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Paulo Manuel Pego-Fernandes
Michael J. Mack
Tea E. Acuff
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Ann Thorac Surg 1996;62:1883-1884
© 1996 The Society of Thoracic Surgeons

Correspondence

Minimally Invasive Bypass

Fabio Biscegli Jatene, MD, Paulo Manuel Pego-Fernandes, MD

Instituto do Coracao, HC-FMUSP, Av Dr Enéas de Carvalho Aguiar, 44, 2nd Andar, Divisão de Cirurgia, São Paulo SP, Brazil 05403–001

To the Editor:

Regarding the recent article by Acuff and associates [1], we would like congratulate them and report a small technical variation.

In the period from January to July 1996, we have operated on 26 patients using minimally invasive coronary artery bypass grafting in association with video-assisted thoracic surgery. All patients had an isolated lesion in the anterior descending artery with more than 80% obstruction. Three patients had previously been submitted to angioplasty. Orotracheal intubation with a double-lumen tube was used. The patient was placed in the lateral decubitus position with 30-degree rotation. An anterior minithoracotomy between 8 and 10 cm was made in the fourth intercostal space. In 2 patients, a fragment of the fourth rib was removed in the cartiliginous portion, to improve exposure. Through this incision the thoracoscope and necessary surgical instruments were inserted to provide dissection of the entire internal thoracic artery from its origin to its distal portion. An extended tip on the electrocautery was useful for this procedure (Fig 1Go).



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  		Fig 1. . Complete internal thoracic artery dissection using electrocautery.

 
The anastomosis of the mammary artery with descending anterior coronary artery was performed as related by Acuff and associates, through direct vision with 7–0 polypropylene, without extracorporeal circulation, and with 7,500 U/kg of heparin.

The patients showed satisfactory evolution, and the postoperative angiography performed in 7 patients showed of the anastomoses, with no branches in the mammary artery.

This variation provided complete mammary artery dissection without additional holes in the left chest wall. Any of these approaches present the advantage of complete dissection of the mammary artery with no residual branches, avoiding any potential steal syndrome as well as kinking in an incompletely dissected mammary artery.

Reference

  1. Acuff TE, Landreneau RJ, Griffith BP, Mack MJ. Minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1996;61:135–7.
 

Reply

Michael J. Mack, MD, Tea E. Acuff, MD

Cardiothoracic Surgery Associates of North Texas, PA, 7777 Forest Lane, Suite A-323, Dallas, Tx 75230

To the Editor:

We are well aware of the efforts of Dr Jatene and his group in the field of minimally invasive cardiac surgery over the past 3 years. We were pleased to read their letter to the Editor and learn of the significant progress they have made in the field.

Our experience with minimally invasive coronary artery bypass is now 34 cases, and we have also arrived at the same technique as described by Drs Jatene and Pego-Fernandes. The technique of performing the limited anterior thoracotomy incision first followed by direct harvest of the internal mammary artery (IMA) through this incision with video assistance has significantly facilitated the thoracoscopic technique. The only difference between our current technique and that described by Jatene and Pego-Fernandes is that we place a 30-degree thoracoscope through a separate incision in the fifth left intercostal space for visualization. We find that placement of the thoracoscope at this site allows placement of instrumentation through the thoracotomy incision without interference and gives excellent visualization (Fig 1Go). This site is then used for chest tube placement at the end.



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  		Fig 1. . View of left anterior mini-thoracotomy with thoracoscope in the fifth interspace (arrow). Instruments are placed through the thoracotomy for internal mammary artery harvest, and visualization is through the scope.

 
Most surgeons performing minimally invasive direct-vision coronary artery bypass grafting do not use thoracoscopic imaging for IMA harvest, preferring to mobilize the IMA only one or two interspaces above the anterior thoracotomy incision. We still believe that video-assisted thoracoscopic assistance is preferential for the IMA harvest to alleviate any concerns of IMA steal through side branches, to allow adequate mobilization so that IMA length is not limited, and to prevent kinking of the IMA from attachment to the chest wall when incompletely mobilized.

This is an operation in rapid evolution, and we expect ongoing changes in surgical technique as expertise is gained by more surgeons in this evolving field. We look forward to further contributions by Dr Jatene's group and others working in this area.





This Article
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Right arrow Email this article to a friend
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Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Fabio Biscegli Jatene
Paulo Manuel Pego-Fernandes
Michael J. Mack
Tea E. Acuff
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Jatene, F. B.
Right arrow Articles by Acuff, T. E.
Right arrow Search for Related Content
PubMed
Right arrow Articles by Jatene, F. B.
Right arrow Articles by Acuff, T. E.

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