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1 Effects of Minimal Invasive Coronary Artery Bypass on ulmonary Function and ostoperative ain Artur Lichtenberg, MD, Christian Hagl, MD, Wolfgang Harringer, MD, Uwe Klima, MD, and Axel Haverich, MD Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany Background. Minimally invasive direct coronary artery bypass () requires substantially smaller incisions than conventional coronary artery bypass grafting (). We investigated whether this fact may lead to less postoperative pain and improved pulmonary function. Methods. reoperative and postoperative (days 1, 3, and 5) pulmonary function and postoperative pain were assessed in 15 patients undergoing (group A) by using a standardized score and were compared with 15 patients admitted for (group B). Results. Total operation time (140 minutes versus 189 minutes; p < 0.001) and duration of mechanical ventilation (300 minutes versus 840 minutes; p < 0.001) were significantly less in group A. ulmonary function was comparable between the 2 groups on postoperative day 1 (OD 1). Vital capacity was significantly greater in group A on OD 3 (59.7% versus 40.6%; p < 0.001) and on OD 5 (74.4% versus 53.9%; p < 0.001). Similar results were found for forced expiratory volume in 1 second (group A versus B on OD 3: 56.3% versus 42.2%; p < 0.05; and on OD 5: 68.4% versus 55.5%; p < 0.01). ostoperative pain was significantly higher in group A (OD 1: score 5.5 versus 3.6; OD 3: 4.0 versus 2.9; p < 0.01). Conclusions. procedures lead to better preservation of pulmonary function compared with conventional despite greater postoperative pain. (Ann Thorac Surg 2000;70:461 5) 2000 by The Society of Thoracic Surgeons ulmonary function may decrease significantly after myocardial revascularization using cardiopulmonary bypass (CB). Impairment of pulmonary function after coronary artery bypass grafting () is one of the most common complications in the early postoperative period [1 3]. Sternotomy [1], pleurotomy with opening of the pleural space, harvest of internal mammary artery [4, 5], and pain [4, 6] may lead to deterioration of postoperative pulmonary function. Additionally, CB may cause pathomorphologic and functional pulmonary changes called postperfusion syndrome [7 10]. With a minimally invasive direct coronary artery bypass () technique using a lateral minithoracotomy, and surgery on the beating heart without CB, some of the disadvantages of can be avoided. The purpose of our study was to investigate how this new technique affects postoperative pulmonary function as well as postoperative pain when compared with standard. Material and Methods was composed of 15 men (aged years) who underwent without CB. consisted of 15 men (aged years) who underwent conventional using CB. Inclusion criteria for both groups were male sex, normal cardiac function Accepted for publication Mar 24, Address reprint requests to Dr Lichtenberg, Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany; lichtenberg@thg.mh-hannover. (ejection fraction 55%), New York Heart Association (NYHA) classification I or II and absence of pulmonary or chest wall diseases. ulmonary Function Test and ostoperative ain reoperatively, lung function parameters (vital capacity [VC] and forced expiratory volume in 1 second [FEV 1 ]) were evaluated using a transportable spirometer unit (LA2, Allied Healthcare, St. Louis, MO). Each test was performed three times and the best results were selected for analysis. Tests were then repeated on postoperative day (OD) 1, 3 and 5 by a respiratory therapist. Arterial blood gas analyses (po 2 and pco 2 ) were determined when breathing room air preoperatively and on OD 1, 3 and 5. atients quantified their pain at rest and at forced inspiration during spirometry using a verbal numerical pain scale from 0 (no pain whatever) to 10 (the worst imaginable pain). This standardized test was used previously by us and other investigators [11 13]. The postoperative pain regimen was equal in both groups. The amount of used pain drugs was comparable between the groups. Standard analgetic medication with diclofenac 1.5 mg/kg was administered to all patients postoperatively 1 to 2 hours before spirometry. Anesthesiologic Management For group A, anesthesiologic management included the use of a single-lumen tube for intubation. A bronchial blocker (6 charriere; Rüsch, Kerner, Germany) was placed in the tube to allow selective ventilation of the 2000 by The Society of Thoracic Surgeons /00/$20.00 ublished by Elsevier Science Inc II S (00)

