Coronary artery bypass grafting on the beating heart using the octopus method--a case report

A 74-year-old male was admitted due to chest tightness for one month. He had received percutaneous transilluminal coronary angioplasty (PTCA) because of single-vessel disease one year ago. Cardiac catheterization examination carried out during this admission revealed 90% stenosis of the left anterior descending coronary artery (LAD) and circumflex branch (CX). Because another attempt of PTCA was considered not optimal, the patient was advised to undergo surgical grafting to which he consented. After expediently balancing the merits and demerits of every practicable surgical procedure--the essential determinant in selection of which was that the patient's condition and criteria of indication of that procedure were in perfect harmony--we decided to carry out minimally invasive direct coronary artery bypass (MIDCAB) with the application of Octopus tissue stabilizer. We report the surgical course and anesthetic management of the patient and discourse some detail in MIDCAB.     

Coronary artery bypass grafting on the beating heart: a simple technique for subluxating the heart

Coronary artery bypass grafting on the beating heart is becoming a widely applied procedure. It necessitates proper cardiac stabilization without impairment of hemodynamics. We describe a simple and effective technique to bring the anterolateral coronary arteries to a midline position for the purpose of performing a coronary artery bypass graft on the beating heart. A surgical glove tied to a tube is positioned underneath the left ventricle. Injection of warm saline into the glove will gradually displace the heart and rotate the lateral wall of the ventricle to a midline position. In spite of our use of mechanical stabilizers to decrease mobility of the anastomotic site, compression of the left ventricle is avoided because the water bed created by the injected glove absorbs the movement of the left ventricle and prevents its compression and any potential drop in cardiac output.     

心脏跳动下冠状动脉旁路移植术的走向

二十世纪九十年代被喻为“微创外科”的时代 ,大量的微创外科技术被发明并使用于临床医学的诸多领域。心脏跳动 ,非体外循环下冠状动脉旁路移植术 (off -pumpcoronaryarteryby passgrafting ,OPCAB)的兴起是其在心血管外科领域的主要代表 ,不同于其他微创外科着重于小切口或微小切口 ,OPCAB避免了非生理性的体外循环 ,因此具有特殊的意义。一、心脏跳动下冠状动脉旁路移植术的概况通常的心脏手术需要在体外循环的帮助下完成 ,成熟的体外循环技术使得心脏手术可以在安静、无血的状态下从容的进行 ,然而 ,体外循环还是会给机体带来很大的…     

机器人微创非体外循环冠状动脉旁路移植术

目的 评价da Vincis机器人系统进行胸廓内动脉(IMA)游离、小切口非体外循环下冠状动脉旁路移植术的安全性和手术效果.方法 2007年1月到2011年3月,105例患者接受机器人IMA游离、小切口非体外循环下冠状动脉旁路移植术.其中男性77例,女性28例,年龄33～77岁,平均(59±10)岁.患者术前行64排CT检查评估IMA质量,2例患者左LIMA纤细或走行异常弃用.术者于操作台前、三维成像系统下遥控机器人游离IMA并完成动脉桥与靶血管的徒手吻合.其中4例患者旁路移植后接受了杂交技术于回旋支或右冠状动脉行支架植入术.术中均以超声血流检测仪测量桥血管的波形及血流.术后以冠状动脉造影或64排CT评估桥血管的通畅性,并进行随访.结果 所有患者成功接受上述手术,无手术死亡病例.术中平均IMA血管桥血流量为(21±13) ml/min.1例于术后第1天突发心跳骤停经抢救后痊愈,复查桥血管通畅.1例合并脑梗死患者术后肺部感染,痊愈后出院.其余患者无并发症发生.术中及术后出血少,术后恢复快.随访1～51个月,平均(30±12)个月.术后冠状动脉造影或64排CT复查未见桥血管狭窄或闭塞,心绞痛症状缓解.结论 机器人IMA游离、小切口非体外循环冠状动脉旁路移植术创伤小、疗效确切、安全性好,是微创冠状动脉再血管化的重要方向之一.     

Endoscopic computer-enhanced beating heart coronary artery bypass grafting

Background. Telemanipulation systems have enabled coronary revascularization on the arrested heart. The purpose of this study was to develop a technique for computer-enhanced endoscopic coronary artery bypass grafting on the beating heart.

Methods. The operation was performed using the daVinci telemanipulation system. Through three ports, the left internal thoracic artery was harvested in 10 mongrel dogs (30 to 35 kg) using single right-lung ventilation and CO₂ insufflation. Through a fourth port an articulating stabilizer, manipulated from a second surgical console, was inserted to stabilize the heart. The left anterior descending artery was snared using silicone elastomer slings anchored in the stabilizer cleats and the graft to coronary artery anastomosis was performed.

Results. In 7of 10 dogs, total endoscopic beating heart bypass grafting, cardiac stabilization, arteriotomy, and arterial anastomosis were performed using computer-enhanced technology. Endoscopic stabilization and temporary left anterior descending artery occlusion were well tolerated. All grafts were patent although minor strictures were found in 2. In 3 dogs, the procedure could not be completed (1 ventricular arrhythmia, 1 left atrial laceration, and 1 right ventricular outflow tract compression).

Conclusions. Endoscopic beating heart coronary artery bypass grafting is possible in a canine model using a computer-enhanced instrumentation system and articulating stabilization.     

心脏不停跳下行瓣膜置换及冠状动脉旁路移植术

目的 总结心脏不停跳下瓣膜置换及冠状动脉旁路移植术的体会,并评估其疗效.方法 对2005年1月至2007年8月12例同时合并冠状动脉粥样硬化性心脏病和心脏瓣膜病的病人进行手术.病人术前均存在心绞痛症状,心功能为Ⅱ～Ⅳ级,术前射血分数平均0.53±0.23.不停跳下进行冠状动脉旁路移植及瓣膜置换术,比较术前及术后相关心功能指标.结果 病人均痊愈出院.平均移植血管(3.4±1.5)支.复查时所有病人均无症状.心功能及射血分数均显著提高(P<0.001).结论 在心脏不停跳下行瓣膜置换及冠状动脉旁路移植术可行,并发症少.术后早期心功能、自主症状及生活质量均显著改善.远期疗效尚需观察.     

Right heart assist for beating heart coronary artery bypass grafting.

OBJECTIVE: Cardiopulmonary bypass used in conventional coronary artery bypass surgery (cCABG) entails a risk of complications. Consequently, the trend is moving towards off-pump coronary artery bypass (OPCAB). This procedure, however, may lead to haemodynamic instability due to kinking of the right ventricle when the posterior aspect of the heart is exposed. The aim of the study was to establish if a right-sided circulatory assist device (RHA) was able to maintain haemodynamic stability during OPCAB procedures. METHOD: In a prospective study 50 RHA-OPCAB patients and a control group of 50 cCABG patients were examined. Before accessing the marginal arteries, an RHA was established in the RHA-OPCAB patients. RESULTS: A stable haemodynamic condition was achieved for 98% of the RHA-OPCAB patients. The study group had less postoperative chest drain bleeding (P<0.001), shorter ventilation time (P=0.001), and lower blood levels of creatine kinase (CK) and brain CK (P<0.001) compared to the control group. CONCLUSION: The results indicate that RHA-OPCAB is a realistic alternative to cCABG. The procedure can be safely performed most likely resulting in reduced postoperative bleeding, myocardial damage, and ventilation time.     

Redo coronary artery bypass grafting on the beating heart and transfusion needs

AIM: Reoperative coronary artery bypass grafting is associated with significant morbidity and a difficult perioperative management; in particular, important bleeding is observed. Off pump technique may give specific advantages in redo coronary operations since it is associated to decreased interactions of blood with foreign surfaces. We investigated our 5-year database to evaluate the role of off pump technique in reducing transfusion needs. METHODS: The present single centre case control study was carried out in a university tertiary care hospital on 132 consecutive patients undergoing reoperative coronary artery bypass grafting off pump (OP group, 41 patients) or with cardiopulmonary bypass (CPB group, 91 patients). Univariate and multivariate analysis were performed. RESULTS: There was no preoperative difference between the 2 groups; mean number of grafts per patient differed between groups (OP: 1.4+/-0.7, CPB: 2.5+/-1.0). The frequency of patients transfused with blood products was significantly (P=0.004) higher in the CPB group (47.3%) than in the OP group (19.5%). The only independent predictors of transfusions, determined by stepwise multivariate logistic regression analysis, was the use of cardiopulmonary bypass (OR: 4.1, CI: 1.6 - 10.1), and female gender (OR: 7.0, CI: 2.1 - 16.1). CONCLUSION: In our centre, off pump coronary surgery is associated with reduced transfusion of blood products.     

非体外循环下机器人冠状动脉旁路移植手术的麻醉管理

目的 总结非体外循环机器人冠状动脉旁路移植手术中的麻醉技术.方法 2007年1月至2011年3月共完成机器人心脏跳动下冠状动脉旁路移植手术163例,其中62例全机器人冠状动脉旁路移植手术,101例机器人辅助肋间小切口冠状动脉旁路移植手术.麻醉均采用全麻,左侧双腔气管插管.结果 术中单肺通气和CO2气胸引起动脉氧分压(PaO2)和静脉氧饱和度显著降低,163例患者中有17例出现低氧,SpO2降至0.92.使用5～15 cmH2O的持续气道正压后,PaO2从(59±12)mm Hg升至(115±23)mm Hg(P<0.05).CO2气胸开始阶段平均动脉压和心脏指数明显降低,同时伴有平均肺动脉压增高、心率加快,经快速补液和使用血管活性药得以纠正.术后(7.5±3.1)h拔管,ICU停留平均21h.1例因肺部感染在ICU治疗3天;1例行二次手术止血.全部患者术后住院4～7天.结论 非体外循环机器人冠状动脉旁路移植手术中的单肺通气和CO2气胸对患者循环和呼吸功能的影响是麻醉管理的关键.心脏外科医师和麻醉医师要熟练掌握单肺通气和CO2气胸的相关技术知识,恰当处理术中缺氧和血流动力学波动.

Abstract：

Objective Anesthesia for endoscopic robotic coronary artery bypass grafting surgery on beating heart to deal with the hemodynamic compromise, hypoxia and hypercarbia relevant to one lung ventilation ( OLV ) and intrathoracic inflation of CO2 with positive pressure (CO2 pneumothorax) is crucial. Methods Between February 2007 and January 2011, 163 patients underwent robotically assisted coronary artery bypass surgery on beating heart using the da Vinci S Surgical System. Of them, 62 patients underwent totally endoscopic coronary artery bypass grafting ( TECAB). Other 101 patients underwent robotically assisted endoscopic atraumatic coronary artery bypass ( ENDOACAB) in which the left internal mammary artery was harvested robotically and direct anastomosis via a small left anterior thoractomy incision. Results PaO2 and SvO2 after initiate of OLV and CO2 pneumothorax showed a significant decrease. Meanwhile, the SpO2 decreased to 0.92 in 17 of the 163 patients.In these patients, application of CPAP setting 5-15 cmH2O to the collapsed lung resulted in an increase in PaO2 from (59 ±12) mmHg to (115 ±23) mmHg (P < 0.05). At the beginning of CO2 pneumothorax the most dramatic fall in MAP and CI was showed with an increase in MPAP and HR. The hemodynamie compromise was counteracted by transfusion and inotropes/ vasopressors. Postoperatively, the average extubation time was (7. 5 ±3. 1) hours, and median ICU length of stay was 21 hours. One patient remained in the ICU for 3 days for treatment of a postoperative pneumonia. One patient who had underwent ENDOACAB were reexplored for bleeding in the left anterior thoracotomy incision. All patients were discharged home 4 to 7 days after surgery. Conclusion Anesthetic management for the procedures requires detailed knowledge of OLV and CO2 pneumothorax in addition to expertise required in conventional cardiac surgery.     

Experience of coronary artery bypass grafting on the beating heart with right heart bypass; 3 cases of octogenarian

Right heart bypass (RHB) yields more stable hemodynamics by increasing left ventricular preload and collapse right ventricular chamber during the displacement of the heart on beating heart coronary artery bypass grafting (CABG). Recently beating heart CABG gaining popularity, and the indications for CABG have increasingly expanded to elderly person. Using RHB while exposing posterior branches by displacing the beating heart, we have attempted to make total revascularization in beating heart CABG. We performed beating heart CABG with RHB in 3 cases of octogenarian. All patients had left main trunk lesion and needed revascularization of posterior vessels. Introduction of RHB enabled us to approach to posterior target vessels in better exposure and under greater hemodynamic stability. All three patients had no complications postoperatively. Strictly speaking CABG with RHB is not off-pump CABG, but RHB system does not include either artificial lung or manipulation of the aorta. Therefore we think it is very effective support system which enables multiple coronary revascularization for elderly person.     

Coronary artery bypass grafting in adults with congenital heart disease

Abstract Background: Adults with congenital heart disease (CHD) and coronary artery disease (CAD) have unique clinical manifestation due to the coexistence of intracardiac anomalies and CAD. Case reports are rare in surgical management of CHD combined with CAD. Our goal is to study the outcome of surgical intervention of CHD and CAD concomitantly. Methods: From February 2002 to August 2009, 29 adult patients underwent coronary artery bypass grafting (CABG) and surgical correction of CHD concomitantly. Congenital cardiac anomalies include atrial septal defect (ASD) in 21 cases, ventricular septal defect in four cases, atrioventricular septal defect in three cases, and cor triatriatum in one case. Coronary angiography demonstrated: one‐vessel disease in 10 cases, two‐vessel disease in 11 cases, and three‐vessel disease in eight cases. Coronary revascularization and intracardiac anomalies were corrected with cardiopulmonary bypass in 23 cases. There were six patients who had off‐pump coronary artery pass grafting (OPCAB) and intraoperative device closure of ASD. Results: One patient died of pulmonary infection and multiorgan failure. Follow‐up time was from 2 to 89 months (mean, 42 ± 25 months). One patient with recurrent angina did not need intervention of the revascularization. Six patients who acquired OPCAB and intraoperative device closure of ASD had no complications after surgery. Conclusions: Surgery for adult patients who had CHD with CAD was a safe and effective management. OPCAB with intraoperative device closure of ASD was a reasonable approach for some selective patients. (J Card Surg 2010;25:629‐632)     

Coronary artery bypass grafting

Objectives: The aim of this study was to analyze the long-term results of coronary artery bypass grafting in Japanese patients who were followed more than 10 years after surgery, and, without resorting to actuarial methods, to determine the factors that influence long-term survival.Subjects and Methods: From January 1984 through December 1986, 376 patients received coronary artery bypass grafting at the Department of Cardiothoracic Surgery of Juntendo University; it is these patients who comprise the subject of this study. Of the 376 patients, 328 were males (87.2%) and the mean patient age was 58.5 years (range: 32 to 78 years). Single vessel disease was present in 36 patients (10.8%), double vessel disease in 89 patients (26.7%), triple vessel disease in 150 patients (45.0%) and 58 patients (17.4%) with 50% of more stenosis of the left main coronary artery. The mean number of grafts used was 2.3 grafts per patient, while internal thoracic artery conduits were used in 66 patients (17.6%).Results: The 10-year survival rate for the entire series of patients was 81.4%. Patients receiving internal thoraci? artery grafts had a 10-year survival rate of 94.0%, superior to the 78.0% rate found in patients who received only saphenous vein grafts. Other risk factors associated with reduced survival rates, besides non-use of internal thoracic artery, were: advanced age, diabetes mellitus, hypertension, presence of left main coronary artery disease, and severely impaired left ventricular function. The 10-year cardiac event free rate in the total group was 80.4%. Of 70 patients who died during the follow-up period, 19 deaths were due to cardiac causes (27.1%), 19 due to malignant neoplasm (27.1%) and 13 due to cerebral vascular accident (18.6%).Conclusions: Univariate analysis revealed that: the use of only saphenous vein grafts (P=0.0055), advanced age (P<0.0001), diabetes mellitus (P<0.0001), hypertension (P=0.0282), presence of left main coronary artery disease (P=0.0140), and severely impaired left ventricular function (P=0.0075) are associated with reduced survival in patients undergoing coronary artery bypass grafting in this cohort of patients.     

