Minimally invasive direct coronary artery bypass grafting for third-time coronary artery revascularization.

We performed a minimally invasive direct coronary artery bypass (MIDCAB) on two patients for third-time revascularization. The first patient was a 66-year-old woman who had patent bilateral internal thoracic artery (ITA) grafts and an occluded radial artery (RA) graft anastomosed to the posterolateral (PL) branch. She underwent her third revascularization for left circumflex coronary artery reconstruction with the MIDCAB technique using the right gastroepiploic artery. The second patient was a 65-year-old man who had occluded saphenous vein grafts (SVGs) on the anterior aspect of the heart, a stenotic left ITA graft to the left anterior descending artery, and a stenotic SVG to the PL branch. He underwent his third revascularization by MIDCAB using a bilateral RA-Y graft. Postoperative angiography of the two cases showed that the new grafts were widely patent.     

Triple coronary artery revascularization on the stabilized beating heart: initial experience

Objective

To decrease health costs and morbidity related to extracorporeal circulation, surgeons have modified the coronary artery bypass (CAB) technique so that it can be completed without the use of extra-corporeal circulation. This study summarizes initial experience with direct coronary artery revascularization on the beating heart using a coronary stabilizer.

Design

A case series.

Setting

The Montreal Heart Institute, a university-affiliated centre, specializing in the treatment of cardiac illnesses.

Patients

Ten patients underwent CAB by this technique. They presented with double or triple coronary artery disease with no intramyocardial, heavily calcified, diffused atheromatous coronary vessels, or left main coronary disease.

Intervention

CAB grafting in the beating heart. The anterior wall was grafted in all patients, the inferior wall in 7 and the posterior wall in 7.

Main outcome measures

Patient survival and graft patency.

Results

One patient died of multiple organ failure not related to the grafting technique itself, and 1 patient suffered a non-Q myocardial infarction. Early coronary angiography performed on 8 patients showed 100% graft patency, most with excellent distal runoff (21/22 grafts).

Conclusion

In patients with adequate anatomy, performance of CAB without extracorporeal circulation can achieve excellent early results provided there is appropriate mechanical stabilization of the beating heart.     

机器人非体外循环冠状动脉旁路移植术

目的 总结使用da Vinci S机器人系统完成的微创机器人非体外循环冠状动脉旁路移植术(CABG)的技术特点和临床效果.方法 2007年4月至2008年12月,共有56例患者接受微创机器人非体外循环CABG.所有患者术前均有心绞痛症状,冠状动脉造影显示严重的前降支病变,10例患者合并有回旋支或右冠状动脉病变.其中25例患者有心肌梗死病史.心功能(NYHA分级)Ⅱ级45例,Ⅲ级11例,平均射血分数为57%±11%.所有患者肺功能良好,无胸膜炎和左侧胸腔手术史.术前常规行64排CT检查双侧胸廓内动脉(ITA)的解剖情况.共采用三种术式:(1)机器人单侧或双侧ITA游离并同期小切口非体外循环CABG;(2)全机器人非体外循环CABG;(3)对合并有回旋支或右冠状动脉局限性狭窄的患者,接受上述两种术式的一种后行分站式支架置入杂交术.行单支或多支CABG时于左侧胸壁第4肋间做长6 cm的小切121,直视、心脏跳动下行ITA和前降支的吻合;行全机器人非体外循环CABG时无需胸壁切口.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 所有患者成功接受了上述手术.术中平均ITA桥血流量为(23.2±16.7)mL/min,无中转开放手术和手术死亡.ITA移植到前降支53例,双支桥3例,其中10例患者旁路移植后接受了回旋支或右冠状动脉的支架植入杂交术.术后复查未见桥血管狭窄或闭塞.结论 微创机器人非体外循环CABG手术效果确实、可靠,不破坏胸腔骨性结构、创伤小,是微创CABG的发展方向之一.     

Spontaneous coronary artery dissection: value of beating heart myocardial revascularization

Spontaneous coronary artery dissection is a rare and generally fatal disease. It usually occurs in women during the post-partum period or women taking oral contraceptives. Treatment depends on the clinical presentation and the results of coronary angiography. Beating heart myocardial revascularization is particularly useful in this case, as it allows coronary artery bypass graft to be performed without manipulating the ascending aorta, thereby minimizing the risk of post-CPB aortic dissection, and without important modification of arterial pressure.     

Myocardial revascularization in the elderly using beating heart coronary artery bypass surgery

BACKGROUND: Beating heart or "off-pump" coronary artery bypass (OP-CAB) has become an accepted method of myocardial revascularization by reducing the perioperative morbidity related to cardiopulmonary bypass (CPB). However, the efficacy of OP-CAB has not been well established in the elderly patient population. METHODS: OP-CABs were performed in 53 patients aged 75 years and older, at Pitt County Memorial Hospital from January 1996 to October 1999, either through a median sternotomy or an anterior thoracotomy. These results were compared with 220 patients who underwent standard coronary artery bypass graft (CABG) operation using CPB during the same time period. RESULTS: Mean patient age for both groups was 79+/-0.5 years and preoperative risk factors were similar. There were no differences in postoperative myocardial infarction, atrial fibrillation, bleeding, neurologic complications, or renal failure. There were no deaths after OP-CAB, compared with the 7.6% operative mortality rate after CABG (p<0.05). The OP-CAB group had a significantly shorter postoperative length of stay (4.4+/-0.4 days vs. 8.4+/-0.6 days) and lower transfusion requirements (0.4+/-0.1 units packed red blood cells vs 1.9+/-0.2 units packed red blood cells) than the CABG group. CONCLUSIONS: Our data demonstrate that OP-CAB is a safe and efficacious method of myocardial revascularization in the elderly, and may actually be preferential in these patients when applicable.     

