Which place for Port AccessTM surgery in coronary artery bypass grafting A mid-term follow up study
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《血管的通路杂志》
a Department of Cardiovascular Surgery (Pr Jegaden), Hpital Pradel, Universite Claude Bernard, INSERM E0226, 28, avenue du doyen Lepine, 69677 Bron Cedex, France
b Department of Anaesthesia (Pr Lehot), Hpital Pradel, Bron, France
Abstract
Between May 1997 and November 2002, 68 patients with one or two-vessel disease (55±9 years) underwent Port AccessTM CABG using the Heartport endoCPB. The LITA was used in 63 cases, the RITA in 14, a radial artery in 2 and a vein graft in 3. Mean distal anastomoses was 1.3±0.5. Cross clamping, CPB, and operative times were 42±20 min, 64±27 min, and 3.8±1.5 h. Postoperative ventilation was 11±17 h, and ICU stay was 1.9±2.6 days. At day-1, troponin level was 2.3±2.9 UI and blood loss was 398±240 ml. Two patients needed long intubation and two had pleural re-drainage. One patient had a stroke, one had a myocardial infarction, and one underwent revision for bleeding. Hospital stay was 7±3 days. 65% were discharged to home. Follow up was completed in all cases (4.1±1.8 years). CCS score was significantly reduced (from 3.1±0.3 to 1.1±0.3, P<0.0001). Two patients had PTCA and stenting of non-grafted arteries. Five other patients had recurrent angina. Angiograms showed patent grafts in all cases. Two patients died after 19 months and 5 years from non cardiac reasons. In conclusion, Port AccessTM CABG remains a safe technique with stable results at mid-term follow up.
Key Words: Port AccessTM; Coronary; Follow up
1. Introduction
Port AccessTM coronary artery surgery has become a safe and reliable technique since the first reported cases in the mid 1990s [1,2]. Femoro-femoral coronary artery bypass (EndoCPB) systems allow cardiac assistance and arrest, owing endovascular aortic clamping with fluoroscopy or transesophageal echography (TEE) guided balloons [3]. Thus, single- or multiple-vessel diseases could be treated through left anterior small thoracotomies (LAST) after videoassisted internal thoracic arteries (ITA) harvesting [4]. Slowly, most of the procedures have turned into off pump approaches (MIDCAB) [5] and recently to totally endoscopic techniques with the help of robotic assistance (TECAB) [6,7]. Nevertheless, few authors report mid- and long-term results [8]. Herein, we present the series of the Louis Pradel hospital and analyse the long-term outcome of the patients.
2. Patients and methods
From May 1997 to November 2002, 68 consecutive patients who underwent Port AccessTM coronary artery bypass surgery were analysed prospectively. All patients were in NYHA class I. Mean CCS (Canadian cardiovascular society angina scale) score was 3.1±0.3. Most of the patients had good left ventricular ejection fractions (Table 1). Preoperative angiograms revealed single or double vessel diseases (respectively in 47 and 21 cases). Fourteen patients (20.6%) had a previous percutaneous transluminal coronary angioplasty (PTCA).
2.1. Surgical preparation
After general anaesthesia, patients were intubated selectively to allow single lung ventilation. A venting was positioned into the pulmonary artery root to avoid excessive backbleeding [9].
2.2. Surgical access and graft harvesting
A 4-cm incision was made in the 4th anterior intercostal space (ICS) in the infra-thoracic groove, and a medium size Soft Tissue RetractorTM (Heartport Inc., USA) was placed into the incision. A 10-mm port was created on the front axillary line in the 4th left ICS to allow a zero degree thoracoscope. The left internal thoracic artery (LITA) was harvested through the small thoracotomy using electrocautery and titanium clips. In case of double ITA harvesting, the RITA was dissected in a totally endoscopic approach through the right chest then passed to the left side through the anterior mediastinum or used as a free graft. In patients with right coronary artery disease, the thoracotomy was performed into the 4th right intercostal space.
2.3. Cardiopulmonary bypass
Venous cannulation: a purse string was made on the anterior wall of the femoral vein and snared. A double stage cannula (28 F) was placed using a Seldinger technique into the right atrium under TEE guidance [9].
Femoral arterial cannulation: in the first patients, an arteriotomy was made on a clamped artery. Then, a Seldinger technique was preferred in order to avoid clamping. Two overlapping U stitches of PTFE were placed on the anterior wall of the artery. Arterial cannulas were introduced over a guide wire, after dilatation. Fluoroscopy and TEE guided showed the image of the guidewire into the aorta.
Direct aortic cannulation: in case of patients with peripheral arterial lesions, a trocar was positioned into the second left intercostal space, through which an EndodirectTM arterial cannula was introduced and secured into the ascending aorta with a double purse string.
Aortic clamping: the Y-arm of the arterial cannula allowed a safe introduction of the Endo-Aortic ClampTM, positioned using fluoroscopy and TEE, and the balloon was inflated (pressure 280–350 mmHg). In the last 17 cases, a rapid injection of 0.25 mg/kg of adenosine was made at the balloon's tip before inflation to obtain an immediate cardiac arrest and to avoid balloon migration during inflation [10]. After complete aortic occlusion, antegrade cold crystalloid cardioplegia (St Thomas) was delivered at the balloon tip.
The coronary anastomoses were then performed under direct view. No heart positioner was used. The T-grafts anastomosis, as well as the proximal implantation of the saphenous vein on the aorta, were performed after aortic declamping. Proximal vein anastomosis was made with a lateral clamp passed through the left thoracotomy. The CPB was weaned as usual and the incisions closed.
3. Results
3.1. Peroperative data and early outcome
Mean aortic cross clamping, CPB and intervention times were respectively 42±20 min, 64±27 min and 3.8±1.5 h. The patients had a mean anastomosis number of 1.3±1.5 for 75% of complete revascularisations. The LITA was used in 63 cases, the RITA in 14, a radial artery in 2 and a vein graft in 3. Seven sequential grafts as well as seven T-grafts (ITA-ITA or ITA-radial) were performed (Table 2). Postoperative troponin level at 24 h was 2.3±2.9. Total drainage at 24 h was 398±240 ml. Intubation and ICU stay were 11.5±17.3 h and 1.9±2.6 days, respectively.
We didn't have mortality in the postoperative period. One patient had postoperative anterior infarcts. Control angiogram showed only and an occlusion of a septal branch. Three patients with double thoracic arteries presented with postoperative hypoxemia needing long respiratory assistance (range from 18 to 144 h), and two others had a pulmonary infection needing antibiotic treatment. Two patients had residual pleural effusion needing new drains repositioning. One patient with abdominal aortic aneurysm had a stroke due to thrombus embolism with the retrograde arterial flow. One patient underwent an early revision for chest wall bleeding. Thus, 10 patients (14.7%) had one perioperative major complication. Minor complications concerned three patients (two chest wound infections and one groin lymphocele).
Five patients had a postoperative angiogram, one for anterior infarcts, and in the others for complex T-grafts. All grafts were patent. One patient had a partially regressive hemiplegia during angiographic control.
Mean hospital stay time was 7.3±3.2 days. Seventeen patients (25%) were discharged to postoperative rehabilitation, 6 (8.8%) to the medical department and 44 (64.7%) returned home. One patient was readmitted after one month for recurrent chest pain. This patient had a lesion on a marginal branch that was not grafted because of technical reasons. Control angiogram confirmed the graft patency and allowed a dilatation and stenting of the lesion.
3.2. Late follow up
Follow up was made by mail enquiry and completed for all patients. Mean follow up was 4.1±1.8 years. Cumulated follow up was 279.9 years.
Late mortality: one patient died 60 months after surgery from renal failure. Another patient died 19 months after surgery from gastric cancer. Survival curve is shown in Fig. 1 (94±10% at 7 years).
Late morbidity: NYHA classification was higher after surgery (1.3±0.5 vs. 1.0±0.0, P<0.0001). CCS score was reduced after surgery (1.1±0.3 after vs. 3.1±0.3, P<0.0001). Five patients presented with a recurrent pectus angina (including acute infarcts) after a mean follow up of 3.6±1.4 years. In all cases, an angiogram was performed, showing a patency of the grafts and a progression of the lesions on the native network. For these patients, an incomplete revascularisation was not found to be a risk factor of recurrence of angina (P=ns). All patients were treated with medication except one who had a PTCA and stenting of an occluded right coronary artery. No patients underwent iterative surgical revascularisation. Survival rate with freedom from cardiac events is shown in Fig. 1 (83±13% at 7 years).
4. Discussion
The Heartport technique has demonstrated to provide adequate perfusion and satisfactory myocardial protection [11,12]. After a first period of coronary artery bypass grafting (CABG) done under cardiac arrest, most of the surgeons turned to mini-invasive direct coronary artery bypass (MIDCAB) [5]. This progression was motivated by the will of the surgeons to avoid endoCPB and its related complications, especially aortic dissection [3]. In our series, most of the patients could have been done off-pump, but our department politics was to do systematically video-assisted CABG on arrested hearts. More recently, totally endoscopic CABG with the help of telemanipulation robots (Da VincyTM, Intuitive Surgical) [6,7] became a routine technique in some centres.
All over the evolution of our series, we had to face several technical problems:
–The installation of the femoral arterial cannula and the progression of the endoclamp led us to perform systematically a preoperative arterial Doppler and to progressively use a Seldinger technique. In patients with severe peripheral arterial disease, we decided to do central aortic cannulation [13]. The problem of the balloon migration during the inflation was another pitfall of the technique. We proposed for the last 17 patients a rapid injection of adenosine at the tip of the balloon just before cardioplegia [10]. By this way, we could obtain a rapid and sustained (about 20 s) cardiac arrest, allowing the cardioplegia to achieve myocardial protection without any cardiac activity during balloon inflation. All that time, the balloon catheter was pulled out firmly from the femoral cannula to avoid its migration towards the aortic valve.
–We had to face only one groin lymphocele in all the series. For the first 20 patients, postoperative Doppler controls were performed and showed no stenosis at the cannulation sites.
–A word of caution should be brought to the double thoracic arteries harvesting. For these patients, we encountered postoperative respiratory problems due to prolonged single lung ventilation. The use of saphenous vein revealed also to be problematic. The proximal anastomosis on the aorta was most of the times difficult because of the small access and the difficulty in positioning a side clamp. In these cases, the use of an aortic connector could have been of help [14]. For these reasons, revascularisation was incomplete in some patients, but always concerned small coronary branches.
The immediate postoperative results of our series are comparable to what is reported in the Port AccessTM international registry [3]. We did not relate postoperative mortality, and the overall morbidity is acceptable. Yet, some of the complications could have been easily avoided. In some patients with multiple vessel diseases, we have chosen to perform double thoracic grafting. But for these patients, a longer surgical procedure went along with more pulmonary complications (longer intubation, pulmonary infections). For them, the use for example of T-grafts with the LITA and a radial artery could have been interesting. Second, in the case of the patient who presented with postoperative stroke, a direct aortic cannulation would have been preferable because of the presence of an abdominal aortic aneurysm.
Our series is the first to analyse mid-term follow up for Port-AccessTM CABG. Most of the authors describe their surgical technique and the immediate post-operative results [8]. Yet, follow up has not been reported until now. None of the patients had iterative revascularisation of the grafted vessels. Mean CCS score was significantly reduced (1.1±0.3) in comparison to preoperative. Eight patients presented with a CCS score of 2. Nevertheless, all of them gained at least one CCS class. In the case of patients with recurrent angina, the angiograms revealed an evolution on the native network. At a mean follow up of 4.1 years, survival was over 98% without cardiac related mortality.
In the evolution of the mini-invasive coronary techniques, two different approaches were adopted. MIDCAB presented the problem of reducing the indications to simple LITA-to-LAD grafts in most of the cases. Meantime, the use of intra-coronary shunts and adequate stabilisers gave more insurance of graft patency. Recently, some new devices like endoscopic stabilisers and exposition systems (Starfish NSTM, Medronic Inc.) rendered easier multiple vessel approaches through small anterior thoracotomies. The TECAB approach on the beating heart seemed also to be reserved for LITA-to-LAD grafts. The access to the marginal branches and to the right coronary artery can be easy but their stabilisation and the suturing process is often difficult. For this reason, we think that the Port AccessTM EndoCPB system is mandatory for multiple vessel TECAB [15]. We have started robotic procedures since September 2003, first for LAD disease, then in larger indications. The marginal branches can be grafted in some cases using the LITA but the conversion to thoracotomy rate is still high because of access or stabilisation difficulties [6]. According to the long-term results of our Port AccessTM series, the combination with robotic surgery seems seldom. On an arrested heart, the left ventricle is downloaded and can be lifted and mobilised with the help of an endoscopic retractor using a supplementary port to allow the access to posterior branches. Second, the endoscopic stabiliser is not necessary in a motionless and bloodless field. Since the cardioplegic protection delivered by the balloon tip is sufficient to allow a durable cardiac arrest, the procedure can be carried out in a safe and comfortable way.
Appendix A. ICVTS on-line discussion
Author: Ernesto Greco (Policlinica Gipuzkoa, San Sebastian, Spain)
eComment: The article from Dr. Farhat opens again a window of opportunity to use the minimally invasive approach and Endocpb in the field of coronary disease. In our experience of more than 250 cases of Port Access in mitral valve surgery, we only performed a few cases of myocardial revascularization. That was for several reasons:
–higher incidence of atherosclerotic disease of femoral vessels making troublesome the extra-thoracic approach for CPB
–difficulty of performing when necessary proximal anastomosis through a very small working port (4 cm) and without the help of an automatic anastomotic device especially in cases where the aorta is also calcified
–the limited access to the diaphragmatic area of the heart through the left cardiac surgery: expe-side making necessary double access for the complete revascularization.
–However, the results presented are very encouraging especially if we look at operative and mid-term outcome but to really reach a field of minimally invasive coronary surgery, this approach needs to allow for a wider and more complete revascularization.
References
Galloway AC, Ribakove GH, Grossi EA, Sternberg B, Zakow PK, Baumann FG, Buttenheim P, Colvin SB. Port-Access coronary artery bypass grafting: technical considerations and results. J Card Surg 1998; 13:281–285.
Groh MA, Sutherland SE, Burton HG 3rd, Johnson AM, Ely SW. Port-access coronary artery bypass grafting: technique and comparative results. Ann Thorac Surg 1999; 68:1506–1508.
Galloway AC, Shemin RJ, Glower DD, Boyer JH Jr, Groh MA, Kuntz RE, Burdon TA, Ribakove GH, Reitz BA, Colvin SB. First report of the Port Access International Registry. Ann Thorac Surg 1999; 67:51–56. discussion 57–58.
Wimmer-Greinecker G, Matheis G, Dogan S, Aybek T, Mierdl S, Kessler P, Moritz A. Patient selection for Port-Access multi vessel revascularization. Eur J Cardiothorac Surg 1999; 16:Suppl_2S43–S47.
Mack M, Acuff T, Yong P, Jett GK, Carter D. Minimally invasive thoracoscopically assisted coronary artery bypass surgery. Eur J Cardiothorac Surg 1997; 12:20–24.
Farhat F, Aubert S, Blanc P, Jegaden O. Totally endoscopic off-pump bilateral internal thoracic artery bypass grafting. Eur J Cardiothorac Surg 2004; 26:845–847.
Mohr FW, Falk V, Diegeler A, Walther T, Gummert JF, Bucerius J, Jacobs S, Autschbach R. Computer-enhanced ‘robotic’ cardiac surgery: experience in 148 patients. J Thorac Cardiovasc Surg 2001; 121:842–853.
Ribakove GH, Miller JS, Anderson RV, Grossi EA, Applebaum RM, Cutler WM, Buttenheim PM, Baumann FG, Galloway AC, Colvin SB. Minimally invasive Port-Access coronary artery bypass grafting with early angiographic follow-up: initial clinical experience. J Thorac Cardiovasc Surg 1998; 115:1101–1110.
Blanc P, Aouifi A, Chiari P, Bouvier H, Jegaden O, Lehot JJ. Minimally invasive cardiac surgery: surgical techniques and anesthetic problems. Ann Fr Anesth Reanim 1999; 18:748–771.
Farhat F, Coddens J, Vanermen H, Mikaeloff P, Jegaden O. Adenosine in Port-AccessTM surgery. A mean for stabilization of the endoaortic clamp. Heart Surg Forum 2002; 5:5341.
Stevens JH, Burdon TA, Siegel LC, Peters WS, Pompili MF, St Goar FG, Berry GJ, Ribakove GH, Vierra MA, Mitchell RS, Toomasian JM, Reitz BA. Port-access coronary artery bypass with cardioplegic arrest: acute and chronic canine studies. Ann Thorac Surg 1996; 62:435–440. discussion 441.
Dogan S, Graubitz K, Aybek T, Khan MF, Kessler P, Moritz A, Wimmer-Greinecker G. How safe is the port access technique in minimally invasive coronary artery bypass grafting. Ann Thorac Surg 2002; 74:1537–1543. discussion 1543.
Glower DD, Clements FM, Debruijn NP, Stafford-Smith M, Davis RD, Landolfo KP, Smith PK. Comparison of direct aortic and femoral cannulation for port-access cardiac operations. Ann Thorac Surg 1999; 68:1529–1531.
Semrad M, Stritesky M, Vondracek V, Lindner J, Vanek I, Kristof J, Aschermann M. Port access video-assisted proximal anastomosis with the symmetry aortic connector in MIDCABG procedure. Ann Thorac Surg 2003; 76:919–921.
Dogan S, Aybek T, Khan MF, Neidhart G, Auch-Schwelk W, Moritz A, Wimmer-Greinecker G. Totally endoscopic bilateral internal thoracic artery bypass grafting in a young diabetic patient. Med Sci Monit 2002; 8:95–97.(Fadi Farhat, Mathieu Verg)
b Department of Anaesthesia (Pr Lehot), Hpital Pradel, Bron, France
Abstract
Between May 1997 and November 2002, 68 patients with one or two-vessel disease (55±9 years) underwent Port AccessTM CABG using the Heartport endoCPB. The LITA was used in 63 cases, the RITA in 14, a radial artery in 2 and a vein graft in 3. Mean distal anastomoses was 1.3±0.5. Cross clamping, CPB, and operative times were 42±20 min, 64±27 min, and 3.8±1.5 h. Postoperative ventilation was 11±17 h, and ICU stay was 1.9±2.6 days. At day-1, troponin level was 2.3±2.9 UI and blood loss was 398±240 ml. Two patients needed long intubation and two had pleural re-drainage. One patient had a stroke, one had a myocardial infarction, and one underwent revision for bleeding. Hospital stay was 7±3 days. 65% were discharged to home. Follow up was completed in all cases (4.1±1.8 years). CCS score was significantly reduced (from 3.1±0.3 to 1.1±0.3, P<0.0001). Two patients had PTCA and stenting of non-grafted arteries. Five other patients had recurrent angina. Angiograms showed patent grafts in all cases. Two patients died after 19 months and 5 years from non cardiac reasons. In conclusion, Port AccessTM CABG remains a safe technique with stable results at mid-term follow up.
Key Words: Port AccessTM; Coronary; Follow up
1. Introduction
Port AccessTM coronary artery surgery has become a safe and reliable technique since the first reported cases in the mid 1990s [1,2]. Femoro-femoral coronary artery bypass (EndoCPB) systems allow cardiac assistance and arrest, owing endovascular aortic clamping with fluoroscopy or transesophageal echography (TEE) guided balloons [3]. Thus, single- or multiple-vessel diseases could be treated through left anterior small thoracotomies (LAST) after videoassisted internal thoracic arteries (ITA) harvesting [4]. Slowly, most of the procedures have turned into off pump approaches (MIDCAB) [5] and recently to totally endoscopic techniques with the help of robotic assistance (TECAB) [6,7]. Nevertheless, few authors report mid- and long-term results [8]. Herein, we present the series of the Louis Pradel hospital and analyse the long-term outcome of the patients.
2. Patients and methods
From May 1997 to November 2002, 68 consecutive patients who underwent Port AccessTM coronary artery bypass surgery were analysed prospectively. All patients were in NYHA class I. Mean CCS (Canadian cardiovascular society angina scale) score was 3.1±0.3. Most of the patients had good left ventricular ejection fractions (Table 1). Preoperative angiograms revealed single or double vessel diseases (respectively in 47 and 21 cases). Fourteen patients (20.6%) had a previous percutaneous transluminal coronary angioplasty (PTCA).
2.1. Surgical preparation
After general anaesthesia, patients were intubated selectively to allow single lung ventilation. A venting was positioned into the pulmonary artery root to avoid excessive backbleeding [9].
2.2. Surgical access and graft harvesting
A 4-cm incision was made in the 4th anterior intercostal space (ICS) in the infra-thoracic groove, and a medium size Soft Tissue RetractorTM (Heartport Inc., USA) was placed into the incision. A 10-mm port was created on the front axillary line in the 4th left ICS to allow a zero degree thoracoscope. The left internal thoracic artery (LITA) was harvested through the small thoracotomy using electrocautery and titanium clips. In case of double ITA harvesting, the RITA was dissected in a totally endoscopic approach through the right chest then passed to the left side through the anterior mediastinum or used as a free graft. In patients with right coronary artery disease, the thoracotomy was performed into the 4th right intercostal space.
2.3. Cardiopulmonary bypass
Venous cannulation: a purse string was made on the anterior wall of the femoral vein and snared. A double stage cannula (28 F) was placed using a Seldinger technique into the right atrium under TEE guidance [9].
Femoral arterial cannulation: in the first patients, an arteriotomy was made on a clamped artery. Then, a Seldinger technique was preferred in order to avoid clamping. Two overlapping U stitches of PTFE were placed on the anterior wall of the artery. Arterial cannulas were introduced over a guide wire, after dilatation. Fluoroscopy and TEE guided showed the image of the guidewire into the aorta.
Direct aortic cannulation: in case of patients with peripheral arterial lesions, a trocar was positioned into the second left intercostal space, through which an EndodirectTM arterial cannula was introduced and secured into the ascending aorta with a double purse string.
Aortic clamping: the Y-arm of the arterial cannula allowed a safe introduction of the Endo-Aortic ClampTM, positioned using fluoroscopy and TEE, and the balloon was inflated (pressure 280–350 mmHg). In the last 17 cases, a rapid injection of 0.25 mg/kg of adenosine was made at the balloon's tip before inflation to obtain an immediate cardiac arrest and to avoid balloon migration during inflation [10]. After complete aortic occlusion, antegrade cold crystalloid cardioplegia (St Thomas) was delivered at the balloon tip.
The coronary anastomoses were then performed under direct view. No heart positioner was used. The T-grafts anastomosis, as well as the proximal implantation of the saphenous vein on the aorta, were performed after aortic declamping. Proximal vein anastomosis was made with a lateral clamp passed through the left thoracotomy. The CPB was weaned as usual and the incisions closed.
3. Results
3.1. Peroperative data and early outcome
Mean aortic cross clamping, CPB and intervention times were respectively 42±20 min, 64±27 min and 3.8±1.5 h. The patients had a mean anastomosis number of 1.3±1.5 for 75% of complete revascularisations. The LITA was used in 63 cases, the RITA in 14, a radial artery in 2 and a vein graft in 3. Seven sequential grafts as well as seven T-grafts (ITA-ITA or ITA-radial) were performed (Table 2). Postoperative troponin level at 24 h was 2.3±2.9. Total drainage at 24 h was 398±240 ml. Intubation and ICU stay were 11.5±17.3 h and 1.9±2.6 days, respectively.
We didn't have mortality in the postoperative period. One patient had postoperative anterior infarcts. Control angiogram showed only and an occlusion of a septal branch. Three patients with double thoracic arteries presented with postoperative hypoxemia needing long respiratory assistance (range from 18 to 144 h), and two others had a pulmonary infection needing antibiotic treatment. Two patients had residual pleural effusion needing new drains repositioning. One patient with abdominal aortic aneurysm had a stroke due to thrombus embolism with the retrograde arterial flow. One patient underwent an early revision for chest wall bleeding. Thus, 10 patients (14.7%) had one perioperative major complication. Minor complications concerned three patients (two chest wound infections and one groin lymphocele).
Five patients had a postoperative angiogram, one for anterior infarcts, and in the others for complex T-grafts. All grafts were patent. One patient had a partially regressive hemiplegia during angiographic control.
Mean hospital stay time was 7.3±3.2 days. Seventeen patients (25%) were discharged to postoperative rehabilitation, 6 (8.8%) to the medical department and 44 (64.7%) returned home. One patient was readmitted after one month for recurrent chest pain. This patient had a lesion on a marginal branch that was not grafted because of technical reasons. Control angiogram confirmed the graft patency and allowed a dilatation and stenting of the lesion.
3.2. Late follow up
Follow up was made by mail enquiry and completed for all patients. Mean follow up was 4.1±1.8 years. Cumulated follow up was 279.9 years.
Late mortality: one patient died 60 months after surgery from renal failure. Another patient died 19 months after surgery from gastric cancer. Survival curve is shown in Fig. 1 (94±10% at 7 years).
Late morbidity: NYHA classification was higher after surgery (1.3±0.5 vs. 1.0±0.0, P<0.0001). CCS score was reduced after surgery (1.1±0.3 after vs. 3.1±0.3, P<0.0001). Five patients presented with a recurrent pectus angina (including acute infarcts) after a mean follow up of 3.6±1.4 years. In all cases, an angiogram was performed, showing a patency of the grafts and a progression of the lesions on the native network. For these patients, an incomplete revascularisation was not found to be a risk factor of recurrence of angina (P=ns). All patients were treated with medication except one who had a PTCA and stenting of an occluded right coronary artery. No patients underwent iterative surgical revascularisation. Survival rate with freedom from cardiac events is shown in Fig. 1 (83±13% at 7 years).
4. Discussion
The Heartport technique has demonstrated to provide adequate perfusion and satisfactory myocardial protection [11,12]. After a first period of coronary artery bypass grafting (CABG) done under cardiac arrest, most of the surgeons turned to mini-invasive direct coronary artery bypass (MIDCAB) [5]. This progression was motivated by the will of the surgeons to avoid endoCPB and its related complications, especially aortic dissection [3]. In our series, most of the patients could have been done off-pump, but our department politics was to do systematically video-assisted CABG on arrested hearts. More recently, totally endoscopic CABG with the help of telemanipulation robots (Da VincyTM, Intuitive Surgical) [6,7] became a routine technique in some centres.
All over the evolution of our series, we had to face several technical problems:
–The installation of the femoral arterial cannula and the progression of the endoclamp led us to perform systematically a preoperative arterial Doppler and to progressively use a Seldinger technique. In patients with severe peripheral arterial disease, we decided to do central aortic cannulation [13]. The problem of the balloon migration during the inflation was another pitfall of the technique. We proposed for the last 17 patients a rapid injection of adenosine at the tip of the balloon just before cardioplegia [10]. By this way, we could obtain a rapid and sustained (about 20 s) cardiac arrest, allowing the cardioplegia to achieve myocardial protection without any cardiac activity during balloon inflation. All that time, the balloon catheter was pulled out firmly from the femoral cannula to avoid its migration towards the aortic valve.
–We had to face only one groin lymphocele in all the series. For the first 20 patients, postoperative Doppler controls were performed and showed no stenosis at the cannulation sites.
–A word of caution should be brought to the double thoracic arteries harvesting. For these patients, we encountered postoperative respiratory problems due to prolonged single lung ventilation. The use of saphenous vein revealed also to be problematic. The proximal anastomosis on the aorta was most of the times difficult because of the small access and the difficulty in positioning a side clamp. In these cases, the use of an aortic connector could have been of help [14]. For these reasons, revascularisation was incomplete in some patients, but always concerned small coronary branches.
