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Ann Thorac Surg 1996;62:1244-1245
© 1996 The Society of Thoracic Surgeons
Feiring Heart Clinic, 2093 Feiring, Norway
To the Editor:
The excellent long-term patency of the internal mammary artery (IMA) is well recognized. Angioplasty is an alternative technique for treating single-vessel or double-vessel disease. Although less invasive, this technique suffers from higher restenosis frequency.
Increasing interest and recent reports about non-pump coronary artery bypass grafting (CABG) [1, 2] have inspired us to perform non-pump CABG in selected cases. We have previously reported the combination of transmyocardial laser revascularization and nonpump CABG [3]. Our present technique of nonpump CABG has been simplified further: Anesthetic methods are modified to allow extubation in the early postoperative period, and in opposition to others [1, 4], we do not use a double-lumen endotracheal tube. The exposure and dissection of the IMA is well accomplished with single-lumen intubation. Hemodynamic monitoring is established using transesophageal echocardiography.
The patient is placed in a semioblique position and draped as for conventional CABG. A limited anterior thoracotomy is then made over the fourth intercostal space; no resection of the ribs is needed. The pericardium is incised and stay sutures are placed. These traction sutures are important both for visualization of the left anterior descending coronary artery (LAD) and for partial immobilization of the heart. We now inspect the LAD and determine the level of the anastomosis. The LAD is then harvested under thoracoscopic guidance using a 30-degree scope, which is introduced through a separate incision. A long ordinary cautery instrument is used for dissection of the IMA pedicle. An endoscopic dissector is used to maintain traction of the pedicle (Endo-Dissect 176645; United States Surgical Corp, Norwalk, CT). Both of these instruments are introduced through the thoracotomy incision in the fourth intercostal space. Therefore only one extra access site is needed. The IMA is treated with intraarterial papaverine to provide better initial flow and facilitate the anastomotic procedure. Heparin is administered (5,000 to 10,000 IU). Use of the Blower instrument (Research Medical, Inc, Midvale, UT) to clear the coronary artery facilitates the anastomotic procedure, and no snare sutures are placed around the LAD to avoid damage to the coronary artery. If the LAD is occluded, no ischemic preconditioning is performed. The heart rate is slowed by administration of esmolol. The anastomosis between the IMA and LAD is performed using continuous 7.0 polypropylene. The incision is closed, leaving a chest tube for 24 hours.
References
Cirurgia Cardiaca, R. Borges Lagoa 783.5.andar, Sao Paulo SP CEP 04038, Brazil
To the Editor:
My colleagues and I agree with Dr Saatvedt and associates' comments about the advantages of a mammary artery anastomosed to the LAD versus any technique of percutaneous treatment including stents.
The association of a mammary artery grafted to LAD and angioplasties of other coronary arteries may expand the indications of this technique. Nevertheless, we do not think that it is necessary to use video-assisted dissection of the mammary artery. Through an 8-cm incision in the fourth intercostal space it is possible to reach the mammary artery two intercostal spaces higher and obtain sufficient length.
Our experience of 35 cases with left anterior minor thoracotomy with 29 restudies clearly demonstrated that it is not necessary to ligate higher intercostal branches.
Regarding the technique, we prefer 8.0 polypropylene instead of 7.0.
Cardiothoracic Surgery Associates of North Texas, 4401 A North I-35, Suite B7, Denton, Tx 76207
To the Editor:
It is interesting to see the communication by Drs Saatvedt, Dragsund, and Nordstrand concerning the Feiring method for minimally invasive CABG. Since our initial report [1] we have evolved an approach similar to their approach described with the fourth interspace incision used for instrumentation. A separate port is used for the camera, and sometimes a third port is used for instrumentation depending on the anatomic situation.
I continue to use a double-lumen tube, although apparently this is not necessary routinely. Resection of the costal cartilage provides a larger working space than the interspace incision alone. I personally have ceased preconditioning the LADs and no longer use esmolol unless the heart is tachycardic and hyperdynamic. Some of my group use the CO2 blower to help clear and distend the LAD during the anastomosis. It is difficult to maintain tension with an 8.0 suture, so we also prefer 7.0 polypropylene to complete the running anastomosis of the IMA to the LAD. In the arrested heart most surgeons retract upward on the epicardial tissue to provide exposure. However, in the beating heart it is better to push downward to stabilize and expose the LAD to prevent tearing with each heartbeat.
In short, with experience in suturing the beating heart and minimal exposures, surgeons will adapt to more efficient operative protocols. Only in sharing our experiences, both successes and failures, will surgeons be able to provide the best heart-invasive method of successful myocardial revascularization. I thank the Feiring group for their comments.
Reference
This article has been cited by other articles:
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  B. H. Walpoth, A. Bosshard, I. Genyk, B. Kipfer, P. A. Berdat, O. M. Hess, U. Althaus, and T. P. Carrel Transit-time flow measurement for detection of early graft failure during myocardial revascularization Ann. Thorac. Surg., September 1, 1998; 66(3): 1097 - 1100. [Abstract] [Full Text] [PDF]
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