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Eur J Cardiothorac Surg 1999;16:S34-S38
© 1999 Elsevier Science NL

Influence of median sternotomy on the psychosomatic outcome in coronary artery single-vessel bypass grafting

Vassilios Gulielmos, Markus Eller, Sebastian Thiele, Hans-Martin Dill, Thorsten Jost, Sems Malte Tugtekin, Stephan Schueler*

Cardiovascular Institute, University Dresden, Fetscherstrasse 76, D-01307 Dresden, Germany

* Corresponding author. Tel.: +49-351-450 1801; fax: +49-351-450 1802 (Email: hkz{at}rcs.urz.tu-dresden.de).


   Abstract
Top
 Abstract
1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 References
 
Objectives: New less invasive surgical techniques for the treatment of coronary artery single-vessel disease have been developed by either avoiding median sternotomy or cardiopulmonary bypass or both, however, until now no prospective randomized trial has been carried out to compare these techniques to the conventional approach with special respect to the psychosomatical effects. Methods: In a prospective randomized trial four different surgical techniques were compared. Group 1: conventional technique (median sternotomy, cardiopulmonary bypass) in ten patients (eight male, two female, age 59.6±11.0 years); Group 2: off-pump coronary artery bypass with median sternotomy in nine patients (six male, three female, age 65.7±11.1 years); Group 3: lateral minithoracotomy and cardiopulmonary bypass in eight patients (five male, three female, age 62.3±9.9 years). Group 4: off-pump procedure and lateral minithoracotomy in nine patients (eight male, one female, age 63.8±11.3 years). All patients due to coronary artery single-vessel disease. The tests used for psychosomatic situation were post-traumatic stress disorders scale, pain behavior rating scale, pain visual analog scale, and 6' walking-distance. For detection of false results due to surgical technical failures 3-month follow-up was undertaken including echocardiography and coronary angiogram. Results: There were no deaths or major complications. Operative time was longer in lateral minithoracotomy procedures, but intensive care unit stay and hospitalization were equal in all groups. Pain visual analog scale and pain behavior rating scale showed a peak on post-operative day 4 in median sternotomy procedures. Post-traumatic stress disorder scale revealed higher values on post-operative day 4 and equalizing with lateral minithoracotomy procedures 1 month post-operatively. Six-minutes walking distance on post-operative day 4 was longer in the group with lateral minithoracotomy. Three-month follow-up revealed patency of all grafts. Conclusions: Even if surgery is successful in all procedures, operative time is longer in lateral minithoracotomy procedures without compromising intensive care unit stay and hospital stay. More pain with multiple post-traumatic stress disorders is related to median sternotomy, and post-operative convalescence is superior for lateral minithoracotomy procedures.

Key Words: Coronary artery disease (CAD) • Minimally invasive coronary artery bypass grafting • Psychosomatic evaluation • Median sternotomy • Minithoracotomy


   1. Introduction
Top
 Abstract
 1. Introduction
2. Material and methods
 3. Results
 4. Discussion
 References
 
Small skin incisions replacing conventional surgical access are believed to be combined with less intraoperative trauma if the surgical outcome is not compromised. Trying to reduce surgical trauma in coronary artery bypass surgery less invasive surgical techniques were developed since 1994 [1–6]. The golden standard of conventional cardiac surgery i.e. median sternotomy and cardiopulmonary bypass (CPB) can be replaced by mini-thoracotomy including CPB or on the basis of beating heart technology. Acceptance of the procedures using small chest incisions on behalf of the patients at the cardiovascular institute in Dresden was major, so that the question rose ‘how much do psychosomatical parameters influence the post-operative convalescence after cardiac surgery if median sternotomy is used or not'. In order to answer this question a prospective randomized clinical trial was designed operating upon patients suffering from coronary artery single-vessel disease using four different surgical techniques.


   2. Material and methods
Top
 Abstract
 1. Introduction
 2. Material and methods
3. Results
 4. Discussion
 References
 
The conventional technique (median sternotomy and cardiopulmonary bypass), off-pump coronary artery bypass (OPCAB) surgery (median sternotomy, without CPB), the Dresden technique (DT, minithoracotomy, with CPB), and the minimally invasive direct coronary artery bypass (MIDCAB, minithoracotomy, without CPB) were used. Exclusion criteria used were obesity (body mass index [BMI] over 30), impaired left ventricle ejection fraction (LVEF<30%), and major calcification of the ascending aorta. All patients were referred for bypass of the left internal mammary artery (LIMA) bypass to the left anterior descending coronary artery (LAD). In case of multivessel coronary artery disease, the patients were only included in the study if the other coronary vessels were not amendable for surgery.

Gas anesthesia (Enflurane) was used in combination to analgesia (Phentanyl) and relaxation (Vecuronium) using a single lumen endotracheal tube. All patients received 2 million i.u. aprotinin i.v. and the operation took place in systemical heparinisation (500 i.o/kg). Thirty-six patients (27 male, nine female, age 62.75±10.64 years) were evaluated for a randomized study using the four techniques. Hospital and IRB approval and informed consent of all patients were obtained.

