Eur J Cardiothorac Surg 2001;19:105-107
© 2001 Elsevier Science NL
A simple method for heart stabilization during off-pump multi-vessel coronary artery bypass grafting: surgical technique and short term results
Akhtar Rama,
Siamak Mohammadi,
Pascal Leprince,
Iradj Gandjbakhch
Department of Thoracic and Cardiovascular Surgery, La Pitié Hospital, 47 Boulevard de l'hôpital, 75013 Paris, France
Received 18 April 2000;
received in revised form 6 September 2000;
accepted 19 October 2000.
Corresponding author. Tel.: +33-1-4217-7005; fax: +33-1-4217-7030
e-mail: siamakmohammadi{at}yahoo.com
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Abstract
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Minimally invasive cardiac surgery regroups several technical options including small incision, video-assisted surgery and beating heart surgery but mechanical stabilization for off-pump multi-vessel coronary artery bypass grafting (CABG), remains a problem. We developed a simple method of stabilization with a fenestrated polytetrafluroethylene patch. Four sutures were passed deeply into the myocardium surrounding the anastomotic site. The sutures were then passed through the patch. Gentle traction on tied sutures, allowed immobilization and exposure in the selected area. This method which was carried in 95 patients, provides good stabilization for performing off-pump multi-vessel CABG in all cardiac territories.
Key Words: Off-pump coronary artery bypass grafting • Patch stabilization • Surgical technique
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1. Introduction
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Initial experience with beating heart multi-vessel coronary artery bypass grafting (CABG) showed that stabilization of remote circumflex or left posterior descending artery (PDA) territories could be very challenging. During the past 3 years, we have developed a simple, efficient, and cost-effective technique, which can be used to stabilize any coronary artery.
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2. Patients and methods
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We evaluated the effectiveness and reproducibility of anastomotic site stabilization achieved through a traction system in the first 95 patients from January 1997 to November 1998.
Patients were selected according to patients general condition, analysis of coronary angiogram to rule out diffuse coronary artery calcification or intramyocardial situation [1–2]. A 4x4 cm square patch of polytetrafluroethylene felt (Boston Scientific, MEADOX®, Oakland, NJ) was fenestrated in its center to keep a peripheral edge of 1–2 cm.
Two heavy sutures of 2.0 Ethibond® were passed under the target vessel proximally and distally to the selected anastomotic site, deeply into the myocardium (Fig. 1a). Two other sutures widely separated were placed on each side of the anastomotic site, parallel to the vessel (Fig. 1b). The two adjacent sutures were passed through the patch (Fig. 1c) close to one of the four corners of the fenestration and tied loosely together. Exposure and stabilization of the anastomotic site was achieved through gentle traction on the four loosely tied sutures (Fig. 1d).
To obtain a bloodless field, we used direct compression on the coronary artery through the patch or a circumferential compression suture loop. In case of ST-T changes, arrhythmia or hemodynamic instability, we used an intraluminal shunt.
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3. Results
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The patients characteristic data are shown in Table 1. Forty-one percent of the patients had a left ventricular ejection fraction (LVEF) lower than 50%. In 25 patients (24.2%) the left main artery was involved.
The procedure was performed through a sternotomy (95.8%) or a left lateral thoracotomy (4.2%). A total of 219 distal anastomosis were carried out with an average of 2.3 grafts per patient. Target vessels were left anterior descending artery (LAD) (n=93), obtuse marginal (OM) artery (n=51), diagonal artery (n=25), right coronary artery (RCA) (n=34), and PDA (n=16). Left and right internal thoracic artery (ITA) and right gasteroepiploic artery were used as a conduit in 94.7, 17.8 and 9.4% respectively. In two patients, a sequential LAD-diagonal bypass was performed with the LITA. Two patients underwent LAD or RCA endarterectomy. Conversion to cardio-pulmonary bypass (CPB) surgery was required in two patients with a low LVEF since they developed hemodynamic instability during heart displacement.
Mean troponin IC level was 1.5 ng/ml at 6 h and 1.4 ng/ml at 24 h. There were no perioperative myocardial infarctions. Two in-hospital deaths occurred at the first and second post-operative day related to myocardial infarction. All the remaining patients in cardiologic follow up are symptom free. Coronary angiography was performed during the first postoperative month in 20 patients. All LITA grafts were patent, and one occluded saphenous grafts was detected.
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4. Discussion
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We consider that the less invasive approach is to avoid the use of CPB and its complications [3,4]. However, beating heart surgery presents its own problems: heart motion, regional ischemia, bleeding, and hemodynamic instability. High levels of pressure to exposure the posterolateral wall is associated with hemodynamic instability. Moreover, the free space available to work in is more limited and in some cases, the surgeon has to compete with the stabilizer. Finally, even if CPB can be avoided, the cost of the stabilizer has to be taken into account.
With this technique, we could convert the convex surface of the target area to a flat and immobile area. Only the anastomotic site is visible, and the heart can move freely underneath the stabilizer. With this technique we can displace the heart in an anterolateral direction to expose the circumflex and distal RCA branches without any hemodynamic deterioration. The small size of the patch and its texture as well as the absence of pressure at the target area of the myocardium may explain the good hemodynamic tolerance during off-pump CABG. Moreover, the absence of a rigid holder for the stabilizer allows free access to the target area without competing with the stabilizer especially when a small incision has been used. We used the left thoracotomy for OM grafting in redoes patients. This approach is very useful for avoiding pericardial cavity adhesions [5] and potential injury of a patent LITA-LAD anastomosis.
Moreover, remote cardiac territories like OM or PDA were grafted in most of the patients. In two cases, conversion to CPB was decided on at the time of heart displacement before passing the stabilizer sutures through the myocardium. Therefore, conversion was not an emergency procedure because stable hemodynamic conditions returned as soon as the heart was returned into the pericardial cavity.
Coronary blood flow interruption is well tolerated in most of the cases due to the presence of a well-developed collateral circulation. However, the use of an intracoronary shunt is very useful to reduce the incidence of myocardial ischemic event [6].
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Acknowledgments
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We acknowledge and greatly thank Mr François Lintz, medical student, for illustrations.
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References
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Abstract
1. Introduction
