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 Cardiac
Surgery
Recent Advances
and Techniques
 Cardiac
Surgery
Recent Advances
and Techniques
Edited by
Narain Moorjani
Sunil K. Ohri
Andrew S. Wechsler

Boca Raton London New York

CRC Press is an imprint of the

Taylor & Francis Group, an informa business
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© 2014 by Taylor & Francis Group, LLC
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Version Date: 20130626

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Contents
Preface������������������������������������������������������������������������������������������������������������������������������������������������������������������������vii
Foreword by Lawrence H. Cohn����������������������������������������������������������������������������������������������������������������������������������ix
Editors��������������������������������������������������������������������������������������������������������������������������������������������������������������������������xi
Contributors���������������������������������������������������������������������������������������������������������������������������������������������������������������xiii

Chapter 1 Minimally Invasive Coronary Artery Bypass Surgery��������������������������������������������������������������������������� 1

Michael E. Halkos and John D. Puskas

Chapter 2 Minimized Cardiopulmonary Bypass��������������������������������������������������������������������������������������������������� 15

Narain Moorjani and Sunil K. Ohri

Chapter 3 Transcatheter Aortic Valve Implantation���������������������������������������������������������������������������������������������� 27

Ardawan J. Rastan, Michael A. Borger, Martin Haensig, Jörg Kempfert and Friedrich W. Mohr

Chapter 4 Aortic Valve Repair������������������������������������������������������������������������������������������������������������������������������� 45

Joel Price and Gebrine El Khoury

Chapter 5 Minimally Invasive Mitral Valve Surgery�������������������������������������������������������������������������������������������� 59

Hazaim Alwair, Evelio Rodriguez, W. Randolph Chitwood Jr. and L. Wiley Nifong

Chapter 6 Tricuspid Valve Surgery������������������������������������������������������������������������������������������������������������������������ 67

K. M. John Chan and Gilles D. Dreyfus

Chapter 7 Arrhythmia Surgery������������������������������������������������������������������������������������������������������������������������������ 77

Lindsey L. Saint, Jason O. Robertson, Richard B. Schuessler and Ralph J. Damiano Jr.

Chapter 8 Valve-Sparing Aortic Root Replacement���������������������������������������������������������������������������������������������� 97

Neel R. Sodha, Kaushik Mandal and Duke E. Cameron

Chapter 9 Endovascular Stent Grafting of the Thoracic Aorta����������������������������������������������������������������������������111

Prashanth Vallabhajosyula, Wilson Y. Szeto, G. William Moser, Tyler J. Wallen
and Joseph E. Bavaria

Chapter 10 Cellular Cardiomyoplasty and Stem Cell Therapy����������������������������������������������������������������������������� 133

Philippe Menasche

v
© 2010 Taylor & Francis Group, LLC
vi Contents

Chapter 11 Left Ventricular Remodelling Surgery������������������������������������������������������������������������������������������������ 147

Lorenzo Menicanti and Serenella Castelvecchio

Chapter 12 Mechanical Circulatory Support����������������������������������������������������������������������������������������������������������161

Stephen Westaby

© 2010 Taylor & Francis Group, LLC

Preface

The field of cardiac surgery continues to expand with current trials relating to each new procedure. Each ­chapter
the development of new techniques and operations, as contains images and drawings to illustrate the surgical
well as the refinement of established surgical procedures. technique supported with important references for further
In parallel with this, the demand for knowledge regard- reading and greater depth of knowledge. The book is rele-
ing how these new procedures are performed is increas- vant to everyone involved in the practice of cardiac surgery,
ing. Although ­ several large volume textbooks exist to both residents at any stage of their training programme
provide information regarding cardiac surgery in general, and established cardiac surgeons. Adult cardiologists and
there are very few books that specifically cover the latest cardiothoracic intensive care unit specialists will also find
developments in adult cardiac surgery. ‘Cardiac Surgery: this book useful for the surgical management of patients
Recent Advances and Techniques’ provides a current and undergoing these new techniques, as they are integral to
contemporary text that systematically covers all the new the cardiac surgical process. With the modern need for
developments in the field of cardiac surgery. The chapters all cardiac surgeons to keep up-to-date with current prac-
have been written by the recognised leaders and innovators tice for recertification purposes, ‘Cardiac Surgery: Recent
throughout the world with regard to each technique. The Advances and Techniques’ provides an ideal synopsis of
chapters also include up-to-date information regarding the latest developments in the field of cardiac surgery.

