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Ann Thorac Surg 1996;62:1884-1885
© 1996 The Society of Thoracic Surgeons

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Correspondence

Mini-Sternotomy for Coronary Artery Bypass Grafting

Department of Cardiothoracic Surgery, St. Mary's Hospital, Praed St, London W2 1NY Uk

To the Editor:

We read with interest the communication by Arom and associates [1] concerning the approach to the left anterior descending artery, right coronary artery, or both via a single limited incision of the chest.

We have also embarked on a minimal approach in suitable patients for single or double coronary artery bypass grafting using one or two internal mammary arteries. We have performed grafts to the left anterior descending artery with or without sequential graft to a diagonal branch of the left anterior descending artery and to the right coronary artery.

We use small 5-cm parasternal anterior thorocotomies with removal of 3 cm of two costal cartilages to allow for mobilization of the internal mammary artery. Through these incisions the pericardium is opened, revealing the left anterior descending artery on the left and the right coronary artery on the right immediately below. Once proximal and distal stay sutures have been applied, the coronary artery can be opened and direct anastomosis using a continuous suture of 7-0 Prolene (Ethicon, Somerville, NJ) is performed on the beating heart.

We note the advantages advocated by Arom and associates for their technique and would like to give an alternative viewpoint. We have used our technique in 27 patients and have not needed cardiopulmonary bypass in any. We believe this is because, unlike in Arom and associates' technique, we are directly over the coronary artery in question and swabs or sponges are not required beneath the left ventricle (which is a potent source of arrhythmia and hypotension) to bring the coronary artery into view. Initially we did expose the femoral vessels [2], but now no groin incision is made. With regard to chest pain from our incisions, we have routinely infiltrated the area with local anesthetic, and we use aliquots of local anesthetic through a small intrapleural drain. We have not found postoperative pain to be troublesome.

With the lateral approach, a midline sternotomy would still be virgin territory when further revascularization is required and thus would decrease the risk in redo operations. Also in patients with previous midline sternotomy the lateral incision provides virgin access, and we have used this approach in one redo patient [2].

As in Arom and associates' communication [1], our patients too had excellent recovery with shortened hospital stay [3] and no intensive care unit admission. We agree that minimally invasive coronary artery bypass grafting requires continued and further study, but it appears in a defined subgroup of patients to confer several advantages over conventional techniques.

References

1. Arom KV, Emery RW, Nicoloff DM. Mini-sternotomy for coronary artery bypass grafting. Ann Thorac Surg 1996;61:1271–2.[Abstract/Free Full Text]
2. Stanbridge RD, Symons GV, Banwell PE. Minimal access surgery for coronary artery revascularisation [Letter]. Lancet 1995;346:837.[Medline]
3. Stanbridge R, Cohen A, Hadjinicolau L, Al-Katoubi A. Early experience with minimal invasive coronary artery bypass grafting. Heart 1996;75(Suppl):69.

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Leonidas Hadjinikolaou Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Cohen, A. S. Articles by De L. Stanbridge, R. Search for Related Content PubMed PubMed Citation Articles by Cohen, A. S. Articles by De L. Stanbridge, R.