a special instrument or technique. The surgical results have been satisfactory. We found application of the vascular clamp to be very helpful for MIDCAB.

[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.

Intraoperative considerations during minimal-access cardiac surgery

The range of minimal-access cardiac surgery approaches has many implications in intraoperative management. A modified anesthetic regimen is required to deal with the type of surgical exposure, hemodynamic instability, whether cardiopulmonary bypass is used, and early extubation. Intraoperative considerations include hemodynamic monitoring, one-lung ventilation, pharmacological stabilization of the myocardium, pacing, hypothermia, bleeding, and rapid emergence with a minimum of postoperative mechanical ventilation. As a result, anesthetic methods and intraoperative management were modified to meet these specific needs of minimally invasive cardiac procedures.

Morbidity, cost, and six-month outcome of minimally invasive direct coronary artery bypass grafting

BACKGROUND

Minimally invasive direct coronary artery bypass grafting (MIDCABG) promises to reduce the morbidity of coronary bypass, but this has not been proved.

METHODS

This retrospective study compares the morbidity, mortality, cost, and 6-month outcome of patients less than 80 years old undergoing elective left internal mammary artery to left anterior descending artery bypass grafting via MIDCABG (n = 60) or sternotomy (n = 55) between January 1995 and December 1996. There were no differences between the groups in mean age, sex distribution, or preoperative risk level. The left internal mammary artery was mobilized from the fifth costal cartilage to the subclavian artery in all patients. The anastomoses were done with a beating heart in the MIDCABG group and with cardioplegic arrest in the sternotomy group.

RESULTS

There were no operative deaths in either group. The MIDCABG patients had a lower transfusion incidence (10/60 [17%] versus 22/55 [40%]; p< or =0.02) and a shorter postoperative intubation time (2.1+/-4.2 versus 12.6+/-9 hours; p< or =0.0001). One patient in each group was reexplored for bleeding. Three sternotomy patients (3/55, 5%) required ventilatory support for greater than 48 hours, but no MIDCABG patient was ventilated for more than 24 hours. Median postoperative length of stay was 4 days for MIDCABG and 7 days for sternotomy. Estimated hospital costs were $11,200+/-3100 for MIDCABG and $15,600+/-4200 for CABG (p < 0.001). The reduced morbidity and cost of MIDCABG was found mostly in high-risk patients. At 6-month follow-up, 5 MIDCABG patients (5/60, 8%) had evidence of recurrent ischemia involving the left anterior descending artery, primarily the result of anastomotic stricture.

CONCLUSIONS

This analysis shows that MIDCABG reduces the initial morbidity and cost of coronary bypass, but some patients require subsequent reintervention. Long-term follow-up is needed before MIDCABG can be judged better than traditional bypass, but the initial results are promising, especially in high-risk patients.

Minimally invasive direct coronary artery bypass: anesthetic, monitoring, and pain control considerations

OBJECTIVE

Minimally invasive direct coronary artery bypass (MIDCAB) provides many anesthetic challenges including monitoring, managing myocardial ischemia, and pain control. The objective was to evaluate the monitoring requirements and the potential benefits of preischemic conditioning and intrathecal morphine sulfate in MIDCAB patients.

DESIGN AND SETTING

This review was retrospective and unrandomized and was conducted at Allegheny University Hospitals, Allegheny General, Pittsburgh, PA.

PARTICIPANTS

Sixty-four patients with single coronary artery lesions (> 70% obstruction) underwent attempted MIDCAB during a 1-year period between November 1995 and November 1996. Seven patients required conversion to conventional coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB) and two patients required extended thoracotomy incisions. This report describes the remaining 55 patients who underwent MIDCAB.

INTERVENTIONS

Some of the MIDCAB patients received intrathecal morphine before anesthetic induction. Ischemic preconditioning was assessed in a subset of patients.

RESULTS

MIDCAB was performed in 55 of 64 patients. Transesophageal echocardiography (TEE) was used in all patients and a pulmonary artery catheter was used in 43% of patients. Esmolol was used in 25% of patients to reduce motion of the left ventricle (LV) during the left internal mammary artery (LIMA)-LAD anastomosis, but was used less often as the surgeons adapted to the use of a retractor that stabilized the ventricular wall adjacent to the site of the LIMA-LAD anastomosis. LAD occlusion caused reversible, regional systolic dysfunction by TEE in the anterior and apical LV segments. During LAD occlusion, nitroglycerin was used in 61% of patients and phenylephrine in 24%. Ischemic preconditioning did not prevent increases in systemic or pulmonary artery pressures during LAD occlusion. Most (85%) patients were extubated in the operating room. Intrathecal morphine decreased postoperative analgesic requirements. The mean hospital length of stay (LOS) was 4.0 +/- 1.7 days (range, 1 to 10 days).