vii
© 2010 Taylor & Francis Group, LLC
Foreword

Cardiac Surgery: Recent Advances and Techniques is The newer approaches are excellent and can lead to
an excellent summary of all of the latest techniques and better patient outcomes, but the experience of the opera-
results of minimally invasive cardiac surgery, endovas- tor is critical to the success of these techniques and
cular aortic surgery and new therapies for heart failure, the use of these should be based on skill, not market-
including stem cell therapy, left ventricular remodeling ing by hospitals. The exceptional chapters on surgery
and the indications for the rapidly increasing usage of of the aorta from Johns Hopkins and the University
mechanical circulatory support. The authors are well of Pennsylvania are written by the leaders in the field.
known and are perfectly suited to describing these Dr. Puskas from Emory has put minimally invasive
kinds of advances. Dr. Moorjani (Papworth Hospital, approaches to coronary bypass surgery into proper per-
Cambridge, England), Dr. Ohri (Southampton University spective as well. There are also excellent chapters on the
Hospital, England) and Dr. Wechsler (Drexel University, various catheter-based devices now being used for trans-
Philadelphia, USA) have organized 12 chapters that apical or transarterial valve implantation, a field that is
cover the entire spectrum of minimally invasive heart growing by leaps and bounds. The use of hybrid technol-
surgery, a field that is growing rapidly because of its ogy, as well as hybrid operating rooms, one of the great
improved results in patients who recover faster than tra- advances in hospital organizations, is also summarized
ditional open operations. An important note, however, is throughout this excellent volume.
that all of the techniques beautifully described in this In short, Cardiac Surgery: Recent Advances and
volume, have to be performed by experienced surgeons Techniques does just that by summarizing succinctly and
to obtain the desired results outlined in this book. objectively all of the new and modern techniques used in
All of the authors are experts in the areas they acquired cardiac surgery operations, written by experts
have written about. For example, Chapter 5 entitled in the field promulgating not only their ideas, but pre-
“Minimally Invasive Mitral Valve Surgery” focuses senting the global excellent surgical outcomes as well.
quite a bit of attention on robotic mitral valve surgery,
which in the proper hands is a very effective therapy, but Lawrence H. Cohn, MD
in inexperienced hands this technology is not indicated. Hubbard Professor of Cardiac Surgery
Thus, the message of this book is, in order to be profi- Harvard Medical School
cient in advanced surgical techniques, the surgeon has to Brigham and Women’s Hospital
be very well versed in pathology and conventional sur- Boston, MA
gical approaches before tackling these new innovative USA
techniques.

ix
© 2010 Taylor & Francis Group, LLC
Editors

Narain Moorjani, MB ChB, MRCS, MD, FRCS interests and has published over 120 peer reviewed
(C-Th) Consultant Cardiothoracic Surgeon at publications and co-authored two textbooks entitled
Papworth Hospital, Cambridge, UK, where he spe- ‘Key Topics in Cardiac Surgery’ and ‘Key Questions in
cialises in repair procedures of the mitral and aortic Cardiac Surgery’. Sunil Ohri has held national office with
valves, as well as performing minimally invasive aortic the Society for Cardiothoracic Surgery in Great Britain
valve and coronary artery surgery. He had previously and Ireland both as Communications Officer and mem-
worked as a Consultant Cardiac Surgeon at the Royal ber of the Executive Committee from 2004 to 2011. He
Brompton Hospital, London, UK and Assistant Professor was also a board member for CTSNet and remains on the
in Cardiothoracic Surgery at Hahnemann University editorial board of Heart journal. He has had a keen inter-
Hospital, Philadelphia, USA. He has been appointed as est in education and training and is currently Training
an Associate Lecturer at the University of Cambridge, Programme Director for cardiothoracic surgery for the
UK, with his current research interests focusing on the Wessex and Oxford Deaneries and has been an examiner
genes responsible for thoracic aorta aneurysms. Prior for the Intercollegiate Board for Cardiothoracic Surgery
to that, he completed a research doctorate of medicine since 2005.
(MD) at the University of Oxford, UK and National
Heart and Lung Institute, London, UK, investigating the Andrew S. Wechsler, MD, FACC, FAHA Professor
role of cardiomyocyte apoptotic genes in the develop- of Cardiothoracic Surgery at Drexel University College
ment of heart failure. More recently, he has published of Medicine in Philadelphia, USA. Dr. Wechsler has had
the award winning international best-selling textbook a long career in clinical and research cardiac surgery. In
entitled ‘Key Questions in Cardiac Surgery’, is co-editor addition to his current position, he has been Professor of
of ‘Key Topics in Cardiac Surgery’ and is currently edit- Surgery and Physiology at Duke University Medical Center
ing two further cardiac surgery books. in Durham, North Carolina and Virginia Commonwealth
University in Richmond, Virginia. He has served as
Sunil K. Ohri, MD, FRCS (Eng, Ed & CTh), Chairman of the National Institutes of Health Surgery
FESC Consultant Cardiac Surgeon at University and Bioengineering Study Section, as a Director of the
Hospital Southampton and Honorary Senior Lecturer American Board of Thoracic Surgery, Senior Consultant
at the University of Southampton. He qualified from the to the National Heart Institute Division of Cardiovascular
Middlesex Hospital Medical School (University College Sciences, Treasurer of the American Association for
London) in 1985 and trained in cardiac surgery at the Thoracic Surgery and on the Councils of the Society of
Hammersmith Hospital, Royal Postgraduate Medical Thoracic Surgeons, The American Association for Thoracic
School, the Middlesex Hospital and the National Heart Surgery and the European Association of Cardiothoracic
and Lung Institute at Harefield Hospital. His clini- Surgery. He served as Editor of the Journal of Thoracic
cal interests include beating heart surgery, endoscopic and Cardiovascular Surgery from 2000 to 2008 and in
vein harvesting and transcatheter aortic valve implan- 2009 was awarded the Scientific Achievement Award from
tation. He completed his MD thesis as a British Heart the American Association for Thoracic Surgery. He has
Foundation Fellow in 1995, investigating the pathophysi- ­contributed more than 400 peer reviewed manuscripts,
ology of splanchnic dysfunction during cardiopulmo- books and book chapters and maintains an active practice
nary bypass. Subsequently, he has continued his research of cardiac surgery.

