Automated distal coronary bypass with a novel magnetic coupler (MVP system)

OBJECTIVE: We sought to assess the feasibility of performing sutureless distal coronary artery bypass anastomoses with a novel magnetic coupling device. METHODS: From May 2000 to April 2001, single-vessel side-to-side coronary artery bypass grafting on a beating heart was performed in 39 domestic white pigs (35-60 kg) without the use of mechanical stabilization, shunts, or perfusion bridges. Animals were divided into 2 groups. Seventeen pigs underwent right internal thoracic artery to right coronary artery bypass grafting through a median sternotomy (group 1) with a novel magnetic vascular positioning system (MVP system; Ventrica, Inc, Fremont, Calif). Twenty-two pigs underwent left internal thoracic artery to left anterior descending artery grafting with the MVP anastomotic device through a left anterior minithoracotomy (group 2). This system consists of 2 pairs of elliptical magnetic implants and a deployment device. One pair of magnets forms the anastomotic docking port within the graft; the other pair forms an identical anastomotic docking port within the target vessel. The anastomosis is created when the 2 docking ports magnetically couple. Anastomotic patency was evaluated by means of angiography during the first postoperative week and at 1 month. Histologic studies were performed at different time points as late as 6 months. RESULTS: Right internal thoracic artery to right coronary artery anastomoses and left internal thoracic artery to left anterior descending artery anastomoses were successfully performed with the system in all animals. The self-adherent and self-aligning properties of the implants allowed for immediate and secure approximation of the arteries (total anastomotic time between 2-3 minutes). Anastomoses were constructed without a stabilization platform. Five nondevice-related deaths occurred postoperatively. One-week angiography, performed in 35 surviving animals, showed a patent graft and anastomosis in all cases. The patency rate at 1 month was 97% (33/34). Histologic studies as late as 6 months demonstrated neointimal coverage of the magnets without any significant luminal obstruction. Histology also confirmed the presence of viable tissue between magnets. CONCLUSION: The MVP anastomotic system uses magnetic force to create rapid and secure distal coronary artery anastomoses, which might facilitate minimally invasive and totally endoscopic coronary artery bypass surgery.     

Facilitated MIDCAB using a magnetic coupling device

A 59-year-old male with chronic occlusion of the left anterior descending coronary artery underwent a minimally invasive direct coronary artery bypass procedure using the second generation of a magnetic anastomotic coupling device. Postoperative angiogram demonstrated excellent patency and flow.     

Combined use of off-pump techniques and a sutureless proximal aortic anastomotic device reduces cerebral microemboli generation during coronary artery bypass grafting

OBJECTIVE: Intraoperative cerebral microemboli are associated with the development of postoperative stroke and neurocognitive decline in patients undergoing coronary artery bypass grafting. Although cardiopulmonary bypass is responsible for the generation of a significant number of such emboli, the elimination of cardiopulmonary bypass alone has not been conclusively shown to improve neurocognitive outcome. The current study was performed to determine the effects of combined off-pump coronary artery bypass grafting and sutureless proximal aortic anastomotic techniques on the generation of intraoperative cerebral microemboli compared with standard coronary artery bypass grafting techniques of cardiopulmonary bypass and hand-sewn proximal anastomoses. METHODS: Fifty-three patients underwent off-pump coronary artery bypass grafting by using the sutureless Symmetry aortic connector device (St Jude Medical, St Paul, Minn) for all proximal anastomoses. Eighteen of these patients received intraoperative transcranial Doppler ultrasonography to determine right- and left-sided cerebral microembolic counts. These results were compared with those obtained from a similar group of 17 patients undergoing standard coronary artery bypass grafting, in whom cardiopulmonary bypass and hand-sewn proximal anastomoses were used. RESULTS: Our use of the proximal anastomotic device in patients undergoing coronary artery bypass grafting was safe, with no aortic complications, postoperative strokes, or in-hospital deaths. Microembolic counts to both the right and left cerebral circulation were significantly reduced in the patients undergoing off-pump coronary artery bypass grafting (right = 21.9 +/- 20.7 emboli, left = 24.9 +/- 19.2 emboli) compared with those in patients undergoing standard coronary artery bypass grafting (right = 181.6 +/- 85.3, left = 189.9 +/- 60.401, P <.0001). CONCLUSIONS: Our use of a sutureless proximal anastomotic device during off-pump coronary artery bypass grafting is safe and significantly decreases cerebral microembolism when compared with standard coronary artery bypass grafting with cardiopulmonary bypass and hand-sewn anastomoses. Long-term follow-up is needed to determine the effects of this technical strategy on neurocognitive outcome.     

