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J Thorac Cardiovasc Surg 1999;117:390-391
© 1999 Mosby, Inc.
BRIEF COMMUNICATIONS |
From the Division of Cardiothoracic Surgery, Department of Surgery, Baylor College of Medicine, The Methodist Hospital, Houston, Tex.
Received for publication Oct 21, 1997. Accepted for publication Nov 21, 1997. Address for reprints: Michael J. Reardon, MD, 6550 Fannin, Suite 1619, Houston, TX 77030.
Coronary artery bypass (CAB) without the use of cardiopulmonary bypass (CPB) has been performed since the earliest days of coronary surgery. Recently, interest in off-pump bypass has increased rapidly as a way to perform CAB at less cost and morbidity. Most current publications on minimally invasive direct coronary artery bypass (MIDCAB) deal with surgical technique, feasibility, and early results. The recent review of MIDCAB grafting by Calafiore and associates
1 provides an excellent summary of this subject, as well as addressing concerns with the procedure. The evolution of this procedure has also seen the emergence of complications associated with MIDCAB that may represent an under-reporting of problems. 2,3 We report the case of a patient requiring orthotopic cardiac transplantation after MIDCAB.
Clinical summary
A 68-year-old man was admitted on March 4, 1997, with shortness of breath and extreme fatigue with minimal exertion consistent with severe congestive heart failure. Five years before this admission he was evaluated for angina and found to have an isolated 90% stenosis of the left anterior descending (LAD) coronary artery and an ejection fraction of 45%. Successful percutaneous transluminal coronary angioplasty (PTCA) was accomplished with relief of angina. Two years later recurrent angina and LAD stenosis developed and he again responded to successful PTCA. Six months before admission, angina again developed. The patient was found to have a long stenosis of the LAD as an isolated lesion and an ejection fraction of 35%. MIDCAB with a left internal thoracic artery graft to the LAD was performed at another institution and he was discharged without angina. Three weeks after discharge, angina developed yet again, with the additional symptoms of shortness of breath with moderate exertion. Cardiac catheterization revealed a severe stenosis of the left internal thoracic artery graft at its anastomosis to the LAD, as well as an ejection fraction of 20%. Attempted PTCA of the anastomosis was unsuccessful. Further clinical deterioration prompted transfer to our facility with admission for intravenous inotropic support. Cardiac catheterization at that admission showed a cardiac index of 1.29 L/min per square meter, a pulmonary artery pressure of 65/37 mm Hg, a pulmonary capillary wedge pressure of 32 mm Hg, and a central venous pressure of 19 mm Hg. Deteriorating clinical status, as well as rising hepatic enzyme levels and decreasing renal function, prompted consideration for cardiac transplantation. On March 1, 1997, orthotopic cardiac transplantation from a 35-year-old male donor was successfully accomplished. The postoperative course was uneventful, and the patient is doing well at home without symptoms at this time.
Discussion
The surgical treatment of ischemic heart disease has a long and interesting history. The initial direct approaches to coronary artery obstruction were done without the use of CPB. 1,2 However, without CPB for hemodynamic support, the extent and accuracy of the coronary surgery often suffered. Subsequently, median sternotomy, CPB, and myocardial protection became the cornerstones of modern coronary artery surgery, allowing an excellent operating environment and access to all coronary arteries. Recently a rapid recurrence of interest in off-pump CAB as a form of minimally invasive CAB has arisen. 1 This world-wide phenomenon follows the explosion of laparoscopic techniques in general surgery in an attempt to extend minimally invasive technique into thoracic surgery. The majority of the recent literature on beating-heart CAB has been focused on surgical techniques, feasibility, and early results. 4-7 Growing experience with this technique led to its application in patients with decreased left ventricular function. 8 However, complications with the beating-heart anastomosis have been reported 2 and seen in cases performed by experts at MIDCAB conferences. In our clinical setting, we have seen referrals for PTCA and redo CAB after anastomotic failure in patients undergoing MIDCAB, and we have reported our concerns with the procedure. 9 The case reported here is the first one in which we have had to perform a cardiac transplantation after failed MIDCAB and, to our knowledge, the first reported cardiac transplantation after an unsuccessful MIDCAB procedure.
Summary
Recent experience at our institution and others supports the feasibility of the MIDCAB procedure in selected cases. Whether it can be mastered by the average cardiac surgeon and provide equal or better early graft patency, completeness of revascularization, and long-term outcome remain to be proved. In the meantime, complications of this procedure should be studied to allow adequate assessment of the risk involved.
References
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