xi
© 2010 Taylor & Francis Group, LLC
Contributors

Hazaim Alwair Martin Haensig G. William Moser

East Carolina Heart Institute University of Leipzig University of Pennsylvania
Greenville, North Carolina Leipzig, Germany Philadelphia, Pennsylvania

Joseph E. Bavaria Michael E. Halkos L. Wiley Nifong

University of Pennsylvania Emory University School of East Carolina Heart Institute
Philadelphia, Pennsylvania Medicine Greenville, North Carolina
Emory University Hospital Midtown
Michael A. Borger Atlanta, Georgia Sunil K. Ohri
University of Leipzig Southampton University Hospital
Leipzig, Germany Jörg Kempfert Southampton, United Kingdom
Kerckhoff-Clinic
Duke E. Cameron Bad Nauheim, Germany Joel Price
The Johns Hopkins Hospital The Johns Hopkins Hospital
Baltimore, Maryland Kaushik Mandal Baltimore, Maryland
The Johns Hopkins Hospital
Serenella Castelvecchio Baltimore, Maryland John D. Puskas
I.R.C.C.S. Policlinico San Donato Emory University School
Milan, Italy Philippe Menasche of Medicine
Hôpital Européen Georges Emory University Hospital
K. M. John Chan Pompidou Midtown
Sarawak General Hospital Heart Université Paris Descartes Atlanta, Georgia
Centre Paris, France
Kota Samarahan, Sarawak, Malaysia Ardawan J. Rastan
Lorenzo Menicanti Heart Center Rotenburg
W. Randolph Chitwood Jr. I.R.C.C.S. Policlinico San Donato Rotenburg, Germany
East Carolina Heart Institute Milan, Italy
Greenville, North Carolina Jason O. Robertson
Friedrich W. Mohr Washington University/­
Ralph J. Damiano Jr. University of Leipzig Barnes-Jewish Hospital
Washington University School Leipzig, Germany St. Louis, Missouri
of Medicine
St. Louis, Missouri Narain Moorjani Evelio Rodriguez
Papworth Hospital St. Thomas Heart Hospital
Gilles D. Dreyfus University of Cambridge Nashville, Tennessee
Cardio Thoracic Centre of Monaco Cambridge, United Kingdom
Monte Carlo, Monaco

xiii
© 2010 Taylor & Francis Group, LLC
xiv Contributors

Lindsey L. Saint Wilson Y. Szeto Andrew S. Wechsler

Washington University/­ Penn Presbyterian Medical Center Drexel University College
Barnes-Jewish Hospital Philadelphia, Pennsylvania of Medicine
St. Louis, Missouri Philadelphia, Pennsylvania
Prashanth Vallabhajosyula
Richard B. Schuessler University of Pennsylvania Stephen Westaby
Washington University School of Philadelphia, Pennsylvania John Radcliffe Hospital
Medicine Oxford, United Kingdom
St. Louis, Missouri Tyler J. Wallen
University of Pennsylvania
Neel R. Sodha Philadelphia, Pennsylvania
The Johns Hopkins Hospital
Baltimore, Maryland