2.1 Conventional group (group 1)
Out of ten patients (eight male, two female, median LVEF 71.3%, median BMI 26.7 kg/m2) four patients were suffering from multivessel disease, and six patients had a previous myocardial infarction. Median value of forced expiratory volume (FEV1) was 90.5%. Clinical staging revealed 10% to be in Canadian Cardiovascular Society (CCS) stage 1, 30% in stage 2, 40% in stage 3 and 20% in stage 4; 20% of the patients were in New York heart association (NYHA) functional class I, 30% in class II, 40% in class III and 10% in class IV. At surgery over a median sternotomy using a LIMA take-down retractor the LIMA was harvested from the 1st to the 6th rib as a pedicle using lower grade diathermy and ligation clips. After systemical heparinisation the distal end of the LIMA was dissected and papaverine was given extern to the pedicle. On CPB and after cross clamping the LIMA to LAD anastomosis was performed in a standard fashion. Leaving one drain in the left pleural cavity one in the pericardium and one in the mediastinum, eight single steel wires were used for sternal fixation. The wound was closed in layers.

2.2 OPCAB group (group 2)
Nine patients (six male, three female, median LVEF 62.6%, median BMI 25.5 kg/m2) were operated in this group. Seven patients were suffering form coronary artery multivessel disease, and four of them had a previous myocardial infarction. FEV1 was 99.1%. Clinical staging found 66.7% in CCS 2, 11.1% CCS 3 and 22.2 in stage 4; 44.4% of the patients were in NYHA functional class I, 22.2 in NYHA II, and 33.3% in NYHA III. At surgery LIMA was harvested over a median sternotomy as described already in the section ‘conventional group'. Using stay sutures between the left half of the pericardium and the soft tissue, the heart was rotated to the right, resulting in medialization of the LAD, thus providing better access to this coronary vessel. Suction paddles of the stabilizing device (Octopus) were placed on each side of the target vessel. The coronary artery was occluded using a snare (4.0 Prolene). The anastomosis was performed with the help of the air blower for keeping the operative sites free from blood. After antagonizing heparin with protamin the pericardium was always closed and the wound was closed in layers, as described in the section ‘conventional group'.

2.3 Dresden technique (group 3)
Eight patients with CAD (five male, three female, median LVEF 77%, BMI 26.0 kg/m2), including two patients suffering from coronary artery multivessel disease and two patients with a previous myocardial infarction were treated with the Dresden technique. FEV1 was 91%, 12.5% of the patients were in CCS 1, 50% in CCS 2, 25% CCS 3 and 12.5% in stage CCS 4; 37.5% of the patients were in NYHA functional class I, 37.5% in NYHA II, and 25% in NYHA III. The technique was used as described by Gulielmos et al. [4]. For institution of CPB there was no necessity for groin dissection as the right atrium was cannulated percutaneously via the right femoral vein.

2.4 MIDCAB group (group 4)
Nine patients (eight male, one female, median LVEF 63.8%, BMI 25.6 kg/m2) were operated using MIDCAB. Among them three patients suffered from multivessel CAD and three further had a previous myocardial infarction. FEV1 was 87.2%. Clinical staging found 11.2% of the patients to be in CCS 1, 33.3% in CCS 2, 33.3% CCS 3 and 22.2 in stage CCS 4; 11.2% of the patients were in NYHA functional class I, 44.4% in NYHA II, and 44.4% in NYHA III. The procedure was performed as described by Boonstra et al. [7]. In this series fully heparinisation was used and application of Protamin as well. A small technical difference consisted in the dissection of the intercostal muscle further laterally underneath the skin, in order to avoid fractures while spreading, and to decrease post-operative wound pain.

There were no differences in terms of LVEF, BMI, previous infarction, FEV1, NYHA and CCS between the four groups.

Psychosomatical evaluation of these these techniques was based on

1. Visual analog scale (VAS) (pain scale) [8] before 24 h, four days and 1 month after operation.
2. Pain behavior rating scale (BRS) [9] before, 4 days and 1 month after operation.
3. Six-minute walking distance on post-operative day 4.
4. Posttraumatic stress disorder (PTSD) scale [10] pre-operatively, on post-operative day 4 and 1 month after operation.

All these tests were performed according to the ‘statement of consensus on assessment of neurobehavioral outcomes after cardiac surgery' [11].

In addition perioperative values as operative time, post-operative ventilation time, CPB time (if used), intensive care unit (ICU) stay, and hospitalization were monitored. Further conversion to CPB or to median sternotomy, reexploration due to bleeding, value of CKMB/CK fraction, post-operative atrial fibrillation and further complications were monitored. The 3-month follow up included echocardiography, and coronary angiogram.


