Angiographic results after minimally invasive coronary bypass grafting using the minimally invasive direct coronary bypass grafting (MIDCAB) approach.

OBJECTIVE: The aim of the study was to evaluate the early and mid-term angiographic results after minimally invasive coronary bypass grafting using an 'off-pump' technique via a lateral minithoracotomy. METHODS: In 221 out of 271 patients (81.5%) who underwent minimally invasive direct coronary bypass grafting (MIDCAB) the quality of the internal thoracic artery (ITA)-graft and the anastomosis was evaluated by conventional coronary angiography between the 2nd and 6th postoperative day (POD). A subgroup of 130 patients (47.9%) of the initial cohort were repeatedly controlled by angiography 6 months later. RESULTS: The early postoperatively patency rate of the grafts was (96.8%). Moderate anastomotic stenosis between 50 and 75% was found in 13/221 (5.8%) patients, whereas severe stenosis of more than 75% was seen in 10/221 (4.5%) and occlusion of the graft in 3/221 (1.3%) patients. A stress-ECG was performed in patients with a severe stenosis to provoke ST-segment changes or clinical findings of myocardial ischemia. A positive stress test was found in 4/221 patients (1,8%). Early re-intervention was required in 7/221 (3.1%) patients. After 6 months, angiographic follow-up revealed a patency rate of (95.4%). Of 130 patients 5 (3.8%) presented with moderate anastomotic stenosis, whereas 3/130 (2.0%) patients showed a severe stenosis with one patient (0.7%) having myocardial ischemia during stress test. Occlusion of the graft was seen in 3/130 patients (2.3%). During follow-up, 4/130 (3.0%) patients underwent re-intervention. A comparison between early postoperative and 6-months angiogram revealed a decrease or a disappearance of the severity of the stenosis in 4/15 patients (26.6%). CONCLUSION: Since stenosis of the anastomosis may occur after minimally invasive, beating heart coronary bypass grafting, postoperative angiography should be performed to provide quality control and to guide appropriate further treatment. The latter is necessary if the stenosis is accompanied by reduced run-off and evidence of myocardial ischemia during stress test. An improvement of early stenosis at the anastomosis may be expected in more than 25%.     

Early experience with minimally invasive direct coronary artery bypass grafting with the internal thoracic artery

OBJECTIVE: Minimally invasive direct coronary artery bypass is performed under direct vision without sternotomy or cardiopulmonary bypass. The technique can be used in both primary and reoperative cases by employing the internal thoracic artery to perform arterial revascularization of the anterior surface of the heart. METHODS: Patients were selected who had significant coronary artery disease limited to 1 or 2 coronary distributions on the anterior surface of the heart. Coronary target vessels were grafted with the internal thoracic artery through a small anterior thoracotomy. After partial heparinization the anastomosis was facilitated by local coronary occlusion and handheld stabilization. RESULTS: Between August 1994 and July 1997, 162 patients underwent minimally invasive direct coronary artery bypass grafting with the internal thoracic artery. The left and right internal thoracic arteries were used for grafting of the left anterior descending artery in 142 patients (88%), the proximal right coronary artery in 7 patients (4%), existing saphenous vein grafts in 5 patients (3%), and diagonal branches in 2 patients (1%). Sequential grafting with the left internal thoracic artery was performed in 2 patients (1%) and bilateral internal thoracic artery grafting was performed in 4 patients (3%). Eight patients (4.9%) died within 30 days after the operation, 3 of cardiac causes. Seven additional patients died during the follow-up period. Nine patients (5.6%) required reintervention for graft stenosis or occlusion during follow-up. Of 141 patients seen 2 or more weeks after the operation, 135 (96%) had resolution of their anginal symptoms at a mean follow-up of 12 months (range 0-31 months). CONCLUSIONS: Anterior minimally invasive direct coronary artery bypass grafting with the internal thoracic artery avoids the risks of repeated sternotomy, aortic manipulation, and cardiopulmonary bypass. There was a low rate of reintervention, and patients had excellent resolution of anginal symptoms. Postoperative length of stay was comparatively short, and continued follow-up will be essential to evaluate long-term graft patency and patient survival.     

Necessity of postoperative angiography after minimally invasive coronary bypass grafting

We present a case of two missiles in the heart causing coronary artery disease with first onset 44 years after the injury. The missiles were close to the right coronary artery and the left anterior descending coronary artery. The missiles initiated local arteriosclerosis in these vessels, with an extremely stretched time frame from injury to the onset of symptoms for coronary artery disease.     

