VATS for complete dissection of LIMA in minimally invasive coronary artery bypass grafting

Videothoracoscopic Internal Mammary Artery Harvest for Coronary Bypass

Between March 1996 and September 1997, videothoracoscopy was performed in 50 of 140 patients who underwent minimally invasive coronary artery bypass grafting. Mean age was 45.3 ± 6.8 years. The left internal mammary artery was harvested by thoracoscopy alone in 21 patients and by both thoracoscopy and direct vision in 29. Coronary artery bypass was then performed through a left anterior minithoracotomy. In 48 patients, the internal mammary artery was grafted directly to the left anterior descending artery; a small saphenous vein graft was interposed in the other 2 patients. The diagonal branch was bypassed with saphenous vein in 2 patients, the first obtuse marginal in 1, the right posterior descending branch in 1, and the right ventricular branch of the right coronary artery in 1. Concomitant carotid endarterectomy was performed in 1 patient. There was no mortality. Two patients had perioperative myocardial infarction. It was concluded that videothoracoscopy can help to achieve complete mobilization of the left internal mammary artery for minimally invasive coronary artery bypass grafting. These techniques can be regarded as safe and effective, giving excellent results and a shortened hospital stay with the advantage of avoiding some morbidity due to costal cartilage resection.

Minimally invasive procedures - direct and video-assisted forms in the treatment of heart diseases

BACKGROUND

Minimally invasive cardiovascular procedures have been progressively used in heart surgery.

OBJECTIVE

To describe the techniques and immediate results of minimally invasive procedures in 5 years.

METHODS

Prospective and descriptive study in which 102 patients were submitted to minimally invasive procedures in direct and video-assisted forms. Clinical and surgical variables were evaluated as well as the in hospital follow-up of the patients.

RESULTS

Fourteen patients were operated through the direct form and 88 through the video-assisted form. Between minimally invasive procedures in direct form, 13 had aortic valve disease. Between minimally invasive procedures in video-assisted forms, 43 had mitral valve disease, 41 atrial septal defect and four tumors. In relation to mitral valve disease, we replaced 26 and reconstructed 17 valves. Aortic clamp, extracorporeal and procedure times were, respectively, 91,6 ± 21,8, 112,7 ± 27,9 e 247,1 ± 20,3 minutes in minimally invasive procedures in direct form. Between minimally invasive procedures in video-assisted forms, 71,6 ± 29, 99,7 ± 32,6 e 226,1 ± 42,7 minutes. Considering intensive care and hospitalization times, these were 41,1 ± 14,7 hours and 4,6 ± 2 days in minimally invasive procedures in direct and 36,8 ± 16,3 hours and 4,3 ± 1,9 days in minimally invasive procedures in video-assisted forms procedures.

CONCLUSION

Minimally invasive procedures were used in two forms - direct and video-assisted - with safety in the surgical treatment of video-assisted, atrial septal defect and tumors of the heart. These procedures seem to result in longer surgical variables. However, hospital recuperation was faster, independent of the access or pathology.

Lung isolation during port-access cardiac surgery: double-lumen endotracheal tube versus single-lumen endotracheal tube with a bronchial blocker

OBJECTIVE

The purpose of this study was to compare the use of a double-lumen endotracheal tube to a single-lumen tube combined with a bronchial blocker for lung isolation during Port-Access cardiac surgery.

DESIGN

Prospective, randomized, controlled trial.

SETTING

Tertiary care university hospital.

PARTICIPANTS

Thirty-two patients undergoing Port-Access cardiac surgery via a right minithoracotomy.

INTERVENTIONS

Patients were randomized to intubation with either a left-sided double-lumen tube (double-lumen group) or a single-lumen tube with concomitant use of a bronchial blocker (blocker group). Comparisons between groups included (1) intubation time, (2) number of laryngoscopy attempts, (3) time required for tube exchange at the end of the operation, and (4) surgical satisfaction with the lung deflation (1-5 scale: 5 = excellent).

MEASUREMENTS AND MAIN RESULTS

The initial intubation time was similar between groups (118 +/- 82 seconds, double-lumen v 144 +/- 32 seconds, blocker; p = 0.2781). An additional 105 +/- 37 seconds was needed to exchange the double-lumen tube at the end of the operation. The double-lumen group also required more laryngoscopy attempts compared with the blocker group (2.3 +/- 0.6, double-lumen v 1.1 +/- 0.4, blocker; p = 0.0001). The lung deflation was better in the double-lumen group (5 [4-5], double-lumen v 4 [3-5], blocker, p = 0.0414).

