MINIMALLY INVASIVE

CARDIAC SURGERY

CONTEMPORARY CARDIOLOGY

CHRISTOPHER P. CANNON SERIES EDITOR

1. MANAGEMENT OF ACUTE CORONARY SYNDROMES

Edited by Christopher P. Cannon, 1999

2. MINIMALLY INVASIVE CARDIAC SURGERY

Edited by Mehmet C. Oz and Daniel J. Goldstein, 1999

3. ANNOTATED ATLAS OF ELECTROCARDIOGRAPHY

By Thomas M. Blake, 1999

MINIMALLY INVASIVE

CARDIAC SURGERY

Edited by

MEHMET C. OZ, MD

DANIEL J. GOLDSTEIN, MD Columbia Presbyterian Medical Center, New York, NY

'*- SPRINGER SCIENCE+BUSINESS MEDIA, LLC

o 1999 Springer Science+BusillCSS Media New York Originally p ... blishcd by HlIJ1Iana. Press lne. in 1999 Sofu:over reprint ofthe hardcover 1$1 edition 1999

AU rigllts reserved. No pari oflhis book may be reproduced, 5!Ored in a retrieval system, or IransmiUed in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, orolherwise witho\ll written permission from lhe Publisher.

Allarticles, comments, opinions, conclusions, or recommendalions arc those ofthe author(s), and do nOI necessarily rcf1ect the views ofthe publisher.

This publica lion is prinled on acid-free paper. ® ANS I Z39.48-1984 (American National Standards Institute) Permanence of Paper for Printed Library Materials.

Cover design by Patricia F. Clcary and Karen Sch ... lz.

Pholoeopy Aulhoriza lion Poliey: A uthorizalion 10 photocopy items for inlemal or personal use_ or the inlerna l or personal use ofspeci fie dients, is granted by Springer Science+B ... siness Media, LLC provided Ihal the base fce of US S8.oo per eopy, plus US SOO.25 per page,

is paid direclly 10 the Copyright Clearance Cenler at 222 Rosewood Drive, Danvers, MA 01923. For those organizalions thal have been granled a photocopy license from Ihe CCC. a separate syslemofpayment has been arrangedand is acceptable 10 Springer Science+Business Media, LLC.

The fee code for users ofthe Transaetional Reponing Service is: {0-89603-635-9/99 S8.00 + SOO,25}.

10 9 8 7 6 5 4 3 2 1 Minimally invasive cardiac surgery / edited by Mehmet C. Oz, Daniel J . Goldstein.

p. cm. -- (Contemporary cardiology ; 2) Includes index.

978-1-61737-108-0 ISBN ISBN 978-1-4757-3036-4 (eBook) 0.1007/978-1-4757-3036-4 DOI 1

1. Heart--Surgery--Miscellanea. 2. Coronary artcry bypass--Miscellanca. 3. Operalions, Surgical--Miscellanea. 1. Oz, Mehmet C .. 1961}- Il. Goldstcin, Daniel J .. MD. III. Series: Contemporary cardiology (Totowa. NJ) : 2.

{DNLM: 1. Heart Diseases--surgery. 2. Surgical Procedures. Minimally Invasive --methods. 3. Cardiac Surgical Pro-ccdures--methods. 4. Vascular Surgical Pro-cedures--melhods. WG 169M665 1999J

RD598.M525 1999 617.4'12--dc21 DNLM/ DLC for Library ofCongress 98-30788

CIP

PREFACE

The purpose of Minimally Invasive Cardiac Surgery is to introduce the reader to the exciting developments in the field of "minimally invasive" or "minimal access" cardiac surgery. All the chapters have been written by investigators actively involved in their respective fields. We are appreciative of the concerted effort made by our collaborators to provide us with the most up-to-date material possible, thus making the book both timely and useful for those working in this rapidly evolving field. More than highlighting specific experiences and surgical procedures, we hope this text will outline an optimal approach to a rapidly developing new field of cardiac surgery, one that will substantially benefit future investigators and practitioners, as well as their patients.

Minimally Invasive Cardiac Surgery is organized into three major sections. The first part, Physiology of Injury, consists of a basic science review of the pathophysiological mechanisms underlying cardiopulmonary bypass and endothelial injury. To understand the benefits of avoiding cardiopulmonary bypass, Dr. Ron H. Speekenbrink and his colleagues examine the effect of extracorporeal circulation on the stimulation of coagulation pathways, the generation of interleukins and cytokines, the expression of adhesion molecules, and the regulation of vascular tone by the endothelium. Potential approaches to the attenuation of these effects are also discussed.

