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Eur J Cardiothorac Surg 1998;13:641-649
© 1998 Elsevier Science NL

Reoperative MIDCAB grafting: 3-year clinical experience¹

^a Division of Cardiac Surgery, Johns Hopkins and Sinai Hospital of Baltimore, 600 North Wolfe Street, Blalock 618, Baltimore, MD 21287, USA
^b Division of Cardiac Surgery for Adventist Heart, Washington Adventist Hospital, 7610 Carroll Avenue, Suite 410, Takoma Park, MD 20912, USA

Received 30 September 1997; received in revised form 17 March 1998; accepted 24 March 1998.

Corresponding author. Tel.: +1 301 8915313; fax: +1 301 8916043; e-mail: jfonger@heartnet.org

Objective: Minimally invasive direct coronary artery bypass (MIDCAB) is performed under direct vision without sternotomy or cardiopulmonary bypass. The technique is used in reoperative patients through various incisions to revascularize one or two areas of the heart. The internal mammary artery, gastroepiploic artery, radial artery, or saphenous vein are used as graft conduits. Methods: Anterior coronary targets are grafted with the internal mammary artery via a small anterior thoracotomy. Inferior coronary targets are grafted with the gastroepiploic artery via a small midline epigastric incision. Lateral coronary targets are grafted with radial artery or saphenous vein via a posterior thoracotomy. After partial heparinization, the anastomosis is facilitated by local coronary occlusion and stabilization. Graft follow-up consists of outpatient Doppler examination and selective recatheterization. Results: Between January 1994 and August 1997, 81 patients underwent reoperative MIDCAB grafting. Twenty-one patients (25.9%) had internal mammary grafting, 39 (48.2%) had gastroepiploic grafting, and 21 (25.9%) had lateral grafting with radial artery or saphenous vein. There were nine early deaths (four cardiac, five non-cardiac), five late deaths (three cardiac, two non-cardiac), and nine myocardial infarctions in remaining patients. Sixteen patients underwent recatheterization; there were one graft occlusion, two graft stenoses, and eight anastomotic stenoses. Mean postoperative length of stay was 3.8 days. Ninety percent (55/61) of patients are free of symptoms at a mean follow-up of 7.8 months (range 0–39). Conclusions: Reoperative MIDCAB grafting avoids the risks of resternotomy, aortic manipulation, and cardiopulmonary bypass. The techniques yield an early patency rate of 94%, which includes eight patients who had postoperative catheter-based interventions. Reoperative MIDCAB grafting had lower rates of supraventricular arrhythmia and transfusion when compared with conventional coronary artery bypass grafting, but did not offer an advantage for mortality, stroke or myocardial infarction. This 3-year experience suggests that while reoperative MIDCAB grafting can effectively revascularize focal areas of the heart, patients should be carefully selected to minimize operative risk.

Key Words: Minimally invasive direct coronary artery bypass (MIDCAB) • Minimally invasive surgery • Direct coronary surgery • Coronary artery bypass • Reoperative surgery

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