Eur J Cardiothorac Surg 1998;14:S43-S47
© 1998 Elsevier Science NL
Totally minimally invasive cardiac surgery for coronary artery disease 1
Chi-Hsiao Yeh,
Chau-Hsiung Chang,
Pyng Jing Lin*,
Feng-Chun Tsai,
Min-Wen Yang,
Peter P.C Tan
Division of Thoracic and Cardiovascular Surgery, Department of Anesthesiology, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
* Corresponding author. Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University, 199, Tun-Hwa North Road, Taipei, Taiwan. Tel.: +886 3 3281200; fax: +886 3 3285818.
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Abstract
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Objective: We report our experience using minimally invasive techniques both to perform coronary artery bypass and harvesting of saphenous vein grafts in 25 patients with left main or triple vessels disease. Methods: From March 1997 to June 1997, 25 patients received elective coronary artery bypass grafting using minimally invasive surgical techniques for left main or triple vessels disease. Saphenous vein grafts were harvested using minimally invasive techniques under direct vision. The coronary artery bypass grafting was performed through a limited left anterior parasternal minithoracotomy under femoro–femoral or aorto–atrial cardiopulmonary bypass. The myocardium was protected by antegrade infusion of cold blood cardioplegic solution while the aorta was cross-clamped. Results: Three to four distal anastomoses were performed with the saphenous vein graft and the left internal thoracic arterial graft. The aortic cross-clamp time was 60–135 min. The duration of cardiopulmonary bypass was 89–172 min. The postoperative course was uneventful for all patients. All patients were found to be in New York Heart Association functional class I or II on follow-up from 3–7 months after surgery. Conclusions: Minimally invasive coronary artery surgery is technically feasible and can be performed in left main or triple vessel disease safely and effectively for complete revascularization.
Key Words: Minimally invasive cardiac surgery • Coronary artery bypass grafting
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1. Introduction
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Coronary artery bypass grafting is traditionally carried out with median sternotomy, extracorporeal circulation, aortic cross-clamping, infusion of cardioplegic solution, and multiple grafting with internal thoracic artery and saphenous vein grafts. However, poor cosmetic results and possible complications of median sternotomy are occasionally troublesome [4].
Minimally invasive surgical methods have been developed to provide patients the benefits of open operations with decreased pain and suffering [2, 3, 7–11, 14]. These surgeries have been performed through minithoracotomy with or without the guidance of video-assisted endoscopy. The minimally invasive nature of these surgeries can lessen incisional pain, minimize incisional length, enhance functional recovery, and shorten hospital stay.
Minimally invasive coronary artery surgery has been performed in one- or two-vessel disease through limited left anterior thoracotomy with [10]or without [1]cardiopulmonary bypass support. However, this technique has only recently been utilized in left main or triple vessel disease [12]. It was performed through a left parasternal minithoracotomy and the stenotic coronary arteries were bypassed with saphenous vein grafts and internal thoracic arterial graft under femoro–femoral cardiopulmonary bypass. However, the saphenous vein grafts were harvested by conventional methods with long incisions on the legs. Lately, the use of video-assisted endoscopy in the harvesting of saphenous vein grafts [5]has significantly shortened the length of the leg incisions. In this report we review our initial results of minimally invasive coronary artery bypass through a left parasternal minithoracotomy in combination with minimally invasive harvesting of saphenous vein grafts, through two limited leg incisions, performed under femoro–femoral or aorta-pulmonary artery-right atrium cardiopulmonary bypass with blood cardioplegic arrest in 25 patients with left main or triple vessel disease at Chang Gung Memorial Hospital, Taipei, Taiwan.
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2. Material and methods
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2.1 Patients
From March 1, 1997 to June 30, 1997, 25 patients (20 men and five women) received minimally invasive cardiac surgery without median sternotomy, and with minimally invasive harvesting of saphenous vein grafts, at Chang Gung Memorial Hospital, Taipei, Taiwan for the surgical revascularization of left main or triple vessel disease. Their ages ranged from 40.9 to 75.8 years (mean 63.4±6.8 years). Smoking was noted in 15 patients. Diabetes mellitus was diagnosed in seven patients. Hypertension was noted in eight patients. Hypercholesterolemia occurred in 13 patients. Previous stroke was noted in seven patients. A myocardial infarction had occurred in four patients. Percutaneous transluminal coronary angioplasty had been performed on five patients. Coronary angiographic examinations showed left main coronary arterial lesion in nine patients and triple vessel disease in 22 patients. The left ventricular ejection fraction ranged from 17 to 80% (mean 44±18%). All the patients or their family members were informed that a median sternotomy might be necessary and all signed an operative consent form.
2.2 Operative techniques
The surgical techniques used in these patients have been previously reported [12], but with some modification. Patients were put in a supine position with exposure of the left groin and lower limbs and transesophageal echocardiographic monitoring was set up. A left anterior parasternal minithoracotomy (length 8–12 cm, Fig. 1
) was performed and the costal cartilage of the third and fourth ribs was resected. Care was taken not to damage the underlying left internal thoracic artery. The internal thoracic arterial graft was identified beside the sternal border and was mobilized from the first to the fifth intercostal space under direct vision.