Vascular endothelium has emerged as a crucial player in the genesis of the diverse biological events that occur during the perioperative course of patients undergoing car­diac surgery. Indeed, surgical manipulation, shear stress, vasospasm, and ischemia/ reperfusion injury are just a few of the important mediators of endothelial cell injury. This topic is reviewed in detail by Drs. Talia Spanier and Ann Marie Schmidt, prominent researchers in the field of vascular biology.

The second theme, Less Invasive Approaches to Coronary Bypass Grafting, is the most extensive section in the book, owing to the burgeoning interest in less invasive approaches to myocardial revascularization. Dr. LeRoy Rabbani and associates present the interventional cardiologist'S perspective on minimally invasive approaches to coronary revascularization. A comprehensive review of the data derived from the randomized trials comparing angioplasty and stent therapy with surgical revascularization is presented and the benefits, disadvantages, and indications for each therapy are discussed.

Optimal visualization, careful and meticulous harvest of the internal mammary artery, and reduction of cardiac motion are the three key factors underlying the success of beating heart coronary bypass grafting through limited incisions. In the following three chapters, renowned authors discuss these topics. Dr. Michael J. Mack dissects the elements that presently comprise videoscopic systems in his chapter on visualization techniques. A glimpse into the state-of-the-art in videoscopic surgery, including the use of head­mounted displays and "virtual" surgery, is presented.

Controversy persists on the vessel length and incision necessary to achieve an optimal internal mammary artery conduit. Based on the various techniques of less invasive

v

vi Preface

revascularization currently practiced, Dr. Patrick Nataf presents an overview of the different approaches to the harvest of the internal thoracic artery. Particular attention is focused on the advantages of the thoracoscopic approach.

A factor critical to the success of beating heart bypass grafting is immobilization of the surgical field. Dr. M. Clive Robinson from the University of Kentucky has pioneered the use of pharmacological techniques to achieve myocardial wall stabilization. In the chapter entitled "Myocardial Stabilization Techniques During Off-Pump Coronary Grafting," the author presents the rationale and clinical experience with adenosine­induced transient asystole for the creation of coronary anastomosis and reviews the different mechanical stabilizers that are currently available to achieve optimal surgical conditions for beating heart surgery.

The ensuing two chapters encompass the clinical experience of pioneering groups of investigators who have advanced our knowledge of beating heart coronary grafting through their extensive clinical experience. Drs. Antonio M. Calafiore and Valavanur A. Subramanian are largely responsible for the introduction and dissemination of coronary grafting on the beating heart through limited incisions in Europe and the United States, respectively.

Port-access coronary bypass grafting, a major alternative to off-pump revascularization, was in part developed by the New York University group who discuss in detail the technique and excellent results that can be obtained. Unlike off-pump techniques, the port-access method relies on the conventional use of cardiopulmonary bypass and myocardial protec­tion, achieved through endovascular access and tiny incisions.

The final five chapters of this section deal with aspects peripherally related to less invasive bypass grafting. Dr. Nader Moazami discusses the different systems available for endoscopic saphenous vein harvest and reviews the clinical experience in the literature. Though the hand-sewn technique remains the preferred method for creation of a vascular anastomosis, many investigators in the field believe that broader applicability of beating heart bypass grafting is contingent upon the development of facilitated methods for creation of coronary anastomosis. Dr. Paul M. N. Werker, from the Hospital of Utrecht, presents a comprehensive historical perspective on alternative methods of anastomosis, including the use of mechanical devices, laser welding, glues, and automated staplers.

The use of miniature axial flow pumps instead of cardiopulmonary bypass to unload the left ventricle and to reduce ventricular motion while maintaining coronary and sys­temic perfusion is currently being investigated. Dr. Robert K. Jarvik who pioneered and developed one such device collaborates with Dr. Joseph J. DeRose to describe the current state of the art in cardiac support using these innovative pumps.

Increasingly, the success of innovative ideas hinges on the cost-effectiveness associ­ated with their application. To this effect, Dr. Gerald M. Lemole and colleagues examine the economic impact associated with the use of off-pump coronary grafting procedures at one institution, and dissect the New York State Database to identify the predictors for length of stay. In the last chapter in this section our group reviews the generally neglected yet very important quality-of-life issues that are associated with the use of less invasive cardiac procedures.

