Eur J Cardiothorac Surg 1999;16:S103-S106
© 1999 Elsevier Science NL
The clinical and financial impact of port-access coronary revascularization
Daniel R Watson*,
Steven B Duff
Riverside Methodist Hospitals, Columbus, OH, USA
* Corresponding author. Tel.: +1-614-261-8377; fax: +1-614-261-8695
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Abstract
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Objective: Port-access coronary bypass grafting (CABG )was performed in an attempt to impact the clinical course of patients with coronary artery disease. Methods: One hundred patients (56 men and 44 women) with a median age of 61 years underwent port-access coronary revascularization. The clinical and financial profiles of these patients were compared with fiscal year 1997 patients (n=531) who underwent standard median sternotomy coronary bypass. Results: Preoperative clinical demographics were similar in both groups of patients. Among the port-access population there were no incidences of aortic dissection, deep vein thrombosis, conversion to median sternotomy, or death. Total time in the Intensive Care Unit (ICU), incidence of atrial fibrillation, transfusion requirements, and (subjective) pain rating at 28 days postoperatively were less in the port-access group. The average hospital cost per case was $2703.00 (US dollars) more in the port-access patients, despite a similar length of stay versus conventional sternotomy patients. Conclusions: Coronary bypass surgery can be performed safely with port-access technology with significant clinical benefits in selected patients. Currently these benefits are attained at a significant cost to the institution.
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1. Introduction
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In order for port-access coronary artery bypass grafting (CABG) to become established in the field of cardiothoracic surgery, clinical and financial outcomes should be comparable to those achieved via standard coronary revascularization by median sternotomy [1]. Theoretically, the proven patient benefits of endoscopic access in other surgical specialties should translate into cost saving advantages with regard to patient care [2]. We began a program of port-access coronary artery bypass utilizing the endovascular cardiopulmonary system in an attempt to favorably impact the clinical course of our patient population while analyzing the influence of this program on our resource utilization and costs.
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2. Materials and methods
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From July 1997 to September 1998, 100 patients underwent port-access CABG at the Riverside Methodist Hospital (Columbus, OH). Patients were considered for port-access coronary revascularization if their arterial stenosis involved the right or left coronary systems individually, or had disease involving both systems and a contraindication to sternotomy. This system is manufactured by Heartport, Inc. (Redwood City, CA) and utilizes a transfemoral endoaortic occlusion catheter in conjunction with femoral venous access for cardiopulmonary bypass. Our surgical technique mirrors that which have been reported previously [3].
The port-access group (n=100) was compared to a consecutive group of patients (n=531) who underwent CABG from January 1997 to December 1997. Both groups were operated by the same two surgeons. Preoperative risk factors that are known to affect morbidity and cost were analyzed (Table 1
). We also analyzed intraoperative variables which were thought to influence clinical course and resource utilizations (Table 2
). All patients were tracked for their entire hospital stay and subsequently interviewed at 28 days postoperatively.
Hospital costs were tabulated beginning from the day of their procedure and ending on the day of the hospital release. Professional costs were not included in the analysis. Nine cost centers were identified: nursing, ICU, anesthesia, perfusion, operating room, blood bank, respiratory therapy, pharmacy, and laboratory. Costs were calculated by our accounting department's ‘unit-cost' method, which was tabulated for each individual patient. Our cost data was utilized for comparative purposes between these two patient populations and thus may not be applicable to other for-profit hospitals [4].
Continuous data were compared using the Levene test for equality of variances and unpaired t-tests. Categorical data were compared between groups using 
2 or Fisher exact test as appropriate. Univariate analysis was performed to identify the variables that are associated with morbidity and mortality in this population. Although the importance of a multivariate analysis to adjust for differences between groups in this type of study is acknowledged, there were an insufficient number of events to allow meaningful performance of such an analysis.
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3. Results
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Preoperative characteristics of each group were similar (Table 1). The average number of grafts performed in the port access population was approximately half of the sternotomy population (1.6 versus 3.2). No patient required conversion to sternotomy to complete the procedure, nor were any of the primary procedures ‘redone' in the study period to correct problems from the initial revascularization (Table 2). Examination of intraoperative variables revealed a longer time spent in the operative suite due to longer preparation time prior to incision, internal mammary harvest time, cross clamp time per graft, and duration of cardiopulmonary bypass (Table 2). There were no deaths in the port-access patients and their stay in the open-heart recovery unit and step-down were less than the median sternotomy group (Table 3
).
Procedural related complications (aortic dissection, iliac artery dissection, femoral artery injury, deep venous thrombosis) were absent in the port-access population. The incidence of complications inherent to myocardial revascularization (CVA, reoperation for bleeding, wound infection, atrial fibrillation) were essentially equal in both groups. None of the port-access patients required blood or blood-product transfusion (Table 4
). Wound pain assessment at 4 weeks postoperatively revealed less subjective discomfort expressed by the port-access patients (Table 5
) and a majority had returned to their previous employment (Table 3).
Cost analysis revealed that time and device expenses resulted in a considerable increase in cost for the perfusion and operating room cost centers. Nursing, ICU, and anesthesia costs were approximately equal while port-access patients utilized less cost-units from the blood bank, respiratory therapy, pharmacy, and laboratory departments (Table 6
).
