Correspondence

Minimally Invasive Coronary-Artery Bypass Surgery

N Engl J Med 1997; 336:67-68January 2, 1997

Article

To the Editor:

Minimally invasive procedures involving endoscopic instruments have become routine in many surgical specialties. In cardiac surgery, only a few procedures have been performed with such devices, such as ligation of a patent ductus arteriosus and pericardial fenestration.1 A new technique of endoscopic coronary-artery bypass surgery that uses cardiopulmonary bypass and cardioplegic arrest has recently been developed in dogs.2 We attempted to perform bypass surgery through a port-access mini-thoracotomy with the protection of cardiopulmonary bypass and cardioplegia.

Twelve patients with isolated lesions of the left anterior descending coronary artery were evaluated for the procedure. At surgery, a small incision (6 to 8 cm) was made parasternally over the fourth rib (Figure 1Figure 1Thoracic Skin Incision Used in Minimally Invasive Coronary-Artery Bypass Surgery.). The cartilaginous portion of the rib was removed. The left internal thoracic artery was dissected and taken down through the thoracic incision alone in nine patients and with an additional thoracoscopic approach through three small ports in the lateral chest in the remaining three patients. Endovascular cardiopulmonary bypass was instituted through femoral cannulation. An endoarterial balloon catheter (Heartport, Redwood City, Calif.) was introduced into the ascending aorta through the arterial cannula with monitoring by fluoroscopy and transesophageal echocardiography and used for aortic occlusion, aortic-root venting, monitoring of aortic-root pressure, and the anterograde delivery of a cold crystalloid cardioplegia solution. The pulmonary artery was vented with a special catheter passed percutaneously through the internal jugular vein and advanced into the main pulmonary artery. After the institution of cardiopulmonary bypass and cardioplegia, the left internal thoracic artery was anastomosed to the left anterior descending coronary artery under direct vision.

All the patients were removed from cardiopulmonary bypass in sinus rhythm without inotropic support. Table 1Table 1Median (6SE) Duration of Various Aspects of Minimally Invasive Coronary Bypass Surgery and the Associated Hospitalization. shows the time required to take down the left internal thoracic artery, the duration of cardiopulmonary bypass, the time required for aortic occlusion, the total duration of mechanical ventilation, the time spent in the intensive care unit, and the total hospitalization. Two patients had delayed healing of their wounds at the site of femoral cannulation, and there was minor lymphatic drainage in one of them; there were no other complications. The patients were discharged after an average of eight days (Table 1). Short-term follow-up has revealed no complications.

Minimally invasive bypass surgery appears to be feasible without an increase in risk to the patient. With this procedure, complications related to sternotomy can be avoided, and the safety and efficacy of cardiopulmonary bypass and cardioplegic arrest are the same as in conventional bypass surgery.

Hermann Reichenspurner, M.D., Ph.D.
Vassilios Gulielmos, M.D.
Werner G. Daniel, M.D.
Stephan Schüler, M.D.
University Hospital Dresden, D-01307 Dresden, Germany

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Citing Articles (20)

Citing Articles

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   Utz Kappert, Jens Schneider, Romuald Cichon, Vassilios Gulielmos, Ina Schade, Joachim Nicolai, Stephan Schueler. (2000) Closed chest totally endoscopic coronary artery bypass surgery: Fantasy or reality?. Current Cardiology Reports 2:6, 558-563
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2. 2

   Romuald Cichon, Utz Kappert, Jens Schneider, Ina Schramm, Vassilios Gulielmos, Sems M Tugtekin, Stephan Schüler. (2000) Robotic-enhanced arterial revascularization for multivessel coronary artery disease. The Annals of Thoracic Surgery 70:3, 1060-1062
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3. 3

   Utz Kappert, Jens Schneider, Romuald Cichon, Vassilios Gulielmos, Klaus Matschke, Sems M Tugtekin, Stephan Schüler. (2000) Wrist-enhanced instrumentation: moving toward totally endoscopic coronary artery bypass grafting. The Annals of Thoracic Surgery 70:3, 1105-1108
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4. 4