2 462 LICHTENBERG ET AL Ann Thorac Surg ULMONARY FUNCTION AND AIN AFTER 2000;70:461 5 right lung. Anesthesia was usually achieved by the use of etomidate, fentanyl, pancuronium bromide, and sodium thiopental. Before performing the anastomosis, heparin was administered at a dosage of 100 IU/kg body weight. Depending on the intraoperative bleeding tendency, protamine was given at a dosage to antagonize either half or all of the administered heparin. In selected cases pharmacologic reduction of the heart rate was necessary and accomplished with -blockers (esmolol hydrochloride 0.5 to 2.0 mg/kg). All patients received prophylactic antibiotics (ceftriaxon sodium 2 g) at induction of anesthesia and for 12 hours after operation. For group B, the differences from group A were singlelumen intubation without using a bronchial blocker. Heparin was given at a dose of 300 IU/kg. On bypass, heparin was administered additionally to keep the activated clotting time longer than 400 seconds. After CB, heparin was antagonized completely with protamine. Operative Technique For group A, the patient was placed in a 30-degree right lateral decubitus position, and the left hemithorax was entered through the fourth or fifth intercostal space [14]. The usual length of incision was 8 cm. The pedicle of the left internal thoracic artery (ITA) was dissected from the caudal part of the sixth rib up to the cranial origin of the ITA. Exposure was obtained by a Thora-LIFT Retractor (Auto Suture; U.S. Surgical Corp, Norwalk, CT). Side branches were cut by electrocautery or clipped. After ITA preparation, diluted papaverine was applied externally. Then the pericardium was opened and formed a cradle to lift the heart. A mechanical U-shaped stabilizer (Cardio- Thoracic Systems, Inc, Cupertino, CA) was placed parallel to the left anterior descending artery (LAD). The LAD was then surrounded by a 4/0 polypropylene tourniquet proximal to the chosen site for the anastomosis and also distally in case of significant bleeding. The artery was opened longitudinally, and the left ITA to LAD anastomosis was performed with a running 8/0 polypropylene suture. After the anastomosis one pleural chest drain was placed through the sixth or seventh intercostal space. The wound was closed in layers. No intercostal pain catheter was used. For group B, coronary bypass grafting was carried out through a midline sternotomy. The left ITA pedicle was mobilized after wide opening of the left pleura. Cardiopulmonary bypass was established using a single venous and arterial cannula. Moderate systemic hypothermia (32 C to 34 C) was applied and CB was carried out with a disposable membrane oxygenator (Sorin-Biomedica; Saluggia, VC, Italy). Myocardial preservation was achieved by using cold crystalloid cardioplegia (St. Thomas Solution) every 20 minutes during the crossclamp period. The distal coronary anastomosis were performed in standard technique. The chest was closed using six to eight steel wires (Sherwood Medical, St. Louis, MO) after one left pleural chest drain as well as a subxiphoid mediastinal drainage tube were placed through the sixth or seventh intercostal space. Fluid drainage in both groups was monitored hourly. Table 1. reoperative, Intraoperative, and erioperative atient Characteristics in Both Groups Daily chest roentgenograms and ultrasonographic examinations were done to evaluate diaphragmatic motion, retention of intrapleural fluid, and atelectasis. On OD 1 the subxiphoid tube was removed in all patients in group B. The pleural tube