Ann Thorac Surg 1999;67:870-871
© 1999 The Society of Thoracic Surgeons
How To Do It
Coronary artery bypass grafting on the beating heart: a simple technique for subluxating the heart
Hani Shennib, MDa,
Amr Bastawisy, MDa
a Department of Cardiothoracic Surgery, McGill University, Montreal, Quebec, Canada
Accepted for publication August 21, 1998.
Address reprint requests to Dr Shennib, 1650 Cedar Ave, Room L9 121, Montreal, PQ, H3G 1A4, Canada
e-mail: mchs{at}musica.mcgill.ca
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Abstract
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Coronary artery bypass grafting on the beating heart is becoming a widely applied procedure. It necessitates proper cardiac stabilization without impairment of hemodynamics. We describe a simple and effective technique to bring the anterolateral coronary arteries to a midline position for the purpose of performing a coronary artery bypass graft on the beating heart. A surgical glove tied to a tube is positioned underneath the left ventricle. Injection of warm saline into the glove will gradually displace the heart and rotate the lateral wall of the ventricle to a midline position. In spite of our use of mechanical stabilizers to decrease mobility of the anastomotic site, compression of the left ventricle is avoided because the water bed created by the injected glove absorbs the movement of the left ventricle and prevents its compression and any potential drop in cardiac output.
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Introduction
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Midline sternotomy remains the most popular approach for off-bypass multivessel revascularization [1, 2]. The laterally positioned descending diagonal and high obtuse marginal arteries may not be surgically accessible for comfortable performance of anastomosis on a beating heart. Furthermore, the positioning of mechanical stabilizers around the arteries away from the midline can be cumbersome and less effective. To correct this, surgeons often position wet sponges underneath and to the left of the heart so that the coronary vessels will be rotated anteriorly and to the midline. This can result in compromising left ventricular function and hemodynamic instability. We describe a simple method to subluxate the left ventricle to the midline position permitting stabilization of the lateral coronary arteries with minimal effect on hemodynamics.
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Material and methods
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A size 6 surgical glove is tied at its wrist to any silicone elastomer tube, eg, a nasogastric tube. This is then connected to a 50-mL syringe (Fig 1). The glove is then positioned inferolaterally to the left ventricle through the midline sternotomy (Fig 2). Warm saline is injected into the glove, which gradually displaces the left ventricle toward the midline and rotates the lateral wall of the ventricle to a more anterior position. Despite impressive visible rotation and subluxation of the left ventricle, no or minimal hemodynamic changes are observed. As expected, the amount of injectable warm saline required to visualize the left anterior descending artery will be less than that needed for a diagonal or an obtuse marginal artery. When a mechanical stabilizer is used to steady the coronary artery with the glove expanded, left ventricular function will not be compromised and hemodynamic measurements remain the same. This is likely because of the ability of the water bed to absorb the variation in left ventricular volume during systole and diastole. Now, we routinely use this technique on all beating-heart coronary artery bypass grafting operations done through the midline. Furthermore, by reversing the position of the glove with the fingers pointed toward the posterior descending branch of the right coronary artery with minimal manipulation, mechanical stabilizers may then be applied with excellent exposure and stabilization of the deeper segments of the posterior descending artery.
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Fig 2. The heart with (right) and without (left) injection of the glove illustrating its subluxation and displacement of the left anterior descending coronary artery (arrow) medially.
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Comment
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Performing coronary artery bypass grafting on the beating heart without the use of a heart-lung machine is perceived by the majority of surgeons as the most important component of rendering a procedure less invasive [3]. Because most multivessel coronary artery bypass grafts performed on a beating heart are done though some form of sternotomy, exposure of the lateral or inferiorly positioned coronary arteries can be challenging. This usually requires the positioning of wet packs under the heart to elevate it, suspending pericardial sutures to rotate the pericardial sac, or the use of some form of sling to subluxate the heart. These maneuvers often result in hemodynamic compromise. Although most of these maneuvers will be tolerated, some will require the administration of vasoactive drugs and positioning the patient in Trendelenburg’s position. With this, however, the level of the surgeon’s anxiety can increase, rendering the performance of coronary artery bypass grafting uncomfortable and hasty. In this article, we describe a method of subluxating the heart without impeding the hemodynamics. We have repeatedly monitored arterial blood pressure and cardiac output as well as left and right ventricular volumes by echocardiography with and without glove injection and failed to note significant variations. This is likely because of the soft malleable water bed created by the saline-filled glove. As shown in the figures, the left anterior descending coronary artery and adjacent diagonal branches are moved centrally. Similarly, high ramus branches of the circumflex and posterior descending artery can also be well exposed. We believe this technique is simple, effective, and of little cost.
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References
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Benetti F.J., Naselli G., Wood M., Geffner L. Direct myocardial revascularization without extracorporeal circulation, experience in 700 patients. Chest 1991;100:312-316.[Abstract/Free Full Text]
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Shennib H., Lee A., Akin J. Safe and effective method of stabilization for coronary artery bypass grafting on the beating heart. Ann Thorac Surg 1997;63:988-992.[Abstract/Free Full Text]
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Shennib H., Mack M., Lee A. A survey on minimally invasive coronary artery bypass grafting. Ann Thorac Surg 1997;64:110-115.[Abstract/Free Full Text]
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Abstract
Introduction
