Intraoperative Angiography in Minimally Invasive Direct Coronary Artery Bypass Grafting (original) (raw)
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Video-assisted minimally invasive coronary bypass surgery without cardiopulmonary bypass
European Journal of Cardio-Thoracic Surgery, 1998
Background: There is a growing interest in cardiac surgery towards minimally invasive approach to coronary bypass operations without cardiopulmonary bypass. Patients and methods: From March 1995 to March 1997, 41 patients underwent a single left internal mammary artery (LIMA) to the left anterior descending artery (LAD) coronary grafting without cardiopulmonary bypass through a small left anterior thoracotomy (MIDCABG). The mean age was 61.2 ± 8.7 years (range 43-77 years), 28 patients. were male (68.2%) and the redo rate was 4.8% (2/41). In all patients the coronary artery disease involved the LAD, which was occluded in seven patients (17.1%). Thirty-eight patients (96.2%) selected for MIDCABG had a monovascular disease on LAD not suitable for percutaneous coronary angioplasty; two (4.8%) a bivascular disease, and one (2.4%) a trivascular disease. Skin incision was performed in the 4th anterior intercostal space from the left parasternal line for a 10.5 cm length on average. The LIMA harvesting was partially video-assisted by thoracoscopy. Results: The LAD temporary occlusion was achieved with two double 5/0 polypropilene round-LAD sutures. The mean LAD ischemic time was 22 ± 8 min (range 4-35 min). No thoracotomy procedure was changed into a sternotomy approach. We had one (2.4%) perioperative AMI; two patients (4.8%) were reoperated for bleeding. All patients underwent a postoperative angiographic reinvestigation within 1 month after surgery. All anastomoses were perfectly patent but two (4.8%). One patient was reoperated via a sternotomy access recycling the LIMA graft, the other one underwent successful PTCA. All patients also underwent an early and mid-term (6 months after surgery) echo-Doppler study of the LIMA flow and patency. At follow-up, performed at a mean of 8.7 months (range 1-23) after discharge, all patients were alive; no one experienced recurrence of angina. All patients also performed a mid-term negative treadmill stress test. Conclusions: MIDCABG is, in selected patients, reliable and safe, and offers encouraging early and mid-term clinical results.
Less-invasive coronary artery bypass grafting: different techniques and approaches
European Journal of Cardio-Thoracic Surgery, 1998
Objective: The aim of this study was to compare four different techniques for less-invasive coronary artery bypass surgery with and without cardiopulmonary bypass (CPB) in terms of feasibility as well as in terms of the intra-and postoperative course. Methods: One hundred and fourteen patients were divided into four groups, according to the surgical technique. Group I: minithoracotomy, internal thoracic artery (ITA) harvesting and anastomosis under direct vision using cardiopulmonary bypass (CPB) on the fibrillating heart (n = 31). Group II: sternotomy and beating heart without CPB (n = 13). Group III: MIDCAB with CPB and cardioplegic cardiac arrest using endo-aortic balloon-occlusion, Port Access system (n = 9). Group IV: MIDCAB on the beating heart without CPB (n = 61). In total, 104 single and ten double graft procedures were performed using the radial artery T-graft technique in seven cases (groups III and IV). Results: Harvesting of the ITA graft took 41 ± 16.2 min in group I and could be reduced to 31 ± 8.3 min in group IV by the use of a specially-designed retractor. Complications were: death (n = 1, group I), myocardial infarction, (n = 1, group I), early occlusion of the graft (n = 1, group IV), early stenosis of the anastomosis (n = 2, groups I and IV), late stenosis of the anastomosis (n = 1, group IV), thrombosis of the femoral vein (n = 1, group III). Postoperative ventilation, ICU and hospital stay were similar among groups. Conclusions: Based on our results, the following strategy has been developed: MIDCAB without CPB is the preferred technique for one-vessel graft procedures to the left anterior descendens (LAD) or RCA. The Port Access system (with CPB) is reserved as a second option for young patients requiring multiple-vessel grafting to the left coronary circulation (LAD/CX) and as a backup to avoid conversion. Sternotomy and an off-pump technique is used for single-vessel or multiple-vessel graft procedures in selected patients (emergency procedure, acute myocardial infarction, in the very obese).