was removed in all patients of groups A and B on OD 2. Statistical Analysis Data are expressed as mean SD. atient variables were analyzed by Student s t test for unpaired data when appropriate. Results of pain scores and blood gas analysis as well as pulmonary function parameters were analyzed with repeated measures of analysis of variance. Multiple pairwise comparisons were done using the Bonferroni t test. robability values less than 0.05 were considered significant. Results Age (years) NS Weight (kg) NS Number of bypass grafts Aortic clamp time (min) Time of CB (min) Time of operation (min) Time of intubation (min) minimally invasive direct artery bypass; coronary artery bypass grafting; CB cardiopulmonary bypass; NS not significant. There were no significant differences in demographic data. The operation time, number of bypass grafts, and the duration of mechanical ventilation in the intensive care unit were significantly greater in group B (p 0.001; Table 1). All patients in both groups had no pulmonary complications postoperatively. No patient had inappropriate drainage with fluid retention or diaphragmatic immobility because of phrenic nerve injury. Table 2 shows the results of pulmonary function preoperatively and on OD 1, 3, and 5. reoperative VC and FEV 1 were comparable between groups. The decrease in VC and FEV 1 on OD 1 were slightly less in group A, but the differences observed were not statistically significant. The decreases in VC were significantly greater in group B on OD 3 (40.6% versus 59.7%; p 0.001) and OD 5 (53.9% versus 74.4%; p 0.001) compared with group A. Similar results were found for FEV 1 (OD 3: 42.2% versus 56.3%; OD 5: 55.5% versus 68.4%; group B versus A; p 0.01; Fig 1). Arterial blood gas analyses showed no significant differences in the postoperative period between groups A and B (Table 3). In group A, patients showed significantly higher pain scores on OD 1 (5.5 versus 3.6; p 0.001) and OD 3 (4.0

3 Ann Thorac Surg LICHTENBERG ET AL 2000;70:461 5 ULMONARY FUNCTION AND AIN AFTER 463 Table 2. Comparison of reoperative and ostoperative ulmonary Function of atients Undergoing () and () Variable reoperative VC NS redicted % NS reoperative FEV NS redicted % NS ostoperative VC (OD 1) NS redicted % NS ostoperative FEV 1 (OD 1) NS redicted % NS ostoperative VC (OD 3) redicted % ostoperative FEV 1 (OD 3) redicted % ostoperative VC (OD 5) redicted % ostoperative FEV 1 (OD 5) redicted % coronary artery bypass grafting; FEV 1 forced expiratory volume in one second; minimally invasive direct artery bypass; NS not significant; OD postoperative day; VC vital capacity. versus 2.9; p 0.01) than in group B during forced inspiration (Fig 2). ain score was comparable between groups at rest (Table 4). Table 3. Comparison of Arterial Blood Gases reoperatively and ostoperatively Comment reoperative day po 2 (mm Hg) NS pco 2 (mm Hg) NS ostoperative day 1 po 2 (mm Hg) NS pco 2 (mm Hg) NS ostoperative day 3 po 2 (mm Hg) NS pco 2 (mm Hg) NS ostoperative day 5 po 2 (mm Hg) NS pco 2 (mm Hg) NS coronary artery bypass grafting; minimally invasive direct artery bypass; NS not significant. The aim of minimal surgical trauma is revolutionizing many surgical subspecialties, including cardiac surgery. Cardiac surgery has entered the era of minimal access surgical trauma through the introduction of these surgical approaches to coronary artery disease. is an evolving strategy for treating limited Fig 1. Vital capacity and FEV 1 preoperatively and for the first 5 postoperative days in the (group A) and (group B) groups. Data are shown as the mean SD. ( minimally invasive direct coronary artery bypass; coronary artery bypass grafting; VC vital capacity; FEV 1 forced expiratory volume in 1 second; OD postoperative day.) Fig 2. ain level for the first postoperative 5 days in group A (MID- CAB) and group B (). ain score: 0 no pain whatsoever; 10 the worst imaginable pain. Data are shown as the mean SD. ( minimally invasive direct artery bypass; coronary artery bypass grafting; OD postoperative day.)

