Ann Thorac Surg 1998;66:961-962
© 1998 The Society of Thoracic Surgeons
How to Do It
Hybrid-type stabilizer for off-pump direct coronary artery bypass grafting
Toshio Konishi, MDa,
Kazuhiko Higuchi, MDa,
Mutumu Fukata, MDa,
Shinji Akisima, MDa,
Shoji Fukuda, MDa
a Department of Cardiovascular Surgery, Yokohama Rosai Hospital, Yokohama, Japan
Accepted for publication May 12, 1998.
Address reprint requests to Dr Konishi, Department of Cardiovascular Surgery, Yokohama Rosai Hospital, 3211, Kozukue, Kouhoku-ku, Yokohama, 222-0036, Japan
e-mail: (konix{at}muf.biglobe.ne.jp)
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Abstract
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We have developed a mechanical stabilizer for use in off-pump direct coronary artery bypass grafting. We consider it an improvement on the sucker-type stabilizer, although it uses the mechanisms of the compressor-type. Our hybrid stabilizer effectively immobilizes the local heart surface with light compression and low evacuation. We believe that its use will eliminate the need for further immobilization and thus reduce cardiac invasiveness.
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Introduction
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Immobilization of the target coronary artery plays an important role in minimally invasive direct coronary artery bypass grafting [1]. For this reason, several types of mechanical stabilizers have been developed to improve anastomotic quality. After comparing the mechanisms of these devices, we integrated their advantages into a model described herein.
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Technique
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The heart is accessed through either an anterior small thoracotomy or a midline sternotomy. The coronary artery is snared around the anastomotic site. Our stabilizer, which consists of a U-shaped rubber disk with a stainless steel frame inside and a stainless steel pipe shaft connected to the frame, is applied to the epicardial surface (Fig 1). The rubber disk has a cavity that opens wide on the epicardial side, and the lumen of the shaft communicates with the cavity. The anastomotic segment of coronary artery is accommodated inside the disk and is immobilized after evacuation of air through the shaft. Arteriotomy is then performed, followed by anastomosis.
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Fig 1. The rubber disk of the stabilizer is viewed from the bottom side, which traps the epicardial surface of the heart. The cavity inside the disk communicates with the lumen of the stainless steel pipe shaft.
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The stabilizer shaft is 3 mm in diameter, with enough rigidity to resist heart motion, but is easily adaptable by manual bending. The compact size and adaptability of our stabilizer will be great assets in the small thoracotomy approach. Our stabilizer has a special adapter that enables it to be attached to any kind of retractor (Fig 2). In off-pump coronary artery bypass grafting through a midline sternotomy, it can be applied with an ordinary retractor. When the right coronary artery is bypassed, the stabilizer can be positioned to the inferior aspect of the heart by reshaping the shaft.
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Fig 2. The stabilizer is attached to an ordinary type of sternal retractor with the aid of a special adapter, which enables this stabilizer to be set with many kinds of retractor. The pipe shaft of the stabilizer, which is bendable on the site, fits well with a low profile.
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Comment
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Mechanical stabilizers are classified into two categories, compression-type [2, 3] or suction-type [4, 5]. As to the former type, it is attractive that the heart motion can be suppressed by a simple pressuring framework. However, intense pressure may affect circulatory stability and increase the distance to the anastomotic site. Sucker-type instruments do not present these problems, but they introduce vacuuming pressure that can rise to a level that causes epicardial damage. We thought that if the two mechanisms were combined, the resulting reduction in compression or suction would decrease the risk of circulatory instability or epicardial damage.
We devised our stabilizer with these things in mind. It traps the surface of the heart "on the site" with slight compression and moderate suction. The elastic feature of the disk surface minimizes injury to the epicardium, and its open circle shape allows easy detachment. Since this stabilizer has been introduced in our institution, other measures of immobilization, including pharmaceutical, are almost dispensable. We have routinely applied this stabilizer to the left anterior descending or right coronary artery system through either a small thoracotomy or a midline sternotomy. Especially when the posterior descending artery has been bypassed, great benefits have been obtained. Therefore, its extensive use on branches on the lateral aspect of the heart could also be expected.
We anticipate that this hybrid-type stabilizer will enhance the procedural refinement and reduce invasiveness in off-pump direct coronary artery bypass grafting.
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References
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- Subramanian V.A., McCabe J.C., Geller C.M. Minimally invasive direct coronary artery bypass grafting: two-year clinical experience. Ann Thorac Surg 1998;64:1648-1655.
- Boonstra P.W., Grandjean J.G., Mariani M.A. Improved method for direct coronary grafting without CPB via anterolateral small thoracotomy. Ann Thorac Surg 1997;63:567-569.[Abstract/Free Full Text]
- Izzat M.B., Yim A.P. Cardiac stabilizer for minimally invasive direct coronary artery bypass. Ann Thorac Surg 1997;64:570-571.[Abstract/Free Full Text]
- Borst C., Jansen E.W.L., Tulleken C.A.F., et al. Coronary artery bypass grafting without cardiopulmonary bypass and without interruption of native coronary flow using a novel anastomosis site restraining device ("Octopus"). J Am Coll Cardiol 1996;27:1356-1364.[Abstract]
- Takahashi M., Yamaguchi S., Yamamoto S. A new instrument for immobilization and hemostasis during minimally invasive direct coronary artery bypass ("MIDCAB doughnut"): experimental study. J Card Surg 1997;12:185-189.[Medline]
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Abstract
Introduction