Preface vii

The third and [mal section in this book addresses growing areas of less invasive cardiac surgery, including valvular and congenital heart operations. Drs. W. Randall Chitwood and Steven R. Gundry, pioneers in the less invasive revolution describe their extensive experiences with "mini" approaches to mitral and aortic valve pathology. Finally, Dr. Gregory P. Fontana delineates the advances made in both extracardiac and intracardiac repairs via less invasive approaches and hints at the roadblocks that must be overcome and the advances that are likely to take place to achieve less invasive correction of complex congenital cardiac repairs.

Mehmet C. Oz, MD

Daniel J. Goldstein, MD

CONTENTS

Preface ........................................................................................................ v

Contributors .............................................................................................. xi

1 Introduction: What is Minimally Invasive Cardiac Surgery? .......... 1

Daniel l. Goldstein and Mehmet C. Oz

PART I PHYSIOLOGY OF INJURY

2 Pathophysiology of Cardiopulmonary Bypass ................................. 9 Ron G. H. Speekenbrink, Wim van Oeveren,

Charles R. H. Wildevuur, and Leon Eijsman

3 Endothelial Cell Injury ................................................................... 31 Talia Barzel Spanier and Ann Marie Schmidt

P AlIT II LEss INvASIVE APPROACHES m CoRONARY BYPASS GRAFIlNG

4 Minimally Invasive Coronary Bypass Grafting vs Percutaneous Coronary Interventions: The Cardiologist's Perspective .......... 45

LeRoy E. Rabbani, Alan D. Simon, and Allan Schwartz

5 Visualization Techniques for Minimally Invasive Cardiac Surgery ................................................................ ........................ 55

Michael l. Mack

6 Techniques of Minimally Invasive Internal Mammary Artery Harvest .......................................................... .............................. 69

Patrick Nataf and M. Anno Diegeler

7 Myocardial Stabilization During Off-Pump Coronary Artery Bypass Grafting ............................................................ .............. 79

M. Clive Robinson and loao Mota

8 Minimally Invasive Coronary Artery Bypass Grafting on the Beating Heart: The American Experience ...................... 89

Valavanur A. Subramanian

9 Minimally Invasive Coronary Artery Bypass Grafting on the Beating Heart: The European Experience .. .................. 105

Antonio M. Calafiore, Marco Contini, Giuseppe Vitolla, Teresa Iovino, and Angela Iaco'

10 Port-Access Coronary Artery Bypass ........................................... 117 Greg H. Ribakove, Aubrey C. Galloway, Eugene A. Grossi,

and Stephen B. Colvin

11 Minimally Invasive Saphenous Vein Harvest .............................. 129 Nader Moazami and Michael Gardocki

ix

x Contents

12 Alternative Approaches to Vascular Anastomosis Surgery ......... 141 Paul M. N. Werker

13 Device-Supported Myocardial Revascularization ....................... 155 Joseph J. DeRose, Jr. and Robert K. Jarvik

14 Economic Impact of Less Invasive Cardiac Operations .............. 165 Gerald M. Lemole, Asim F. Choudhri, Mehmet C. Oz,

Daniel J. Goldstein, Robert Gianguzzi, and Hiep C. Nguyen

15 Minimally Invasive Coronary Artery Bypass Grafting: Quality of Life Issues ................................................................ 173

Lorraine Choi, Windsor Ting, and Prashant Sinha

PART III NONCORONARY MINIMALLY INVASIVE CARDIAC SURGERY

16 Minimally Invasive Mitral Valve Surgery ................................... 187 W. Randolph Chitwood, Jr.

17 Aortic Valve Surgery via Limited Incisions ................................ 205 Steven R. Gundry

18 Minimally Invasive Approaches to Congenital Heart Surgery .... 215 Gregory P. Fontana

Index ....................................................................................................... 231

CONTRIBUTORS

ANTONIO M. CALAFIORE, MD, Division of Cardiac Surgery, S. Camillo de Lellis Hospital, G. D'Annunzio University, Chieti, Italy

W. RANDOLPH CHITWOOD, JR., MD, Division ofCardiothoracic Surgery, Department of Surgery, East Carolina University School of Medicine, Greenville, NC

LORRAINE CHOI, BA, Division ofCardiothoracic Surgery, Columbia Presbyterian Medical Center, New York, NY

As 1M F. CHOUDHRI, BA, Division ofCardiothoracic Surgery, Columbia Presbyterian Medical Center, New York, NY

STEPHEN B. COLVIN, MD, Division ofCardiothoracic Surgery, New York University Medical Center, New York, NY

MARCO CONTINI, MD, Division of Cardiac Surgery, S. Camillo de Lellis Hospital, G. D'Annunzio University, Chieti, Italy