"Gumnut" device for off-pump proximal aortocoronary anastomosis

Abstract   Use of side-biting clamps in patients with coronary artery disease and atheromatous disease of ascending aorta, undergoing coronary artery surgery can lead to major postoperative neurological events. We describe the use of a simple device to avoid use of side-biting clamp on aorta for proximal aortocoronary anastomosis.     

Anomalous left coronary artery from pulmonary artery: autogenous arterial tube for aortic implantation

Many surgical procedures for the implantation of anomalous left coronary artery from pulmonary artery have been described. A dual coronary system offers most benefit and is most advantageous for the patient. Two autogenous flaps of the pulmonary trunk and ascending aorta, without mobilizing the coronary artery, were created for use in this procedure. This technique was successfully used in an 8 month-old patient with severe myocardial dysfunction and moderate mitral regurgitation. This procedure allows 2 coronary systems to be repaired for any anatomic change of the left coronary artery without the use of prosthetic material. There were no technical complications. During the postoperative course minimal inotropic support was used. The magnetic resonance study, 11 months postoperative, showed wood flow of the left coronary artery and mild mitral regurgitation. The operative technique was simple and its execution easy. The follow-up in the intermediate and late period showed the growth of this endothelized tube.     

Clampless arterial coronary artery bypass grafting with the use of magnetic coupling devices

BACKGROUND: The aim of our study was to evaluate the feasibility of using the Ventrica MVP device to perform proximal anastomoses as part of the clampless off-pump coronary artery bypass (OPCAB) arterial revascularization procedure. METHODS: We present our preliminary experience of these first nine coronary artery cases performed in the UK from April 2003 to December 2004. RESULTS: The device was used in eight patients for the proximal anastomosis of a radial artery (n = 8) or right internal thoracic artery (n = 1) graft as a Y-graft from the left internal thoracic artery to the circumflex territories. One patient died in this series although the autopsy showed that the device was intact and free of clots and the reported cause of death was an acute cardiac event due to myocardial ischemia. Anastomotic patency was confirmed in five patients with the use of multidetector row computed tomography coronary angiogram. The anastomosis time in our series was 6.3 +/- 2.1 minutes and the blood loss 814 +/- 245 mL. The mean length of stay was 5.2 +/- 1.2 days. No other significant major morbidity events were observed postoperatively (neurological complications, renal failure, and reopening for bleeding). The assessment of quality of life at 6 months postoperatively using SF-36 questionnaires revealed improvement. CONCLUSION: The versatile use of Ventrica MVP distal anastomotic device is feasible in clinical practice allowing surgeons to perform proximal anastomoses and arterial OPCAB surgery with short learning curve and without compromising the clinical outcome and quality of life.     

Clinical Experience With the Jahnke-Barron Heart Support

The Jahnke-Barron heart support has proven to be a useful adjunct to coronary artery surgery by allowing an easy access to the coronary arteries while maintaining a quiet operating field. Further, the use of this device eliminates the need for a surgical assistant or a heart holder.     

A simple technique for multigraft cardioplegic infusion during coronary artery bypass

The use of a Silastic four-armed cardioplegic infusion device during coronary artery bypass grafting, which has facilitated multidose cardioplegic infusion through the aorta and vein grafts, is described. The device also permits transaortic needle sump suction for decompression of the left ventricle. This device has been used effectively in more than 250 patients.     