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4. Discussion
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The gold standard for coronary revascularization remains an approach utilizing median sternotomy and cardiopulmonary bypass. Acceptable morbidity and mortality rates with excellent long-term graft patency rates have been established. Although many alternative and innovative techniques for minimally invasive coronary revascularization have been introduced, port-access was developed to allow surgeons to perform these procedures on an arrested, protected heart through a mini-thoracotomy incision. Thus, this approach theoretically offers the perioperative benefits of a small incision and the technical advantages associated with hemodynamic stability and optimal stabilization during coronary anastomoses.
Because of our trepidation with this technology and the unfamiliarity of our anesthesia team with transesophageal echocardiography (TEE), both fluoroscopy and TEE were used for placing the catheters via the femoral vessels. Cardiologic assistance was utilized for TEE guidance when attempts were made to place the transjugular catheters for coronary sinus cardioplegia administration.
With the port-access approach, multi vessel coronary artery bypass procedures were feasible. All coronary arteries were readily accessible through a fourth interspace, left anterior thoracotomy. In patients requiring revascularization of the right coronary artery, a fourth interspace, right anterior thoracotomy was utilized. The aorta served as the site for proximal anastomoses in all multi vessel bypass patients except the first three, in whom the internal mammary artery was utilized. This transformation coincided with our improved familiarity and comfort in adjusting the position and access to the aorta via small incisions. No patients in this series required conversion to sternotomy or extension of the thoracotomy for central cannulation, cross-clamping, proximal anastomoses, or control of hemorrhage.
The technical difficulty with this approach, reflected in our extended cardiopulmonary bypass (CPB) and cross-clamp times, is a result of the learning curve transcending the realm of the surgeon and extending to the nurses, perfusionists, and anesthesiologists as they participate in the instrumentation, extracorporeal perfusion, and cardioplegic delivery. Conversely, their collective effort and expertise aid the eventual improvement in performance. Our initial clinical results utilizing the port-access approach are encouraging. We incurred none of the disastrous sequelae occasionally encountered in femoral cannulation, including arterial injury or aortic dissection. There were no deaths or revisions of the primary procedure. Although the procedure time was prolonged, the perioperative variables failed to show a deleterious effect on our port-access population, with a trend toward shorter intensive care and overall hospital stays. One complication that was not impacted was the incidence of atrial fibrillation, which we hoped would be improved by port-access due to the absence of external manipulation of the atrium. However, the criticism of this approach exists in its introduction opposite traditional CABG, an effective and durable therapy that can be performed at reasonable cost. Clearly, for port-access to flourish, it must prove to provide superior results at a lower cost.
Towards evaluating this end we attempted to measure the costs consumed by the port-access population while hospitalized, versus the costs involved in treating our standard median sternotomy coronary revascularization patients during fiscal year 1997. Riverside Methodist Hospital uses a computerized billing system that links each patient with the resources he or she consumes during the hospitalization. The resource consumption patterns in the port-access and median sternotomy CABG patients were significantly different. The length of stay in the hospital and ICU were shorter in the port-access patients, resulting in the greatest differences in ancillary services occurring in the blood bank, laboratory, pharmacy, and respiratory care services. However, the significant up-front cost of the disposable devices, recorded in perfusion charges, overshadowed the savings accrued in the aforementioned cost centers, resulting in an overall increase in costs consumed by patients who underwent port-access coronary revascularization.
That difference notwithstanding, the impact of increased mobility and quicker return to work among the port-access population remains unknown. The medical costs of a procedure are easy to quantify, but non-medical costs are largely ignored. There are, perhaps, two aspects of non-medical costs. One is that the increased cost of medical care may actually decrease non-medical costs. That is, workers who are able to return to work sooner may keep their jobs and lose less income. This is especially attractive to self-insured companies who are particularly interested in how quickly people can return to work. This rapid return to functional status may be worth the increased medical expenditure toward that end.
In conclusion, we believe that port-access coronary revascularization can be performed safely, with morbidity comparable to conventional median sternotomy. However, perfusion and operating room costs are formidable and are increased by the steep technical learning curve, which extends to all members of the cardiac surgery team. As our experience grows, we continue to track the aforementioned variables as we believe that further follow-up is required to ascertain whether the substantial cost of port-access technology is offset by diminished perioperative morbidity and improved patient mobility and comfort.
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Footnotes
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Presented at the 2nd MITSIG International Symposium: Controversies in Cardiothoracic Surgery, Hong Kong, November 20–21, 1998.
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References
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- Stevens JH, Burdon TA, Peters WS, Stevens JH, Burdon TA, Peters WS, Siegel LC, Pompili MF, Vierra MA, St. Goar FG, Ribakove GH, Mitchell RS, Reitz BA. Port-access coronary artery bypass grafting: a proposed surgical method. J Thorac Cardiovasc Surg 1996;111:567-573.[Abstract/Free Full Text]
- Burke RP, Werrovsky G, VanderVelde M, Hansen D, Castaneda D. Video assisted thoracoscopic surgery for congenital heart disease. J. Thorac Cardiovasc Surg 1995;109:499-507.[Abstract/Free Full Text]
- Goar St FG, Siegel LC, Stevens JH, Burdon TA, Pomili MF, Peters WS, Reitz BA. Catheter based cardioplegic arrest facilitates port-access cardiac surgery. Circulation 1996;94(Suppl 1):52.[Abstract/Free Full Text]
- Finkler SA. The distinction between cost and charges. Ann Intern Med 1982;96:102-109.[Medline]
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Abstract
1. Introduction