Coronary artery bypass grafting after orthotopic heart transplantation.

OBJECTIVE: Graft coronary disease (GCD) remains the major determinant of long-term survival after heart transplantation. Therapeutic strategies for the prevention or retardation of GCD in the cardiac allograft are limited, and palliative surgical coronary revascularization has been attempted. The aim of this report was to retrospectively analyze our results of coronary artery bypass grafting after cardiac transplantation. This paper correlates the outcome of patients with the pathohistological and angiographic type of lesion in order to identify transplant recipients who may profit from surgical myocardial revascularization. METHODS: Seven patients with a mean age of 55 years (range 45-61 years) underwent coronary artery bypass grafting as a result of GCD at a mean of 67 months (range 6-128 months) after cardiac transplantation. By the inclusion of the clinical history and the angiographic pattern of GCD lesions, the primary indications for surgical revascularization, operative results, pathohistological studies and follow-ups were examined. RESULTS: Elective surgery was performed in two patients with proximal, severe triple vessel disease (Type A lesion) and in one patient in whom the primary reason for cardiac surgery was severe tricuspid regurgitation. This patient electively received a tricuspid valve replacement and concomitant single vessel bypass surgery for proximal GCD (Type A lesion). Emergency surgery was performed in four patients: preoperatively three patients post-infarction developed worsening congestive heart failure, which resulted in low cardiac output syndrome. One patient with combined Types A and B/C lesions required emergency surgery for dissection of the right coronary artery (RCA) after an angioplasty procedure. Angiographically all these patients showed diffuse, distal arteriopathy (combined Type B/C lesions). The electively operated patients (n = 3) and the patient with dissection of the RCA (n = 1) had successful operations and survived beyond hospital discharge (overall survival for coronary artery bypass graft (CABG) in GCD patients 4 out of 7; 57%). All three patients with distal arteriopathy, who underwent emergency surgery, died in hospital from left ventricular failure (43%). The four patients discharged from hospital with a mean follow-up of 10 months (range 2-32 months) are all in good clinical condition. CONCLUSIONS: Coronary artery bypass grafting can be successfully performed in a subgroup of cardiac transplant patients with Type A lesions. However, the state of diffusely diseased distal arteries (Type B/C lesions), which is prevalent in this group of patients, limits the use of bypass surgery.     

