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Eur J Cardiothorac Surg 1999;15:680-684
© 1999 Elsevier Science NL

Angiographic results after minimally invasive coronary bypass grafting using the minimally invasive direct coronary bypass grafting (MIDCAB) approach¹

Clinic of Cardiac Surgery, University of Leipzig, Heartcenter, Russenstraße 19, 04289 Leipzig, Germany
Clinic of Cardiology, University of Leipzig, Heartcenter, Russenstraße 19, 04289 Leipzig, Germany

Received 21 September 1998; received in revised form 23 November 1998; accepted 30 November 1998.

Corresponding author. Tel.: +49-341-865-1421; fax: +49-341-865-1452.

	Abstract

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Objective: The aim of the study was to evaluate the early and mid-term angiographic results after minimally invasive coronary bypass grafting using an `off-pump' technique via a lateral minithoracotomy. Methods: In 221 out of 271 patients (81.5%) who underwent minimally invasive direct coronary bypass grafting (MIDCAB) the quality of the internal thoracic artery (ITA)-graft and the anastomosis was evaluated by conventional coronary angiography between the 2nd and 6th postoperative day (POD). A subgroup of 130 patients (47.9%) of the initial cohort were repeatedly controlled by angiography 6 months later. Results: The early postoperatively patency rate of the grafts was (96.8%). Moderate anastomotic stenosis between 50 and 75% was found in 13/221 (5.8%) patients, whereas severe stenosis of more than 75% was seen in 10/221 (4.5%) and occlusion of the graft in 3/221 (1.3%) patients. A stress-ECG was performed in patients with a severe stenosis to provoke ST-segment changes or clinical findings of myocardial ischemia. A positive stress test was found in 4/221 patients (1,8%). Early re-intervention was required in 7/221 (3.1%) patients. After 6 months, angiographic follow-up revealed a patency rate of (95.4%). Of 130 patients 5 (3.8%) presented with moderate anastomotic stenosis, whereas 3/130 (2.0%) patients showed a severe stenosis with one patient (0.7%) having myocardial ischemia during stress test. Occlusion of the graft was seen in 3/130 patients (2.3%). During follow-up, 4/130 (3.0%) patients underwent re-intervention. A comparison between early postoperative and 6-months angiogram revealed a decrease or a disappearance of the severity of the stenosis in 4/15 patients (26.6%). Conclusion: Since stenosis of the anastomosis may occur after minimally invasive, beating heart coronary bypass grafting, postoperative angiography should be performed to provide quality control and to guide appropriate further treatment. The latter is necessary if the stenosis is accompanied by reduced run-off and evidence of myocardial ischemia during stress test. An improvement of early stenosis at the anastomosis may be expected in more than 25%.

Key Words: Angiographic • Minimally invasive direct coronary bypass grafting • Heart

	Introduction

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Technical accuracy of the anastomosis is crucial for early and long-term patency of coronary artery bypass graft. Concerns have been raised about the quality of anastomosis between the internal thoracic artery (ITA) and the left anterior descending artery (LAD) when performed on the beating heart without cardiopulmonary bypass 1 2. The aim of this study was to evaluate the angiographic results after minimally invasive coronary bypass grafting in `off-pump' technique using the lateral approach by minithoracotomy.

	Methods

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Out of 271 patients who underwent minimally invasive direct coronary artery bypass grafting (MIDCAB) without cardiopulmonary bypass (CPB) between December 1996 and April 1998, 221 patients gave their consent to an early postoperative angiogram before discharge from hospital. By October 1998, 130 patients (47.9%) from the initial cohort have been controlled by angiography 6 months later, according to our institutional follow-up protocol. In all patients a left anterolateral minithoracotomy approach (MIDCAB) to the ITA and the coronary arteries was used as described elsewhere 3. The ITA graft was harvested under direct vision using a special retractor either from CTS^TM (CadioThoracic Systems^TM, Cuportina, CA) or US-Surgical^TM, (US-Surgical, Norwalk, CN). Heparin (100 IU/kg) was applied before the ITA was dissected. The activated clotting time (ACT) was kept on an elevated level of more than 250 s by repeated application of Heparin if necessary. The anastomosis was performed applying local mechanical immobilization of the myocardial surface at the anastomotic site. This was achieved by various commercially available mechanical stabilizers. To gain a bloodless field during the performance of the anastomosis, temporary occlusion of the graft was achieved with proximal and distal snares (4/0 monofile suture), soft PVC-tubes and a small piece of pericardium. Anastomosis was performed using a continuous running technique with one suture. The ITA-pedicle was fixed at the myocardial surface using stay sutures or fibrin glue. Protamin was applied to neutralize 80% of the Heparin dosage at the end of the procedure. Multiplane angiography was performed between postoperative days 2 and 6 and follow-up angiography after 6 months. All angiograms were done at the same institution. The angiograms were qualitatively categorized as described by FitzGibbon et al. 4 by one cardiologist and one surgeon not involved in the procedure. All patients who showed stenosis at the anastomosis of more than 50% had a stress-ECG to check for any evidence of myocardial ischemia before discharge from hospital.

	Results

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Demographics and clinical results are depicted in Table 1. The conduits used were left ITA in 266 patients, right ITA in five, and radial artery graft in 19 patients. In 250 patients single graft revascularization was performed (ITA to LAD: n=245 patients, ITA to RCA: n=5). In 19 patients Y-graft to the LAD and the diagonal branch or intermedius branch using radial artery grafts was performed. Intraoperative conversion to CPB or sternotomy was necessary in 12 patients (4.4%) due to intramyocardial running LAD, injury of the ITA, hemodynamic instability during LAD occlusion or technical reasons. Perioperative myocardial infarction occurred in six patients (2.2%) without hemodynamic alteration. Postoperative complications included atrial fibrillation in 28 patients (10.3%), early pneumothorax after removal of the chest tube in 10 patients (3.7%), transient psychotic disorder in 10 patients (3.7%), pneumonia in two patients (0.7%) and transient renal failure in one patient (0.4%). Mortality was 1/271 (0.4%). This patient suffered sudden ventricular fibrillation 8 h after surgery. Death was caused by ischemic brain damage due to prolonged resuscitation. The ITA-graft was confirmed to be patent at autopsy.

At 6-months follow-up another three of 130 patients (2.3%) showed an ITA graft occlusion (n=2) or occlusion of the radial artery (n=1). Three patients (2.3%) showed a 75% stenosis at the anastomosis together with evidence of ischemia during stress-ECG. In these patients and in one patient with an occluded graft a re-intervention was performed. These included three percutaneous coronary angioplasty (PTCA) – and stenting procedures of the stenotic segment at the heel of the ITA – anastomosis and one conventional redo LAD-grafting using a saphenous vein graft. One patient with an occluded ITA-graft refused reoperation. In another patient with an occluded ITA-graft no re-intervention was necessary as the former LAD lesion completely disappeared during follow-up. Interestingly, disappearance of the native LAD-stenoses could be detected in 3/130 patients (2.3%) at 6 months follow-up. Among 15 anastomotic stenoses shown at early angiogram, 4 (26.6%) disappeared or significantly decreased. An example is given in Fig 1 .

View larger version (111K): [in this window] [in a new window]   Fig. 1.

