European Journal of Cardio-Thoracic Surgery, Vol 10, 1058-1062, Copyright © 1996 by European Association for Cardio-thoracic Surgery
Clinical experience with minimally invasive reoperative coronary bypass surgery
VA Subramanian
Department of Surgery, Lennox Hill Hospital, New York, NY 10021, USA.
OBJECTIVE: To minimize the risk of standard and reoperative coronary artery
bypass, we developed a minimally invasive approach. In this study we have
evaluated the effectiveness of this technique. METHOD: Between April 1994
and September 1995, 12 men and 6 women, aged 55-84 years (mean, 69 years)
with chronic stable angina (4) and recent post- myocardial infarction
unstable angina (14), with left ventricular ejection fractions ranging
17-60% (mean 37%), underwent reoperative coronary artery bypass grafting
using 7-cm mini-left and right anterior thoracotomy and subxiphoid
incisions. Coronary artery anastomoses were carried out on beating hearts
with local coronary occlusion. Ischemic preconditioning, beta and calcium
channel blockers and the maintenance of mean arterial pressure at 75-80 mm
Hg, were used as adjuncts for myocardial protection. The internal mammary
artery was isolated under direct vision up to the second rib with excision
of the fourth costal cartilage. Coronary artery target sites were the left
anterior descending in 12, right coronary artery in 4, obtuse marginal in
3, posterior descending in 1 and diagonal branch in 1 patient. Arterial
grafts (mammary, right gastroepiploic, radial), either as single or
composite grafts, were used liberally. Preoperative risk factors included
congestive heart failure (7), chronic renal insufficiency (5), second
reoperation (2), third reoperation (1), cerebrovascular disease (5), prior
angioplasty (8) and preoperative intra-aortic balloon pumping in two
patients. RESULTS: There was no perioperative mortality with minimal
morbidity. Twelve patients underwent patency study of the grafts 48-72 h
postoperatively. Ten of the twelve grafts were patent; one internal mammary
artery graft to the left anterior descending coronary artery (<1.5 mm)
early in our series was occluded and one additional left internal mammary
graft had a kink several centimeters away from the anastomosis, which was
successfully opened by angioplasty. At a mean follow-up interval of 8
months all 16 surviving patients are in functional class I or II and all of
them remain free of angina. CONCLUSION: In selected patients reoperative
coronary artery bypass grafting can be performed with this minimally
invasive approach with a low perioperative morbidity and mortality rate and
satisfactory early graft patency rate with good symptomatic improvement.