   3. Results
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
4. Discussion
 References
 
All patients survived the procedure and all operations were completed in sinus rhythm without any signs of ischemia or inotropic support. In no case there was necessity for conversion to median sternotomy or to CPB. Perioperative values as time of operation, postoperative ventilation time, CPB time, ICU stay and hospitalization and occurrence of atrial fibrillation are listed in Table 1 . There were no major complications and CKMB/CK fraction 6 h after operation revealed no myocardial infarction. PTSD values revealed higher scores already pre-operatively in median sternotomy groups as soon as the patients were informed about the procedure. PTSD values remained at the same level until post-operative day 4 and normalized 1 month post-operatively (Fig. 1). VAS analysis showing pre-operatively and on post-operative day 1 equal values in all procedures, revealed more pain for median sternotomy procedures at post-operative day 4 (P<0.05). One month after operation VAS values were equal in all procedures (Fig. 2). BRS pain scale also being equal in all patients pre-operatively showed higher pain levels on post-operative day 4 for median sternotomy procedures, and equalized 1 month after operation (Fig. 3). Patients receiving procedures avoiding median sternotomy walked longer distances within 6 minutes on post-operative day 4 (P<0.05) (Fig. 4). Three-month echocardiography revealed equal or better LVEF compared to values obtained before operation. Coronary angiograms always showed patency of the LIMA bypass.


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  		Table 1. Pertioperative data a
 

Figure 1
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  		Fig. 1. Post-traumatic stress disorder scale. Preop., preoperative; postop., postoperative.

 

Figure 2
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  		Fig. 2. Pain visual analog scale. There is a significant difference on post-operative day 4. (P<0.05; Mann–Whitney U test). Preop., preoperative; postop., postoperative.

 

Figure 3
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  		Fig. 3. Pain behavior rating scale. Preop., preoperative; postop., postoperative.

 

Figure 4
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  		Fig. 4. Six-minute-walking-distance on post-operative day 4. Mean±SEM. P<0.05; t-test.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
References
 
Even though coronary artery single-vessel disease is the domain of percutaneous transluminal coronary angioplasty (PTCA) and stenting due to the low invasiveness, there are still cases in which surgery is unavoidable. If the golden standard in cardiac surgery as CPB and median sternotomy is used, perioperative morbidity can be related to each one [12–15]. In the treatment of singlevessel CAD the surgical procedure of choice either avoiding median sternotomy, or CPB, or both should always include LIMA bypass to LAD [16]. Benetti et al. (1995) proposed MIDCAD for less surgical trauma in the treatment of coronary artery single-vessel disease [17]. At the same time a cardiac surgical team at the Stanford University worked on an experimental model performing LIMA bypass to LAD using small lateral thoracotomy and cardiopulmonary bypass with cardioplegic arrest [6]. If the ‘port access' technique is used aortic dissection and wound healing problems in the groin occur [18,19]. The Dresden group established a less invasive surgical technique avoiding median sternotomy (MS) using CPB in order to avoid these complications [4]. In parallel the Utrecht group proposed median sternotomy avoiding CPB for less invasiveness in coronary artery bypass grafting [20]. After 2.5 years experience with all of these techniques at the Cardiovascular Institute Dresden and already having experienced the learning curve, a prospective randomized trial was undertaken comparing these less invasive techniques to the conventional technique in order to evaluate the role of median sternotomy and lateral minithoracotomy, assessing psychosomatical outcome and post-operative pain. An isolated psychosomatical analysis of the new methods without the evaluation of the surgical outcome would may false the results in case of surgical failures. Therefore surgical analysis was made in addition.

Even though time of operation for median sternotomy procedures is less, post-operative ventilation, ICU stay and hospitalization are equal in all procedures, showing no influence upon the clinical outcome. As CKMB/CK values and 3-month coronary angiogramm showed no pathological results, surgery failure related errors can be excluded.

PTSD scale indicates that the first psychosomatical trauma for the patient, is the knowledge of the use of median sternotomy since patients receiving MS procedures already showed higher rates as soon as they were informed about the procedure. These levels remained until post-operative day 4 and normalized within 1 month after operation, as probably patients seem to forget about the operation. BRS pain scale, already performed pre-operatively, in order to detect abnormal behavior to pain of any patients, revealed on post-operative day 4 more pain in patients receiving median sternotomy. The pain status equalized between all groups one month after operation. In agreement to these findings VAS pain had the same course as BRS pain scale. VAS values on post-operative day 1 correlate to those reported by others after cardiac surgery [21–23] and are comparable with rates admitted after abdominal surgery [24,25]. Six-minute walking distance on post-operative day 4 confirmed pain and post-traumatic stress disorders. Patients suffering from more pain and PTSD as those receiving MS procedures do not walk the long distances, that patients receiving minithoracotomy procedures do. Post-operative convalescence is a balance between physical and psychosomatical comfort. In the surgical treatment of singlevessel CAD performing LIMA-bypass to LAD median sternotomy is combined with more pain and post-traumatic stress disorders thus resulting in faster convalescence for lateral minithoracotomy procedures.


   Footnotes
 
{star} Presented at the International Symposium ‘Present State of Minimally Invasive Cardiac Surgery – Meet the Experts', Dresden, Germany, December 3–5, 1998.


   References
Top
 Abstract
 1. Introduction
 2. Material and methods
 3. Results
 4. Discussion
 References
 

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