CONCLUSIONS

Compared with a single-lumen tube/bronchial blocker combination the double-lumen endotracheal tube required more laryngoscopy attempts and additional time to replace the tube at the end of the case but resulted in slightly better overall lung deflation.

Angiographic evaluation of graft patency in minimally invasive direct coronary artery bypass grafting

BACKGROUND

The objective of this report is to describe our experience using minimally invasive direct coronary artery bypass grafting and to evaluate angiographic patency of anastomoses.

METHODS

A total of 120 patients (86 men) were operated on, with ages ranging from 30 to 83 years (mean = 61.2 years). Two access routes were used: for single left anterior descending coronary artery lesions an 8 cm anterior minithoracotomy was performed at the fourth left intercostal space. Extracorporeal circulation was not used. In the last 82 patients a restraining device was used for the regional reduction of heart beats. Coronary cineangiography was carried out between postoperative days 1 and 3 in 84 (70%) patients. Anastomoses were graded: grade A, no blocks; grade B, blocks of more than 50%; grade C, occlusion. This evaluation was performed for two different periods: in the first period a restraining device was not used and in the second period a restraining device was used.

RESULTS

In the first study period (38 anastomoses) coronary cineangiography showed grade A, 79%, grade B, 5.2%, and grade C, 15.8%. In the second study period (62 anastomoses), angiography showed grade A, 90.4%, grade B, 6.4%, and grade C, 3.2%. Early mortality was 1.6%.

CONCLUSIONS

Minimally invasive coronary artery bypass grafting is a good alternative for some groups of patients. Anastomotic results seem to be better when a restraining device is used.

Coronary Artery Bypass Grafting without Cardiopulmonary Bypass

Between March 1994 and April 1998, 2869 patients underwent coronary artery bypass grafting at our institution. Of these, 415 (14.5%) with a mean age of 54.4 ± 9.9 years were operated on without cardiopulmonary bypass. Internal thoracic artery was used in 402 cases (97%) and the left anterior descending artery was revascularized in all except 1. Distal anastomoses ranged from 1 to 3, with a mean of 1.45 ± 0.58. Major postoperative complications comprised reoperation because of internal thoracic artery spasm in 1 patient, lower extremity ischemia due to intraaortic balloon pumping in 1 patient, revision for excessive bleeding in 3, and perioperative myocardial infarction in another 3. Hospital mortality was 1.2% (5 deaths). Coronary angiography was performed in 38 patients, 1 to 44 months postoperatively. Examination of 56 distal anastomoses revealed a patency rate of 86.1% for internal thoracic artery grafts and 55% for saphenous vein grafts. It was concluded that coronary bypass surgery without cardiopulmonary bypass gave favorable results in the early postoperative period. However, considering the late graft patency rates, either patient selection or the technique should be reevaluated.

Evaluation of a new device for quick sutureless coronary artery anastomosis in surviving sheep

OBJECTIVE

A new device for performing quick sutureless vascular anastomosis by means of stent technology has recently been developed by Jomed International, Helsingborg, Sweden. The efficacy of this GraftConnector was studied in a sheep model.

METHODS

In adult sheep, a left anterior thoracotomy under the fourth rib extended across the sternum gave good access to the left anterior descending branch (LAD) and the right internal mammary artery (RIMA). On beating hearts, the GraftConnector group had the RIMA connected to the LAD by means of the new device, while the control animals had the same anastomoses sutured with continuous 7-0 polypropylene sutures. The time for completing the anastomosis (ischemic time) was recorded and the blood flow in the RIMA was recorded with the proximal LAD open and closed, respectively. An intra-operative fluoroscopy with contrast injection directly into the graft was done. Finally the proximal LAD was ligated. The surviving animals are to be followed up.

RESULTS

Seven (46%) of the 15 animals operated on with the traditional suturing technique and seven (63%) of the 11 GraftConnector sheep survived the procedures and are to be followed up. The 11 anastomoses done with the GraftConnector were completed in 2.41+/-0.2 min, and the 14 anastomoses sutured with continuous suture were completed in 6.93+/-0.419 min (P<0.0001). The RIMA blood-flows in the two groups were comparable and are presented. All the surviving animals had open anastomoses at fluoroscopy.

CONCLUSIONS

Quick coronary artery anastomoses without suturing on beating hearts can be completed with the new GraftConnector. The GraftConnector creates reproducible anastomoses in much less time than suturing, the per-operative mortality in the GraftConnector Group was accordingly lower. Long-time follow-up of the patency in surviving animals is pending. The presented device may ultimately permit quick anastomoses endoscopically.

