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Minimally invasive coronary artery bypass grafting on a beating heart
A M Calafiore1, G Teodori, G Di Giammarco
1Department of Cardiac Surgery, University G. D'Annunzio, Chieti, Italy. calafiore@unich.it
Insights
This study demonstrates that left internal mammary artery (LIMA) to left anterior descending artery (LAD) bypass grafting on a beating heart via small thoracotomy offers low risk and good midterm outcomes in select patients.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
- Coronary Artery Bypass Grafting
Background:
- Review of experience with left internal mammary artery (LIMA) to left anterior descending artery (LAD) anastomosis.
- Procedure performed on a beating heart through a left anterior small thoracotomy.
Purpose of the Study:
- To evaluate the safety and efficacy of LIMA-to-LAD anastomosis.
- To assess midterm results of this minimally invasive surgical technique.
Main Methods:
- Performed on 343 of 358 scheduled patients.
- Utilized left anterior small thoracotomy with LIMA harvested (4-15 cm).
- LAD occlusion with Prolene sutures; anastomosis with 8-0 Prolene sutures; early postoperative angiography or doppler flow assessment.
Main Results:
- Successful LIMA-to-LAD anastomosis in 310 patients; additional grafts used in 33 patients.
- Low mortality (0.9% early, 1.2% late).
- Reoperation rate of 7.3% for anastomotic or conduit failure; 98.0% alive and asymptomatic at mean 9.5 months follow-up.
Conclusions:
- LIMA-to-LAD anastomosis on a beating heart via left anterior small thoracotomy is feasible.
- The procedure offers low risk and acceptable midterm results in selected patients.
Background:
We reviewed our experience with left internal mammary artery (LIMA)-to-left anterior descending artery (LAD) anastomosis on a beating heart through a left anterior small thoracotomy.
Methods:
This procedure was performed in 343 of 358 scheduled patients; in 15 (4.2%) the LAD was not suitable or was too small. The chest was opened in the fourth (127, 37.0%) or fifth (197, 57.4%) intercostal space, or both (19, 5.6%); the length of the harvested LIMA was 4-15 cm. The LAD was occluded by means of two 4-0 Prolene (Ethicon, Somerville, NJ) sutures, both snared on a small piece of silicone tubing. The anastomosis was performed with two 8-0 Prolene sutures. In the early postoperative period all patients underwent angiography or a doppler flow assessment of the LIMA or both.
Results:
In 310 patients the LIMA was connected directly to the LAD; to elongate the LIMA, in 30 patients an inferior epigastric artery and in 3 patients a saphenous vein was used. In 2 patients the diagonal branch was also grafted using an inferior epigastric artery from the LIMA. Three patients (0.9%) died during the first 30 days after the operation, and 4 other patients (1.2%) died after the first month. Twenty-five patients (7.3%) were reoperated on because of anastomotic or conduit failure, 18 (5.2%) early and 7 (2.1%) late; one additional patient had a late percutaneous transluminal coronary angioplasty for anastomotic stenosis. At a mean of 9.5 +/- 5.7 months of follow-up, 336 patients (98.0%) were alive, asymptomatic with or without medical treatment, and without cardiac events.
Comment:
Left internal mammary artery-to-LAD anastomosis performed on a beating heart through a left anterior small thoracotomy is a procedure that can be performed with low risk and acceptable midterm results in selected patients.