Coronary artery bypass grafting: yesterday, today & tomorrow
AME Medical Journal, 2020
Despite the changing landscape of treatment of coronary artery disease (CAD), coronary artery bypass grafting (CABG) remains a safe and effective option for treatment of multivessel obstructive CAD. Since its introduction in mid 1960s, CABG has evolved tremendously making it the only evidence-backed standard of care for treatment of CAD with well-established symptomatic and prognostic benefits. Discovery of the cardiopulmonary bypass (CPB) and introduction of myocardial protection strategies made performance of CABG on the beating heart obsolete in the 1970s. Advances in myocardial protection methods, improved CPB techniques and refined anaesthetic management translated into improved outcomes in the 1980s (1). Advances in technology in the 1970s and 1980s were accompanied by enhanced understanding of vascular biology particularly behaviour of the saphenous vein grafts. The pioneering work of FitzGibbon and colleagues brought to the fore phenomenon of early and late vein graft bypass failure (2,3). This reignited interest in use of left internal mammary artery (LIMA) as a bypass conduit. The seminal publications from Cleveland Clinic in the 1980s and 1990s established the status of LIMA as the gold standard for grafting of the left anterior descending (LAD) artery (4) and the superiority of two IMAs over single IMA in improving survival and reducing reoperation rate (5). Additional arterial conduits such as gastroepiploic artery and radial artery have also been used over the years on the premise that they improve long-term outcome (6). However, choice of second best conduit for CABG remains a controversial issue in the current era especially following the publication of the intention-to-treat analysis of Arterial Revascularisation Trial at 10 years (7). Late 1990s and early 2000 saw a boom in percutaneous coronary interventions worldwide. This was accompanied by increasing realisation that conventional CABG despite its safety profile was an invasive procedure. The use of CPB was associated with systemic inflammatory response which along with manipulation and clamping of the ascending aorta increased the morbidity of the procedure (8). Off-pump CABG was rediscovered in late 1990s as a strategy to counteract the invasiveness of conventional on-pump CABG. It remains a highly scrutinised technique with excellent outcomes reported by high-volume centres (9). However, concerns about long-term survival, graft patency and increased repeat revascularization rate remain the Achilles heel of the procedure precluding its universal adoption. Similarly, grafting of isolated LAD with LIMA through a small left anterior thoracotomy termed minimally invasive direct coronary artery bypass (MIDCAB) is a technique that is superior to the state of the art PCI technology but not very popular due to its steep learning curve and technically demanding nature (10). This focused issue of AME Medical Journal is dedicated to providing an overview of CABG covering the various surgical techniques in particular and the evolution of CABG in general. Manuscripts in this focused issue have been contributed by world experts and opinion leaders and are expected to provide an insight to the readers into the past, present and future of CABG.
Video-assisted coronary bypass surgery: clinical results
European Journal of Cardio-Thoracic Surgery, 1997
Objective: Clinical experience with a video-assisted coronary artery bypass grafting procedure using the internal mammary artery is reported. The technique consists of a videoscopic harvesting of the left internal mammary artery (LIMA) to revascularise the left anterior descending artery (LAD) through a 4-cm left thoracotomy. Methods: Between September 1995 and July 1996, we performed this procedure on 30 patients (29 males, 1 female; aged 38-71) with an isolated proximal LAD stenosis (n=21) or occlusion (n=9). All patients were symptomatic despite appropriate medication. A history of non-transmural myocardial infarction with myocardial viability was found in nine patients. Fourteen patients had a restenosis after previous percutaneous transluminal coronary angioplasty (PTCA). Mean left ventricular ejection fraction was 0.61 (B 0.3 in two patients). The LAD-LIMA anastomosis was performed on the beating heart without cardiopulmonary bypass (CPB) in 26 patients. Femoralfemoral CPB was used in three patients because of unstable angina (n= 1) and intramyocardial LAD (n =2). Conversion to sternotomy and standard CPB was necessary in one patient for extensive endarterectomy of the LAD. Results: There were no operative complications and no reoperations for haemorrhage. Pulmonary infection was observed in one patient and wound infection in one patient. Patients who underwent the complete procedure on the beating heart without conversion or CPB were ready for discharge on the 5th postoperative day (36 h-13 days). Control coronary angiography was performed in 20 patients. In all cases, the graft was patent. In 17 cases, there was a patent graft with no evidence of anastomotic stenosis. An occlusion of the distal segment of the LAD with a retrograde perfusion of the proximal segment and septal branches by the LIMA was found in one case. This patient was symptom-free and the stress test was negative. An anastomotic stenosis was noted in two patients and was treated by angioplasty (n=1) or conventional surgery (n= 1). Conclusion: In conclusion, the efficiency of this minimally invasive approach should be prospectively compared with similar revascularisation with PTCA or surgical approaches using sternotomy with or without CPB.