JOSEPH J. DEROSE, JR., MD, Division ofCardiothoracic Surgery, Columbia Presbyterian Medical Center, New York, NY

M. ANNO DIEGELER, MD, Klinikfur Herzchirurgie, Universita Leipzig Herzzentrum, Leipzig, Germany

LEON EIJSMAN, MD, PHD, Department of Thoracic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands

GREGORY P. FONTANA, MD, Division ofCardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA

AUBREY C. GALLOWAY, MD, Division ofCardiothoracic Surgery, New York University Medical Center, New York, NY

MICHAEL GARDOCKI, PA, Division ofCardiothoracic Surgery, Columbia Presbyterian Medical Center, New York, NY

ROBERT GIANGUZZI, Medical Pavillion, Division of Cardiovascular Surgery, Medical Center of Delaware, Newark, DE

DANIEL J. GOLDSTEIN, MD, Division of Cardiothoracic Surgery, Department of Surgery, Columbia Presbyterian Medical Center, New York, NY

EUGENE A. GROSSI, MD, Division ofCardiothoracic Surgery, New York University Medical Center, New York, NY

STEVEN R. GUNDRY, MD, Division ofCardiothoracic Surgery, Lorna Linda University Medical Center, Lorna Linda, CA

ANGELA IACO', MD, Division of Cardiac Surgery, S. Camillo de Lellis Hospital, G. D'Annunzio University, Chieti, Italy

TERESA IOVINO, MD, Division of Cardiac Surgery, S. Camillo de Lellis Hospital, G. D'Annunzio University, Chieti, Italy

ROBERT K. JARVIK, MD, Jarvik Heart Incorporated, New York, NY GERALD M. LEMOLE, MD, Medical Pavillion, Division of Cardiovascular Surgery,

Medical Center of Delaware, Newark, DE

xi

xii Contributors

MICHAEL J. MACK, MD, Section of Thoracic Surgery, Columbia Hospital Medical Center, Dallas, TX

NADER MOAZAMI, MD, Division ofCardiothoracic Surgery, Columbia Presbyterian Medical Center, New York, NY

JOAO MOTA, MD, Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, KY

PATRICK NATAF, MD, Departement de Chirurgie Cardiaque, Centre Cardiologique du Nord, St. Denis, France

HIEP C. NGUYEN, MD, Medical Pavillion, Division of Cardiovascular Surgery, Medical Center of Delaware, Newark, DE

WIM VAN OEVEREN, PHD, The Center for Blood Interaction Research, Department of Cardiopulmonary Surgery, University Hospital Groningen, The Netherlands

MEHMET C. Oz, MD, Division of Cardiothoracic Surgery, Department of Surgery, Columbia Presbyterian Medical Center, New York, NY

LERoy E. RABBANI, MD, Division of Cardiology, Department of Medicine, Columbia Presbyterian Medical Center, New York, NY

GREG H. RIBAKOVE, MD, Division ofCardiothoracic Surgery, New York University Medical Center, New York, NY

M. CLIVE ROBINSON, MD, Division of Cardiovascular and Thoracic Surgery, University of Kentucky, Lexington, KY

ANN MARIE SCHMIDT, MD, Department of Surgery, Columbia Presbyterian Medical Center, New York, NY

ALLAN SCHWARTZ, MD, Division of Cardiology, Department of Medicine, Columbia Presbyterian Medical Center, New York, NY

ALAN D. SIMON, MD, Division of Cardiology, Department of Medicine, Columbia Presbyterian Medical Center, New York, NY

PRASHANT SINHA, SB, MENG, Division ofCardiothoracic Surgery, Columbia Presbyterian Medical Center, New York, NY

TALIA BARZEL SPANIER, MD, Department of Surgery, Columbia Presbyterian Medical Center, New York, NY

RON G. H. SPEEKENBRINK, MD, Department of Thoracic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands

VALAVANUR A. SUBRAMANIAN, MD, Department of Surgery, Lenox Hill Hospital, NewYork,NY

WINDSOR TING, MD, Division ofCardiothoracic Surgery, Columbia Presbyterian Medical Center, New York, NY

GIUSEPPE VITOLLA, MD, Division of Cardiac Surgery, S. Camillo de Lellis Hospital, G. D'Annunzio University, Chieti, Italy

PAUL M. N. WERKER, MD, PHD, Department of Plastic, Reconstructive, and Hand Surgery, University Hospital Utrecht, The Netherlands

CHARLES R. H. WILDEVUUR, MD, PHD, Department of Thoracic Surgery, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands