Minimally invasive direct coronary bypass surgery via distal mini-sternotomy

Promising clinical results with anaortic, multivessel, all-arterial technique

Minimalinvasive direkte koronare Bypass-Operation über eine distale Ministernotomie

Vielversprechende klinische Ergebnisse mit anaortaler komplett arterieller Mehrgefäßtechnik

Herz volume 44, pages666–672(2019)Cite this article

Abstract

Background

Minimally invasive direct coronary artery bypass grafting (MIDCAB) was developed to decrease perioperative morbidity, some of which may be related to the use of cardiopulmonary bypass and to cross-clamping of the aorta. We report our initial experience with multivessel MIDCAB via distal mini-sternotomy (DIMS). DIMS is performed to gain access to the left and right internal thoracic arteries and to reach the left anterior descending coronary artery (LAD), diagonal branches, and right coronary artery (RCA).

Methods

Between January 2016 and January 2017, 12 patients with significant coronary artery disease of the LAD and the RCA underwent multivessel, all-arterial MIDCAB through a distal midline skin incision from the fourth intercostal space to the xyphoid process, with L‑ or T‑shaped division of the sternum. The mean age of the patients was 61.5 ± 5.2 years (range: 52–71 years).

Results

We performed all-arterial revascularization using the left internal mammary artery in 12 patients, the radial artery in ten, and the right internal mammary artery in two patients. The mean number of grafts per patient was 2.08 ± 0.4 (range: 2–3). The mean length of the skin incision was 8.5 ± 1.3 cm (range: 7–11 cm). There was no perioperative ischemia, postoperative bleeding, or arrhythmia events. No postoperative cognitive dysfunction occurred. The mean hospital stay was 5.6 days. No major adverse cardiac events (MACE) occurred at the 12-month follow-up. At follow-up, all patients were in New York Heart Association class I and there were no wound complications.

Conclusion

Although MIDCAB-DIMS is technically more demanding than conventional procedures and our experience is limited, we conclude that this technique can be used safely in selected patients, with promising 12-month follow-up results.

Zusammenfassung

Hintergrund

Die minimalinvasive direkte Koronararterien-Bypass-Operation („minimally invasive direct coronary artery bypass grafting“, MIDCAB) wurde entwickelt, um die perioperative Morbidität zu senken, denn diese ist möglicherweise z. T. durch die Verwendung der Herz-Lungen-Maschine und das Abklemmen der Aorta bedingt. Die Autoren stellen ihre initialen Erfahrungen mit der Mehrgefäß-MIDCAB über eine distale Ministernotomie (DIMS) dar. Die DIMS erfolgt, um Zugang zur linken und rechten A. thoracica interna zu erhalten und den Ramus interventricularis anterior („left anterior descending coronary artery“, LAD), Diagonaläste sowie die rechte Koronararterie („right coronary artery“, RCA) zu erreichen.

Methoden

Zwischen Januar 2016 und Januar 2017 wurde bei 12 Patienten mit signifikanter koronarer Herzkrankheit (KHK) der LAD und der RCA eine komplett arterielle Mehrgefäß-MIDCAB über eine Hautinzision in der distalen Mittellinie vom 4. Interkostalraum bis zum Processus xiphoideus mit L‑ oder T‑förmiger Durchtrennung des Sternums durchgeführt. Das Durchschnittsalter der Patienten lag bei 61,5 ± 5,2 Jahren (Spanne: 52–71 Jahre).

Ergebnisse

Die Autoren führten die komplett arterielle Revaskularisierung bei 12 Patienten unter Verwendung der linken A. mammaria interna durch, bei 10 mit der A. radialis und bei 2 Patienten mit der rechten A. mammaria interna. Durchschnittlich erhielt ein Patient 2,08 ± 0,4 Transplantate (Spanne: 2–3). Die mittlere Länge der Hautinzision betrug 8,5 ± 1,3 cm (Spanne: 7–11 cm). Es gab weder Fälle mit perioperativer Ischämie noch postoperativer Blutung oder Arrhythmien. Eine postoperative kognitive Funktionsstörung trat nicht auf. Die mittlere Verweildauer im Krankenhaus betrug 5,6 Tage. Bis zum 12-Monats-Follow-up traten keine schweren unerwünschten kardialen Ereignisse auf („major adverse cardiac events“, MACE). Bei der Nachuntersuchung waren alle Patienten in Klasse I gemäß New York Heart Association, Wundkomplikationen lagen nicht vor.

Schlussfolgerung

Die MIDCAB-DIMS ist zwar technisch anspruchsvoller als konventionelle OP-Verfahren und die Erfahrung der Autoren begrenzt, doch schlussfolgern die Verfasser, dass diese Technik sicher und mit vielversprechenden 12-Monats-Follow-up-Ergebnissen bei ausgewählten Patienten eingesetzt werden kann.

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Affiliations

  1. Department of Cardiovascular Surgery, Philipps University of Marburg, Baldinger Straße 6, 35043, Marburg, Germany

    I. Martinovic MD, PhD & M. Irqsusi MD

  2. Department of Cardiology, Helios Hospital, Warburg, Germany

    S. Lindemann MD, PhD

  3. Department of Internal Medicine, “J.J. Strossmeyer” University Osijek, Osijek, Croatia

    I. Martinovic MD, PhD, J. Mirat MD, PhD & A. Vcev MD, PhD

  4. Department of Cardiology, Asklepios Hospital Goslar, Goslar, Germany

    T. Wittlinger MD, PhD

  5. Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Straße 40, 06120, Halle (Saale), Germany

    M. Noutsias MD, PhD

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  1. I. Martinovic MD, PhD
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  2. S. Lindemann MD, PhD
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Correspondence to I. Martinovic MD, PhD.

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I. Martinovic, S. Lindemann, M. Irqsusi, J. Mirat, A. Vcev, T. Wittlinger, M. Noutsias declare that they have no competing interests.

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

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Martinovic, I., Lindemann, S., Irqsusi, M. et al. Minimally invasive direct coronary bypass surgery via distal mini-sternotomy. Herz 44, 666–672 (2019). https://doi.org/10.1007/s00059-018-4696-0

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Keywords

  • Coronary artery stenosis
  • Coronary artery bypass grafting
  • Minimal surgical procedure
  • Myocardial revascularization
  • Follow-up

Schlüsselwörter

  • Koronararterienstenose
  • Koronararterien-Bypass-Operation
  • Minimalinvasive Operationstechnik
  • Myokardrevaskularisierung
  • Nachbeobachtung