The immediate postoperative results of our series are comparable to what is reported in the Port AccessTM international registry [3]. We did not relate postoperative mortality, and the overall morbidity is acceptable. Yet, some of the complications could have been easily avoided. In some patients with multiple vessel diseases, we have chosen to perform double thoracic grafting. But for these patients, a longer surgical procedure went along with more pulmonary complications (longer intubation, pulmonary infections). For them, the use for example of T-grafts with the LITA and a radial artery could have been interesting. Second, in the case of the patient who presented with postoperative stroke, a direct aortic cannulation would have been preferable because of the presence of an abdominal aortic aneurysm.
Our series is the first to analyse mid-term follow up for Port-AccessTM CABG. Most of the authors describe their surgical technique and the immediate post-operative results [8]. Yet, follow up has not been reported until now. None of the patients had iterative revascularisation of the grafted vessels. Mean CCS score was significantly reduced (1.1±0.3) in comparison to preoperative. Eight patients presented with a CCS score of 2. Nevertheless, all of them gained at least one CCS class. In the case of patients with recurrent angina, the angiograms revealed an evolution on the native network. At a mean follow up of 4.1 years, survival was over 98% without cardiac related mortality.
In the evolution of the mini-invasive coronary techniques, two different approaches were adopted. MIDCAB presented the problem of reducing the indications to simple LITA-to-LAD grafts in most of the cases. Meantime, the use of intra-coronary shunts and adequate stabilisers gave more insurance of graft patency. Recently, some new devices like endoscopic stabilisers and exposition systems (Starfish NSTM, Medronic Inc.) rendered easier multiple vessel approaches through small anterior thoracotomies. The TECAB approach on the beating heart seemed also to be reserved for LITA-to-LAD grafts. The access to the marginal branches and to the right coronary artery can be easy but their stabilisation and the suturing process is often difficult. For this reason, we think that the Port AccessTM EndoCPB system is mandatory for multiple vessel TECAB [15]. We have started robotic procedures since September 2003, first for LAD disease, then in larger indications. The marginal branches can be grafted in some cases using the LITA but the conversion to thoracotomy rate is still high because of access or stabilisation difficulties [6]. According to the long-term results of our Port AccessTM series, the combination with robotic surgery seems seldom. On an arrested heart, the left ventricle is downloaded and can be lifted and mobilised with the help of an endoscopic retractor using a supplementary port to allow the access to posterior branches. Second, the endoscopic stabiliser is not necessary in a motionless and bloodless field. Since the cardioplegic protection delivered by the balloon tip is sufficient to allow a durable cardiac arrest, the procedure can be carried out in a safe and comfortable way.
Appendix A. ICVTS on-line discussion
Author: Ernesto Greco (Policlinica Gipuzkoa, San Sebastian, Spain)
eComment: The article from Dr. Farhat opens again a window of opportunity to use the minimally invasive approach and Endocpb in the field of coronary disease. In our experience of more than 250 cases of Port Access in mitral valve surgery, we only performed a few cases of myocardial revascularization. That was for several reasons:
–higher incidence of atherosclerotic disease of femoral vessels making troublesome the extra-thoracic approach for CPB
–difficulty of performing when necessary proximal anastomosis through a very small working port (4 cm) and without the help of an automatic anastomotic device especially in cases where the aorta is also calcified
–the limited access to the diaphragmatic area of the heart through the left cardiac surgery: expe-side making necessary double access for the complete revascularization.
–However, the results presented are very encouraging especially if we look at operative and mid-term outcome but to really reach a field of minimally invasive coronary surgery, this approach needs to allow for a wider and more complete revascularization.
References
Galloway AC, Ribakove GH, Grossi EA, Sternberg B, Zakow PK, Baumann FG, Buttenheim P, Colvin SB. Port-Access coronary artery bypass grafting: technical considerations and results. J Card Surg 1998; 13:281–285.
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