	Discussion

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Based on our data, the early patency rate after MIDCAB-grafting can be expected to exceed 95% and the 6-months patency more than 90%. Although follow-up data are not complete so far, we believe that our data reflect the postoperative angiographic results, after MIDCAB-grafting, realistically. These data compare well with a study presented by FitzGibbon et al. 5, who found a comparatively early (<6 months) occlusion-rate for the ITA graft to LAD in conventional coronary artery bypass grafting. In this study the authors described a so called grade B stenosis (>50% in relation to the grafted coronary artery) in 10% of the patients. Our results demonstrate a comparable outcome with 10.3% of patients showing stenosis of 50% or more at the postoperative angiogram. It is of interest, that only 1.8% of these patients showed a reduced run-off through the graft combined with symptoms of myocardial malperfusion. We believe that only these patients are candidates for an early re-intervention. In all patients with good run-off having no evidence of ischemia during stress-test and without symptoms of angina, a `wait and see' attitude may be justified. This policy is supported by the fact, that some of the early stenotic lesions (26.6%) disappeared after 6 months. Nevertheless, 2.3% of the patients need a re-intervention at an early stage after surgery and 3% during follow-up. On the basis of our experience we recommend a PTCA in all patients having a short stenotic segment proximal to the heel of the anastomosis. In our opinion this is a safe procedure 3 months after surgery.

The cause of early stenosis of the anastomosis seen in this study remains unknown. In our series, there was no `de novo stenosis' at the site of temporary snaring. Moreover, the anastomosis itself demonstrated normal outflow conditions in all but two patients. Most of the stenoses were located at the heel of the anastomosis or in the distal segment of the ITA-graft. In our opinion five causes of these phenomena should be discussed: (1) a narrowing by the running suture at the heel of the anastomosis due to a technical mistake (2), a narrowing by bridging adventitial tissue, along a placement of a clip at a side branch close to the anastomosis (3), kinking of the anastomosis, due to lacking or wrong epicardial fixation of the pedicle or non-sufficient opening of the pericardium (4), thrombotic appositions due to turbulent flows and a hyperactive coagulation response early after surgery (5), postoperative spasm of the distal part of the ITA-graft.

How can these problems be avoided? The narrowing of the anastomosis by the suture, by bridging tissue or by kinking of the ITA-graft are avoidable by a meticulous surgical technique. Thus, apart from a accurate suture-technique, we recommend cleaning of the last distal segment (0.5 cm) of the graft from all bridging tissue. The anastomosis should be fixed by fibrin glue, if necessary, to prevent any kinking at the heel. Apart from the technically related causes the 6-months follow-up demonstrated a dynamic process in more than 25% of the early stenoses with a disappearance over this period. Thus, early postoperative spasm of the distal segment of the LAD is an entity and could be overcome by medical treatment with Diltiazem 17. To avoid thrombotic formation at the anastomosis, early application of acetyl-salicylic-acid may be discussed, as well 18.

However, all these possible reasons for early postoperative stenosis at the anastomosis after MIDCAB-grafting are speculative, since the real morphological condition in the stenotic segment could not be identified so far. In addition, the presented results are part of the first learning period of MIDCAB-grafting using both, the `off-pump'-technique and the lateral minithoracotomy approach. Thus, improved results may be expected by gaining experience. With the former described technical changes, the early rate of moderate and severe stenosis could be reduced to zero in the last series of 65 patients of one experienced surgeon.

	Conclusion

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Minimally invasive direct coronary bypass grafting on the beating heart is a safe and effective treatment for proximal LAD lesions. The angiographic control revealed an early patency rate of 96.8%, and 95.5% 6 months after surgery, which equals the patency rates for conventional ITA grafting and is clearly superior to the reported results for the PTCA of comparable lesions 19. However, moderate or even severe early postoperative stenosis at the anastomosis is seen after MIDCAB-grafting which should be overcome by meticulous surgical techniques. This very promising new surgical treatment for single LAD-coronary artery disease will be judged by the quality and patency of the anastomosis. Thus, for a defined period of time postoperative angiographic control should be a part of the treatment after MIDCAB-grafting to achieve both, learning by a critical follow-up and providing valid information about the patency and quality of the graft and anastomosis. This is necessary to analyze the maximum benefit of this treatment in comparison with conventional coronary artery bypass grafting and percutaneous coronary angioplasty (PTCA) with or without stenting.

