Eur J Cardiothorac Surg 1998;14:347-352
© 1998 Elsevier Science NL
Experiences with a minimally invasive surgical technique for the treatment of coronary artery multivessel disease in 100 patients1
Vassilios Gulielmos,
Michael Knaut,
Romuald Cichon,
Klaus Matschke,
Utz Kappert,
Michael Brandt,
Jörg Hoffmann,
Stephan Schueler
Cardiovascular Institute, University Hospital Dresden, Fetscherstr. 76, D-01307 Dresden, Germany
Received 30 March 1998;
received in revised form 15 July 1998;
accepted 28 July 1998.
Corresponding author. Tel.: +49 351 4501801; fax: +49 351 4501802.
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Abstract
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Objective: The treatment of coronary single vessel disease under minimally invasive surgical conditions was followed by the treatment of coronary multivessel disease using a new technique. Methods: Using this technique 100 patients (80 male, 20 female, median age 61.0±8.9 years, ranged from 39 to 82 years) with coronary single vessel disease, double vessel disease or multivessel disease were treated between November 1996 and December 1997. Via a small (6–9 cm) left lateral chest incision in the second or third intercostal space, the left internal thoracic mammary artery (LIMA) was harvested and access to the central portion of the heart including the ascending aorta was obtained. In parallel, saphenous vein segments were harvested. Arterial cannulation was instituted via the ascending aorta, thus avoiding retrograde flow. In all patients except three the LIMA was used for the left anterior descending artery (LAD). In addition vein grafts were used for revascularization of the other coronary arteries. All cardiac anastomoses were performed during cardioplegic arrest after external aortic cross clamping and antegrade application of cardioplegia. Results: No death or intraoperative complications were observed in this series. The median hospital stay was 6.0±1.4 days (median±SEM). Postoperative complications were reexplored for bleeding (n=1), delayed wound healing (n=2), wound infections (n=4), lymphatic fistulas (n=4), and a chest wall hernia (n=1). Conclusions: This minimally invasive surgical technique presents a safe alternative to conventional coronary artery surgery avoiding sternotomy related complications and decreasing hospital stay and morbidity.
Key Words: Minimally invasive coronary artery bypass surgery • Multivessel coronary artery disease • Cardiopulmonary bypass • Conventional aortic cross clamping
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Introduction
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The use of LIMA bypass to the left anterior ascending aorta (LAD) should be considered as standard in the field of coronary artery disease (CAD)
[1]. Although the treatment of CAD has been standardized in the last years there is a new trend in cardiac surgery using minimally invasive surgical techniques avoiding median sternotomy due to serious complications, varying from continuous pain situations to septic mediastinitis
[2]
[3]. Our own experience started with the Port-Access system including the safety standards of cardiac surgery such as cardiopulmonary bypass (CPB) and cardioplegic arrest (CA). In March 1996 this technique has been successfully introduced in Europe at our institution
[4]. Due to our protocol the method was applicable only for coronary artery single vessel disease. A new surgical technique for the treatment of multivessel disease developed at our institution
[5]. Using femoral institution for CPB and cardioplegic arrest learning from the complications and problems that occurred in the Port AccessTM series, some modifications were made with the aim to develop a more simple and safe procedure.
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Methods
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One hundred patients with coronary artery single vessel disease, double vessel disease or triple vessel disease were evaluated from November 1996 to December 1997 for minimally invasive coronary artery bypass grafting (MICABS) among 2300 open heart cases. The age of 80 male and 20 female patients ranged between 39 and 82 years (median 61.0±8.9 years). The exclusion criteria used were calcified aorta, overweight (more than 130% BMI), and impaired left ventricular function (LVEF<35%). Of the patients 15.8% were in CCS-stage 1, 46.4% in stage 2, 35.4% in stage 3 and 2.4% in stage 4; 39.0% of the patients were in the New York Heart Association (NYHA) class I, 46.3% in the NYHA class II and 14.7% in NYHA class III. Fifty-two patients suffered from double or triple vessel disease.
Following the pattern of the stenosed vessels:
| LAD |
n=25 |
| LAD and diagonal branch |
n=22 |
| LAD and intermediate branch |
n=2 |
| LAD and LCX |
n=11 |
| LAD, diagonal branch and LCX |
n=5 |
| Main stem |
n=7 |
| LAD and RCA |
n=7 |
| LAD, diagonal branch and RCA |
n=5 |
| LAD, RCA and intermediate branch |
n=1 |
| LAD, LCX and RCA |
n=11 |
| LAD, RCA, LCX and intermediate branch |
n=3 |
| LAD muscle bridge |
n=1 |
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A single lumen endotracheal tube was used for general anesthesia. The patient was placed in supine position with a rubber cushion under the left shoulder and the left arm was attached to the body dorsally to the posterior axillary line. The left lateral chest wall and the sternum were accessible in case of conversion to median sternotomy. The third or the second intercostal space (ICS) was chosen for the surgical gate depending on the anatomy of the patients thorax. A 6–9 cm skin incision was made and the sternal edge of the upper and the lower rib were divided using a sternal saw, but not removed. The use of a small wound retractor enabled LIMA harvesting as a pedical up to the first rib and down to the fifth or sixth rib. In one patient both internal mammary arteries were harvested via the left lateral chest incision without any additional right lateral chest port. The LIMA was harvested under direct vision. The right internal thoracic mammary artery (RIMA) was dissected transmediastinally thoracoscopically using endoscopical instruments in one patient. Mediastinal fat was dissected as a flap but not removed in order to be used at the end of the procedure for covering the heart, as proposed by Grandjean for MIDCAB
[6]. The pericardium was opened longitudinally towards the aortic arch and stay sutures were placed between the right edge of the pericardium and the soft tissue in order to retract the ascending aorta towards the surgical gate. In parallel saphenous vein segments were harvested. In our initial series the groin was dissected for femoral cannulation of the right atrium for CPB. In the last 15 consecutive patients the femoral vein was cannulated and removed percutaneously. In two patients the right atrium was cannulated instead of the femoral vein using a double stage cannula. After cannulation of the ascending aorta the ascending aorta was dissected from the pulmonary trunk. A conventional aortic clamp was used for external cross clamping and antegrade cold crystalloid cardioplegia was applied into the ascending aorta. During cardioplegic arrest aortic root venting was made and the relaxed heart was rotated for exposure of coronary arteries of the left or the right coronary system. End-to-side anastomoses were performed between vein grafts and the coronary arteries in a standard fashion followed by anastomosis of the LIMA to the LAD (
Fig. 1
).
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Fig. 1. Schematic drawing of the operative situs. The third and the fourth rib are dissected at the sternal edge and spreaded from each other. A, ascending aorta; B, pulmonary trunk; C, right ventricle; D, left ventricle; E, right atrium; F, LAD; G, right coronary artery; H, aortic return cannula for cardiopulmonary bypass; I, venous drainage catheter with the tip in the right atrium inserted percutaneously via the femoral vein.
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Via the ascending aorta antegrade de-airing was made before removing the aortic cross clamp. Proximal anastomoses were performed using a conventional side biting clamp (
Fig. 2
). The patient was weaned from CPB and aortic and femoral vein cannulae were removed. After hemostasis the sternal edges of the third and fourth rib were attached to the sternum using two steel wires and both ribs were approximated to each other using a 1 mm diameter strong suture (Poly-p-dioxanon). Two chest tubes were left in place and the chest incision was closed (
Fig. 3
).
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Fig. 3. Cosmetic result after minimally invasive coronary artery bypass grafting in a patient with triple vessel disease.
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Results
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The pattern of the coronary vessels grafted (rate of grafts per patient: 1.76) and the conduits used are listed in Table 1. No patient had to be converted to median sternotomy intraoperatively and all patients were weaned from CPB without inotropic support, in sinus rhythm without signs of ischemia. There was no death in our series. One patient received a reexploration due to bleeding. Postoperative complications were reexplored for bleeding in one patient, delayed wound healing in the chest incision in two patients, wound infections in the chest incision in one patient, wound infections in the groin in three patients, lymphatic fistula in the groin in 2 patients and a chest wall hernia in one patient. Table 2 shows duration of operation, time of LIMA harvesting, intensive care unit (ICU) stay, and hospitalization of the overall of the procedures. At present all patients included in this study are alive and doing well up to 13 months after the operation.
