Life ScienceS | Medicine Minimally invasive direct coronary artery bypass: preliminary results at University Medical Center of Ho Chi Minh city Hoang Dinh Nguyen*, Tuan Anh Vo, Thi Thu Trang Nguyen, Tran Viet Chuong Pham, Tam Thien Vu Department of Cardiovascular surgery - University Medical Center of Ho Chi Minh city Received 10 October 2017; accepted 12 December 2017 Abstract: meticulous surgery, requiring the Background - Objectives: In the recent years, minimally invasive direct coronary artery bypass (MIDCAB) is under rapid development worldwide. The number of MIDCAB is growing dramatically in developed countries. This study aimed for the assessment of indications, techniques, and short-term result of MIDCAB and the experience in building a new technique in our center. Method: We reported 4 patients who underwent minimally invasive coronary artery bypass at the University Medical Center of Ho Chi Minh city. Results: 4 patients were operated with MIDCAB procedure. Mean ICU time was 1.4, mean mechanical ventilation time was 5.7 hours, and in-hospital time was 8.4 days. In postoperative time, patients recovered quickly; they experienced less pain than normal and returned to normal activities in a short time. Conclusions: In our very first experiences with MIDCAB procedure, the early outcomes are satisfactory with low morbidity and no mortality. MIDCAB is safe and feasible, provided that patient selection is good and safety protocols are followed. Keywords: coronary artery bypass, left minithoracotomy, minimally invasive cardiac surgery. Classification number: 3.2 surgeon to not only have good strategies and be knowledgeable, but also have good skills. The classic opening is the median sternotomy. Internal thoracic artery, saphenous vein, gastroepiploic artery have been used as graft materials. Surgery is performed with cardiopulmonary bypass (cardiac arrest) or off-pump technique (using a specially designed holder to fix the heart), or under the support of cardiopulmonary bypass without cardiac arrest. The advantage of median sternotomy is a large surgical field, where the surgeon can operate easily and conveniently. However, this approach also has its own disadvantages. One of the disadvantages of median sternotomy is the risk of postoperative deep sternal wound infection. In coronary Background First described in 1910 by Alexis Carrels, coronary artery bypass grafting is one of the three major areas of adult heart surgery. The first selected graft is the internal thoracic artery. In 1955, vein grafts were put into use. In 1958, off-pump coronary surgery was first performed by Longmire [1]. Coronary artery disease has so far been widespread, with a long-term survival of around 77% after 10 years (Domburg, et al.) [2]. Currently, in Vietnam, coronary artery bypass surgery has been widely performed in heart centers. At University Medical Center of Ho Chi Minh city, coronary artery bypass surgery has become a routine surgery. Technically, this is one of the most artery bypass surgery via median sternotomy, there is an increase in the risk of sternal dehiscence. In addition, there are general drawbacks such as postoperative pain, slower recovery than less invasive surgery, increased hospital stay, and increased costs [3]. Since the internal thoracic artery is the first choice graft, when this artery is harvested, blood supply to the sternum decreases, leading to increased risk of infection and reduced bone healing. From 2005 *Corresponding author: Email: December 2017 • Vol.59 Number 4 Vietnam Journal of Science, Technology and Engineering 47 Life ScienceS | Medicine to 2010 in India, Okonta, et al. found that the mean length of stay for sternal wound infection was 23.5±8.9 days, which was much longer than the length of hospital stay after surgery without these complications [4]. However, until now, total arterial coronary artery bypass grafting is still the gold standard for cases of triple vessels disease, having the best long-term graft patency, long-term mortality, as well as lower incidence of cardiovascular events than other methods [5]. Currently, triple vessels disease with stentable lesions in the left circonflex and right coronary systems in high-risk patients (elderly, obesity, diabetes mellitus), median sternotomy and bilateral internal thoracic arteries harvesting may increase the postoperative mortality and complications, particularly deep sternal wound infection and long recovery time of the patient. Therefore, the trend of minimally invasive surgery has opened a new direction for these Method A total of 4 patients underwent MIDCAB surgery via left anterior thoracotomy at the Department of Cardiovascular surgery of the University Medical Center of Ho Chi Minh city from January 2017 to October 2017 (Table 1). In four patients, there were three cases of chronic total occlusion of the Left anterior descending artery (LAD), one early stent stenosis of LAD in relatively young patients (54 years), the patient and his family chose less invasive coronary artery bypass surgery. All patients underwent MIDCAB via left anterior thoracotomy. Techniques Patients were placed in supine position with a cushion under the left scapula to facilitate exposure; two first patients were anesthetized with double lumen endobronchial tube selective left lung isolation, single lumen endotracheal tube was used for the following two patients. An incision of 7 cm was made, the LAD are at the first or the middle part, we choose the IV intercostal space (ICS), if LAD lesions are at the third part, we choose the fifth ICS (Fig. 1). A special thoracic retractor (Geister’s Thoragate) is specially designed to harvest the left internal mammary artery (LIMA). The goal is to harvest to the origin of the artery in order to avoid stealing blood from the collateral branches of the internal thoracic artery to the chest wall. The median duration of chest harvesting in four patients was 46.5 minutes. The two early patients were longer than the two following ones. After being harvested from the chest wall, the LIMA was cut down to check the blood flow and ensure no dissection or damage that affect the flow. The pericardium was opened at the level of the LAD. Traction sutures were placed to give better exposure to this artery. In the first two cases, we used supported cardiopulmonary bypass from the femoral vessels; in the latter two cases, patients: coronary intervention in intercostal space was selected depending we performed the complete off-pump combination with surgery. on the lesions on the LAD. If lesions of LIMA-LAD anastomosis (Figs. 2, 3). Fig. 1. Thoragate retractor (left) and surgeon’s position (right). 48 Vietnam Journal of Science, Technology and Engineering December 2017 • Vol.59 Number 4 Life ScienceS | Medicine Table 1. Description of the variables. Variables Number of patients Mean ventilation time (hour) Mean ICU time (days) Mean postoperative time (days) Fig. 2. LAD stent restenosis. Results 4 5.7 1.4 8.4 After performing the anastomosis, hemostasis was checked, a chest tube and a pericardial drainage were placed and the thoracotomy was closed. Results and discussions By the 1980s, coronary artery bypass surgery had been established as a widespread and safe surgery. Since the 1990s, less invasive cardiac surgery has been widely accepted to meet the needs of patients (less traumatic, cosmetic) and the requirements of economic benefits (rapid recovery, reduction in hospitalization time). As a result, new surgical instruments and peripheral cardiopulmonary bypass techniques have been developed (outside the thoracic aorta and the vena cava) to help create a limited access to the surgical field while maintaining the quality of the operation. Minimally invasive cardiac surgery uses a variety of approaches such as ministernotomy, minithoracotomy and small trocar holes (total endoscopic and robotic surgery). This type of cardiac surgery reduces bleeding, pain, and the incidence of surgical site infections. Additionally, it helps patients recover quickly, reduces hospital stay, and reduces medical costs. Many studies have shown that all of the techniques performed in cardiac surgery with classic sternotomy are applicable in less invasive cardiac surgery without altering the prognosis of the patient, even when performed for patients with high surgical risk. A meta-analysis of P. Modi, et al. from 43 studies published between 1998 and 2005 (two RCTs, 17 case-control studies, 24 cohort studies), found that compared to conventional full sternotomy, minimally invasive cardiac surgery did not increase mortality, and postoperative cerebrovascular accident. Reoperation due to bleeding was significantly higher but tended to decrease with time. Moreover, infection was significantly lower (1.8% vs. 7.7%, p = 0.03). The level of postoperative pain was reduced, and the recovery time to normal activities was faster (4 weeks vs. 9 weeks, p = 0.01) [6]. In 1998, Duhaylongsod, et al. described LIMA harvesting through Fig. 3. LIMA harvested (left) and LIMA - LAD anastomosis (right). a small thoracotomy with thoracic December 2017 • Vol.59 Number 4 Vietnam Journal of Science, Technology and Engineering 49 Life ScienceS | Medicine endoscopy, which contributed to put the off-pump coronary artery bypass first steps in minmally invasive coronary (OPCAB) grafts on single vessel disease, artery bypass surgery [1]. which demonstrated no difference in mortality, recurrent myocardial infarction, postoperative cerebrovascular accident, treating modalities for this very important atrial fibrillation, and reoperation [8] coronary artery. If the artery is severly stenosis and the lesion is complicated, and unstentable, harvesting the LIMA via a small thoracotomy