Publications

Planned Simultaneous Beating-heart Totally Endoscopic Coronary Artery Bypass (TECAB) and Percutaneous Intervention in a Single Operative Setting

Sudhir Srivastava, Suresh Gadasalli, Orlando Tijerina, Reyna Barrera, Shaune Quismundo, and Vishwa Srivastava

Abstract

Background: Staged hybrid revascularization integrated with minimally invasive coronary artery bypass grafting (CABG) and arrested heart totally endoscopic CABG has been reported. We report the first case of planned simultaneous hybrid coronary revascularization, integrating beating-heart TECAB, and percutaneous intervention (PCI) in the same operative setting.

Methods: A 73-year-old woman with symptoms of angina and a history of diabetes was found to have 2-vessel coronary artery disease involving the left anterior descending (LAD) and the right coronary artery (RCA). Left internal thoracic artery (LITA) to the LAD grafting was done on a beating heart in a totally endoscopic manner using the da Vinci robotic system through 4 ports. Immediately after LITA to LAD TECAB, percutaneous angioplasty and stent placement was done through the right femoral artery using the OEC 9800 mobile C-arm in the operating room.

Results: There was no stenosis noted in the RCA after the intervention. LITA angiography showed a completely patent anastomosis. The total operative time for both procedures was 165 minutes. Occlusion and anastomotic times were 14 and 8 minutes, respectively. Total PCI and fluoroscopy times were 10 and 3 minutes, respectively. The patient received clopidogrel (Plavix) and aspirin in the immediate postoperative period and was discharged home on the second postoperative day.

Conclusion: This planned hybrid approach involving a beating heart single-vessel TECAB and simultaneous angioplasty-stent in a single operative setting achieved complete coronary artery revascularization in a less invasive way.

Key Words: Hybrid coronary revascularization, Beating-heart
TECAB, Percutaneous coronary intervention.
(Innovations 2006;1: 239–242)

Hybrid coronary artery revascularization is a combined approach involving minimally invasive coronary artery bypass grafting (CABG) and percutaneous intervention (PCI) of other significantly diseased coronary arteries that are suitable for PCI. There have been reports describing hybrid approaches where left internal thoracic artery (LITA) to left anterior descending (LAD) grafting has been done using minimally invasive approaches and PCI for other affected coronary arteries.^1–3 Superiority and better long-term patency of LITA to LAD has been well established.⁴ Saphenous vein grafts (SVG) to non-LAD coronary arteries continue to show unsatisfactory occlusion rates. There is reported 20% to 30% occlusion in the first year and approximately 25% to 30% of the open SVG in 10 years show significant disease.^5–7 Bilateral ITAs can be used to achieve complete arterial revascularization in many patients through a lateral thoracotomy approach (ThoraCAB) with shorter hospital length of stay.⁸

Newer drug-eluting stents or larger size bare metal stents show significantly lower in-stent stenosis.⁹ CABG may be reduced by up to 46% because of increasing use of the newer stents,^10,11 but drug-coated stents may not be the answer for better long-term outcomes when compared with established superior LITA to LAD graft patencies.

TECAB is currently the least invasive approach to achieve surgical revascularization in selected coronary arteries. The procedure can be performed through 4 or 5 ports on a beating heart, thus allowing for the advantages of off-pump CABG. Revascularization with arterial grafts will offer reduced major adverse cardiac events (MACE). There is reduced hospital length of stay and fast functional recovery in the majority of our patients.¹²

Hybrid coronary revascularization, combining the beating- heart TECAB approach and a simultaneous or staged PCI, could pave the way to a least invasive approach while achieving complete coronary revascularization and offering the best benefit of both surgical and PCI revascularization techniques.^13,14

Methods

LITA to LAD TECAB

A 73-year-old woman with history of diabetes and hypertension controlled with medical treatment presented with exertional angina and dyspnea. The family history was positive for coronary artery disease. An exercise stress test was positive for myocardial ischemia. Cardiac catheterization revealed 90% stenosis of proximal LAD and 75% stenosis of proximal right coronary artery (RCA). Left ventricular ejection fraction was 49% with hypokinesia of apex, mid, and distal anterior walls. Based on the findings of coronary angiography, the patient was considered for LITA to LAD beating-heart TECAB immediately followed by PCI of RCA in the operating room.

The patient was placed in a supine position with the left arm supported in a partial hanging position with flexion at the elbow. General anesthesia with double-lumen endotracheal intubation was initiated. After sterile preparation and draping and before initiating the surgical procedure, a size 6 femoral sheath was introduced by Seldinger technique into the right femoral artery. During the surgical procedure, the sheath was kept patent with heparinized saline flush.

After deflating the left lung, the camera port was inserted in the left fifth intercostal space, 4 cm anterior to the anterior axillary line. The right and left instrument arm ports were inserted through the third and seventh intercostal spaces, respectively, forming a straight line with the camera port. After insertion of the camera port, carbon dioxide insufflation was initiated maintaining a positive intrathoracic pressure of 8 to 10 mm Hg. The LITA was dissected in a completely skeletonized fashion from the first rib to its bifurcation. The LITA was left partially attached to the chest wall, preventing it from lying over the pericardium. Mediastinal and pericardial fat was dissected off the pericardium laterally. Anterior pericardiotomy was extended obliquely toward the left atrial appendage. LAD was identified and its suitability for endoscopic anastomosis was determined.

The subxiphoid port was inserted in the left subcostal area approximately 3 cm below and lateral to the xiphoid process. The endoscopic stabilizer (Octopus TE, Medtronic Inc, Minneapolis, MN) was inserted into the cannula. Systemic heparin (2 mg/kg) was given. Activated clotting time was monitored and was maintained over 300 seconds. Two silastic SaddleLoops (Quest Medical Inc, Allen, TX) were brought in and tacked on to the chest wall. A bulldog clamp (Vascu-Statt Plus, Scanlan Intl, St. Paul, MN) with a silk suture attached to it was applied to the LITA and the end of the silk string was tacked onto the chest wall to prevent LITA from rotation or migration. Two hemoclips were applied distally and LITA was spatulated leaving approximately 1 mm of the apex intact. The bulldog was partially released to check the blood flow from the distal end of the LITA.

Five Nitinol S-18 short flex U-Clips (Medtronic Inc) were brought into the operative field mounted on the U-Clip cartridge delivery tool (Medtronic Inc). These U-Clips were passed through the spatulated LITA as follows: 1 in the heel, 3 through the free edge away from the surgeon, and 1 in the apex. An S-35 short flex U-Clip was passed through the fat attached to LITA for later tacking to the epicardial fat. After this, LITA was completely freed from the chest wall and the distal end transected. Five additional S-18 short flex U-Clips were brought in and placed on the medial part of the pericardium.

Throughout the procedure, intravenous nitroglycerin was infused continuously. A 100 mg bolus of lidocaine was given before preparation of LAD and an intravenous drip continued at 2 mg/min until after completion of the anastomosis and release of the LAD occlusion to minimize reperfusion arrhythmia.

The endoscopic stabilizer was positioned over LAD and secured. An irrigator, which is part of the endoscopic stabilizer, was brought over the LAD. Warm normal saline with 120 mg/L papaverine was used as irrigation fluid. After placing the SaddleLoops proximally and distally around LAD, the artery was prepared using a beaver blade. Occlusion was initiated by tightening the SaddleLoops. Arteriotomy was done using a sharp knife and extended with Potts scissors to 3.5 to 4 mm. The LITA was tacked on to the epicardial fat with the previously placed S-35 U-Clip.

LITA to LAD anastomosis was performed by placing the heel U-Clip of LITA through the heel of the LAD arteriotomy. The remaining previously placed U-Clips were passed through the LAD wall away from the surgeon in a sequential manner, finally placing the fifth U-Clip through the apex of the LAD. These U-Clips were initially left loose; once all the U-Clips were passed through LAD, the LITA was parachuted down. Three additional U-Clips were passed through the surgeon’s side of the arteriotomy. The bulldog was partially released to de-air the LITA. All the U-Clips were crimped and the needles placed on one area of the pericardium. The bulldog was released and after inspecting the anastomosis, the SaddleLoops were removed. The endoscopic stabilizer was removed from the operative field.

A Medi-Stim Butterfly Flowmeter (Medtronic Inc) designed for endoscopic use was brought through the subxiphoid port. A 5 Fr feeding catheter was secured to the probe for application of ultrasonic gel at the tip of the probe. Flow measurement recordings were obtained. All supplies brought inside the chest were removed with an endoscopic grasper under endoscopic vision. A magnet was used to remove all the U-Clip needles. Heparin was not reversed. A single size 19 Fr Blake drain (Ethicon Inc, Somerville, NJ) was placed through the left instrument port and positioned behind the lung and the left lung was reinflated. After removing the robotic arms, all the incisions were closed in subcuticular manner using 4-0 Monocryl and Dermabond (Ethicon Inc, Piscataway, NJ) was applied to seal the incisions.

Percutaneous Angioplasty and Stent Placement of RCA

The preexisting right femoral artery 6 Fr sheath inserted prior to the start of TECAB was changed to an 8 Fr sheath. The patient continued to be heparinized and therapeutic anticoagulation was maintained. The OEC 9800 mobile Carm (General Electric Co) with recording and playback capability was positioned for PCI. A Judkins Right 48 Fr guiding catheter, choice polymer tip 0.014 extra support 182 cm guide wire and a 3.0 12 mm Liberte bare metal stent was delivered under fluoroscopic guidance. Excellent lesion coverage and a TIMI 3 flow were seen after stent deployment. LITA to LAD angiography was undertaken with the same guide catheter.

Results

Planned LITA to LAD and simultaneous PCI to RCA were successfully achieved. Total operative time was 165 minutes. LITA harvesting time was 49 minutes. Occlusion and anastomotic times were 14 and 8 minutes, respectively. The mean graft flow and pulse index were 30 mL/min and 1.5, respectively. Total PCI time was 10 minutes with fluoroscopy time of 3 minutes, which included LITA to LAD angiography. The 75% stenosis of RCA was reduced to 0% with TIMI 3 flow on post-PCI angiography (Fig. 1). The LITA to LAD anastomosis and flow was excellent (Fig. 2). Clopidogrel (Plavix) 600 mg was given through a nasogastric tube immediately upon arrival in the coronary care unit (CCU). The total chest tube blood loss was 260 mL. The patient did not receive any blood products during or after surgery. The patient was extubated 8 hours postoperatively in CCU and transferred to the telemetry unit on postoperative day 1. The chest tube was removed on the second postoperative day and the patient was discharged home. Postoperative electrocardiogram showed no evidence of myocardial ischemia. After discharge, the patient was to continue clopidogrel (Plavix) 75 mg daily for 3 months and aspirin 81 mg for life.

DISCUSSION

Since the use of da Vinci robotic system for TECAB, over 350 arrested heart and 500 beating-heart TECABs have been performed worldwide. The US Multicenter Arrested Heart Trial established the safety and feasibility of TECAB with da Vinci robotic system and reported a 91% freedom from graft failure or reintervention.¹⁵ The trial was considered a platform for beating-heart TECAB. Katz et al13 reported staged hybrid revascularization in 27 patients undergoing arrested-heart TECAB.

In our series of 129 patients with intent to treat as beating-heart TECAB, 109 patients had successful TECAB. Single, double, and triple vessel beating-heart TECAB was performed in 60 (55%), 44 (40%), and 5 (5%), respectively. The short-term graft patency was 99.3% (135/136). In this series, 20 patients underwent planned staged hybrid revascularization.¹² Hybrid coronary revascularization continues to be reported with other minimally invasive coronary bypass grafting approaches.

Superior long-term survival and MACE-free interval continue to be reported with the use of single or bilateral ITA in CABG. We have been able to graft LAD, DX, RB, OM1, OM2, and RCA using single or bilateral ITA in beating-heart TECAB. In multivessel coronary artery disease, the hybrid revascularization integrating beating-heart TECAB with ITA and PCI may achieve complete revascularization in a less invasive way. In planned staged hybrid approach, TECAB followed with PCI is desirable. This sequence allows for assessment of graft patency during PCI and minimizes concern of excessive postoperative bleeding that may be associated with the use of clopidogrel (Plavix). However, in patients presenting with acute coronary syndrome, PCI of the culprit vessel may be followed by TECAB. In our series, 4 patients who underwent beating-heart TECAB after PCI did not experience excessive postoperative bleeding. A team approach between cardiac surgeon and cardiologist may help evolve anticoagulation protocols for each procedure. Since the experience with this particular case, in simultaneous hybrid coronary revascularization, we reverse the heparin fully and proceed with closure of port incisions. Angiomax infusion is given for percutaneous intervention, which is immediately followed by clopidogrel (Plavix). In our experience of 26 planned hybrid revascularizations in beatingheart TECAB cases, none required conversion to thoracotomy or sternotomy. Intraoperative graft flow measurement followed by graft angiography, may help establish correlation and value of flow measurement in TECAB procedures.

Simultaneous hybrid coronary revascularization integrated in the operating room or PCI in the cardiac catheterization laboratory may offer the most expeditious way of achieving complete revascularization. The OEC 9800 mobile C-arm appears to offer acceptable views and resolution, particularly for the RCA and the anterior coronary arteries. A hybrid suite combining the cardiac catheterization laboratory and operating room may provide a comfortable environment for both surgeon and cardiologist. This may further reduce the hospital length of stay and cost and enhance the functional recovery in these patients.

The case above shows feasibility of a planned simultaneous beating-heart TECAB and PCI in the same intraoperative setting.⁴ Follow-up studies and randomized trials may identify the best candidates for simultaneous hybrid revascularization. These studies may determine ideal interventions for a specific coronary artery. Fast computed tomography scan with 3-dimensional image reconstruction may offer a less invasive way to assess long-term patency in many of the clinically asymptomatic patients. Advances in robotic and anastomosis technology may pave the way for this innovative approach with significant patient benefits.

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