The 12-weeks follow-up completed in 53 patients revealed no angina pectoris in all patients. Minor angina like symptoms were found in two patients during major exercise. These two patients underwent coronary angiography showing stenosis of the LAD anastomosis in the first patient and in the second patient a de novo stenosis in the LAD about 2 cm distal to the LIMA anastomosis. Both patients underwent an uncomplicated PTCA.
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Discussion
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The trend to reduce surgical trauma in general surgery using minimally invasive surgical techniques (MIST) has stimulated cardiac surgeons over the last 2 years to develop several MIST for the treatment of coronary artery single vessel disease
[7]
[8]
[9]
[10]
[11]. Some of the proposed techniques not only avoid median sternotomy, but cardiopulmonary bypass as well. However, long term results of beating heart procedures are still unknown. Starting with methods performing bypass surgery through a small chest incision the surgeon has always a great fear concerning the quality of the anastomoses. The initial European trial with the Port-Access technique at our institution, coronary angiograms revealed good quality of the coronary anastomoses since the Port-Access technique preserves the current standards of cardiac surgery such as cardiopulmonary bypass and cardioplegic arrest. However, even if the results of our initial series were very promising we faced vascular complications due to the retrograde flow caused by femoral arterial institution of CPB and the application of endovascular catheters. Furthermore, due to our protocol the method was applicable only for single vessel disease. These limitations led us to develop a new surgical technique.
Locating the chest incision in the third ICS and dividing but not removing the third and the fourth rib from the sternum allows LIMA harvesting down to the sixth rib and up to the first rib, and most importantly the ascending aorta can be reached for direct arterial cannulation, application of cardioplegia and attachment of proximal graft anastomoses. This allows the treatment of extended coronary artery disease, which so far seemed to be impossible using small chest incisions.
The vascular complications we experienced using the Port-Access technique made us to search for a way to avoid retrograde flow. Stay sutures to the right part of the open pericardium can retract the ascending aorta towards the surgical gate so that the ascending aorta can safely be cannulated. Due to the limitation of the skin incision the whole circumference of the ascending aorta is not accessible, therefore preoperative assessment of the aortic wall is needed. Thus antegrade flow for arterial return for CPB can be established. An umbilical loop around the ascending aorta facilitates the positioning of the line for antegrade application of cardioplegia and external occlusion of the ascending aorta by pulling the ascending aorta towards the surgical gate. Recently, percutaneous femoral cannulation of the right atrium was used as proposed by Carpentier
[12] in order to avoid lymphatic fistulas and wound infections in the groin. Using an umbilical loop around the heart, rotation of the heart to the left gives good access to the right coronary artery system and rotation to the right gives good access to the left coronary artery system. At the same time the heart is being lifted up so that the anastomoses do not have to be performed deep in the mediastimun but the target coronary vessel is practically on the surface of the small opening.
The described minimally invasive surgical procedure avoids median sternotomy, reduces surgical trauma due to the small chest incision, uses the safety standards of current cardiac surgery as cardiopulmonary bypass and cardioplegic arrest, and avoids retrograde flow and its related vascular complications. The Dresden technique gives access to all areas of the heart and enables complete arterial revascularization. The excellent patients convalescence and the cosmetic results suggest a broader application of this technique.
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Footnotes
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Presented at the 11th Annual Meeting of the European Association for Cardio-thoracic Surgery, Copenhagen, Denmark, September 28 – October 1, 1997. 
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Appendix A. Conference discussion
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Professor A. Yim (Shatin, Hong Kong): Have you any objective or subjective pain study data to show that your minithoracotomy is in fact less traumatic than a conventional median sternotomy? If you have to excessively spread the ribs in order to compensate for the small incision, one may be defeating the purpose of minimally invasive surgery. Minimal access does not equate minimal invasiveness.
Dr Gulielmos: Yes. We did a pain assessment, and we found out that patients receiving this procedure have less pain. I know that most thoracic surgeons would say that a thoracotomy, a left thoracotomy, a lateral thoracotomy, produces a lot more pain than a median sternotomy does; but my question is, what does hurt about lateral thoracotomy? It's not the dissected muscle, it's not the dissected nerves. It's the spreading of the wound, the spreading of the nerves, that hurts. So we found that patients receiving this kind of surgery have less pain than patients receiving median sternotomy.
