Eur J Cardiothorac Surg 1998;14:S48-S53
© 1998 Elsevier Science NL
Minimally invasive cardiac surgery for the treatment of coronary artery multi-vessel disease 1
Vassilios Gulielmos*,
Stephan Schueler
Cardiovascular Institute, University Hospital Dresden, Fetscherstrasse 76, D-01307 Dresden, Germany
* Corresponding author. Tel.: +49 351 4501790; fax: +49 351 4501512.
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Abstract
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Objective: In order to avoid sternotomy-related complication after cardiac surgery minimally invasive cardiac surgery has been developed successfully for the treatment of coronary artery disease, however, those techniques were still limited to the treatment of single-vessel disease. Therefore a new surgical technique for the treatment of multi-vessel disease has been developed. Methods: From November 1996 to May 1997 61 patients (age 39–78 years) with coronary artery disease were treated with this new technique. This technique included a small (6–9 cm) left lateral chest incision via the 3rd intercostal space. The left internal thoracic mammary artery (LIMA) was harvested through the chest incision and access to the central portion of the heart including the ascending aorta was obtained. During LIMA harvesting saphenous vein segments were harvested. Cardiopulmonary bypass was instituted through femoral vein cannulation and cannulation of the ascending aorta in most cases. After external aortic cross clamping cold antegrade cardioplegia was applied. In all patients except one the LIMA was used for the left anterior descending artery (LAD). In addition vein grafts were used for revascularisation of the other coronary arteries. Results: There were no intraoperative complications and all patients survived the procedure. All patients could be weaned from CPB and the postoperative course was uneventful in most patients. Wound complication occurred in two patients. The median hospital stay was 6 days (median±SEM). Conclusions: This new technique combines minimally invasive surgical conditions with the safety standards of routine cardiac surgery. With this approach even extensive coronary artery disease can be treated.
Key Words: Coronary artery bypass surgery • Minimally invasive cardiac surgery • Multi-vessel disease • Cardiopulmonary bypass
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1. Introduction
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The successful treatment of single-vessel coronary artery disease (CAD) using a minimally invasive approach has been reported recently [1–4]. Our own experience started with a Port-AccessTM system including the safety standards of cardiac surgery such as cardiopulmonary bypass (CPB) and cardioplegic arrest (CA). This technique has been successfully introduced in Europe in our institution in March 1996. The results in this first series of 42 patients were very encouraging, however, this technique was limited to patients with single-vessel disease [5, 6]. There was a significant risk of vascular complications using femoral arterial cannulation and the endoaortic balloon catheter. Furthermore Port-AccessTM technology did not allow access to the ascending aorta for the attachment of proximal vein graft anastomoses. Therefore a new surgical technique was developed in order to avoid femoral arterial cannulation and the use of the endoaortic balloon occlusion catheter, in addition the treatment of triple-vessel disease with the use of the left internal thoracic artery (LIMA) and additional vein grafts was feasible if necessary.
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2. Methods
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Between November 1996 and May 1997 61 patients with CAD were evaluated for minimally invasive coronary artery bypass grafting (MICABS). The patients age ranged between 39 and 78 years (median 65.0 years). There were 13 female and 48 male patients. The exclusion criteria at present for this procedure were overweight (more than 130%) and impaired left ventricular function (LVEF<40%). Furthermore patients with sonographic serious arteriosclerotic lesions of the femoral artery and the iliac artery as well of the aorta were not accepted. Preoperatively 18.9% were in CCS-stage 1, 28.3% in stage 2, 37.7% in stage 3, and 15.1% in stage 4; in New York Heart Association (NYHA) class I 38.5%, in NYHA class II 28.8%, in NYHA class III 28.8%, and 3.9% in NYHA class IV. The pattern of the patients being evaluated for MICABS included single-vessel disease (LAD) in 24 patients, double vessel disease in 25 patients including six patients with significant main stem stenosis, seven patients with stenosis of the LAD and the circumflex artery, one patient with stenosis of the LAD and the intermediate branch, seven patients with stenosis of the LAD and the diagonal branch, and four patients with significant lesions of the LAD and the right coronary artery. Twelve patients suffered from triple-vessel disease (Table 1
).
At surgery the patient was placed in supine position with a rubber cushion under the left shoulder. A single-lumen airway tube was used for double-lung ventilation. A 6–9 cm skin incision was made at the level of the 3rd intercostal space (Fig. 1
) and the sternal edge of the 3rd and the 4th rib were dissected but not removed. Using a small wound retractor the LIMA was harvested through the chest incision as a pedical up to the 1st rib and divided distally. Mediastinal fat was dissected and the pericardium was opened towards the ascending aorta and stay sutures were placed in order to retract the ascending aorta towards the chest incision. During LIMA harvesting saphenous vein segments were harvested. The ascending aorta was dissected from the pulmonary trunk. After cannulation of the femoral vein for venous return and arterial cannulation of the ascending aorta cardiopulmonary bypass was started. In one patient the right atrium was cannulated using a double stage cannula (Fig. 2
). On bypass as aorta and pulmonary trunk become smoother they were dissected from each other and the ascending aorta was surrounded using an umbilical loop. Pulling on the umbilical loop enabled the positioning of an additional line at the aortic root for antegrade delivery of cardioplegic solution, for aortic root venting during cardioplegic arrest, and for antegrade de-airing before removing the aortic clamp. In one patient both internal mammary arteries were harvested via the left lateral chest incision. The LIMA was prepared by direct vision, the RIMA was dissected thoracoscopically using endoscopical instruments. The ascending aorta was pooled by the umbilical loop towards the surgical gate and was that way safely cross clamped. Cold antegrade crystalloid cardioplegia was delivered via the aortic root line. During cardioplegic arrest aortic root venting was performed. Exposure of all coronary arteries was facilitated by rotating the heart. An end-to-side anastomosis was performed between the vein graft and the coronary arteries in a standard fashion (Fig. 3
Fig. 4
) followed by anastomoses of the LIMA to the LAD (Fig. 5
). In one patient total arterial revascularisation was performed using the LIMA and RIMA. The LIMA was used as a conduit for the LAD and the RIMA was attached to the intermediate branch of the LCA. The proximal end of the RIMA was anastomosed end-to-side as a `T-graft' to the LIMA (Fig. 6
).