Minimally invasive coronary artery revascularization: off-pump bypass grafting and the hybrid procedure

Background. Coronary artery bypass grafting without cardiopulmonary bypass (off-pump-CAB; OPCAB) as a minimally invasive procedure has been used increasingly to treat coronary artery disease. The procedure makes multivessel revascularization possible, with new instruments and techniques, and hybrid therapy (combination of angioplasty and OPCAB) can be a new method of treating coronary disease. We present our experience using OPCAB and our strategy for coronary revascularization.

Methods. Of 216 patients treated with OPCAB, the lesion was single in 100 and multivessel in 116. Preoperative risks that could increase the mortality and morbidity rates were present in 127 patients, excluding 55 who were 75 years old or older.

Results. There were four hospital deaths, three of which were noncardiac, and five operative morbidities: transient cerebral ischemia in 3, perioperative myocardial infarction in 1, and congestive heart failure in 1. A postoperative angiogram was done in 157 patients (220 grafts), and with heart stabilization the patency rate without stenosis improved to 93.6%. For 116 patients with multivessel disease, technically complete revascularization was done in 84%, either with multivessel revascularization in 61 patients or the hybrid procedure in 37 patients. Among 20 patients with left main trunk lesion, five had the hybrid procedure. Angina recurred in 3, including 1 who died suddenly of infarction. The angiogram at recurrence showed restenosis of left main lesion and occlusion of the graft to the left anterior descending artery. Postoperative follow-up for 2 years showed 12 patients with recurrent angina and five late deaths from noncardiac-related events.

Conclusions. The heart stabilizer and new techniques for coronary revascularization with a beating heart have improved the anastomotic quality of grafts. The hybrid procedures were effective in selected patients but were considered contraindicated in patients with left main trunk lesion. OPCAB was safe, effective, and suitable especially in patients with high risks for coronary artery bypass grafting.     

Minimally invasive coronary artery bypass grafting

Minimally invasive cardiac surgery (MICS)-CABG is a technique that at its core has patient comfort, early return to routine activities, meeting patient expectations for less invasive options, and maintaining the highest possible standards of care and outcomes. The technique requires not only surgical dexterity but also integration of significant technological advancements in patient care. At a time when percutaneous interventions are often prescribed on the pretext of increased patient comfort and demand, minimally invasive myocardial revascularization becomes even more relevant. Minimally invasive myocardial revascularization is ever evolving and encompasses both small-incision open techniques as well as endoscopic-assisted procedures. The success of the procedure depends not only on the learning curve and familiarity with the technology but also on appropriate patient selection. Mere feasibility of the technique is not sufficient, and the results have to be comparable with the long-established techniques of conventional coronary artery bypass grafting both in terms of early morbidity and mortality as well as long-term outcomes. In this review, we discuss patient selection and technical aspects of minimally invasive coronary artery bypass grafting. We also provide an evidence-based comparison to early and long-term outcomes with conventional coronary artery bypass grafting. Finally, we review the uptake and outcomes of minimally invasive revascularization in the Indian subcontinent.     

Minimally invasive coronary artery bypass surgery

From 19.06.97 to 06.01.2000 36 patients with coronary heart disease underwent direct myocardium revascularization surgery by minimally invasive method (through minithoracotomy, off-pump and on the beating heart), anastomosis between left internal mammaria artery and anterior descending artery (ADA). The majority of the patients (55.6%) had one-vessel damage of ADA coronary bed, in the patients with damage of two and more vessels full revascularization of coronary bed was achieved by two coronary arteries bypass at once or by combination of minimally invasive coronary bypass (MICB) with PTCA. MICB is performed in specially selected patients according to stuct indications. Technique of operation, early postoperative course, possibilities of combination of MICB with other methods of treatment is described. Potential of MICB is discussed.     

Minimally invasive coronary artery bypass grafting

Limited access, off-pump coronary artery bypass grafting for revascularization of all the various coronary arteries is an acceptable alternative to standard on-pump coronary bypass grafting through sternotomy. A variety of small, targeted incisions are used to approach various coronary locations. Technical advances in conduit harvesting, stabilization, cardiac positioning devices, and anastomotic connectors have made these procedures more standardized and replicable. This has resulted in reduced morbidity as a consequence of less invasive approaches. These efforts have paved the way for the ultimate goal of same day surgical coronary revascularization.     