Serial dobutamine stress echocardiography with Doppler assessment of the left internal thoracic artery graft after minimally invasive bypass for a patient with an orthotopic heart transplant.

Select patients who have undergone orthotopic heart transplantation with proximal left anterior disease may be candidates for minimally invasive direct coronary artery bypass surgery. Combining left internal thoracic artery transthoracic Doppler flow assessment with wall motion assessment during dobutamine stress echocardiography adds to the utility of this test by focusing attention on the graft's status as well as detecting ischemia due to cardiac allograft vasculopathy.     

Simple exposure of the internal thoracic artery for minimally invasive coronary artery bypass.

A simple method is described for harvesting a pedicle of internal thoracic artery for minimally invasive coronary artery bypass grafting with the use of a small scapular retractor. The technique has been used successfully in 39 patients. All patients were followed up early postoperatively by angiography, and the patency rate was 96%. Follow-up angiography (mean [and standard error] 9.6 [4.8] months) was carried out in 63% of the patients, demonstrating a cumulative patency rate of 95.4% with no evidence of steal. None of the patients died and there were no cases of myocardial infarction perioperatively. Recurrent angina developed in 2 patients. This technique is safe, effective and inexpensive.     

Refractory coronary artery spasm after minimally invasive direct coronary artery bypass grafting

Postoperative coronary arterial spasm is a rare but potentially fatal complication. A 51-year-old male patient with a history of a reactive ergonovine stress test coronary angiogram developed refractory coronary artery spasm after undergoing minimally invasive direct coronary artery bypass grafting of the left anterior descending coronary artery. The patient was successfully managed with rapid implementation of intra-aortic balloon-pump counter pulsation and extracorporeal membrane oxygenation.     

Postoperative internal thoracic artery spasm after coronary artery bypass grafting

Spasm of the left internal thoracic artery in the perioperative period represents a life-threatening complication after coronary artery bypass grafting. We present a case in which graft spasm was treated with the administration of intra-arterial nitroglycerin and verapamil. Although vasospasm is more often seen in radial artery grafts, this case demonstrates that left internal thoracic artery grafts are also prone to spasm.     

Assessment of minimally invasive direct coronary artery bypass grafting of the left internal thoracic artery by means of magnetic resonance imaging

OBJECTIVES: We sought to evaluate graft patency, flow, and flow reserve in patients with minimally invasive direct coronary artery bypass surgery of internal thoracic artery grafts by a combined magnetic resonance protocol with a phase-contrast technique and magnetic resonance angiography. METHODS: At 1.5 T (Magnetom Sonata, Siemens), 30 symptomatic patients with 30 left internal thoracic artery grafts were examined 6 years after minimally invasive surgical intervention. Navigator-gated magnetic resonance angiography and contrast-enhanced FLASH-3D magnetic resonance angiography (0.2 mmol gadopentate-diethylene triamine pentetic acid [Gd-DTPA]/kg body weight) was used to assess bypass patency. Phase-contrast flow measurements with retrospective gating were performed in the internal thoracic artery grafts at rest and after stress induction with dipyridamole (0.57 mg/kg body weight). Graft patency was evaluated by means of multidetector computed tomography (Sensation 16, Siemens). RESULTS: Internal thoracic artery grafts were occluded in 5 of 30 patients. In 6 patients the anastomosis to the left anterior descending artery was highly stenotic (>70 % ) at multidetector computed tomography. In patients with regular grafts (multidetector computed tomography), a significant improvement of graft flow ( P < .001) and diastolic/systolic peak velocity ratio ( P < .001) after stress induction was detected. Magnetic resonance angiography combined with flow reserve measurements could differentiate between occluded-stenotic and regular minimally invasive direct coronary artery bypass grafts. CONCLUSIONS: Magnetic resonance imaging allows a combined assessment of bypass patency and flow with flow reserve in patients after the minimally invasive direct coronary artery bypass operation. The protocol of this study might be applicable for the evaluation of graft status in symptomatic patients after revascularization.     