A new mechanical connector for distal coronary artery anastomoses in coronary artery bypass grafting: a randomized, controlled study

OBJECTIVE: A new mechanical anastomotic device was evaluated, aiming at its future use in minimally invasive techniques or limited access surgery in patients undergoing coronary artery bypass grafting. METHODS: Between April and December 2002, a total of 60 patients scheduled for elective multivessel bypass grafting were randomly assigned. One vein graft-coronary artery anastomosis per patient was either performed with the St Jude Medical ATG coronary connector system (n = 30; St Jude Medical Inc, St Paul, Minn) or hand sewn (n = 30). Selective coronary angiography or coronary magnetic resonance imaging of the studied graft and vessel was included in the 6-month follow-up. RESULTS: Twenty-eight of the connectors were successfully implanted. Two patients were excluded from the study because of conversion to hand-sewn anastomoses. Six connector-made anastomoses were bleeding at the anastomotic site. At the time of follow-up (190 postoperative days), all control anastomoses and grafts were patent, whereas 26% of the connector anastomoses were occluded. One graft in each group was patent but with stenosis. CONCLUSION: The St Jude Medical ATG coronary connector system for distal anastomoses represents a new concept for sutureless anastomoses in cardiac surgery. This randomized, controlled study shows lower graft patency for anastomoses performed with the connector than for hand-sewn control anastomoses. It illustrates the importance of controlled studies when evaluating new technical equipment in medicine.     

Emergency conversion in off-pump coronary artery bypass grafting

Emergency conversion to cardiopulmonary bypass in off-pump coronary artery bypass grafting is recognized to increase operative mortality and morbidity. We conducted a retrospective review of 616 consecutive patients who were planned for off-pump coronary artery bypass grafting from April 2001 to July 2004. Fourteen patients (2.3%) required emergency conversion to cardiopulmonary bypass. Operative mortality was 13.3% in the conversion group and 1.2% in the non-conversion group (P<0.001). The incidence of reoperation for bleeding was 7.1% and 1.0%, respectively (P=0.032) and that of respiratory failure was 35.7% and 3.3%, respectively (P<0.001). Multivariable analysis showed that mitral regurgitation and chronic obstructive pulmonary disease were predictors of emergency conversion with all causes except for bleeding, and that mitral regurgitation and no use of a heart positioning device were predictors of emergency conversion due to hemodynamic compromise during distal anastomosis of the circumflex artery territory. In conclusion, emergency conversion in off-pump coronary artery bypass grafting increases operative mortality and morbidity. Mitral regurgitation and chronic obstructive pulmonary disease are risk factors for emergency conversion. Use of a heart positioning device decreases hemodynamic compromise during anastomosis of the circumflex artery territory.     

Redo-OPCAB via left thoracotomy using symmetry aortic connector system: a report of two cases

Left thoracotomy is an established approach for redo coronary artery bypass grafting (CABG). This approach has also been successfully used in off-pump coronary artery bypass (OPCAB). Traditionally, the grafts have been anastomosed proximally to the descending thoracic aorta or the left subclavian artery. Recently, proximal connectors have been introduced by various manufacturers for use on ascending aorta during primary CABG and OPCAB. One such device is the Symmetry aortic connector system (St. Jude Medical, Minneapolis, MN). These devices have obviated the need for partial occluding clamps for the construction of the proximal anastomoses and hence are extremely useful when the aorta is heavily calcified. We used this device successfully in two patients undergoing redo-OPCAB, where the proximal anastomosis was constructed on the descending aorta. In so doing, we also used the shortest possible length of vein graft since the descending aorta at that level was much closer than the left subclavian artery. This can be an additional factor in redo-operations where the availability of vein can be an issue.     

Exposure of the circumflex coronary artery

A simplified method of obtaining exposure of the circumflex coronary artery using a mesh envelope is described. The device is constructed of readily available materials. Its construction, use, and clinical application are presented.     

Off-pump coronary artery bypass via left thoracotomy in patient with infective pancreatic fistula after surgery for bile duct carcinoma; report of a case

A 62-year-old man with infective pancreatic fistula after surgery for bile duct carcinoma underwent off-pump coronary artery bypass (OPCAB) through left thoracotomy to avoid the use of cardiopulmonary bypass and the postoperative mediastinitis, since this patient has infective pancreatic fistula close to the xiphoid process. The coronary arterial revascularizations were performed: left internal thoracic artery to left anterior descending branch and saphenous vein graft to descending thoracic aorta. The aortic mechanical anastomosis device, aortic connector, was utilized the proximal anastomosis of saphenous vein graft so as to avoid aortic clamp, while the distal anastomoses were completed with stabilizer and apical retraction device. Postoperative angiogram showed both grafts were patent. No signs of infection or recurrence of malignant neoplasm was observed. OPCAB via left thoracotomy is one of useful options for patients in whom median sternotomy is not suitable approach for myocardial revascularizations.     