Closed chest coronary artery bypass on the beating heart

Minimally invasive surgical procedures have become a part of routine cardiac surgery. The surgical techniques have been developed for the treatment of coronary artery disease in order to minimize surgical trauma. With the introduction of a 3-D-based totally endoscopically functioning system into minimally invasive cardiac (MIC) surgery, further reduction of skin incisions became possible and enhanced MIC techniques could be improved. Due to the 6 degrees freedom of motion allowed by wrist-enhanced instruments and a newly developed endoscopic stabilizer, totally endoscopic coronary artery bypass procedures on a beating heart became feasible. We present here our initial series of totally endoscopic "off-pump" coronary artery bypass grafting in patients suffering from coronary artery single vessel disease. In all patients, the procedure was successfully performed via four 1 cm chest incisions as closed-chest procedures.     

Left main coronary artery stenosis and revascularization in the beating heart. Short- and long-term experience

OBJECT: To determine the safety of surgical revascularization without cardiopulmonary bypass in left main coronary artery stenosis. METHODS: Between October 1996 and October 1998, 67 patients with a left main stem stenosis (LMS) (> 50%) underwent revascularization on beating heart surgery (BHS) and were compared to a cohort of 192 patients with LMS disease that were operated on under cardiopulmonary bypass (CPB) during 1996. RESULTS: Mean age and sex distribution and prevalence of preoperative risk factors were the same in both groups as well as the average number of grafts per patient was 3.1 +/- 0.7 and 2.9 +/- 0.7 in BHS and CPB groups respectively. Perioperative infarction rate (defined arbitrarily as a CK-MB > 100 IUL) was 2.9% in BHS group and 3.1% in CPB group. Postoperative blood transfusion requirements were less in BHS group (38%) compared to CPB group (64%), p < 0.05. Inotropic requirements postoperatively were similar in both groups. Hospital stay was shorter in BHS group (6.8 days) compared to CPB group (7.6 days) although not significant. There was no operative mortality in BHS group whereas 4.7% died postoperatively in CPB group. CONCLUSION: Our experience suggests that non-bypass surgical revascularization is a feasible and safe alternative to conventional cardiopulmonary bypass.     

Complete myocardial revascularization on the beating heart

BACKGROUND: Complete myocardial revascularization with excellent visualization, exposure, and stabilization can be accomplished on the beating heart without cardiopulmonary bypass (CPB). METHODS: Three hundred patients were totally revascularized via median sternotomy with myocardial stabilization using the CardioThoracic System. All patients who underwent coronary artery bypass grafting were considered for the off-pump procedure. Pericardial sutures were placed at the level of the left atrial appendage and were pulled upwards to the right. The stabilizer was applied sequentially from circumflex, obtuse marginal, intermediate, diagonal, left anterior descending, and right coronary artery. Coronaries were occluded using the Calafiore technique, and multiple arterial grafts were inserted. RESULTS: The average number of grafts was 3.4 per patient. Six percent had to be converted to standard CPB. Comorbidity was not a limiting factor with 8% redos, 48% having diabetes, and acute myocardial infarctions in 28%. The unadjusted mortality was 2.3%, and stroke rate was 0.7%. CONCLUSIONS: These results indicate that complete revascularization can safely be accomplished without CPB.     

Minimally invasive transapical beating heart aortic valve implantation--proof of concept.

OBJECTIVE: To evaluate the feasibility of minimally invasive transapical beating heart aortic valve implantation (TAP-AVI) for high-risk patients with aortic stenosis. METHODS: TAP-AVI was performed via a small anterolateral minithoracotomy with or without femoral extracorporeal circulation (ECC) on the beating heart. A pericardial xenograft fixed within a stainless steel, balloon expandable stent (Cribier-Edwards, Edwards Lifesciences, Irvine, CA, USA) was used. Thirty consecutive patients (82 +/- 5.1 years, 21 (70%) female) were operated from 02/06 until 09/06 at one center using fluoroscopic and echocardiographic visualization. Average EuroSCORE predicted risk for mortality was 27 +/- 12%. RESULTS: Valve positioning was successful in 29 patients and one required early conversion to full sternotomy. Implantation (8 mm x 23 mm and 22 mm x 26 mm valves) was performed on the beating heart during brief periods of rapid ventricular pacing. ECC was applied in 13 patients. Neither coronary artery obstruction nor migration of the prosthesis was observed and all valves displayed good hemodynamic function. Echocardiography revealed minor paravalvular leakage in 14 patients (trace in three, mild in nine and moderate in two). Three patients (10%) died, one on postoperative day (POD) three secondary to preoperative global myocardial failure and two on POD 18 and 86 due to abdominal complications. CONCLUSIONS: Minimally invasive beating heart TAP-AVI is feasible. Initial results are encouraging in view of the high-risk profile of the patients. Long-term studies as well as randomized protocols are required.     

Spontaneous coronary artery rupture treated on a beating heart

Primary spontaneous coronary artery rupture (SCAR) without any underlying condition is a rare disorder. The acute and often dramatic nature of hemopericardium with cardiac tamponade advocates immediate pericardial drainage or surgical intervention with timely recognition of coronary artery rupture. This is the first case report of primary SCAR successfully treated on a beating heart without cardiopulmonary bypass.     

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.