Potential risks in coronary artery bypass grafting via mini-thoracotomy: a case report

This paper describes a patient with an occluded left internal thoracic artery, possibly as a result of the proximal 'steal phenomena', following coronary artery bypass grafting via mini-thoracotomy without cardiopulmonary bypass.

Internal mammary artery harvesting using the harmonic scalpel

Internal mammary artery (IMA) harvesting using the harmonic scalpel (HS) was recently introduced. We studied 541 IMAs harvested by the same surgeon through a standard median sternotomy in 472 coronary bypass patients; 252 (47%) with the HS, while 289 (53%) were with electrocautery (EC). Patient demographics included mean ages: 67 years HS vs. 65 years EC (p = NS); male:female ratio: 3:1; and insulin dependent diabetes mellitus (IDDM): 11% HS vs. 12.5% EC (NS). Mean ultrasonic IMA flow at a mean SBP of 70 mm Hg in 10 consecutive patients of each group were: preharvest, HS 11.9 +/- 2.3 ml/min vs. EC 8.5 +/- 1.6 ml/min (p = 0.256); postharvest, HS 35.7 +/- 10.7 ml/min vs. EC 22 +/- 2.9 ml/min (0.235); and postcardiopulmonary bypass (post-CPB), HS 47.8 +/- 6.2 ml/min vs. EC 41.7 +/- 2.5 ml/min (0.381). Histologic samples of 50 consecutive IMAs showed no evidence of vessel injury in either group. Clinical results revealed postoperative bleeding in 6/217 (2.7%) HS vs. 7/255 (2.7%) EC (p = 0.783), none attributed to bleeding from the IMA; phrenic paresis: 0/217 in HS but 1/255 (0.4%) in EC (p = 0.960); sternal wound infection: 5/217 (2.3%) HS vs. 6/255 (2.4%) EC (p = 0.787); postoperative IABP: 6/217 (2.7%) HS vs. 5/255 (2%) EC (p = 0.859); mortality: 2/217 (0.9%) HS vs. 2/255 (0.8%) EC (p = 0.710). Hemodynamic, histologic, and clinical results were comparable in both groups. The authors believe the HS is safe and effective for IMA harvesting.

Procoagulant activity after off-pump coronary operation: is the current anticoagulation adequate?

BACKGROUND

Hemostasis is preserved after off-pump coronary operations compared with conventional coronary procedures. However, this preserved hemostasis may result in a procoagulant activity.

METHODS

We prospectively studied coagulation in 22 patients who underwent off-pump coronary operation either through a midline sternotomy (n = 14) or with minimally invasive anterolateral thoracotomy (n = 8).

RESULTS

Procoagulant activity, represented by prothrombin factor 1 and 2, remained at baseline levels during operation but increased significantly on postoperative day 1. Factor VII remained at baseline levels during the operation but decreased significantly on postoperative day 1. Fibrinolysis was increased as indicated by the fibrin degradation products on postoperative day 1. A promoted hemostasis attributable to endothelial activation was indicated by the increase in von Willebrand factor on postoperative day 1. Platelets counts and platelet activation (beta-thromboglobulin) remained at baseline levels after the operation. No adverse clinical events occurred.

CONCLUSIONS

Patients undergoing off-pump coronary operation show an increased procoagulant activity in the first postoperative 24 hours regardless of the surgical approach (midline sternotomy or anterolateral thoracotomy). This procoagulant activity is not mediated by platelet-related factors. Therefore, a specific perioperative prophylactic pharmacologic regimen is advisable.

Minimally invasive coronary artery bypass grafting: on the beating heart and via limited access

Minimally invasive coronary artery bypass grafting (MICABG) may be achieved by arterial grafting on the beating heart, without cardiopulmonary bypass, and by operations via limited access. The Second Utrecht MICABG Workshop held October 4-5, 1996, focused on beating-heart coronary immobilization, limited-access thoracoscopic and direct-vision mobilization of the internal mammary artery, limited-access left anterior descending coronary artery grafting, and, finally, facilitated distal anastomosis techniques. It has yielded 33 reports in this supplement. The combined, cumulative experience of a number of participants exceeded 3,000 beating-heart cases, including more than 1,000 with arterial grafting through limited access. The average number of anastomoses per patient ranged from 1.0 to 2.0. Therapeutic strategies are evolving, and dedicated instrumentation is being developed. Randomized clinical trials with angiographic follow-up are required to establish that the reduction in invasiveness of coronary bypass grafting is not achieved at the expense of suboptimal quality of the arterial graft and the distal anastomosis.