Evaluation of graft patency during minimally invasive coronary artery bypass grafting with Doppler flow analysis

BACKGROUND: An objective method for determining intraoperative graft patency is an essential part of minimally invasive direct coronary artery bypass. This study compares angiography and Doppler methods for graft analysis during minimally invasive direct coronary artery bypass and presents long-term outcome in a cohort of patients. METHODS: Between March and October 1997, 35 patients had elective minimally invasive direct coronary artery bypass procedures in which the left internal mammary artery was anastomosed to the left anterior descending coronary artery. Immediate graft patency was determined with intraoperative angiography using selective injection of the left internal mammary artery from a femoral approach and with Doppler flow analysis using a 1-mm, 20-MHz Doppler probe placed directly on the graft. RESULTS: There was immediate perfect patency with brisk flow in 91% of patients (32 of 35). A normal Doppler study, defined as a diastolic predominant pattern with a diastolic flow velocity of greater than 15 cm/second, was found in all patients with normal angiograms. All patients with abnormal angiograms also had abnormal Doppler flow. Thus, Doppler analysis was 100% accurate for confirming graft patency and for detecting failed grafts. All abnormal grafts were successfully revised, which allowed 100% early patency. Operative mortality was 2.8% (1 of 35) and there have been no late deaths at a follow-up of more than 2 years. One patient required angioplasty of the anastomosis (1 of 34, 2.9%), but none have required subsequent surgical intervention. CONCLUSIONS: Objective analysis of graft flow in the operating room is necessary to achieve 100% early graft patency with minimally invasive direct coronary artery bypass operations. Doppler analysis is the preferred initial method, because it is safe, accurate, and rapid.     

Anastomotic obstruction after magnetic vascular coupling after minimally invasive direct coronary artery bypass grafting

We report a 61-year-old man who required reoperation 8 months after minimally invasive direct coronary artery bypass grafting after magnetic vascular coupling due to a symptomatic subtotal obstruction at the anastomotic site. It was also determined that the patient had been noncompliant in following the prescribed postoperative antiplatelet therapy.     

On-line assessment of regional ventricular wall motion by transesophageal echocardiography with color kinesis during minimally invasive coronary artery bypass grafting

OBJECTIVE: Our objective was to determine the changes in regional ventricular wall motion during minimally invasive direct coronary artery bypass grafting by color kinesis using transesophageal echocardiography. METHODS: Minimally invasive coronary artery bypass grafting was performed in 34 patients, during which transesophageal echocardiography was used. Thirteen patients had isolated disease of the left anterior descending artery. Regional ventricular wall motion was analyzed by color kinesis with the SONOS 2500 transesophageal echocardiograph (Hewlett-Packard Co, Andover, Mass). On-line assessment of regional wall motion was continued during the operation. RESULTS: Wall motion abnormalities during ischemia were present in 4 cases, left ventricular mid-anterior hypokinesis in 3 cases, and left ventricular apical-lateral hypokinesis in 1 case. In all cases, wall motion was maintained after bypass. In patients with total coronary occlusion, changes in wall motion did not occur during anastomosis. CONCLUSIONS: Color kinesis allowed us to evaluate the change in regional ventricular wall motion induced by myocardial ischemia during minimally invasive coronary artery bypass grafting both objectively and quantitatively.     

Postoperative mediastinitis after the coronary artery bypass grafting using internal thoracic artery graft

It has been pointed out in general that the resistance against infection is decreased in the diabetic patients. This problem is very important in patients undergoing major surgery. In cardiovascular surgery, the median wound infection may result in life threatening sequelae. We have used the internal thoracic artery as the appropriate graft for its excellent long-term patency. In this series of the diabetic patients who underwent coronary artery bypass grafting with bilateral internal thoracic artery grafts, the incidence of postoperative mediastinitis was significantly higher than other cases. Therefore the use of bilateral internal thoracic artery grafts should be avoided, if possible in the diabetic patients.     

Acute cholecystitis after minimally invasive coronary artery bypass grafting: a report 2 cases

Acute cholecystitis following coronary artery bypass grafting (CABG), although rare, is a potentially life-threatening consequence of prolonged cardiopulmonary bypass (CPB)procedures. Minimally invasive direct coronary artery bypass (MIDCAB), performed without sternotomy and without CPB, is perhaps the least traumatic type of CABG procedure.Nevertheless, we present 2 cases of acute cholecystitis following MIDCAB, demonstrating that a MIDCAB does not eliminate the risk of gastrointestinal complications. Our experience with these cases points to the benefits of early and aggressive management in the treatment of acute cholecystitis after MIDCAB.