In the meantime, a greater saphenous vein graft was harvested from the lower limb using minimally invasive technique. Two small incisions (3–4 cm in length) were made on the medial side of the thigh (Fig. 2
). The saphenous vein was identified and harvested under direct vision. Using the conventional surgical instruments and the Vario Retractor System (Aesculap AG, Tuttlingen, Germany) which provides integrated cold light for illumination and retraction, we could dissect the saphenous vein from the surrounding tissue without damage to the vein graft. A 35-cm greater saphenous vein was harvested through these two small incisions.
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Fig. 2. Two small incisions (3 and 4 cm in length) on the left thigh after harvesting the saphenous vein graft using the minimally invasive technique.
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In 17 patients, the left common femoral artery and vein were then isolated for later cannulation. Systemic heparinization (250 units/kg) was injected at this time. The ascending aorta was isolated from the main and the right pulmonary artery and was encircled with umbilical tape. A partial clamp (Kay Clamp, Pilling, Fort Washington, PA) was then applied to the proximal part of the ascending aorta which was pulled into the operative field by the umbilical tape. Proximal anastomosis of the saphenous vein graft to the ascending aorta was performed under direct vision. In eight patients, cannulation of the distal part of the ascending aorta and the main pulmonary artery were then performed and cardiopulmonary bypass was established. Cannulation of the right atrium was also performed in these eight patients to increase venous drainage. In the other 17 patients, cannulation of the femoral artery and vein was performed to establish cardiopulmonary bypass. A double-lumen aortic root cannula (DPL, Grand Rapids, MI) was then inserted at the aortic root for delivery of cardioplegic solution and venting of the left ventricle. A membranous oxygenator (Maxima Plus oxygenation system, Medtronic, Cardiopulmonary Division, Anaheim, CA) was used. Systemic hypothermia (rectal temperature 26.5±0.7°C) was initiated immediately after the start of cardiopulmonary bypass. Topical cooling of the heart was not used. The aorta was cross-clamped. The myocardium was protected by a cold blood cardioplegic solution with a potassium ion concentration of 20 mmol/l which was infused into the aortic root then and after completing of each distal anastomosis. The cardioplegic solution was delivered to the myocardium through the native coronary arteries and the grafted saphenous vein. The heart was soon arrested and cooled, and was decompressed by venting through the aortic root cannula.
The saphenous vein graft was grafted sequentially to the diagonal branch, obtuse marginal branch, and posterior descending branch with a running suture under direct vision. The internal thoracic arterial graft was then anastomosed to the left anterior descending artery while rewarming was started. The anastomotic areas were steady and clear due to cardioplegic arrest and aortic cross-clamping making the anastomosis easy and smooth.
After completing of all the anastomoses, warm blood cardioplegia was infused into the aortic root. The clamp on the internal thoracic arterial graft and the aortic cross-clamp were then removed. Sinus rhythm recovered spontaneously and cardioversion was not necessary in any of the patients. Cardiopulmonary bypass was terminated after rewarming the patients. The pericardium was not closed. A small dosage of sodium nitroprusside was infused. Cardiotonic drugs were required for five patients. An intra-aortic balloon pump was set up in two patients. Temporary pacemaker wires and pleural drainage were set up routinely. Hemostasis and closure of the incisions were easily achieved.
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3. Results
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Three to four distal anastomoses were performed in each patient (mean 3.7 anastomoses). The aortic cross-clamp time was 60–135 min (mean 78±18 min). The duration of cardiopulmonary bypass was 89–172 min (mean 118±20 min). The cardiotonic drugs for the five patients and intra-aortic balloon pumping in the two patient were discontinued within 24 h after surgery. All patients regained consciousness in the early postoperative period and the endotracheal tubes were removed on the operative night or in the early morning of the first postoperative day. There were no operative deaths. There was no wound or lower limb vascular complications. Postoperative pain was assessed before discharge from the hospital with a visual analog pain scale (0, no pain; 10, extreme pain) and was 2–6 (mean 3.7±1.3). Electrocardiographic examination performed before discharge showed no new Q wave in any patients. The postoperative length of stay was 5–12 days with a mean of 6.2 days. Follow-up (3.0–7.1 months after surgery, mean 4.6 months) was completed with no late deaths and no angina. Transthoracic echocardiographic examination showed good ventricular function and the left ventricular ejection fraction was 44–75% (65±9%). Coronary angiography performed in five patients 1–3 months after surgery showed patent grafts. All patients were found to be in New York Heart Association functional class I or II. They were satisfied with the good cosmetic healing of their incision (Fig. 1)
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4. Discussion
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The rapid recovery of our 25 patients from their operations indicates that minimally invasive surgeries can be applied in the surgical revascularization of left main or triple vessel disease with good results.