Coronary artery bypass grafting without cardiopulmonary bypass
The Annals of thoracic …, 1996
This study was undertaken to assess our experience with the first 50 patients who underwent CABG without cardiopulmonary bypass. In seven patients left internal mammary artery to left anterior descending artery (LIMA-LAD) grafting was performed through a short left anterior thoracotomy. In 43 other patients median sternotomy was used. Primary CABG was performed in 48 patients; there were two reoperations. Eleven patients had unstable angina. Three patients had left ventricular ejection fraction (LVEF) equal to or lower than 25%. One patient had carcinoma of the right lung coexisting with unstable angina and underwent also right lower lobectomy. In each patient the clinical course, 12-lead ECG, transthoracic echocardiography and the serum levels of creatine kinase (CPK), alanine aminotransferase (ALAT), aspartate aminotransferase (AspAT) were assessed. The need for inotropic or intraaortic balloon counterpulsation (IABP) support and blood transfusion was also recorded. There were three deaths, all in the sternotomy group (6%). A patient with systemic lupus erythemetodes (SLE) died of postoperative MI due to graft thrombosis. Another patient who was found to have porcelain aorta and had LIMA-LAD grafting as a rescue procedure died of MI with low cardiac output. The third patient with unstable angina and ejection fraction of 30% developed postoperative MI with ventricular arrhythmia. One patient with LIMA-LAD graft in whom percutaneous translaminal coronary angioplasty (PTCA) had been abandoned because of coronary spasm developed acute myocardial ischaemia 5 h postoperatively. He had a vein graft placed to LAD in cardiopulmonary bypass, his further course was uneventful. Six patients had IABP support. Nine patients needed inotropic support. Ten patients received blood transfusion. Twelve-lead ECG did not show acute ischaemia or MI, apart from the above described cases. Echocardiographic check showed improved IVS contractility in three patients and better apex motion in one case. In the other survivors the echocardiografic findings were the same as before the procedure. ALAT and AspAT serum levels were normal in all the survivors, and the CPK levels did not exceed 200 IU/ml. One patient from the mini-thoracotomy group had recurrent angina 2 months after the procedure. His left internal mammary artery (LIMA) graft was occluded; we replaced it with a vein graft. All 47 survivors remain asymptomatic, with the mean follow-up time of 6 months. Coronary surgery without cardiopulmonary bypass seems a valuable alternative for high-risk patients.
Minimally invasive coronary artery bypass grafting for the left anterior descending coronary artery
The Japanese Journal of Thoracic and Cardiovascular Surgery, 2000
Objective: To evaluate the patency of individual and sequential coronary artery bypass in patients with ischemic heart disease. Methods: We searched PubMed, Cochrane Library, Excerpta Medica Database, and ClinicalTrials.gov databases for controlled trials. Endpoints included graft patency, anastomosis patency, occluded rates in left anterior descending (LAD) system and right coronary artery (RCA) system, in-hospital mortality, and follow-up mortality. Pooled risk ratios (RRs) and standardized mean difference (SMD) were used to assess the relative data. Results: Nine cohorts, including 7100 patients and 1440 grafts under individual or sequential coronary artery bypass. There were no significant differences between individual and sequential coronary artery bypass in the graft patency (RR=0.96; 95% CI=0.91-1.02; P=0.16; I 2 =87%), anastomosis patency (RR=0.95; 95% CI=0.91-1.00; P=0.05; I 2 =70%), occluded rate in LAD system (RR=1.03; 95% CI=0.92-1.16; P=0.58; I 2 =37%), occluded rate in RCA system (RR=1.36; 95% CI=0.72-2.57; P=0.35; I 2 =95%), in-hospital mortality (RR=1.57; 95% CI=0.92-2.69; P=0.10; I 2 =0%), and followup mortality (RR=0.96; 95% CI=0.36-2.53; P=0.93; I 2 =0%). Conclusion: No significant differences on clinical data were observed regarding anastomosis patency, occluded rate in LAD system, occluded rate in RCA system, in-hospital mortality, and follow-up mortality, indicating that the patency of individual and the patency of sequential coronary artery bypass are similar to each other.