© 2010 Taylor & Francis Group, LLC

 1 Minimally Invasive Coronary
Artery Bypass Graft Surgery

Michael E. Halkos and John D. Puskas

CONTENTS
Introduction������������������������������������������������������������������������������������������������������������������������������������������������������������������� 1
Off-pump Coronary Artery Bypass������������������������������������������������������������������������������������������������������������������������������� 2
Patient Selection������������������������������������������������������������������������������������������������������������������������������������������������������������ 2
Indications and Contraindications��������������������������������������������������������������������������������������������������������������������������������� 2
Minimally Invasive Direct Coronary Artery Bypass����������������������������������������������������������������������������������������������������� 4
Technique������������������������������������������������������������������������������������������������������������������������������������������������������������������ 4
Outcomes������������������������������������������������������������������������������������������������������������������������������������������������������������������ 4
MIDCAB Versus Drug-eluting Stents for Proximal LAD Stenosis�������������������������������������������������������������������������� 5
Multivessel MIDCAB����������������������������������������������������������������������������������������������������������������������������������������������� 5
Limitations���������������������������������������������������������������������������������������������������������������������������������������������������������������� 5
Endoscopic Atraumatic Coronary Artery Bypass��������������������������������������������������������������������������������������������������������� 5
Outcomes������������������������������������������������������������������������������������������������������������������������������������������������������������������ 6
Limitations���������������������������������������������������������������������������������������������������������������������������������������������������������������� 6
Robotic-assisted Direct CAB���������������������������������������������������������������������������������������������������������������������������������������� 6
Outcomes������������������������������������������������������������������������������������������������������������������������������������������������������������������ 7
Totally Endoscopic Coronary Artery Bypass���������������������������������������������������������������������������������������������������������������� 8
Outcomes������������������������������������������������������������������������������������������������������������������������������������������������������������������ 8
Limitations���������������������������������������������������������������������������������������������������������������������������������������������������������������� 8
Hybrid Coronary Revascularization������������������������������������������������������������������������������������������������������������������������������ 9
Outcomes������������������������������������������������������������������������������������������������������������������������������������������������������������������ 9
Conclusions����������������������������������������������������������������������������������������������������������������������������������������������������������������� 10
References������������������������������������������������������������������������������������������������������������������������������������������������������������������� 12

INTRODUCTION between cardiologists and cardiovascular surgeons has led

to novel minimally invasive approaches, which take advan-
Cardiac surgeons have made significant strides in devel- tage of catheter-based technology combined with surgical
oping less-invasive operations over the past 20 years. An techniques, which can yield excellent results for patients
explosion in new technology has facilitated these advance- with heart disease.
ments and allowed surgeons to perform coronary artery Minimally invasive options for CABG have also
bypass graft (CABG) surgery, valve surgery, ablation for dramatically increased in the past decade. For the pur-
atrial fibrillation procedures, and even proximal aortic poses of this discussion, minimally invasive CABG shall
operations without median sternotomy, which has been the include all surgical revascularization procedures that do
traditional approach for access to the heart. Collaboration not require a complete median sternotomy. Although

