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Eur J Cardiothorac Surg 1999;16:S7-S9
© 1999 Elsevier Science NL

The application of the Octopus^® stabilizing system for the treatment of high risk patients with coronary artery disease

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. Comment References

 
Objectives: If coronary disease is the target of a minimally invasive procedure, median sternotomy or cardiopulmonary bypass or both can be avoided. Similar to the development in other fields of surgery, minimally invasive surgical techniques are gaining increased acceptance in the field of cardiothoracic surgery. Our experience with an off pump coronary artery bypass (OPCAB) technique in a special patients group with serious risk factors for the application of cardiopulmonary bypass has been analyzed. Methods: Between March 1996 and January 1999, 88 patients (64 male, 24 female) with impaired left ventricular function, or other high risk factors jeopardizing the use of cardiopulmonary bypass, such as impaired renal or lung function or heavily calcified aorta, received a beating heart procedure using the Medtronic Octopus^® stabilizing system. Results: All patients survived the actual operation, however, two multimorbide patients died of pneumonia on postoperative day 31 and postoperative day 35. Conclusions: Patients with single-vessel to multivessel disease and serious risk factors for cardiopulmonary bypass can be safely treated by OPCAB surgery. At our institution this technique presents the procedure of choice in this particular patients group.

Key Words: Coronary artery disease • Off pump coronary artery bypass • Octopus^® • Median sternotomy

	1. Introduction

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

 
Minimally invasive surgical techniques have been developed for the treatment of coronary artery disease [1–3] in order to minimize surgical trauma, median sternotomy and cardiopulmonary bypass (CPB) related complications in cardiac surgery [1–6].

Beating heart procedures as minimally invasive direct coronary artery bypass (MIDCAB) were applied primarily in patients with single-vessel disease using stabilizers via a left lateral minithoracotomy.

For patients with multivessel disease (MVD) the off pump coronary artery bypass (OPCAB) technique using median sternotomy was introduced. Stabilization was achieved using the Medtronic Octopus^® system. In a group of patients with well known risk factors for the application of CPB this technique was used.

A retrospective analysis was made in order to define more precise inclusion and exclusion criteria for the adequate application of the above used less invasive surgical technique.

	2. Material and methods

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

 
From July 1997 to January 1999, 88 patients selected for OPCAB techniques and MVD were evaluated. The pattern of the coronary lesions is listed in Table 1 . The age of the 64 male and 24 female patients ranged between 45 and 89 years (median 67.4±8.5 years). Inclusion criteria were impaired left ventricular ejection fraction (LVEF) (median 40.0±16.1%), impaired renal, or lung function, or heavily calcified aorta and cerebrovascular disease, respectively (Table 2 ).

Perioperative data such as total duration of operation, postoperative ventilation, intensive care unit stay and hospital stay were monitored (Table 3 ). All procedures were performed using the Octopus^® stabilizing system (Fig. 1) as described by Gulielmos et al. [5].

View larger version (117K): [in this window] [in a new window]   Fig. 1. Exposure of the right coronary artery using the Octopus® stabilizing system.

After opening of the pericardium, a catheter was introduced into the left atrium (LA) for LA blood pressure monitoring. The temporary pacemaker electrodes are attached to the right atrium and right ventricle. Usually the patients heart rate during the surgery is maintained at 90 beats per minute (bpm) – if necessary by atrial pacing.

For better exposure of the coronaries of the anterior heart wall, some two to three stay sutures were placed on the left side of the pericardium, below the phrenic nerve, and one to two sponges were placed under the heart. Some positioning maneuvers were used like tilting the operating table to the right and applying the Trendelenburg position for assuring the hemodynamic stability and improving the access to the target vessels.

For exposure of the coronary vessels of the posterior or side heart wall – additional sponges, slings or just a positioning by Octopus^® paddles were used.

After placement of the Octopus^® paddles both sides of the coronary artery, the blood flow through this vessel was temporary interrupt by snaring with vessel loops or tourniquets. The graft anastomosing was performed in a usual manner. In order to preserve a blood-less operating field we used a CO₂ blower humifidication.

During the surgery patients systemic blood pressure, LA blood pressure, mixed venous saturation, heart rhythm and ECG were closely monitored. In a case of hemodynamic instability related to interrupted flow through the operated vessel – a temporary coronary shunt was inserted for the anastomosis time.

After the surgery the patient was transferred to the intensive care unit under monitoring of the hemodynamic parameters.

	3. Results

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

 
Six patients needed to be converted to CPB procedure due to haemodynamic instability occurring during manipulation of the heart.

All patients survived the actual operation, however, two multimorbide patients died of pneumonia on postoperative day 31 and postoperative day 35. In another patient with heavily impaired left ventricular ejection fraction, postoperative low cardiac output required an intraaortic balloon pump and low inotropic support for 5 days. This patient was weaned from mechanical and drug support on day 12 and is doing well 12 months postoperatively at this stage.

The 12-week follow-up was completed in 56.8% of the patients revealing no signs of ischemia. A total of 56.3% of the patients receiving the 3-month follow-up were in CCS stage I, 37.5% were in stage II, 6.2% were in stage III; 43.8% were in NYHA class I, 43.8% were in class II and 12.4% were in class III.

	4. Comment

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

 
Multivessel grafting on the beating heart using the Octopus^® stabilization system results in remarkably low perioperative mortality and morbidity, with very low incidences of cerebrovascular, renal, and respiratory complications. The mortality in recent reports is 0%, and the patency rate of the performed anastomoses is 95% [7].

The way this technique is being applied at our institution using median sternotomy, always enables access to the left anterior descending artery (LAD), to the right coronary artery and in a reasonable number, to marginal branches of the circumflex artery as well.

Beating heart surgery in patients with coronary artery disease using the Octopus^® stabilizing system can be performed safely and is applicable in patients with multi vessel disease. Especially patients with serious risk factors for the use of CPB seem to benefit from this technique. The postoperative stay is small in most patients and despite multimorbidity the overall results are satisfying.

	Footnotes

 
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. Comment References

 

1. Benetti FJ, Ballester C, Sani G, Boonstra P, Grandjean J. Video assisted coronary bypass surgery. J Cardiol Surg 1995;10:620-625.
2. 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]
3. Fonger J. Reoperative and alternative MICAB approaches: subxiphoid and lateral thoracotomy [Abstract]. Paris, France: World Congress on Minimally Invasive Cardiac Surgery; 1997. pp. 30-31.
4. Calafiore AM, Giammarco GD, Teodori G, Bosco G, D'Annunzio E, Barsotti A, Maddestra N, Paloscia L, Vitolla G, Sciarra A, Fino C, Contini M. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1665.[Abstract/Free Full Text]
5. Reichenspurner H, Gulielmos V, Daniel WG, Schueler S. Minimally invasive coronary artery bypass (CABS) with the safety of cardiopulmonary bypass and cardioplegic arrest. New Engl J Med 1997;336:67-68.[Free Full Text]
6. Jansen E, Gruendemann P, Borst P, Diephuis C, Nierich J, Robles de Medina A, Bredée J. Use of the Octopus methods in off pump single and multivessel CABG [Abstract]. Paris, France: World congress on Minimally Invasive Cardiac Surgery; 1997. pp. 30-31.
7. Jansen EWL, Gründemann PF, Borst C. Less invasive off pump CABG using a suction device for immobilization: the Octopus method. Eur J Cardiothorac Surg 1997;12:406-412.[Abstract]

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