CONCLUSIONS

MIDCAB may reduce hospital LOS for patients with single vessel coronary artery lesions when compared with median sternotomy with a LIMA-LAD graft performed on cardiopulmonary bypass. Pharmacologic heart rate control during the LIMA-LAD anastomosis is not critical with the use of a surgical retractor which diminishes ventricular motion. A single 5-minute test LAD occlusion did not protect against subsequent regional ischemic dysfunction in our subset of patients with normal baseline function.

Minimally invasive port-access coronary artery bypass grafting with early angiographic follow-up: initial clinical experience

OBJECTIVE

New techniques for minimally invasive coronary artery bypass grafting have recently emerged. The purpose of this study was to determine the safety and efficacy of Port-Access (Heartport, Inc., Redwood City, Calif.) coronary revascularization and to evaluate with angiography the early graft patency rate with this new approach.

METHODS

From October 1996 to May 1997, 31 patients underwent Port-Access coronary artery bypass grafting with an anterior minithoracotomy and endovascular-occlusion cardiopulmonary bypass. There were 26 men and 5 women with a mean age of 62 years (range 42 to 82 years). Fifteen patients underwent single bypass; 12 patients underwent double bypass, and 4 patients underwent triple bypass. Bypass conduits included the left internal thoracic artery (n = 30), right internal thoracic artery (n = 2), radial artery (n = 10), and saphenous vein (n = 6). Three sequential grafts were used. Angiographic studies of the bypass grafts were performed in 27 of 31 patients (87%).

RESULTS

There were no deaths, neurologic deficits, myocardial infarctions, or aortic dissections. Conversion to sternotomy was not required in any case. There were two reoperations for bleeding, one reoperation for tamponade, and one reoperation for pulmonary embolus. Postoperative angiography revealed anastomotic patency of the left internal thoracic artery to left anterior descending artery in 26 of 26 grafts (100%) with overall anastomotic patency in 43 of 44 grafts (97.7%).

CONCLUSION

These results demonstrate that Port-Access coronary artery bypass can be performed accurately and safely with acceptable morbidity. This approach allows for multivessel revascularization on an arrested, protected heart with excellent anastomotic precision and reproducible early graft patency.

Cardiac surgery without the use of cardiopulmonary bypass: the challenges

Minimally invasive bypass grafting of the internal thoracic artery to the left anterior descending artery has become routine in many institutions. Currently, indications for single vessel revascularization are expanding to those patients not suitable to be operated upon using extracorporeal circulation, but surgeons remain rather reluctant when multivessel disease is concerned. In such cases, the 'hybrid technique', i.e. single vessel bypass grafting followed by percutaneous transluminal coronary angioplasty at a different site, seems to be a more appropriate alternative. Despite the merits of minimally invasive surgery, the majority of surgeons do not believe that it is possible to achieve the same quality of anastomosis on a beating heart as on an arrested heart.

Minimally invasive direct coronary artery bypass: our experience with 32 patients

From January 1996 to May 1997, minimally invasive direct coronary artery bypass (MIDCAB) through a small anterior thoracotomy without cardiopulmonary bypass was completed in 31 of 32 patients (Male: Female=1.9:1, mean age=64.6 years, 11 (34.4%)>70 years). Twenty, five, and seven patients had one, two, and three vessel disease respectively. Twelve patients presented with unstable angina, seven had prior myocardial infarction, one had a pre-operative intra-aortic balloon pump, and four had prior coronary artery bypass grafting (CABG). Eight were diabetic, five had chronic obstructive pulmonary disease, and one was morbidly obese. Our newly developed coronary artery immobilizing and occluding device facilitated the coronary anastomosis. There were no post-procedure deaths, no peri-operative myocardial infarctions, and no strokes. One patient required intra-operative conversion to conventional CABG for an intramyocardial target vessel. Two patients had conversion after post-operative angiogram demonstrated incorrect target identification and early graft occlusion. Four patients had limited access graft revision (two kinks, one graft injury, and one haemorrhage). Thirty-one of the 32 patients were followed from 0.5 to 16 months and 30 reported no post-operative cardiac events (one required PTCA to another vessel). We conclude that MIDCAB is safe and effective.

The MIDCAB experience: a current look at evolving surgical and anesthetic approaches

This article reviews and updates the recent modifications in patient selection and revisions in the anesthetic approach to MIDCAB surgery. It outlines the changing surgical selection criteria, current ways to assess graft patency, and evolving anesthetic management. A promising new advancement in coronary artery bypass, the minimally invasive technique has received varying reviews and undergoes careful evaluation. Increasing surgical experience, immediate postoperative assessment of graft patency, and improvement in surgical instruments are expected to improve patient outcome. A stratification of MIDCAB patients into status I and status II patients will aid in future evaluation of surgical and anesthetic outcome. Communication of newly developed techniques to those caring for cardiovascular patients is imperative.