Background. In a prospective clinical trial, a group of patients receiving less invasive surgical procedure, including minithoracotomy in combination with cardiopulmonary bypass (group 1), was compared to a group of patients receiving conventional bypass surgery (group 2) for the treatment of coronary artery disease.
Methods. Group 1 included 85 patients (71 men, 14 women, aged 39 to 82 years, median 61.1 ± 9.0 years); group 2 included 53 patients (38 men, 15 women, aged 51 to 79 years, median 62.0 ± 6.1 years).
Results. There were no perioperative deaths in the whole series of patients. Time of operation was 256 ± 43 minutes in group 1 and 150.0 ± 53.6 minutes in group 2. Hospitalization was 6.0 ± 1.4 days and intensive care unit stay 1 day for both groups. Back pain assessment on postoperative day 3 showed less pain in group 1. Three-month follow-up revealed ischemia in stress electrocardiogram in 2 patients (2.5%) in group 1 and in 2 patients (4.1%) in group 2. Coronary angiograms confirmed the stress-electrocardiogram findings.
Conclusions. Surgical results are equal for both techniques. Even though time of operation is longer in patients receiving less invasive procedures, intensive care unit stay and hospital stays are the same length. Early postoperative back pain is less in group 1 and combined with faster convalescence.
New goals have been added since 1994 in the surgical treatment of coronary artery disease (CAD). Cardiac surgeons have tried to reduce surgical trauma, sometimes avoiding median sternotomy (MS), sometimes avoiding cardiopulmonary bypass, and even sometimes avoiding both [1, 2, 3]. After gaining experience with the Port-Access (Heartport Inc, Redwood City, CA) system , the Dresden group proposed a new approach: avoiding median sternotomy, even in complex cases of CAD, by performing coronary bypass surgery with the help of cardiopulmonary bypass (CPB) . The aim was to reduce surgical trauma and avoid sternotomy-related complications [6, 7, 8]. This so-called “Dresden technique” (DT) enables, in its most recent version, CPB institution without dissection of the groin, which is associated with wound-healing complications, and what is more important, avoiding femoral cannulation of the arterial system, which is associated with severe intraoperative complications such as retrograde aortic dissection . Even if the first 25 patients had an uneventful clinical course without severe complications, despite the extended length of operation, a prospective, nonrandomized clinical trial was started. The trial compares this novel technique with conventional coronary artery bypass surgery, in order to define the benefit provided by this less invasive operation.
Patients and methods
All patients had preoperative assessment of the ascending aorta by transthoracic echocardiography to exclude those with heavily calcified ascending aortas. Body mass index of more than 30 and severely impaired left ventricular ejection fraction less than 30% were further exclusion criteria during the initial phase.
Preoperative patient data and operation
Dresden technique (group 1)
A total of 85 patients with CAD were evaluated for DT surgery. Of these, 40 patients (47%) suffered from single-vessel CAD, but 19 patients (22%) among them were referred for double-bypass surgery because diagonal branches of the left anterior descending coronary artery (LAD) were involved with stenotic lesions as well. In the same group, 32 patients (38%) had double-vessel CAD, and 13 (15%) had triple-vessel CAD. The pattern of coronary lesions is listed in Table 1. Twenty-four (28%) patients had previous percutaneous transluminal angioplasties. Age ranged from 39 to 82 years (median 61.0 ± 9.0 years); 71 men and 14 women. The preoperative left ventricle ejection fraction (LVEF) ranged from 38% to 90% (median 69 ± 12.8%). Fifty-two patients had a previous myocardial infarction and 2 (2.4%) claimed to have unstable angina. Clinical classification revealed that 12 patients (14%) were in Canadian Cardiovascular Society (CCS) stage 1, 44 patients (52%) were in CCS stage 2, 27 (32%) were in CCS stage 3, and 2 patients (2.4%) were in CCS stage 4. A total of 33 patients (39%) were in New York Heart Association (NYHA) class I, 40 patients (47%) were in class II, 11 patients (13%) were in class 3, and 0 patients (0%) were in class IV. Five patients (5.8%) suffered from chronic atrial fibrillation and the values of hematocrit (Hk) and hemoglobin (Hb) were 43.0 ± 5.1% (median ± SEM) and 9.1 ± 4.6 mmol/L (median ± SEM), respectively. Institutional Review Board approval was obtained and informed consent was given by all patients.