Professor Yim: I agree entirely with what you have just said. However, from the pictures you showed, you spread the ribs quite a bit with your retractor. It would surprised me if no ribs were fractured. It would be nice to see your data on pain assessment. After all pain reduction is an important theoretical reason why you are doing this type of surgery
Dr U. Nair (Leeds, UK): In Leeds, in the last few months, we have been doing routine coronary artery surgery through a limited sternotomy, 10 cm long sternotomy, lower sternotomy incision, through a hockey stick incision, and what we have found with this procedure is we can take on all types of cases, including very poor left ventricle. The cannulation is standard with aortic and right atrial cannulation with cardioplegia and retrograde cardioplegia if necessary. The results are good and we have been doing assessment of the pain factor compared with standard sternotomy and those results will be published in due course.
What I wanted to ask you is, from your paper, I understand you remove the venous cannula before doing the proximal aortic anastomosis. What do you do in the case of a very poor left ventricle?
Dr Gulielmos: You're talking about the impaired left ventricular ejection fraction?
Dr Nair: Say 25%.
Dr Gulielmos: Well, you know, we've only done about a hundred cases, so we still choose our patients. And those ones who have an impaired left ventricular ejection fraction less than 35%, we don't use this technique because you cannot evaluate, well enough whether the heart is really empty or not.
Dr R. Cesnjevar (Erlangen, Germany): I have two questions. First, on the cosmetic results. On your one slide you showed a male with nice cosmetic results. How do you think about your incision in women, especially if the breasts are a bit bigger, you cut medial to the mamillary, how about cosmetic results in women if you cut directly into the breast? Secondly, I wanted to ask you, have you been able to cannulate the heart directly, the ascending aorta in all cases, and how often did you have to cannulate the groin? In your presentation in Dusseldorf 1 month ago with a similar topic, you noticed sometimes that you had destruction of the groin vessels because of difficulties with peripheral vessel disease. Could you comment on that, please?
Dr Gulielmos: I answer the second question first, if you don't mind. We started this procedure cannulating the femoral vessels, both, vein and artery. As we focused in avoiding retrograde flow, we always started cannulating the ascending aorta. It has always been possible since. The reason for this is some complication we faced with another technique in patients with coronary heart disease, we had some vascular complications and that was the reason which drove us away from cannulating the femoral artery in order to avoid retrograde flow. It has never been a problem inserting the venous drain cannula via the femoral vein into the right atrium. Concerning your first question, cosmetic results about ladies, you know, you seldom operate on a 25-year-old lady, whose breasts stand a little bit higher than in older ladies, so that has never been a problem.
Dr A. Pavie (Paris, France): You have presented on your first slide several techniques. You have started, it seems to me, with the Heartport system, and at the end of your slide you have made some case without CPB. I would like to know why you have changed your technique on CPB? The second point is, what are the different indications with CPB or without CPB?
Dr Gulielmos: We actually didn't change our technique. This is a more sophisticated way of thinking. Because not everybody's patient is receiving this technique in our institution. I maybe said that we tried these other beating heart procedures. We didn't actually try it. We're still doing it. Patients with single-vessel disease and a good left ventricular ejection fraction, we do CTS, (beating heart, LIMA to LAD). Patients with one- or two-, or sometimes even three-vessel disease, with impaired left ventricular ejection fraction, we perform median sternotomy using the Octopus system because this gives us some sort of safety, being able any time to go on bypass just in case. Patients having a good left ventricular ejection fraction, over 35%, multivessel disease, two- or three-vessel disease, then we use this technique in order to avoid median sternotomy.
Dr C. Alhan (Istanbul, Turkey): If you think that we may extrapolate these results to patients with poor ventricle, how will we deal with the cardioplegic management? I think you don't use blood cardioplegia or retrograde cardioplegia. We did talk about them very often until now, but I think we have forgotten all about the myocardial management.
Dr Gulielmos: You're right. We thought about this problem, and I don't think that our plegias are our problem. Using our plegias, we can reach cross-clamping time of over 2–1/2–3 h. We don't have any problems at all. But the fact is that using a limited skin incision, you cannot see the heart whether it's very well filled or not. So the solution to the problem might be an additional pulmonary vent catheter which would vent continuously.
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Top
Abstract
Introduction