Surgical invasiveness determines the severity of postoperative physiologic derangement and its effect on recovery [15]. The benefits of a minimally invasive approach with less surgical trauma have been adopted by an increasing number of surgical specialties [13]. Technological advances allow miniaturized incisions to be made during coronary artery bypass grafting surgery, not only for the thoracotomy incision but for the vein graft incision as well. In carefully-selected patients these methods may reduce the morbidity of surgical intervention, shorten the hospital stay and lower the cost of care [1–3, 6–15]. In this series, there was no morbidity and no mortality. All of the patients were satisfied with the cosmetic healing. These results indicate that minimally invasive cardiac surgery is a safe procedure.
There are four major changes in our totally minimally invasive coronary artery surgery from classic coronary artery bypass grafting and minimally invasive direct vision coronary artery bypass surgery [1, 15]. The first change is avoidance of a median sternotomy. Classically, median sternotomy is the gold standard of surgical approaches in the revascularization of coronary artery disease [4]. Minimally invasive direct vision coronary artery bypass operations have recently been performed under beating-heart conditions without cardiopulmonary bypass support [1, 15]. This has raised a great deal of enthusiasm and is gaining acceptance among cardiac surgeons and cardiologists. However, limited access and the beating heart restrict the indications for this operation to severe disease of the left anterior descending coronary artery. With the operative method that we have presented, access to the left anterior descending artery, diagonal branches, obtuse marginal branches, and posterior descending branch is easy while the heart is relaxed, decompressed, arrested, and protected. In this way, minimally invasive coronary artery surgery can be expanded to applications in surgical revascularization in left main or triple vessel coronary disease.
The second change is avoidance of a groin incision for cannulation of the femoral artery and vein in some selected patients. In minimally invasive cardiac surgery, simple femoro–femoral or femoro–atrial cardiopulmonary bypass established satisfactory perfusion of all vital organs, including the brain [2, 3, 7–12, 14]. The possibility of vascular complications in the lower limbs, although slight, is always present. Aorto–atrial cardiopulmonary bypass is familiar to most cardiac surgeons. In our series, an aorto–pulmonary arterial–right atrial cardiopulmonary bypass was performed in eight patients, indicating that this technique can be performed in minimally invasive cardiac surgery to avoid a groin incision and its possible complications.
The third change is the establishment of cardioplegic arrest with blood cardioplegia [10, 12]. Cardioplegic arrest is the standard method of myocardial protection. A double-lumen aortic root cannula was easily inserted at the aortic root for delivery of cardioplegic solution and for venting the left ventricle. With the heart relaxed, decompressed, arrested and protected, access and anastomosis to all portions of the coronary arteries is easy, and the aortic cross-clamp time can reasonably extended. In this series, using blood cardioplegic arrest, there was low cardiac output in seven patients postoperatively which was easily treated with the short-term usage of cardiotonic drugs and intra-aortic balloon pumping.
The fourth change is the minimally invasive harvesting of the saphenous vein graft. Traditionally, saphenous vein grafts have been harvested through long incisions on the lower limbs. The poor cosmetic results and possible wound complications make the harvesting of saphenous vein grafts an unpleasant procedure. Recently, video-assisted endoscopic harvesting of the saphenous vein grafts has become a reality [5]. However, the need for technically-demanding and expensive disposable equipment is a major problem in using this procedure. In our series of 25 patients, minimally invasive harvesting of the saphenous vein graft was performed under direct vision with the reusable Vario Retraction System, which provides illumination and retraction. Most cardiac surgeons are familiar with this technique. The saphenous vein graft could be harvested in good quality and adequate length.
Totally minimally invasive coronary artery surgery is technically feasible and can be performed easily and safely. Multiple grafting (mean 3.7 distal anastomoses) with internal thoracic arterial graft and saphenous vein grafts were accomplished using (1) left parasternal minithoracotomy, (2) minimally invasive harvesting of saphenous vein graft, (3) aorto–pulmonary arterial–right atrial or femoro–femoral cardiopulmonary bypass and (4) blood cardioplegic arrest. All our patients were satisfied with the cosmetic results of the limited thoracotomy incision. The postoperative pain assessed by a visual analog pain scale showed reduced pain scores (mean 3.7±1.3) as compared to those following coronary artery bypass grafting performed through median sternotomy (mean 7.5±1.1) (Lin et al., unpublished data). The postoperative length of stay was shorter in this series (mean 6.2 days) than that of uncomplicated coronary artery bypass grafting performed through median sternotomy (8.2 days) [12], as it was in the experience of other series [1, 15]. Comparison between the minimally invasive approach and median sternotomy approach is mandatory. However, at the present time, the number in this series is too small for meaningful statistical comparison with data from patients approached through median sternotomy.
Our experience demonstrated that totally minimally invasive coronary artery surgery can offer decreased postoperative pain, quick functional recovery, excellent cosmetic healing, a shortened hospital stay, and, therefore, lower medical costs.
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Footnotes
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1 Presented at the World Congress on Minimally Invasive Cardiac Surgery, under the auspices of the European Association of Cardiothoracic Surgery, Paris, May 30–31, 1997. 
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Abstract
1. Introduction
