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Interact CardioVasc Thorac Surg 2008;7:402-405. doi:10.1510/icvts.2007.172973
© 2008 European Association of Cardio-Thoracic Surgery
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Institutional report - Coronary

Minimally invasive coronary artery bypass grafting using the inferior J-shaped ministernotomy in high-risk patients

Mauro Del Giglioa, Andrea Dell'Amorea,*, Tommaso Aquinoa, Simone Calvia, Morena Callia, Claudio Marrib, Francesco Bonic and Mauro Lamarraa

a Department of Cardiovascular Surgery, Villa Maria Cecilia Hospital, V. Corriera 1, Cotignola, Lugo (RA), Italy
b Department of Radiology, Villa Maria Cecilia Hospital, V. Corriera 1, Cotignola, Lugo (RA), Italy
c Department of Anesthesiology, Villa Maria Cecilia Hospital, V. Corriera 1, Cotignola, Lugo (RA), Italy

Received 4 December 2007; received in revised form 30 January 2008; accepted 30 January 2008

*Corresponding author. V. Battuti Verdi n.1 Forlì. (FC), Italy. Tel.: +39 335 6223366.

E-mail address: dellamore76{at}libero.it (A. Dell'Amore).


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Operative technique
 4. Results
 5. Discussion
 References
 
In the last years the population of patients referred for coronary surgery has changed toward a high-risk profile. In selected cases minimally invasive approach could be a good option to reduce mortality and morbidity. Between September 2005 and September 2007, twenty-one consecutive patients underwent minimally invasive bypass surgery using the J-shaped inferior mini-sternotomy approach. All patients had a EuroSCORE higher than 6. The operative mortality was 0%. Conversion to on-pump surgery was not necessary. The mean operation time was 89±18 min, the mean ventilation time was 2.4±2.2 h, the mean intensive care unit stay was 47.2±36.5 h. In four patients a hybrid approach to achieve a complete revascularization was used. After six months from the operation the graft patency was evaluated with the 64-slice computed tomography. In high-risk coronary patients the use of the minimally invasive technique appeared a good option to achieve low morbidity and mortality. Through a mini-sternotomy approach, single- or double-vessel revascularization can be performed safely off-pump even in high-risk patients without compromising the accuracy of the anastomosis. Nevertheless, a further investigation is required to evaluate the long-term results in a larger cohort of patients.

Key Words: Minimally invasive coronary bypass surgery; Coronary disease; High thoracic epidural anesthesia; Ministernotomy; Atherosclerosis; Hybrid revascularization; Cardiac surgery


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Operative technique
 4. Results
 5. Discussion
 References
 
In recent years the patients affected by ischemic heart disease have changed and frequently we treat older patients with many comorbidities and risk factors. In this scenario the standard concepts, indications, and surgical techniques of revascularization often produce poor results with high mortality and morbidity [1–3]. Moreover, cardiologists refuse treatment to this kind of complex patient because of high risk at angioplasty (PTCA), and medical therapy alone is not able to treat symptoms and to guarantee a good event-free survival [4]. Recently off-pump surgery, minimally-invasive coronary artery bypass grafting (MIDCAB), and the combination of MIDCAB and interventional cardiology, showed a reduction of the surgical invasiveness and complications obtaining a faster recovery and discharge of the patients [5–8].


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Operative technique
 4. Results
 5. Discussion
 References
 
Between February 2006 and September 2007, twenty-one consecutive patients underwent MIDCAB using the J-shaped inferior mini-sternotomy approach. In all patients high-thoracic epidural anesthesia was used and eight patients were operated on while awake and without tracheal intubation. All patients had a EuroSCORE higher than 6 with a mean score of 11.6±3.1 (range 7–17). The preoperative characteristics are shown in Table 1. Sixteen patients were male and five were female, the mean age was 73.2±9.3 years (range 50–84 years). The mean preoperative ejection fraction (%) was 44.8±10.8 S.D. (range 20–60%), all patients were in CCS III–IV (3.6±0.5 S.D.), the mean NYHA-class was 2.6±0.7 S.D. Four patients had chronic atrial-fibrillation. A moderate mitral regurgitation was present in four patients and a severe regurgitation in one patient. One patient had a moderate aortic stenosis. Eleven patients had a recent (<90 days) acute myocardial infarction. Four patients were previously treated with coronary angioplasty and stenting.


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  		Table 1 Preoperative characteristics of the population

 

   3. Operative technique
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Operative technique
4. Results
 5. Discussion
 References
 
Anesthesia was performed as previously described by Karagoz et al. [9] in the case of awake patients. In the other patients, the same high-thoracic epidural anesthesia was used in addition to tracheal intubation and total intravenous anesthesia with propofol and neuromuscular blockade with roncuronium.

The skin incision was made along the mid-line of the sternum from the fourth intercostal space down to the xiphoid process (Fig. 1a). The inferior part of the sternum up to the fourth intercostal space was divided in the reversed J-shaped approach. A traditional Finochietto retractor was used to lift the hemisternum and to harvest the LIMA (Fig. 1b,c). Before the LIMA division a half dose of heparin (1.5 mg/kg) was given to keep the activated clotting time around 350 s. Using the same retractor, the pericardial sac was opened up to the aortic reflection, the LAD and the diagonal branch were exposed (Fig. 1d). Retraction stitches were placed on the edges of the pericardial sac and attached to the skin to elevate the heart anteriorly. Two or three soaked gauzes were placed under the heart to expose the LAD. A 5/0 polypropylene suture was passed under the proximal part of the LAD and both needles were passed through a Teflon pledget then snared with a tourniquet to occlude the coronary artery. A second 5/0 polypropylene stitch was passed under the LAD distally to the arteriotomy site. Both stitches were gently lifted to stabilize the anastomotic site. In case of important bleeding a coronary shunt was used. The arteriotomy and the anastomosis were performed in the standard fashion. At the end of the procedure protamine was given and chest drains were placed. The lower sternotomy was closed, using sternal wires.


Figure 1
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  		Fig. 1. (a) A skin incision of 5 cm was performed along the mid-line of the sternum from the fourth intercostal space down to the xiphoid process, (b, c) The inferior part of the sternum up to the fourth intercostal space was divided using an oscillanting saw in the reversed J-shaped approach. A small retractor was used to lift the hemisternum and to harvest the LIMA (black arrow), (d) the pericardial sac was open up to the aortic reflection, the LAD and the diagonal branch were exposed (dashed arrow).

 

   4. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Operative technique
 4. Results
5. Discussion
 References
 
The in-hospital mortality was 0%. Conversion to a full median sternotomy was never required and the anastomosis was carried out with the off-pump technique in all patients. The LIMA to the LAD anastomosis was performed in all patients, a sequential anastomosis between LIMA and the diagonal branch and the LAD was performed in four patients. The mean operation time was 89±18 min.

Eight patients were operated on awake without tracheal intubation. The mean mechanical ventilation time of the other 13 patients was 2.4±2.2 h (range 1–8 h). The mean intensive care unit stay was 47.2±36.5 h (range 12–135 h). The mean blood loss in the first 24 h was 361.8±223 ml (range 150–1100 ml) (Table 2). One re-thoracotomy for bleeding was required. Two patients with recent myocardial infarction and main stem disease needed a postoperative IABP because of hemodynamical instability. In both of these patients the IABP was removed 24 h later, similar to the patients with preoperative IABP. Four patients undergoing a hybrid treatment had a re-catheterization and PTCA plus stents on the circumflex artery to complete the revascularization because of left main stem disease three weeks after surgery. During catheterization the LIMA to LAD anastomosis was patent in all patients with a good distal run-off. One of these patients died eight weeks after the angioplasty because of multiorgan failure. The remaining 20 patients are in good clinical condition with good symptoms relief. At a mean follow-up of 11.8 months (range 3–27 months), the mean CCS class was 1.3±0.6 S.D. (P=0.0001), the mean NYHA class was 1.1±0.4 S.D. (P=0.0001) and the EF was 51.3±11.8 S.D. (P=0.0001) (Table 3). In all patients the treadmill test performed at one month was negative for inducible ischemia. To evaluate the grafts patency the patients had a 64-slice tomography three months after the operation (Fig. 2). The grafts patency rate was 100%. In four patients this study was not feasible because of chronic atrial-fibrillation.


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  		Table 2 Postoperative variables

 

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  		Table 3 Follow-up variables

 

Figure 2
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  		Fig. 2. A 64-slice computed tomography performed six month after the operation in a patient in which a sequential graft between the LIMA the diagonal branch and the LAD was performed. The proximal part of the LIMA was shown clearly (black arrow), no side branches were present. The dashed arrows show the anastomosis between the LIMA and the diagonal branch first and then between the LIMA and the LAD. A good distal run-off in the LAD is well detected (white arrow).

 

   5. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Operative technique
 4. Results
 5. Discussion
References
 
In our daily practice the population of patients referred for cardiac surgery has changed. Older and sicker patients with severe co-morbidities, who were in previous years denied treatment, are now accepted for surgery or angioplasty. We report our experience in the treatment of 21 high-risk patients referred to us for coronary artery surgery. All patients had a EuroSCORE >6 due to many comorbidities and age (Table 1). The anticipated reported mortality for coronary bypass surgery varies between 0.8 and 3% in different series [9]. In high-risk patients the surgical mortality is as high as 11.2% when conventional surgery is performed as shown by the EuroSCORE data [1]. Many alternative techniques have been introduced in clinical practice. Elimination of extracorporeal circulation would lead to a more physiologic milieu that would optimize organ function and reduce organ-specific complications, especially in high-risk patients with previous organs damage. Bittner et al. [5] reported very good results in high-risk patients with coronary artery disease operated off-pump with a 30-day mortality of 3.2%. A further improvement in surgical results has been obtained with the introduction of minimally invasive techniques, in particular in high-risk patients with isolated left descending artery stenosis, or isolated left main stem disease [6].

We choose for our patients the inferior J-shaped mini-sternotomy as a preferred approach in minimally invasive coronary surgery. The inferior mini-sternotomy incision provides, in our opinion, a good access to the entire course of the LIMA and to the whole course of the LAD and diagonal branch. With this technique we were able to perform in three patients a sequential anastomosis between the LAD and the first diagonal branch without any technical problem. Furthermore, an urgent conversion to full sternotomy, which was not required in our patients, is much easier and quicker than with left anterior thoracotomy, without the need for additional incisions [10]. In eight patients with a severe chronic obstructive pulmonary disease we used the previously reported technique of awake coronary artery bypass grafting [9]. The mini-sternotomy usually ensures the pleural integrity and spontaneous respiration during surgery is not compromised. Mediastinitis and sternal instability could be the major disadvantage of this approach [10]. In our experience we had neither of these complications. In all our patients we used the high thoracic epidural anesthesia and analgesia because of less stress–response, intense peri-operative analgesia, cardiac sympatholysis, improved vascular graft blood flow, improved postoperative pulmonary and gastrointestinal function for a further reduction in morbidity and mortality [11, 12].

In literature the role of angioplasty and surgery in high-risk patients with a single lesion of LAD or left main stem disease is still under debate. However, the LIMA–LAD bypass appeared superior regarding the need for repeated target vessel revascularization even in the case of drug-eluting stents application [13–15]. Furthermore, the surgical revascularization and MIDCAB in particular, can be offered also in case of occluded vessel, distal disease, high-grade stenosis, complicated lesions, previous stenting and left main stem disease. More challenging is the treatment of high-risk patients with multi-vessel disease. Sometimes MIDCAB surgery is intended to be the ultimate therapy in a multi-morbid state because conventional surgery or angioplasty are regarded as too risky. In these scenarios incomplete revascularization is sometimes accepted as the best and safest approach for very high-risk patients. Calafiore et al. [7] have introduced the use of MIDCAB as an alternative to angioplasty even in multi-vessel disease; in this approach the treatment of the culprit lesion could be considered a satisfactory compromise to improve symptoms and survival in very high-risk patients. In our series we treated four patients with multi-vessel disease in which we decided to bypass only the LAD territory because of chronic coronary artery obstruction without preoperative signs of myocardial vitality or with extensive calcification and very poor quality of the vessels. In our experience, the postoperative period of these patients was uneventful with an improvement of the CCS grade on the follow-up evaluation despite an ‘incomplete’ revascularization (Table 3).

Sometimes, when feasible, a hybrid approach combining minimally invasive LIMA–LAD bypass, and angioplasty plus stenting of the other coronary lesions, appears an effective and attractive alternative. Four of our patients underwent a hybrid approach with a single coronary artery bypass, LIMA on the LAD and then a PTCA on the circumflex artery because of left main stem disease. During catheterization the LIMA graft was patent in all patients. One of these patients died three months after the PTCA because of multiorgan failure (MOF). This patient was an 84-year-old man with a left main stem disease and a chronic obstruction of the right coronary artery, two previous myocardial infarctions with 30% of EF, a severe polyvasculopathy, chronic renal failure, COPD, referred to us for an urgent operation because of anatomy and symptoms (CCS class IV and NYHA class IV). The postoperative period was uneventful but after PTCA he experienced worsening of the renal failure with the necessity of hemodialysis complicated by a pneumonia and MOF as cause of death.

In our experience, this technique seems to be simple and reproducible, we believe that the inferior J-shaped sternotomy is the safest technique to perform minimally invasive coronary bypass surgery. In our patients, as shown by 64-slice multi-detector tomography and by clinical follow-up, the patency of our anastomosis was not compromised by the minimally invasive approach.

In this report we include only patients considered at high risk for conventional surgery. Of course this is a very small number of patients, but the low surgical mortality is a remarkable result in these complex cases. Moreover, during the follow-up time we showed a reduction of CCS and NYHA class in all of our surviving patients. No acute myocardial infarction was documented at the follow-up even in patients with incomplete revascularization. The initial encouraging results convinced us to apply this technique systematically in high-risk patient candidates to a limited revascularization on the LAD territory or in case of multi-vessel disease with poor quality of the other arteries not Onsuitable for surgical or percutaneous treatment. At the same time in selected cases, high-risk patients with multi-vessel coronary artery disease should be treated with a hybrid approach, in order to achieve a complete revascularization with the minimal risk management. Nevertheless, despite good early and midterm results obtained with the minimally invasive strategies in high-risk patients reported by us and others groups, further investigation is required to evaluate the results of the surgical and the hybrid strategies, in particular during the long-term period.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Operative technique
 4. Results
 5. Discussion
 References
 

  1. Riha M, Danzmayr M, Nagele G, Mueller D, Hoefer D, Ott H, Laufer G, Bonatti J. Off pump coronary artery bypass grafting in EuroSCORE high and low risk patients. Eur J Cardiothorac Surg 2002;2:193–198.
  2. Michel P, Roques F, Nashef SA. Logistic or additive EuroSCORE for high-risk patients. Eur J Cardiothorac Surg 2003;23:684–687.[Abstract/Free Full Text]
  3. Toumpolis IK, Anagnostopulos CE, De Rose JJ, Swistel DG. European system for cardiac operative risk evaluation predicts long term survival in patients with coronary artery bypass grafting. Eur J Cardiothorac Surg 2004 1;25:51–58.[Abstract/Free Full Text]
  4. Berger PB, Velianou JL, Aslanidou VH, Feit F, Jacobs AK, Faxon DP, Attubato M, Keller N, Stadius ML, Weiner BH, Williams DO, Detre KM, BARI Investigators. Survival following coronary angioplasty vs. coronary artery bypass surgery in anatomic subset in which coronary artery bypass surgery improves survival compared with medical therapy. Results from the Bypass Angioplasty Revascularization Investigation (BARI). J Am Coll Cardiol 2001 11 1;38:1440–1449.[Abstract/Free Full Text]
  5. Bittener HB, Savitt MA. Off-pump coronary artery bypass grafting decreases morbidity and mortality in a selected group of high-risk patients. Ann Thorac Surg 2002;74:115–118.[Abstract/Free Full Text]
  6. Del Rizzo DF, Boyd WD, Novick RJ, McKenzie FN, Desai ND, Menkis AH. Safety and cost-effectiveness of MIDCABG in high-risk CABG patients. Ann Thorac Surg 1998;66:1002–1007.[Abstract/Free Full Text]
  7. Calafiore AM, Teodori G, Di Giammarco G, Vitolla G, Iaco' A, Iovino T, Cirmeni S, Bosco G, Scipioni G, Gallina S. Minimally invasive coronary artery bypass grafting on a beating heart. Ann Thorac Surg 1997;63:S72–S75.[CrossRef][Medline]
  8. Cohen HA, Zenati M, Smith AJC, Lee JS, Chough S, Jafar Z, Counihan P, Izzo M, Burchenal JE, Feldman AM, Griffith B. Feasibility of combined percutaneous transluminal angioplasty and minimally invasive direct coronary artery bypass in patients with multivessel corornary artery disease. Circulation 1998;98:1048–1050.[Abstract/Free Full Text]
  9. Karagoz HY, Kurtoglu M, Bakkaloglu B, Sonmez B, Cetintas T, Bayazit K. Coronary artery bypass grafting in the awake patient: three years experience in 137 patients. J Thorac Cardiovasc Surg 2003;125:1401–1404.[Abstract/Free Full Text]
  10. Woo YJ, Gardner TJ. Myocardial revascularization with cardiopulmonary bypass. In: Lawrence H, Cohn L, Edmunds H, Jr. (eds), Cardiac surgery in the adult, 2nd edn. McGraw-Hill Professional, 12, 6, 2003:581–607.
  11. Stamou S, Jablonsky K, Hill P, Bafi A, Boyce S, Corso P. Coronary revascularization without cardiopulmonary by-pass versus the convectional approach in high-risk patients. Ann Thorac Surg 2005;79:552–557.[Abstract/Free Full Text]
  12. Detter C, Reichenspurner H, Boehm DH, Thalhammer M, Schutz A, Reichart B. Single vessel revascularization with beating heart techniques – minithoracotomy or sternotomy? Eur J Cardiothorac Surg 2001;19:464–470.[Abstract/Free Full Text]
  13. Ben-Gal Y, Mohr R, Braunstein R, Finkelstein A, Hansson N, Hendler A, Moshkovitz Y, Uretzky G. Revascularization of left anterior descending artery with drug-eluting stents: comparison with minimally invasive direct coronary artery bypass surgery. Ann Thorac Surg 2006;82:2067–2071.[Abstract/Free Full Text]
  14. Diegeler A, Matin M, Kayser S, Binner Ch, Autschabach R, Battellini R, Krankeberg H, Mohr FW. Angiographic results after minimally invasive coronary bypass grafting using the minimally invasive direct coronary bypass grafting (MIDCAB) approach. Eur J Cardiothorac Surg 1999;15:680–684.[Abstract/Free Full Text]
  15. Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic M, Williams GW, Golding LA, Gill CC, Taylor PC, Sheldon WC. Influence of internal-mammary-artery-graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1–6.[Abstract]

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