Correspondence

Minimally Invasive Coronary-Artery Bypass Surgery without Extracorporeal Circulation

N Engl J Med 1997; 336:1454May 15, 1997

Article

To the Editor:

The term “minimally invasive surgery” is currently used for several procedures in cardiac surgery.1-3 Coronary-artery bypass surgery on the beating heart without extracorporeal circulation, using a small lateral approach through the fourth intercostal space, is one form of minimally invasive surgery.3

We used this technique successfully in 19 patients with isolated proximal stenoses of the left anterior descending artery and in 3 patients with isolated stenoses of the right coronary artery. By means of a 7-to-9-cm anterolateral incision and thoracotomy through the fourth intercostal space, the internal thoracic artery was taken down from the chest wall with use of a special rib retractor (CTS, CardioThoracic Systems, Cupertino, Calif.). The coronary artery was snared proximally and distally at the chosen anastomotic site with a soft vessel loop (Medipoint, Hamburg, Germany) to gain a bloodless field. The anastomosis was performed under direct vision. Flow through the graft was measured ultrasonographically (CardioMed CM 4000, Medi-Stim, Oslo, Norway). No procedure had to be converted to a sternotomy. We did not observe left ventricular dysfunction during occlusion of the coronary artery.

The entire operation required a mean (±SD) of 112±13.4 minutes, taking down of the internal thoracic artery required 30.5±7.7 minutes, and the anastomosis required 13.2±3.4 minutes. Postoperative mechanical ventilation averaged 6.6±4.8 hours (range, 0 to 16); the mean stay in the intensive care unit was 12.2±4.1 hours, and hospitalization lasted 8.1±1.5 days (range, 6 to 12). All patients had an uneventful intraoperative and postoperative course.

Minimally invasive coronary-artery bypass grafting to the left anterior descending coronary artery in combination with percutaneous transluminal coronary angioplasty in other coronary branches may be worth pursuing in further studies.

Anno Diegeler, M.D.
Volkmar Falk, M.D.
Thomas Walther, M.D.
Friedrich Wilhelm Mohr, M.D.
Leipzig University, D-04289 Leipzig, Germany

3 References

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   Reichenspurner H, Gulielmos V, Daniel WG, Schuler S. Minimally invasive coronary-artery bypass surgery. N Engl J Med 1997;336:67-68
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   Boonstra PW, Grandjean JG, Mariani MA. Improved method for direct coronary grafting without CPB via anterolateral small thoracotomy. Ann Thorac Surg 1997;63:567-569
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Citing Articles (13)

Citing Articles

1. 1

   Sharif Al-Ruzzeh, Waseem Mazrani, Jo Wray, Thomas Modine, Koki Nakamura, Shane George, Charles Ilsley, Mohamed Amrani. (2004) The Clinical Outcome and Quality of Life Following Minimally Invasive Direct Coronary Artery Bypass Surgery. Journal of Cardiac Surgery 19:1, 12-16
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2. 2

   Yatin Mehta, Rajiv Juneja. (2002) Off-pump coronary artery bypass grafting: new developments but a better outcome?. Current Opinion in Anaesthesiology 15:1, 9-18
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3. 3

   A Diegeler. (2000) The revival of surgical treatment for isolated proximal high grade LAD lesions by minimally invasive coronary artery bypass grafting. European Journal of Cardio-Thoracic Surgery 17:5, 501-504
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4. 4

   Anno Diegeler, Robert Hirsch, Felix Schneider, Lars-Oliver Schilling, Volkmar Falk, Thomas Rauch, Friedrich W. Mohr. (2000) Neuromonitoring and neurocognitive outcome in off-pump versus conventional coronary bypass operation. The Annals of Thoracic Surgery 69:4, 1162-1166
   CrossRef

5. 5

   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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6. 6

   Anno Diegeler. (1999) Left internal mammary artery grafting to left anterior descending coronary artery by minimally invasive direct coronary artery bypass approach. Current Cardiology Reports 1:4, 323-330
   CrossRef

7. 7

   Hideki Okayama, Takumi Sumimoto, Hiroyuki Kawada, Shozo Matsuda, Sadao Kawasaki, Yusaku Takagaki. (1999) Angioplasty-Bypass Surgery Combination Therapy. Japanese Circulation Journal 63:8, 636-639
   CrossRef

8. 8

   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
   CrossRef

9. 9

   Beat H Walpoth, Andreas Bosshard, Igor Genyk, Beat Kipfer, Pascal A Berdat, Otto M Hess, Ulrich Althaus, Thierry P Carrel. (1998) Transit-time flow measurement for detection of early graft failure during myocardial revascularization. The Annals of Thoracic Surgery 66:3, 1097-1100
   CrossRef

10. 10

    Anno Diegeler, Volkmar Falk, Merajoddin Matin, Roberto Battellini, Thomas Walther, Rüdiger Autschbach, Friedrich W Mohr. (1998) Minimally invasive coronary artery bypass grafting without cardiopulmonary bypass: early experience and follow-up. The Annals of Thoracic Surgery 66:3, 1022-1025
    CrossRef

11. 11

    Vassilios Gulielmos, Markus Dangel, Stephan Schüler. (1998) Minimally Invasive Bilateral Internal Mammary Artery Bypass Grafting. The Annals of Thoracic Surgery 65:6, 1774-1776
    CrossRef

12. 12

    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
    CrossRef

13. 13

    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
    CrossRef