Minimally invasive single-vessel coronary artery bypass with the internal thoracic artery and early postoperative angiography: midterm results of a prospective study in 120 consecutive patients

doi:10.1016/S0003-4975(01)03360-4

The Annals of Thoracic Surgery

Volume 73, Issue 2, February 2002, Pages 505-510

https://doi.org/10.1016/S0003-4975(01)03360-4 Get rights and content

Abstract

Background. This prospective study was undertaken to determine the role of the minimally invasive direct coronary artery bypass with early postoperative angiography and midterm follow-up in 120 consecutive patients with single-vessel coronary artery disease.

Methods. Minimal access (6 to 10 cm), without complete sternotomy and no cardiopulmonary bypass, was used. The lesions were located at the proximal left anterior descending coronary artery in 95% of the patients. Routine coronary angiography was performed before discharge.

Results. Postoperative angiography was performed in 104 (90.4%) of those 115 patients who had coronary revascularization concluded by the mini-access method. The internal thoracic artery patency rate was 98.1% (95.2% grade A). Two (1.7%) patients presented with perioperative myocardial infarction, which led to the single in-hospital death (0.8%). Of the remaining 119 patients, 113 (95.0%) were asymptomatic. The event-free probability was 94.9% and the actuarial survival was 98.3% with 42 months of follow-up.

Conclusions. For selected patients with single-vessel coronary artery disease and no major myocardial dysfunction, minimally invasive direct coronary artery bypass is a safe operation and a less invasive alternative to conventional coronary artery bypass grafting.

Section snippets

Patients and methods

This study was approved by the University of São Paulo School of Medicine Scientific and Ethics Committee. All patients gave informed consent to undergo MIDCAB and early routine postoperative angiography. From November 1995 to December 1998, 120 consecutive patients with single-vessel coronary artery disease with normal ventricular function or mild dysfunction (ejection fraction between 0.35 and 0.55) were prospectively selected to undergo MIDCAB. All patients presented symptomatic

Results

In 115 (95.8%) patients, the operation was conducted with the minimal access approach on a beating heart; in 5 patients (4.2%) the MIDCAB was converted to a median sternotomy. In 4 of these patients, the conversion resulted from an insufficient length of the ITA or different coronary artery anatomy, including intramyocardial artery or a lateralized coronary artery. One patient had urgent conversion because of a small right ventricular rupture, during the LAD snare. All 5 patients had uneventful

Comment

We performed MIDCAB using ITA in 120 consecutive patients with symptomatic, isolated stenosis in the LAD or RCA and no major ventricular dysfunction. Our results support the concept that MIDCAB is a safe operation, and could be an alternative to conventional CABG, with similar graft patency and midterm results.

Concerns regarding anastomosis accuracy after MIDCAB led some surgeons, including us, to routinely evaluate, with angiography, ITA patency and the aspect of coronary artery anastomosis.

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Long-Term Results of the Endoscopic Atraumatic Coronary Artery Bypass
2007, Annals of Thoracic Surgery
This retrospective study was undertaken to determine the long-term angiographic patency and clinical outcomes of the endoscopic atraumatic coronary artery bypass (endoACAB) procedure.
Between November 1997 and March 2005, 607 consecutive patients underwent an endoACAB consisting of (1) unilateral or bilateral manual, thoracoscopic internal mammary artery (IMA) harvesting, (2) creation of a needle-directed access port in the thoracic soft tissue (non-rib-spreading), (3) cardiac positioning and stabilization using port-based instrumentation, and (4) off-pump, direct-vision, hand-sewn anastomoses to the left anterior descending (LAD), diagonal, obtuse marginal, or main right coronary arteries, or a combination. Mean follow-up time was 18.0 ± 16.0 months (range, 2.0 to 85.7 months).
The IMA was used to graft the LAD in all cases. A total of 721 anastomoses were constructed using 636 conduits. Thirty-day mortality was 1.0% (6/607). A total of 379 (62.4%) had coronary angiography after operation at a mean of 18.4 ± 17.0 months. The overall patency for the LIMA to LAD was FitzGibbon A, 95.2% (324/340), and FitzGibbon A and B, 98.5% (335/340). At 5 years, event-free survival was 92% ± 2.4%.
The clinical outcome and angiographic patency of grafting the LAD with the LIMA off pump through a non-rib-spreading incision compares favorably with the reported data of arrested heart grafting through a median sternotomy. The endoACAB offers an excellent alternative for patients with LAD disease as a stand-alone procedure, a multivessel grafting procedure in selected patients, or as part of a hybrid procedure in conjunction with a percutaneous intervention.
Revascularization of Left Anterior Descending Artery With Drug-Eluting Stents: Comparison With Minimally Invasive Direct Coronary Artery Bypass Surgery
2006, Annals of Thoracic Surgery
Citation Excerpt :
The MIDCAB technique enables surgical revascularization of the LAD through a small left anterior thoracotomy [13]. The reported patency rate of the anastomosis from the left internal mammary artery to the LAD is more than 90% and is not significantly different than that reported for surgical revascularization incorporating midsternotomy [14–17]. This procedure has a relatively low rate of complications and restenosis.
The proximal left anterior descending artery (LAD) is a challenging area for percutaneous interventions; therefore, coronary artery bypass grafting is often considered and sometimes performed even in patients with single-vessel disease involving the proximal LAD. This study compares mid-term results of LAD revascularization using drug-eluting stents (Cypher) with minimally invasive direct coronary artery bypass grafting (MIDCAB).
From May 2002 to December 2003, 376 consecutive patients underwent myocardial revascularization of the LAD, 272 by Cypher and 104 by MIDCAB. After matching for age, sex, and extent of coronary artery disease, two groups of 83 patients each were used to compare the two revascularization modalities. The groups were similar; however, ejection fraction of less than 0.35 was more prevalent in the MIDCAB group and prior percutaneous coronary intervention in the Cypher group.
Thirty-day mortality was 1.1% in the MIDCAB and 0% in the Cypher group. Mean follow-up was 22.5 months. Two late cardiac deaths occurred in the MIDCAB group and one in the Cypher group (p = NS). Angina returned in 35% of the Cypher group and in 8.4% of the MIDCAB group (p < 0.001). There were 14 (16.8%) reinterventions in the Cypher compared with three (3.6%) in the surgical group (p = 0.005). Cox proportional hazard model showed that assignment to the Cypher group was the only independent predictor of reangina (hazard ratio [HR], 6.17, 95% confidence interval [CI], 2.46 to 15.4). Treatment with Cypher was also an independent predictor of reintervention (HR 8.26, 95% CI, 1.68 to 40).
Despite improved results of percutaneous interventions with Cypher to the LAD, mid-term clinical outcome of patients treated with MIDCAB was better.
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Original article: cardiovascularMinimally invasive single-vessel coronary artery bypass with the internal thoracic artery and early postoperative angiography: midterm results of a prospective study in 120 consecutive patients

Abstract

Section snippets

Patients and methods

Results

Comment

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Original article: cardiovascular
Minimally invasive single-vessel coronary artery bypass with the internal thoracic artery and early postoperative angiography: midterm results of a prospective study in 120 consecutive patients