	Conference discussion

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Dr V. Subramanian (New York, NY, USA): The standard we used to think of as gold is no longer gold and I want to give you two sets of data one of which from an image trial. A total of 645 patients who had LIMA LAD anastomosis, had a cardiopulmonary bypass with a mid-line sternotomy and cardioplegic arrest, which was presented about a year and a half ago at the American Heart Association. In that group there was a mean of 10.8 days when a post-op angiography was performed. This was a randomized multicenter control trial. Therefore it was mandatory that in 10.8 days, a mean angiographic control was performed. The data spells out very clearly 91% of those patients had patent graft with 50% less stenosis and 7.7% had more than 50% stenosis with 1.1% being totally occluded, which clearly correlates with the data of the MIDCAB as you talk observed.

The other data I think you ought to look at, is the angiographic patency with the LIMA and LAD in relation to the diameter of the vessel. There was 3-years patency data from the VA cooperative study looking at aspirin as a platelet inhibitor for graft patency. That was about three years ago. That study clearly pointed out that, if you have a diameter of 1.5 mm or less, you have a 13.7% occlusion rate of LIMA and LAD, and if you have 1.5–2 mm, you have a 9.7% occlusion rate.

In our own experience, most of the early angiographic anastomotic problems you see completely disappear by about 6 months.

I think the technical details of this operation is very important. In my own experience I have found that an adventitial bridge is probably the most important technical problem causing anastomotic irregularities, since we have been very careful about taking these adventitial bridges and making the alignment of the LAD and LIMA anastomosis to be about a 30 or 40 degree angle, we have not seen any of the anastomotic abnormalities. Can you tell us, does this study include the period before the stabilization or after the stabilization, since stabilization has a definite effect?

Dr Diegeler: I agree very well with this. These are all angiograms after or during the period we could stabilize the anastomosis, but one has to take into account that it contains the learning period of three surgeons. It is my opinion that you will have a learning period. This is another reason to do the postoperative angiogram, because you may control your own results. You are right, one has to use meticulous surgical techniques in performing the anastomosis to get comparable good results.

Dr V. Jawali (Banglore, India): Those patients who had severe stenosis or occlusion, how many of them had clinical problems, hemodynamic enzymes or ST changes?

Dr Diegeler: None of these patients had acute problems. The patients who showed problems were reoperated on early or the anastomosis was redone during the initial procedure. All patients who were stable were discharged. Those who were reoperated on showed ST elevation during stress or prebiological myocardial scan with evidence of ischemia. That was the basis of our decision to do a redo. Interestingly all of these patients showed a reduced flow at angiography. Most of the patients with a stenosis, even moderate, showed an excellent run-off of the graft. These patients were discharged for follow-up, but three came back during 6-months follow-up with angina symptoms. In all three a PTCA could be done. The PTCA could prevent these patients for a redo operation.

Dr. U. von Oppell (Capetown, South Africa): Do you use a continuous suture for your anastomosis, and do you use intraoperative Doppler measurements? If so, have you correlated this with an angiographic control?

Dr Diegeler: First, we do a one-suture technique, a running suture beginning in the heel. Second, we usually use intraoperative flow measurement but only to confirm that the graft is patent. There is no relation between the flow you measure and the postoperative angiogram.

Dr P. Boonstra (Groningen, The Netherlands): Why should we not compare the results of MIDCAB with PTCA and a stent?

Dr Diegeler: Okay, that is a philosophical question. I think we are surgeons, and of course we know that the results of an arrested heart, or the anastomosis of an arrested heart should be more precise than that of a beating heart with limited access. I think this is our standard that we have to reach, and firstly we have to convince our own colleagues. We shouldn't go to look at what the cardiological partners have with their PTCA results, of course, this might be the argumentation, to claim the patients for surgery. Our first goal should be to compete with the best we can achieve for the patient. I still think the anastomosis on an arrested heart is the best.

Dr Boonstra: But still both groups treat patients.

Mr T. Treasure (London, UK): Dr. Diegeler pointed out it was philosophical. I think it is an interesting discussion, but there is a time limit. We will pursue that and we will hear more of it later.

	Footnotes

 
Presented at the 12th Annual Meeting of the European Association for Cardio-thoracic Surgery, Brussels, Belgium, September 20–23, 1998.

	References

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