The Heart Surgery Forum, 2005
Hybrid coronary artery revascularization is a combination of minimally invasive coronary artery surgery and catheterbased coronary intervention. Hybrid procedures enable adequate revascularization of patients with multivessel coronary artery disease without complete opening of the chest and with the advantage of the most durable option, a left internal mammary artery (LIMA) graft is placed to the left anterior descending (LAD) artery. The hybrid concept is gaining renewed interest because totally endoscopic LIMA to LAD placement has become feasible and because drug-eluting stents in non-LAD targets may be competitive even for arterial bypass grafts. Simultaneous hybrid procedures would be desirable. We report on a case in which robotic totally endoscopic LIMA to LAD grafting using the da Vinci TM telemanipulation system was combined with placement of a rapamycin coated stent to the right coronary artery in one single procedure.
Repeat Surgery for Coronary Artery Bypass Grafting: The Role of the Left Thoracotomy Approach
The Heart Surgery Forum, 2009
Objective: Repeat coronary artery bypass surgery has increased risks compared with the first operation, including low cardiac output and injury to patent grafts. The left thoracotomy approach has been advocated specifically in patients with intact grafts of the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) needing lateral wall grafting. We have evaluated this technique in conjunction with an off-pump procedure in all patients. Methods: There were 55 patients over an 8-year period, and 6 (10.9%) were female. The mean age was 63.2 years (range, 41-82 years), and the age at the time of the previous operation was 51.7 years (range, 31-69 years). Four patients (7.2%) underwent a third operation. Comorbidities were diabetes mellitus (25 patients, 45.5%), renal impairment (8 patients, 14.5%), calcified ascending aorta (9 patients, 16.4%), carotid disease (4 patients, 7.2%), and peripheral vascular disease (11 patients, 20.0%). Fifteen patients (27.2%) had previous coronary stents. Nine patients (16.4%) had a preoperative intra-aortic balloon pump. Predicted mortality (logistic EuroSCORE) was 14.2%. Results: Forty-three patients (78.1%) had intact LIMAto-LAD grafts. Twenty-two patients (40.0%) required a major posterolateral thoracotomy, and 33 patients (60.0%) had a minor thoracotomy. Thirteen patients (23.6%) had stents placed as a hybrid procedure during the same admission. Thirteen patients (23.6%) additionally underwent anterior wall grafting (LAD to the first marginal area). The LIMA was used in 7 patients where it had not been used before. There were 91 distal grafts (including 4 sequentials). We performed 54 venous grafts and 26 radial artery grafts. Twentyone patients (38.1%) had 1 distal graft, 32 patients (58.1%) had 2 grafts, and 2 patients (3.6%) had 3 distal grafts performed (mean, 1.6 grafts/patient). The proximal graft site was the proximal descending aorta in 20.0% of the patients, the distal aorta in 67.5%, and the subclavian artery in 12.5%. In 10 patients (18.2%), the distal branches of the right coronary (posterior descendens or right posterolateral) were grafted. No patient required conversion to cardiopulmonary bypass or sternotomy. No patient needed an intra-aortic balloon pump postoperatively. The mean blood loss (24 hours) was 380 mL (range, 125-1100 mL), the mean ventilation time was 4.8 hours (range, 0-12 hours), the mean intensive care unit stay was 2.7 days (range, 2-8 days), and the mean hospital stay was 6.3 days (range, 5-20 days). There was 1 postoperative death (1.8% mortality). One late death occurred on followup. Four patients underwent cardiac catheterization for chest pain, and the grafts were shown to be open. Conclusion: The procedure is safe, especially in patients with intact LIMA-to-LAD grafts needing lateral and inferior wall revascularization. Multislice computed tomography scanning allows better preoperative planning, especially regarding the site of implantation of the proximal graft, allowing a less invasive incision. The off-pump technique preserves cardiac and pulmonary function. The in-hospital death rate (1.8%) compares very well with the EuroSCORE-predicted mortality (14.2%).
MINIMALLY INVASIVE CORONARY ARTERY BYPASS: EXPERIENCE IN 114 PATIENTS
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 echocardiography, 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 revascularization was considered to be a simple and effective alternative to the standard operation or angioplasty in selected patients.