Two generations of the St. Jude Medical ATG coronary connector systems for coronary artery anastomoses in coronary artery bypass grafting

BACKGROUND: In the past, coronary anastomoses have been performed using running and, occasionally, interrupted non-resorbable sutures. Recently, special interest has developed in mechanical anastomotic devices to facilitate minimal invasive techniques or limited access surgery. The experience with two series of patients undergoing coronary artery bypass grafting (CABG) using the St. Jude Medical ATG coronary connector systems (investigational stainless steel device, not yet commercially available) for vein-to-coronary artery anastomoses is reported here. METHODS: Between November 2000 and April 2002, we evaluated two generations of distal coronary connector systems in 19 patients who were scheduled for multivessel CABG. One vein graft-to-coronary artery anastomosis per patient was performed with a stainless steel mechanical connector, in an ongoing investigational study. Although these two generations of the St. Jude Medical ATG coronary connectors have the same underlying construction, somewhat cumbersome loading of the first-generation system led to simplification of the second-generation system, which is currently evaluated. RESULTS: With the first generation of distal connector, hemostasis was instantaneous in all cases, and all anastomoses were patent at the end of the procedure. However, retrograde flow to the native coronary artery was restricted in 1 patient. The connector was removed, and the anastomosis was performed with a running suture at the same site. Three-month angiography or magnetic resonance imaging angiography was available in 11 patients with 10 patent connector grafts. With the second-generation connectors one of five had to be removed because of leakage, and the anastomosis could be sutured at the same site. The other four connector anastomoses were patent and hemostatic at the end of the procedure. CONCLUSIONS: The St. Jude Medical ATG coronary connector system is an effective device for sutureless vein graft to coronary artery anastomoses in CABG. The second-generation system presents a further development eliminating some drawbacks of the first generation such as cumbersome, time-consuming loading as well as suitability for smaller coronary arteries. These connectors allow construction of geometrically round anastomoses and theoretically may also be suitable for sequential anastomoses. After tremendous research and development efforts, an optimized mechanical connection system for small vessel anastomoses has been introduced into clinical investigation. This represents a major step in the era of sutureless vascular connections in cardiac surgery.     

Clinical experience with the Novare Enclose II manual proximal anastomotic device during off-pump coronary artery surgery

Objective: The aim of this study was to assess the feasibility and safety of a new proximal anastomotic device during off-pump coronary surgery. Methods: The Novare Enclose II is a manual proximal anastomotic device that enables the surgeon to perform proximal anastomoses without side-biting clamps in a fully pressurized aorta. The device was used in 30 off-pump coronary artery bypass graft (CABG) patients (Group A) for performing 25 vein, 10 free right internal thoracic artery and 14 radial artery anastomoses to the aorta.The number of proximal anastomoses varied between 1 and 3 per patient. Intraoperative transcranial Doppler measurements were performed to detect cerebral microemboli during the use of the device and were compared with transcranial Doppler measurements of 30 off-pump patients where a partial side clamp was used for proximal anastomoses (Group B).The aorta was evaluated using transesophageal echocardiography (TEE) and epiaortic echocardiography (EAE) in both groups before the procedure and patients with a calcified aorta were excluded. Results: In Group A, 49 proximal anostomoses were performed as planned with the device using conventional hand-sewn methods. Twenty-four of these were arterial conduits. In Group B, 32 proximal anastomoses were performed using 25 veins and 7 arterial grafts. There were no procedure related to adverse events or complications in both groups. The median number of microemboli was 15 (range 5–48) in Group A and 68 (range 35–290) in Group B (P<0.05). Conclusion: The Enclose II device can be a valuable tool to perform venous or arterial proximal anastomoses during off-pump CABG. Transcranial Doppler results suggest that the device seems to be less traumatizing than side clamping and may reduce clamp-associated complications during off-pump coronary artery surgery.     