with the usage of a special retractor helps avoid the median - Single vessel disease of LAD and/ sternotomy. This is especially beneficial or diagonal branches with complex, for patients with type 2 diabetes, obesity unstentable lesions. as itodecreases chestf unstability and the lesi- Stent restenosis of LAD, unstentable According to Y. Ling, et al.’s report - Three-vessel disease in high-risk on minimally invasive coronary artery patients, unstentable, revascularisation of bypass surgery, the median duration of the most important cardiac muscle part LIMA harvesting was 43 minutes, mean perfused by LAD is indicated. mechanical ventilation time was 9±7 - Three-vessel disease in high-risk the mean units of red blood cell transfused patients and it is feasible to stent the LCx was 0.79+1.58, and 30 day mortality was - Patients with coronary artery disease who wish to undergo minimally invasive R. Birla, et al. conducted a research to surgery on the LAD in combination with compare the minimally invasive coronary stent placement in the other branches artery bypass surgery and the conventional (right coronary arteries and arteries) [7]. Table 2. In-hospital clinical outcomes and 30-day mortality (N = 200). Collaboration between Cardiac surgeons and Interventional Cardiologists: Cardiologists play an important role in the selection of patients with minimally invasive coronary artery bypass surgery based on the indications. The collaboration between cardiac surgeons and interventional cardiologists to select the patient ensures patient safety, and provides a new option for patients, especially those at high risk for surgery. Conclusions In our very first experiences with MIDCAB procedure, the early outcomes are satisfactory with low morbidity and no mortality. MIDCAB is safe and feasible, provided that patient selection is good and safety protocols are followed. REFERENCES [1] m. Diodato and e.G. chedrawy (2014), “coronary Artery bypass Graft Surgery: The Past, Present, and Future of myocardial revascularisation”, Surgery Research and Practice, 2014, 6 pp, Article ID 726158. [2] r.T. Van Domburg, A.P. Kappetein, A.J. bogers (2009), “The clinical outcome after coronary bypass surgery: a 30-year follow-up study”, European Heart Journal, 30(4), pp.453-458. 30-day mortality, N (%) Perioperative MI, N (%) Duration of mechanical ventilation, hour MIDCAB (n=138) 1 (0.7 %) 1 (0.7 %) 9.93±8.65 Hybrid (n=62) 0 (0.0 %) 0 (0.0 %) 7.79±4.43 Total (N=200) 1 (0.5 %) 1 (0.5 %) 9.27±7.65 [3] Jitumoni baishya, et al.(2017), “minimally invasive compared to conventional approach for coronary artery bypass grafting improves outcome”, Annals of Cardiac Anaesthesia, 20(1), pp.57-60. LOS in ICU, hour 24.17±17.83 24.48±18.03 24.27±17.85 PRBC, units 0.86±1.63 0.61±1.47 0.79±1.58 PAF, N (%) 10 (7.2 %) 4 (6.5 %) 14 (7.0 %) Stroke, N (%) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) Renal failure, N (%) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) Incision complications, N (%) 0 (0.0 %) 0 (0.0 %) 0 (0.0 %) Icu: intensive care unit; loS: length of stay; mI: myocardial infarction; PAF: postoperative atrial fibrillation; Prbc: packed red blood cell. Table 3. Intensive care unit length of stay for MIDCAB and OPCAB groups. MIDCAB (n=74) OPCAB (n=78) p-value Length of stay 38.36 hours 47.87 hours >0.5 Ventilation duration 5.04 hours 5.35 hours >0.5 Table 4. Comparison of early postoperative outcomes between MIDCAB and OPCAB groups. MIDCAB (n=74) OPCAB (n=78) p-value Mortality 0 (0%) 0 (0%) - [4] K.e. okonta, et al. (2011), “Sternal wound infection following open heart surgery: appraisal of incidence, risk factors, changing bacteriologic pattern and treatment outcome”, Indian Journal of Thoracic and Cardiovascular Surgery, 27(1), pp.28-32. [5] m. Zeriouh, et al. (2017), “long-term Survival, Freedom from re-intervention and costs after mIDcAb compared to PcI on the lAD”,The Thoracic and Cardiovascular Surgeon, 65(S 01), pp.S1-S110. [6] P. modi, A. Hassan, W.r. chitwood (2008), “minimally invasive mitral valve surgery: a systematic review and meta-analysis”, European Journal of Cardio-Thoracic Surgery, 34(5), pp.943-952. [7] Y. ling, et al. (2016), “minimally invasive direct coronary artery bypass grafting with an improved rib spreader and a new-shaped cardiac stabilizer: results of 200 consecutive cases in a single institution”, BMC Cardiovascular Disorders, 16, p.42. Reoperation for bleeding Atrial fibrillation Wound infection Cerebrovascular accident 0 (0%) 17 (22.9%) 4 (5.4%) 2 (2.7%) 2 (2.7%) 0.2 12 (15.4%) 0.3 2 (2.7%) 0.4 0 (0%) 0.1 [8] r. birla, et al. (2013), “minimally invasive direct coronary artery bypass versus off-pump coronary surgery through sternotomy”, The Annals of The Royal College of Surgeons of England, 95(7), pp.481-485. 50 Vietnam Journal of Science, Technology and Engineering December 2017 • Vol.59 Number 4