1
© 2010 Taylor & Francis Group, LLC
2 Cardiac Surgery

partial sternotomy approaches have been described, they vessels are more mobile during cardiac contraction and
are relatively infrequent compared with sternal-sparing have more tortuosity during their course. Intramyocardial
approaches; therefore, this discussion focuses on the latter. arteries, especially the LAD, tend to be straight, may
As sternal-sparing approaches have evolved, vary- appear to dive down after an initial superficial proximal
ing terminology has been used to describe the various course and can often be seen ‘emerging’ towards the apex.
techniques for performing minimally invasive CABG These cases can be quite difficult during minimally inva-
(Table 1.1). This includes minimally invasive direct cor- sive approaches, since small incision access to the entire
onary artery bypass (MIDCAB), endoscopic atraumatic LAD is usually impossible. The exception to this is with
coronary artery bypass (EndoACAB), robotic-assisted TECAB, since LAD grafting is performed completely
CABG, and robotic totally endoscopic coronary artery endoscopically. Dissection of the anterior wall, however,
bypass (TECAB). Although the majority of cases involve during any minimally invasive procedure can be chal-
single-vessel grafting using the left internal mammary lenging. LAD identification can also be more challenging
artery (LIMA) to the left anterior descending coronary with minimal access procedures, and careful attention to
artery (LAD), multivessel grafting is also well described parallel or nearby diagonal vessels on the cardiac cath-
and is increasingly performed. eterization can help prevent grafting the wrong vessel.
Space limitations also add another level of complex-
ity to minimally invasive CABG procedures. In general,
OFF-PUMP CORONARY ARTERY BYPASS
the larger the intrathoracic space, the more flexibility
Most commonly performed via median sternotomy, off- one has to manoeuvre endoscopic or robotic instruments.
pump coronary artery bypass (OPCAB) avoids the del- Similarly, for direct hand-sewn anastomoses, larger inter-
eterious effects of cardiopulmonary bypass (CPB) and spaces can facilitate grafting. Conversely, smaller framed
has resulted in comparable and even improved outcomes patients have less intrathoracic space in which to work.
in experienced centres.1,2 Although minimally invasive This, in combination with extrathoracic adipose tissue,
CABG procedures frequently use extracorporeal circula- may limit freedom of motion of endoscopic instruments.
tion, many of the procedures can be performed without Morbidly obese patients pose several limitations, including
CPB support, especially for isolated LIMA–LAD graft- distortion of landmarks for incisions or port placement, as
ing. As surgeons have become comfortable with coronary well as more difficult access because of adipose tissue.
stabilizers and cardiac positioning devices during routine
OPCAB via sternotomy, they have been able to take advan-
INDICATIONS AND CONTRAINDICATIONS
tage of these devices to enable coronary grafting through
smaller incisions. Undoubtedly, off-pump techniques have Critics of minimally invasive CABG raise concerns
played a role in the surgeon’s armamentarium during the about the safety of minimal-access procedures. Unlike
adoption of minimally invasive CABG. sternotomy approaches, access to the aorta and right
heart for cannulation and CPB are limited. Using
the femoral vessels for access may be associated with
PATIENT SELECTION
embolic cerebrovascular events owing to retrograde per-
As with any cardiac operation, careful patient selection fusion. Construction of anastomoses with either manual
and preoperative planning are essential to a successful or robotic assistance is more challenging. Operative
outcome. With any of the described approaches, access times are longer, and the benefits of quicker recovery
and exposure are more difficult with minimally invasive and improved cosmesis need to be balanced against the
CABG. When reviewing coronary angiograms, the sur- risk of more technical complications. Patients referred
geon needs to anticipate the planned site of anastomosis, for CABG frequently have significant comorbidities,
how this relates to LIMA length, the presence of epicar- which include, but are not limited to, left ventricular dys-
dial versus intramyocardial vessels, the size and calibre function, peripheral vascular disease, chronic obstruc-
of the target vessel, and the severity of stenosis of the tive pulmonary disease, and renal insufficiency. These
coronary arteries. Predicting whether a coronary artery comorbidities may frequently influence the outcomes
is intramyocardial or not can be difficult, but subtle of even traditional CABG and deserve special attention
angiographic signs can be helpful. Frequently, epicardial when minimally invasive options are being considered.

© 2010 Taylor & Francis Group, LLC

 TABLE 1.1
Different Approaches for Minimally Invasive Coronary Artery Bypass Surgery
Exposure for Construction
Approach Incisions LIMA Harvest Anastomosis of Anastomosis Complexity Advantages Limitations
MIDCAB Single left Direct visualization Via thoracotomy Manual Low Inexpensive, short Post-thoracotomy
anterolateral facilitated with incision operative time, pain from chest
thoracotomy specially designed larger incision wall retraction,
incision retractor system to allows for access possible
(5–8 cm) elevate anterior to multivessel incomplete
chest wall grafting and LIMA harvest
possible exposure

© 2010 Taylor & Francis Group, LLC

to aorta
EndoACAB Three left-sided Thoracoscopic Through 3–4 cm Manual Medium–high Relatively LIMA harvest
port incisions, microthoracotomy inexpensive, difficult
separate 3–4 cm incision rib-sparing thoracoscopically
microthoraco­ because of
tomy incision two-dimensional
for anastomosis instruments,
Minimally Invasive Coronary Artery Bypass Graft Surgery

access adequate
for LAD and/or
diagonal grafting
only
RADCAB Three left-sided Robotic Through 3–4 cm Manual Medium–high Three-dimensional Expensive, access
port incisions, microthoracotomy visualization and adequate for LAD
separate 3–4 cm incision instrumentation and/or diagonal
microthoraco­ during LIMA grafting only
tomy incision harvest,
for anastomosis rib-sparing
TECAB Three left-sided Robotic Totally endoscopic Robotic High Rib-sparing, allows High complexity,
port incisions and exposure and prolonged
one subcostal port access to entire operative times,
incision for LAD and option expensive, relies
endostabilizer for multivessel on peripheral
grafting cannulation for
CPB support

Abbreviations: CPB, cardiopulmonary bypass; EndoACAB, endoscopic atraumatic coronary artery bypass; LAD, left anterior descending coronary artery; LIMA, left internal mammary artery;
MIDCAB, minimally invasive direct coronary artery bypass; RADCAB, robotic-assisted direct coronary artery bypass; TECAB, totally endoscopic coronary artery bypass.
3
4 Cardiac Surgery

In general, patients referred for minimally invasive MINIMALLY INVASIVE DIRECT

surgery frequently fall into one of two tiers: relatively CORONARY ARTERY BYPASS
healthy patients who prefer to avoid a sternotomy but
want the durability associated with CABG; and older Technique
or sicker patients considered at high risk for traditional
MIDCAB was introduced in the early 1990s and
sternotomy but not amenable to a totally percutane-
gained popularity as a minimally invasive alternative
ous approach or medical therapy. These classifications
to single-­vessel LIMA–LAD grafting via sternotomy.3,4
are broad and poorly defined but represent the authors’
The procedure involves a 5–8 cm anterolateral thora-
current referral patterns for these cases. Indications for
cotomy incision. The left lung is decompressed using a
minimally invasive CABG are similar to those for tra-
double-­lumen endotracheal tube or bronchial blocker.
ditional CABG. There are, however, important contra-
All minimally invasive CABG procedures use selective
indications, which render a minimally invasive approach
ventilation of the right lung or low tidal volume bilateral
impractical (Table 1.2). Although there are only a few
lung ventilation. Specialized retractors have been devel-
absolute contraindications, the surgeon needs to take
oped (Thoratrak, Medtronic, Inc., Minneapolis, MN),
into consideration the possibility of untoward events
which elevate the anterior chest wall to facilitate LIMA
during minimally invasive CABG. This requires careful
harvest under direct vision. After harvest and pericar-
consideration of each patient’s clinical condition, angio-
diotomy, the procedure can be performed off-pump or
graphic details, and patient-specific anatomic variations
with CPB support. For on-pump cases, peripheral can-
associated with minimal-access procedures.
nulation may be necessary because of limited access to
the ascending aorta. A variety of stabilizers exist, which
TABLE 1.2 provide a relatively motionless field during the anasto-
Contraindications to Minimally Invasive mosis on the beating heart (Octopus and Octopus Nuvo,
Coronary Surgery Medtronic, Minneapolis, MN, and Acrobat, Maquet
Angiographicr Intramyocardial coronary arteries Cardiovascular LLC, Wayne, NJ). The anastomosis is
Small target vessels then performed manually to the LAD in a manner that is
Heavily calcified vessels technically identical to a sternotomy approach.
Occluded coronaries without good filling
via collaterals

Clinicala Haemodynamic instability

Outcomes
Ischemic arrythmias Excellent short- and mid-term results have been reported
Acute myocardial infarction by several centres. In an angiographic analysis, Mack et al.
Emergency cases reported a graft patency rate of 99% in 100 consecu-
Cardiogenic shock tive patients undergoing MIDCAB, with perfect graft
Comorbiditiesr Morbid obesity patency (no stenosis >50%) of 91%.5 Similarly, Holzhey
Severe lung impairment et al. reported a patency rate of 95.6% in 709 patients
Severe PVD if femoral cardiopulmonary bypass with a predischarge angiogram.6 Clinical outcomes have
anticipated also been favourable for patients undergoing MIDCAB,
Significant LV dysfunction (ejection fraction <30%) with low rates of periprocedural complications, includ-
Significant LV dilation ing myocardial infarction and mortality.7–12 In a report
Previous sternotomy by Poston et al.,13 MIDCAB ± stenting to non-LAD
Previous left chest surgery vessels was associated with a lower incidence of major
Chest wall deformities adverse cardiovascular events compared with traditional
Previous left chest irradiation OPCAB at 1 year. Patients in the MIDCAB group had
Pulmonary hypertension a LIMA–LAD graft ± stents, whereas patients in the
Abbreviations: LV, left ventricular; PVD, peripheral vascular disease. OPCAB group generally had a LIMA–LAD as well
a Absolute contraindications. as vein grafts. In the same report, as well as others,14
r Relative contraindications. ­quality of life measures, including earlier return to work,
were more favourable in the MIDCAB group.

© 2010 Taylor & Francis Group, LLC

Minimally Invasive Coronary Artery Bypass Graft Surgery 5

MIDCAB Versus Drug-eluting Stents Limitations

for Proximal LAD Stenosis
Despite the publication of excellent results from ­several
The durability and survival advantage of the LIMA–LAD centres performing multivessel MIDCAB, this approach,
graft for patients with multivessel coronary artery disease similar to other minimally invasive CABG procedures,
(CAD) has been well established.15 For patients with isolated has not been widely adopted. This is perhaps due in part
proximal LAD disease, however, the preferred method of to the fact that this operation is more technically chal-
revascularization is usually left to the discretion of the car- lenging, and the risk for complications is not insignifi-
diologist. With the advent of drug-eluting stents (DES), the cant. In cases requiring urgent/immediate conversion to
incidence of restenosis has been reduced. Because of the CPB, limited exposure with a MIDCAB incision makes
long-term durability of the LIMA–LAD bypass, however, access to the right atrium and aorta difficult for cannula-
cardiologists will continue to refer patients for surgical tion, and femoral cannulation carries with it the inher-
revascularization. In a randomized comparison between ent risks of embolization from retrograde perfusion.
MIDCAB and DES, noninferiority of DES was revealed Furthermore, some centres have published less than
for the difference in death and myocardial infarction but favourable outcomes. Vicol et al. found a slightly higher
was not established for the difference in target vessel revas- rate of adverse cardiac events in MIDCAB patients com-
cularization, which favoured MIDCAB.7 Because this was pared with those in traditional OPCAB patients and
only 1-year data, longer term follow-up will be needed to cautioned that this procedure should only be performed
determine if there is a difference in outcomes over time. by surgeons experienced with this technique.18 In a
Results were even less favourable for percutaneous inter- cumulative sum failure analysis, Holzhey et al. reported
vention in the era of bare metal stents.16 different results among surgeons within a single insti-
tution, suggesting that MIDCAB results are case-load
and surgeon dependent.19 Therefore, these reports imply
Multivessel MIDCAB that MIDCAB may not be generalizable to all coronary
Multivessel grafting via a MIDCAB approach (minimally surgeons. Other concerns stem from increased post­
invasive cardiac surgery (MICS) CABG) is a sternal-spar- operative pain (post-­thoracotomy syndrome) due to rib
ing approach designed to allow for grafting coronary arter- spreading and/or fracture compared with sternotomy.20,21
ies on the lateral and inferior walls, in addition to the LAD Finally, some surgeons have expressed anecdotal con-
and diagonal vessels. The skin incision is similar (4–6 cm, cerns about whether or not complete LIMA harvesting is
left anterolateral thoracotomy incision in fifth intercostal possible with a MIDCAB approach, since access to the
space, starting at the mid-clavicular line), but cardiac posi- apex of the left thorax is more difficult.
tioners and coronary stabilizers are used to mobilize the
heart to allow exposure to the inferior and lateral walls. ENDOSCOPIC ATRAUMATIC
The left groin is prepared in the field in case peripheral
CORONARY ARTERY BYPASS
cannulation is necessary. With off-pump equipment, peri-
cardial traction and table positioning, these less-accessible EndoACAB represents the introduction of endoscopic
areas can be exposed to allow for hand-sewn anastomoses. techniques into CABG procedures. The patient is posi-
Furthermore, proximal anastomoses can be performed to tioned in a modified lateral decubitus position with the
the ascending aorta with the use of proximal connectors or left chest slightly elevated. A shoulder roll placed paral-
using traditional partial clamping methods. McGinn et al.17 lel to the spine just beneath the left clavicle allows the left
reported their multicentre experience of 450 consecutive shoulder to hang, which facilitates mobility of the most
MICS CABG procedures with excellent angiographic superior working port. The left arm is tucked loosely to
and clinical results. In their series, 92.4% of procedures the patient’s side. A 10–12 mm camera port is inserted
were performed without CPB, conversion to sternotomy into the left chest in the fourth or fifth interspace (mid-
occurred in <4% of cases, hospital mortality occurred in sternum), two fingerbreadths lateral to the mid-clavicular
1.3% of patients, and the need for mid-term repeat inter- line or near the anterior axillary line. After insufflat-
vention (available for first 300 patients) occurred in <3%. ing the chest with carbon dioxide to 10–15 mmHg, two
Nonetheless, this approach needs to be validated at other 5-mm operating ports are then placed in a line parallel
centres before more widespread adoption is likely. to the camera port two interspaces above and below the