Coronary artery bypass grafting with the right gastroepiploic artery

The excellent results of coronary artery bypass with the internal mammary artery and the increasing numbers of patients who need coronary reoperations, but for whom conventional bypass conduits are not available, have prompted us to evaluate alternative arterial bypass conduits. The right gastroepiploic artery has been used as a coronary bypass graft in 36 patients (32 men), whose ages ranged from 29 to 71 years. Twenty-two patients had had previous coronary bypass grafting and six of these were undergoing their third bypass operation. The right gastroepiploic artery was used as an in situ graft to the right coronary artery or circumflex branches for 17 patients and as an aorta-coronary ("free") graft in 19 patients, six to the left anterior descending or diagonal, six to the circumflex, and seven to the right coronary artery. In conjunction with right gastroepiploic artery grafting, 16 patients received bilateral internal mammary artery grafts and 17 received one internal mammary artery graft. Histologically, right gastroepiploic artery segments from 18 patients could not be distinguished from internal mammary artery segments, and no evidence of atherosclerosis was found. Two patients died in the hospital, one intraoperatively and one 3 months after the operation, of a perioperative stroke. Perioperative morbidity included wound complication in three and reexploration for bleeding in two. At late follow-up 1 to 38 months after operation, two late deaths had occurred and 21 patients were free of symptoms. Postoperative angiography (postoperative interval 1 week to 13 months) was performed in nine grafts, three in situ grafts to the right coronary artery and six free grafts that included two to the left anterior descending, three to the circumflex, and one to the right coronary artery. All right gastroepiploic artery grafts were patient. The right gastroepiploic artery is an arterial conduit that can be used as an in situ graft to posterior coronary vessels and as a free graft to any coronary arterial system. Early graft patency has been excellent, and the histologic similarity between the right gastroepiploic artery and the internal mammary artery suggest that the long-term results will be favorable.     

Coronary artery bypass grafting for ischemic heart disease combined with aortitis

Coronary artery bypass grafting (CABG) was performed in a 67-year-old woman with aortitis. She had a past history of right radical mastectomy. Preoperative coronary angiogram showed diffuse stenotic lesions in both right and left coronary arteries. The pressure gradient between ascending aorta and peripheral radial artery was 90 mmHg and the cause of coronary stenosis seemed to be hypertension due to stenotic distal aorta. The aortogram showed occluded bilateral internal thoracic arteries (ITA) and stenotic abdominal aorta. The cephalic artery was supplied by a large meandering artery via dilated gastroepiploic artery (GEA). And thus the GEA was not useful for CABG. Quadruple CABG was performed with mild varicose saphenous vein (saphenous vein grafts to left anterior descending artery and third branch, and sequential saphenous vein graft to right posterior descending and atrioventricular branches). It seemed to be important to demonstrate the arterial lesion of ITA and GEA before CABG in patients with aortitis.     

Standard coronary artery bypass grafting and beating heart bypass. Indications and long-term results.

OBJECTIVES AND METHOD: We have performed 225 cases of coronary artery bypass grafting (CABG), between October 15 1995 and September 8 1999. We have evaluated the operative results of 121 cases (53.8%) of conventional CABG and 104 cases (46.2%) of minimally invasive coronary artery bypass grafting performed during this period. The average numbers of bypassed grafts was 3.45 for conventional CABG, and 1.41 for minimally invasive coronary artery bypass grafting. Sixty-seven right internal thoracic arteries, 145 left internal thoracic arteries, 71 gastroepiploic arteries, 38 radial arteries and 12 saphenous veins were used for conventional CABG, and 29 right internal thoracic arteries, 81 left internal thoracic arteries, 18 gastroepiploic arteries, 3 radial arteries, 10 saphenous veins and 2 inferior epigastric arteries were used for minimally invasive coronary artery bypass grafting. The total number of 303 grafts were anastomosed to 417 coronary arteries for conventional CABG, and 143 grafts were anastomosed to 147 coronary arteries for minimally invasive coronary artery bypass grafting. RESULTS: Although two saphenous veins were occluded, the early postoperative patency rate was 100% for conventional CABG using right internal thoracic arteries, left internal thoracic arteries, gastroepiploic arteries and radial arteries. Three site of stenosis in 18 left internal thoracic arteries and 2 in 16 right internal thoracic arteries were recognized in minimally invasive coronary artery bypass grafting without the use of stabilizers. One site of stenosis in 63 left internal thoracic arteries was recognized in minimally invasive coronary artery bypass grafting with the use of stabilizers. CONCLUSION: The use of stabilizers enables adaptation of the minimally invasive coronary artery bypass grafting procedure to a wider range of coronary artery bypass procedures, and a higher graft patency can be expected.