4 464 LICHTENBERG ET AL Ann Thorac Surg ULMONARY FUNCTION AND AIN AFTER 2000;70:461 5 Table 4. Subjective ain Score After Removal of Chest Drains At Rest and During Forced Inspiration Variable ostoperative pain level (OD 1) At rest NS Forced inspiration ostoperative pain level (OD 3) At rest NS Forced inspiration ostoperative pain level (OD 5) At rest NS Forced inspiration NS coronary artery bypass grafting; minimally invasive direct artery bypass; NS not significant; OD postoperative day. coronary disease using techniques designed to minimize incisions, avoid cardiopulmonary bypass, and reduce perioperative complications as well as length of postoperative hospital stay. Anesthesia recovery times and intensive care unit and hospital stays were very similar to those reported by others after [14] and were shorter than after conventional [16]. ulmonary impairment in postoperative cardiac surgical patients with CB has been reported previously [1 6, 10, 11, 17]. Many authors found a significant reduction of the lung function in patients having sternotomies [1] for coronary artery bypass procedure with the ITA used as conduit [4, 5, 17]. ain, pleurotomy, and impaired pulmonary mechanics may lead to deterioration of pulmonary function in the postoperative period. The pathologic effects of extracorporeal circulatory support on the lungs have been extensively examined and described [2, 7, 9, 10, 18]. They lead to functional changes that have been designated by Baer and Osborn as postperfusion pulmonary congestion syndrome [7]. Complement activation [18], thrombotic occlusion of pulmonary capillaries, and insufficient coverage of the metabolic demands of lung tissue [2] lead to an increase of extravascular lung fluids as well as atelectasis and ventilation disruptions [3, 9]. These changes are responsible for degradation of lung function after ECC. Additionally, activated leukocytes and oxygen free radicals have been implicated in the pathogenesis of lung injury associated with cardiopulmonary bypass [9]. The comparison of multivessel () and single-vessel () coronary diseases resulted in significantly different operation times and slightly different anesthetic management, factors potentially influencing postoperative pulmonary function that could not be controlled for in this study. Our results indicate that after surgery the irritation of the intercostal nerves during the first 3 days postoperatively proved to cause pain of higher intensity than the sternotomy after procedure despite systematic analgetic therapy. Similar results were described by other authors [19]. Consequently, the influence of pain leads to inadequate and shallow breathing [4]. This explains why VC and FEV 1 in the group on the first postoperative day were not significantly different compared to the procedure. Following reduction of the wound pain better recovery of lung function was observed among the patients on OD 3. During the rest of the study period significantly higher lung function values were documented in these patients compared to patients. One can conclude that with improved pain therapy (e.g. intercostal nerve block) the lung function can be further improved significantly during the postoperative period for patients. However, the oxygen concentration in the blood showed no differences in both groups. In our study, we could demonstrate that the anterolateral approach for procedures, causes significantly more pain in the early postoperative period with standard analgetic treatment. Nevertheless, pulmonary function measurements show a clearly faster normalization rate in patients, even though temporary single lung ventilation was instituted. This might reflect a longer operation time as well as more-aggravated damage of the lungs from CB. atients with significantly impaired pulmonary function, therefore, should preferably undergo a procedure if their coronary status allows for it. We recommend a more sophisticated analgesic treatment, such as intercostal nerve block, to further accelerate the postoperative recovery of patients. References 1. Berrizbeitia LD, Tessler S, Jacobowitz IJ, et al. Effect of sternotomy and coronary bypass surgery on postoperative pulmonary mechanics. Chest 1989;96: Cartwright RS, Lim TK, Luft UC, alich WE. athophysiological changes in the lungs during extracorporeal circulation. Circ Res 1962;10: Gale GD, Teasdale SJ, Sanders DE, et al. ulmonary atelectasis and other respiratory complications after cardiopulmonary bypass and investigation of etiological factors. Can Anaesth Soc J 1979;26: Cohen AJ, Moore, Jones C, et al. Effect of internal mammary harvest on postoperative pain and pulmonary function. Ann Thorac Surg 1993;56: Rolla G, Fogliati, Bucca C, et al. Effect of pleurotomy on pulmonary function after coronary artery bypass grafting with internal mammary artery. Respir Med 1994;88: Vargas FS, Terra-Filho M, Hueb W, et al. ulmonary function after coronary artery bypass surgery. Respir Med 1997; 91: Baer DM, Osborn JJ. The post-perfusion pulmonary congestion syndrome. Am J Clin athol 1960;34: Ghia J, Anderson NB. ulmonary function and cardiopulmonary bypass. JAMA 1970;212: Gu YJ, de Vries AJ, Boonstra W, van Overen W. Leukocyte depletion results in improved lung function and reduced inflammatory response after cardiac surgery. J Thorac Cardiovasc Surg 1996;112: Ratliff NB, Young WG, Hackel DB, et al. ulmonary injury secondary to extracorporeal circulation. J Thorac Cardiovasc Surg 1973;65: Hagl C, Harringer W, Gohrbandt B, Haverich A. Site of pleural drain and early postoperative pulmonary function following coronary artery bypass grafting with internal mammary artery. Chest 1999;115:

5 Ann Thorac Surg LICHTENBERG ET AL 2000;70:461 5 ULMONARY FUNCTION AND AIN AFTER Jamison RN, Brown GK. Validation of hourly pain intensity profiles with chronic pain patients. ain 1991;45: Murphy DF, McDonald A, ower C, et al. Measurement of pain: a comparison of the visual analogue with a nonvisual analogue scale. Clin J ain 1988;3: Cremer J, Struber M, Wittwer T, et al. Off-bypass coronary bypass grafting via minithoracotomy using mechanical epicardial stabilization. Ann Thorac Surg 1997;63:S Acuff TE, Landreneau RJ, Griffith B, Mack MJ. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61: Calafiore AM, Di Giammarco G, Teodori G, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61: Vargas FS, Cukier A, Terra-Filho M, et al. Influence of atelectasis on pulmonary function after coronary artery bypass grafting. Chest 1993;104: Kouchoukos NT, Karp RB. Functional disturbances following extracorporeal circulatory support in cardiac surgery. In: Ionescu MJ, Wooler GH, eds. Current techniques in ECC. London: Butterworth; 1976: Walther T, Falk V, Metz S, et al. ain and quality of life after minimally invasive versus conventional cardiac surgery. Ann Thorac Surg 1999;67: New Requirements for Recertification in the Year 2001 Diplomates of the American Board of Thoracic Surgery who plan to participate in the recertification process within the next few years should pay particular attention to this notice, because the requirements will change effective in the year In addition to an active medical license and institutional clinical privileges in thoracic surgery, beginning in 2001, a valid certificate will be an absolute requirement for entrance into the recertification process. If your certificate has expired, the only pathway for renewal of a certificate will be to take and pass the art I (written) and the art II (oral) certifying examinations. In 2001, the American Board of Thoracic Surgery will no longer publish the names of individuals who have not recertified. In the past, a designation of NR (not recertified) was used in the American Board of Medical Specialities directories if a Diplomate had not recertified. The Diplomate s name will be published upon successful completion of the recertification process. The CME requirements will also change in The new CME requirements will be 70 Category I credits in either cardiothoracic surgery or general surgery earned during the 2 years prior to applying for recertification. SESATS and SESAS will be the only self-instructional material allowed for credit. No Category II credits will be allowed. The hysicians Recognition Award for recertifying in general surgery will not be accepted in fulfillment of the CME requirement for recertification. The preceding information only partially outlines the CME requirements. Interested individuals should refer to the 2000 Booklet of Information for a complete description of acceptable CME credits. Diplomates should maintain a documented list of their major cases performed during the year prior to application for recertification. This practice review should consist of 1 year s consecutive major operative experiences. If more than 100 cases occur in 1 year, only 100 should be listed. Candidates for recertification will be required to complete both the general thoracic and the cardiac portions of the SESATS self-assessment examination. It is not necessary for candidates to purchase SESATS prior to applying for recertification because SESATS will be sent to candidates after their application has been approved. Diplomates may recertify up to 3 years before the expiration of their certificate. Their new certificate will be dated 10 years from the time of expiration of their original certificate or most recent recertification certificate. In other words, recertifying early does not alter the 10-year validation. Recertification is also open to Diplomates with an unlimited certificate and will in no way affect the validity of their original certificate. The deadline for submission of applications for the recertification process is May 1 of each year. A recertification brochure outlining the rules and requirements for recertification in thoracic surgery is available upon request from the American Board of Thoracic Surgery, One Rotary Center, Suite 803, Evanston, IL 60201; telephone number: (847) ; fax: (847) ; abts_evanston@msn.com by The Society of Thoracic Surgeons Ann Thorac Surg 2000;70: /00/$20.00 ublished by Elsevier Science Inc

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