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"Keyhole" coronary artery bypass surgery
R J Landreneau1, M J Mack, J A Magovern
1Division of Cardiothoracic Surgery, Alleghany University of the Health Sciences, Medical College of Pennsylvania/Hahnemann University, Pittsburgh.
Insights
Keyhole coronary artery bypass grafting (CABG) offers a minimally invasive option for single-vessel disease. Early results show it
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Techniques
- Coronary Artery Disease Management
Background:
- Minimally invasive surgery adoption in cardiac procedures has been slow.
- Keyhole thoracotomy, a 6 cm incision, was explored for coronary artery bypass grafting (CABG).
- Internal mammary artery (IMA) pedicle dissection was performed thoracoscopically or via the keyhole incision.
Purpose of the Study:
- To evaluate the utility of keyhole thoracotomy for single-vessel coronary artery bypass surgery.
- To assess the feasibility of IMA to LAD or RCA bypass grafting using this approach.
Main Methods:
- Keyhole CABG was attempted in 49 patients with significant coronary artery obstruction unsuitable for endovascular treatment.
- Procedures involved IMA pedicle dissection and bypass grafting to the LAD or RCA.
- Femoral cardiopulmonary bypass was utilized in 19% of successful cases; beta-blockade was common.
Main Results:
- Successful keyhole CABG was achieved in 46 of 49 patients.
- Average operative time was 248 minutes; median postoperative intubation was 6 hours.
- Conversion to sternotomy occurred in 3 patients; complications included respiratory issues and wound infection. No perioperative infarctions occurred.
Conclusions:
- Early outcomes of keyhole CABG are promising for single-vessel coronary disease.
- This technique may serve as an alternative to sternotomy or repeat interventions.
- Further experience may establish keyhole CABG as a viable option for specific patient groups.
Objective:
The objective of this study was to identify the utility of "keyhole" thoracotomy approaches to single vessel coronary artery bypass surgery.
Summary Background Data:
Although minimally invasive surgery is efficacious in a wide variety of surgical disciplines, it has been slow to emerge in cardiac surgery. Among 49 selected patients, the authors have used a left anterior keyhole thoracotomy (6 cm in length) combined with complete dissection of the eternal mammary artery (IMA) pedicle under thoracoscopic guidance or directly through the keyhole incision to accomplish IMA coronary artery bypass grafting (CABG) to the left anterior descending (LAD) coronary artery circulation or to the right coronary artery (RCA).
Methods:
Keyhole CABG was accomplished in 46 of 49 patients in which this approach was attempted. All patients had significant (> 70%) obstruction of a dominant coronary artery that had failed or that was inappropriate for endovascular catheter treatment (percutaneous transluminal coronary angioplasty or stenting). Forty-four of the 49 patients had proximal LAD and 5 had proximal RCA stenoses. The mean age of the patients (35 men and 14 women) was 61 years, and their median New York Heart Association anginal class was III. The mean left ventricular ejection fraction was 42%. Femoral cardiopulmonary bypass support was used in 9 (19%) of 46 patients successfully managed with the keyhole procedure. Short-acting beta-blockade was used in the majority of patients (38 of 46) to reduce heart rate and the vigor of cardiac contraction.
Results:
As 49 patients have survived operation, which averaged 248 minutes in duration. Median, postoperative endotracheal intubation time for keyhole patients was 6 hours with 25 of 46 patients being extubated before leaving the operating room. The median hospital stay was 4.3 days. Conversion to sternotomy was required in three patients to accomplish bypass because of inadequate internal mammary conduits or acute cardiovascular decompensation during an attempted off-bypass keyhole procedure Postoperative complications were limited to respiratory difficulty in three patients and the development of a deep wound infection in one patient. Nine (19%) of 46 patients received postoperative transfusion. There have been no intraoperative or postoperative infarctions, and angina has been controlled in all but one patient who subsequently had an IMA-RCA anastomotic stenosis managed successfully with percutaneous transluminal coronary angioplasty.
Conclusions:
These early results with keyhole CABG are encouraging. As experience broadens, keyhole CABG may become a reasonable alternative to repeated endovascular interventions or sternotomy approaches to recalcitrant single-vessel coronary arterial disease involving the proximal LAD or RCA.