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Fig. 1. LIMA harvesting and access to the heart was obtained using a 6–9 cm left parasternal incision in the 3rd intercostal space. The ribs are marked from 1st to 4th.
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Fig. 2. Central cannulation of the ascending aorta (A) and double stage venous cannula in the right atrium (B).
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Fig. 4. Vein graft anastomoses to a diagonal branch of the LAD (A) to a marginal branch of the circumflex artery (B).
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Fig. 5. LIMA to LAD anastomosis (A). Vein graft anastomosis to the diagonal branch of the LAD (B). Vein graft to the marginal branch of the circumflex artery (C).
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Fig. 6. The LIMA was anastomosed in end-to-side technique with the LAD (A). The proximal end of the RIMA was attached to the LIMA as a T-graft (B). The RIMA (C) was anastomosed in end-to-side technique with an intermedius branch.
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After standard de-airing aortic cross clamp was removed and the proximal end of the vein grafts were attached end-to-side to the ascending aorta (Fig. 7
). After placing of temporary pace maker wires the patient was weaned from CPB. The sternal edges of the 3rd and 4th rib were attached to the sternal border with two steel wires; two chest tubes were left in place and the chest incision was closed in layers (Fig. 8
).
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Fig. 8. Skin incision after minimally invasive coronary artery bypass grafting in a patient with multi-vessel disease.
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The total time of surgery, LIMA-harvesting time, time of CPB, time of cardioplegic arrest, ventilation time, ICU-stay and hospitalization were monitored. As part of the study all patients had a follow-up including physical examinations, 12 led ECG and X-ray on postoperative day 2 and 14 and in addition patients were followed 6 and 12 weeks after surgery. The 6-weeks follow-up was completed in 48 patients (78.7%) and 26 patients (42.6%) underwent the 12-weeks follow-up.
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3. Results
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All patients survived the procedure and were weaned from cardiopulmonary bypass without inotropic support in sinus rhythms without signs of ischemia. There was no necessity for conversion to median sternotomy in any patient. A total number of 60 LIMA-, one RIMA-, and 46 vein grafts was used. Coronary vessels grafted are listed in Table 2
.
In one patient the LIMA revealed severe arteriosclerotic lesions during harvesting, therefore a vein graft had to be applied to the LAD. In one further patient the LIMA was used as a free graft to the LAD because of a significant lesion of the left subclavian artery. Postoperative complications included delayed wound healing of the groin in one patient, wound infection of the chest incision in one further patient, and lymphatic fistula in one patient. Duration of the operation, time of LIMA harvesting, ICU-stay are listed in Table 3
. In the last ten consecutive patients with coronary multi-vessel disease LIMA harvesting time could be significantly reduced to a mean of 28 min, thus reducing operative time to a median of 230 min.
Hospital recovery time was significantly lower compared with patients with standard sternotomy (Table 3). All patients included in this study wee alive and well up to 4 days after operation.
At time of examination 59 patients (96.7%) were completely free from angina pectoris. Two (3.3%) patients complained of minor angina like symptoms during major exercise. Coronary angiogram showed in the first patient stenosis of the LAD anastomosis and in the 2nd patient a new stenotic lesion in the LAD about 2 cm distal to the anastomosis. Both patients underwent an uncomplicated PTCA. The 3-month follow-up was completed in 17 patients; in NYHA class I were 11 patients (64.7%), in NYHA class II were six patients (35.3%). In CCS stage 1 were 15 patients (88.2%) and two patients (21.8%) in stage 2. The 3-months control stress test with ECG was in all patients with no evidence of myocardial ischemia and pain assessment revealed no pain in any patient except one who had some pain during body exercise.
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4. Comment
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This is the first description of a new surgical technique allowing the treatment of coronary multi-vessel disease under minimally invasive surgical conditions, using the current standards in coronary artery surgery such as cardiopulmonary bypass, cardioplegic arrest, the use of the LIMA to the LAD, and vein grafts for other coronary arteries. The LIMA harvesting has been performed through a chest incision without additional ports. The chest incision via the 3rd intercostal space allows good access to the ascending aorta as well. Moving the chest incision from the bed of the 4th rib [6]towards the 3rd intercostal space, access to the central part of the heart is feasible, also allowing cannulation of the ascending aorta, thus avoiding retrograde flow for CPB being related to vascular complications [7]. Even the placement of a double stage venous cannula via the right atrium in some cases, application of cardioplegia and left ventricle venting. Furthermore proximal vein grafts can be applied to the ascending aorta. Cardioplegic arrest allows complete access to all areas of the heart which is the biggest advantage of this technique against beating heart procedures [1]. With this new minimally invasive surgical technique complete revascularisation in patients with extensive coronary artery disease is feasible under the safety standards of regular coronary bypass surgery. In addition this method allows complete arterial revascularisation using LIMA and other arterial conduits. Hospitalization is 3 days shorter than in patients receiving conventional CABG surgery at our institution. Even if return to normal activities has not been completely evaluated we see that patients receiving this new procedure are a lot faster rehabilitated than patients receiving conventional cardiac surgery.
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Footnotes
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1 Presented at the World Congress on Minimally Invasive Cardiac Surgery, Paris, May 30–31, 1997. 
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References
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Abstract
1. Introduction