A new end graft holder for coronary artery bypass grafting.

This article describes the construction and use of a new end graft holder during coronary artery bypass grafting (CABG). The instrument consists of a pinching device attached to a flexible arm and a fixation clamp. This device provides secure stabilization and enables excellent positioning of the graft without producing graft injury.     

Anomalous left main coronary artery arising from the pulmonary artery in an adult: Treatment by direct reimplantation

We herein report the case of a 37-year-old woman in whom an anomalous origin of the left coronary artery from the pulmonary artery was surgically corrected. A magnetic resonance angiogram showed the left main coronary artery connecting to the right posterior portion of the pulmonary trunk, and exercise-stressed thallium-201 perfusion scintigrams demonstrated a large reversible anterior defect. She was successfully treated by direct aortic reimplantation of the abnormal left coronary artery. We were able to obtain a sufficient length of the left main trunk by excising the large cuff of pulmonary artery wall surrounding the ostium of the anomalous left coronary artery while transecting the pulmonary artery. Postoperative angiograms demonstrated a widely patent left coronary artery, a decrease in the size of the right coronary artery, and no collaterals, and exercise-stressed thallium-201 perfusion scintigrams demonstrated no remaining ischemic defect at all. Direct aortic reimplantation is an ideal operation but is still limited by the anatomical position of the left coronary artery. In this case, magnetic resonance angiography was an excellent method for deciding the optimum operative procedure for the anomalous left coronary artery. In addition, exercise thallium-201 scintigraphy was found to be useful in recognizing the revascularized effect of the left ventricle.     

Off-pump coronary artery bypass grafting with device closure of atrial septal defect

Patients with coronary artery disease and atrial septal defect may have unique clinical characters. We describe an off-pump combined approach for intraoperative device closure of atrial septal defect during coronary artery bypass grafting.     

Automated, compliant, high-flow common carotid to middle cerebral artery bypass

The authors describe the use of the Cardica C-Port xA Distal Anastomosis System to perform an automated, high-flow extracranial-intracranial bypass. The C-Port system has been developed and tested in coronary artery bypass surgery for rapid distal coronary artery anastomoses. Air-powered, it performs an automated end-to-side anastomosis within seconds by nearly simultaneously making an arteriotomy and inserting 13 microclips into the graft and recipient vessel. Intracranial use of the device was first simulated in a cadaver prepared for microsurgical anatomical dissection. The authors used this system in a 43-year-old man who sustained a subarachnoid hemorrhage after being assaulted and was found to have a traumatic pseudoaneurysm of the proximal intracranial internal carotid artery. The aneurysm appeared to be enlarging on serial imaging studies and it was anticipated that a bypass would probably be needed to treat the lesion. An end-to-side bypass was performed with the C-Port system using a saphenous vein conduit extending from the common carotid artery to the middle cerebral artery. The bypass was demonstrated to be patent on intraoperative and postoperative arteriography. The patient had a temporary hyperperfusion syndrome and subsequently made a good neurological recovery. The C-Port system facilitates the performance of a high-flow extracranial-intracranial bypass with short periods of temporary arterial occlusion. Because of the size and configuration of the device, its use is not feasible in all anatomical situations that require a high-flow bypass; however it is a useful addition to the armamentarium of the neurovascular surgeon.     

Robotic Hybrid Procedure and Triple-Vessel Disease

Abstract   A 56-year old man presented with increasing angina pectoris. Coronary angiogram showed a triple-vessel disease, with significant lesions on the main stem, on an obtuse marginal branch of the circumflex coronary artery (Cx), on the right coronary artery (RCA), and a proximal occlusion of the left anterior descending artery (LAD). A hybrid procedure was decided, with a beating heart totally endoscopic double vessel coronary artery bypass grafting (Double BHTECAB) on the LAD and the Cx, with the use of a four-arm robotic device, and a stent placement into the RCA in a second step. Both procedures went uneventfully, and the patient is fully asymptomatic 15 months after the procedure.