   H. Fischer, M. Selig, J. Vagner, B. Vogel, E. Hempel, M. Kaiser, K. Brhel, A. Hinz, A. Felden, A. Schäf, L. Gumb, U. Ullrich, A. Grünhagen, U. Voges, H. Kühnapfel, H. Çakmak, H. Maass, H. Becker, H. Breitwieser, R. Mikut, R. Oberle, W. Eppler, P. Schlossmacher, W. Pfleging, W. A. Kaiser, S. Schüler, R. Cichon, M. Cornelius, U. Kappert, M. O. Schurr, G. Buess, V. Falk. (2000) The medical engineering program of Forschungszentrum Karlsruhe. Minimally Invasive Therapy & Allied Technologies 9:3-4, 255-267
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   U KAPPERT. (1999) Port Access? surgery for congenital heart disease*1. European Journal of Cardio-Thoracic Surgery 16, S86-S88
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   U KAPPERT. (1999) The application of the OctopusS stabilizing system for the treatment of high risk patients with coronary artery disease*1. European Journal of Cardio-Thoracic Surgery 16, S7-S9
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   Dieter H Boehm, Hermann Reichenspurner, Helmut Gulbins, Christian Detter, Bruno Meiser, Paolo Brenner, Helmut Habazettl, Bruno Reichart. (1999) Early experience with robotic technology for coronary artery surgery. The Annals of Thoracic Surgery 68:4, 1542-1546
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   ROBERT M. APPLEBAUM, STEPHEN B. COLVIN, AUBREY C. GALLOWAY, GREG H. RIBAKOVE, EUGENE A. GROSSI, PAUL A. TUNICK, ITZHAK KRONZON. (1999) The Role of Transesophageal Echocardiography During Port-Access Minimally Invasive Cardiac Surgery.. Echocardiography 16:6, 595-602
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   V Gulielmos. (1998) Experiences with a minimally invasive surgical technique for the treatment of coronary artery multivessel disease in 100 patients. European Journal of Cardio-Thoracic Surgery 14:4, 347-352
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    V Gulielmos. (1998) Minimally invasive mitral valve surgery – clinical experiences with a PortAccess system. European Journal of Cardio-Thoracic Surgery 14, 148-153
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    V Gulielmos. (1998) Minimally invasive cardiac surgery for the treatment of coronary artery multi-vessel disease. European Journal of Cardio-Thoracic Surgery 14, 48-53
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    Vassilios Gulielmos, Michael Knaut, Romuald Cichon, Michael Brandt, Thorsten Jost, Klaus Matschke, Stephan Schüler. (1998) Minimally invasive surgical treatment of coronary artery multivessel disease. The Annals of Thoracic Surgery 66:3, 1018-1021
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    Ravi H Dave, Sharon L Hale, Robert A Kloner. (1998) Hypothermic, Closed Circuit Pericardioperfusion: A Potential Cardioprotective Technique in Acute Regional Ischemia. Journal of the American College of Cardiology 31:7, 1667-1671
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    Vassilios Gulielmos, Markus Dangel, Stephan Schüler. (1998) Minimally Invasive Bilateral Internal Mammary Artery Bypass Grafting. The Annals of Thoracic Surgery 65:6, 1774-1776
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15. 15

    Vassilios Gulielmos, Michael Knaut, Florian M. Wagner, Stephan Schüler. (1998) Minimally Invasive Surgical Technique for the Treatment of Multivessel Coronary Artery Disease. The Annals of Thoracic Surgery 65:5, 1331-1334
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16. 16

    F.W. Mohr, V. Falk, A. Diegeler, T. Walther, J.A.M. van Son, R. Autschbach, Hans G. Borst. (1998) Minimally Invasive Port-Access Mitral Valve Surgery. The Journal of Thoracic and Cardiovascular Surgery 115:3, 567-576
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    F. R. Waldenberger, M. Haisjackl, M. Lengsfeld, S. Holinski, W. Konertz. (1998) Koronarchirurgie am schlagenden Herzen während mechanischer Linksherzassistenz (SUPPCAB). European Surgery 30:1, 16-19
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    V. Gulielmos, M. Dangel, Jaqueline Wunderlich, M. Knaut, R. Cichon, M. Brandt, J. Hoffmann, St. Schüler. (1998) Minimal-invasiv-chirurgische Techniken zur Behandlung der koronaren Herzerkrankung. European Surgery 30:1, 11-15
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    (1997) More on “Hybrid Revascularization”. New England Journal of Medicine 337:12, 861-862
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    Diegeler, Anno, Falk, Volkmar, Walther, Thomas, Mohr, Friedrich Wilhelm, . (1997) Minimally Invasive Coronary-Artery Bypass Surgery without Extracorporeal Circulation. New England Journal of Medicine 336:20, 1454-1454
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