© 2010 Taylor & Francis Group, LLC

6 Cardiac Surgery

camera port under endoscopic guidance. The usual port revascularization (HCR) approach.22–25 Thirty-day mor-
configuration is in the second, fourth, and sixth interspaces tality of 607 patients was 1.0%. The overall patency of
or the third, fifth, and seventh interspaces. The LIMA can 379 patients, who had coronary angiography after opera-
then be harvested directly using endoscopic instruments tion, revealed that 335/340 patients had FitzGibbon A
(Figure 1.1). The pericardium is also opened endoscopi- or B patency of the LIMA–LAD graft (98.5%). Finally,
cally. After heparinization, the LIMA is transected distally. the five-year event-free survival was 92%. These prom-
A long spinal needle is then passed through the anterior ising results establish the feasibility and safety of this
chest wall to localize the planned site of incision. The left approach but have not been replicated in other centres.
chest is slowly deflated of carbon dioxide and the planned
site of anastomosis on the LAD is visualized as the heart
Limitations
returns to its normal position within the left hemithorax.
This process facilitates precise localization of the 3–4 cm Similar to the MIDCAB procedure, the main limitation
anterolateral thoracotomy incision, usually in the fourth or of this approach is the technically challenging nature of
fifth interspace. All ports are then removed and the antero- the operation. LIMA harvest is more difficult with two-
lateral thoracotomy incision is made. A soft tissue retractor dimensional instruments working in a three-dimensional
(CardioVations, Edwards Lifesciences, Irvine, CA) is used space. The endoscopic instruments lack the flexibility
to provide exposure through the interspace. The LIMA is associated with robotic technology, and performing a
retrieved into the operating field and prepared. The LAD manual anastomosis through an interspace is difficult.
target is exposed and stabilized using a minimally invasive Furthermore, harvesting the LIMA endoscopically and
stabilizer (Octopus NUVO, Medtronic, Minneapolis, MA) performing the anastomosis through a micro-thoracotomy
and the anastomosis is performed manually, using fine is associated with a significant learning curve. Several
monofilament suture. centres have transitioned to robotic assistance because
of the three-dimensional flexibility associated with
this enabling technology. With off-pump MIDCAB,
Outcomes
EndoACAB, and robotic-assisted direct coronary bypass
Vassiliades et al. have reported the feasibility, safety, and (RADCAB) procedures, the rare but potentially devas-
mid-term outcomes of EndoACAB, both as an isolated tating haemodynamic collapse that may occur with car-
LIMA–LAD bypass and as part of a hybrid coronary diac manipulation and transient coronary occlusion must
be anticipated and prevented, to avoid morbidity and
mortality associated with crash conversions to CPB.26
Left pleural In minimally invasive CABG, converting to sternotomy
space LI
M Rib or exposing the femoral vessels for cannulation can be
A #1
anticipated to require significant time. This is one reason
that surgeons should become experienced in off-pump
procedures via sternotomy before attempting minimally
invasive off-pump procedures. This includes facility
L. Subclavian v. with the use of intracoronary shunts, as well as the avail-
a.
ian ability of supportive personnel and anaesthetists who
lav
n. bc have experience with OPCAB.
Su Supreme intercostal
en
ic L. branch
r
Ph
L.
ROBOTIC-ASSISTED DIRECT CAB
Collapsed L. Lung
RADCAB is another step during the evolution of mini-
FIGURE 1.1 View of intrathoracic anatomy that is seen
mally invasive techniques for coronary surgery. This
with the endoscopic or robotic approach. With the left lung procedure combines the technological advancements
collapsed and carbon dioxide insufflation, the LIMA can be associated with robotic telemanipulation with the direct
clearly visualized for harvest from its origin to the bifurcation. manual anastomosis associated with MIDCAB. The da
Abbreviation: LIMA, left internal mammary artery. Vinci Surgical System (Intuitive Surgical, Sunnyvale,

© 2010 Taylor & Francis Group, LLC

Minimally Invasive Coronary Artery Bypass Graft Surgery 7

CA) combines superior high-definition visualization

with flexible three-dimensional instruments to allow
for complex manipulation and dissection. The pro-
cedure is set up similar to EndoACAB (Figure 1.2). LIMA-LAD
The LIMA is harvested with the da Vinci Surgical anastomosis
System, followed by a pericardiotomy. The target site Proximal and
can be localized under endoscopic guidance with a spi- distal vessel loops
around LAD
nal needle, which allows for precise planning of the
anterolateral thoracotomy incision (Figures 1.3 and
1.4). The anastomosis is then performed with ­standard
coronary instruments and stabilizers as ­ previously
described with endoACAB and MIDCAB.

Outcomes FIGURE 1.3 The anastomosis in robotic-assisted coronary

Although there are no large prospective trials compar- artery bypass or endoscopic atraumatic coronary artery bypass is
performed via a small anterolateral thoracotomy, which is made
ing RADCAB to conventional CABG, several small
after localizing the planned site of anastomosis on the LAD with
series exist, which document the feasibility and safety of a spinal needle under endoscopic guidance. Stabilization of the
this approach.8,27–29 Robotic assistance provides greater LAD can be performed with custom-made or commercially
flexibility and visualization compared with endoscopic available stabilizers. Abbreviations: LIMA–LAD, left internal
approaches, but the lack of tactile feedback during dis- mammary artery–left anterior descending coronary artery.
section is one of the main limitations. A few centres have
used this approach as a transition to TECAB.

12mm camera port

Inferior 8.5mm Superior 8.5mm
operating port operating port

FIGURE 1.2 Port placement for robotic-assisted and robotic

totally endoscopic coronary artery bypass. The camera port is
placed at the mid-sternal level, either two fingerbreadths lateral
to the mid-clavicular line or on the anterior axillary line. The
operating ports are then placed two interspaces above and below
the camera port, slightly more medial than the camera port.
Placement of the operating ports can vary depending on the view
from within the chest. It is important, however, to place the supe-
rior port more medial to avoid interference with the left shoulder. FIGURE 1.4 Skin incisions 2 weeks after surgery.

© 2010 Taylor & Francis Group, LLC

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