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Ann Thorac Surg 1999;67:1153-1154
© 1999 The Society of Thoracic Surgeons

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Case Reports

Video-assisted coronary artery bypass in patients with preexisting tracheostomy

^a Hôpital de la Pitié, Paris, France

Accepted for publication September 21, 1998.

Address reprint requests to Dr Nataf, Cardiac Surgery Department, Centre Cardiologique du Nord, 32 rue des Moulins Gémeaux, 93207 St Denis Cedex, France
e-mail: natafpat{at}worldnet.fr

	Abstract

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A new technique allowing revascularization of the left coronary artery through a small thoracotomy after videoscopic harvesting of both mammary arteries is proposed in patients with total laryngectomy. This anterior thoracotomy approach, of real interest in patients with a preexisting tracheostomy, needs to be compared with a classic sternotomy in terms of functional recovery and the prevention of mediastinal sepsis in certain high-risk categories of patients (eg, obesity, diabetes) for bilateral mammary artery harvesting.

	Introduction

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Myocardial revascularization using a sternal approach in patients who have undergone tracheostomy carries a high risk of wound or sternal infection. In these cases a bilateral thoracotomy with transverse section of the sternum allows optimal exposure of the heart with the possibility of coronary artery bypass grafting using a conventional extracorporeal circuit with a theoretically minimal risk of infection. This approach is, however, traumatic and mutilating. A partial sternotomy with conservation of the manubrium has been previously described with good preliminary results in 2 patients [1].

A new technique allowing revascularization in the territory of the left coronary artery with both mammary arteries using a small thoracotomy was proposed in 2 patients with total laryngectomy. We describe this approach consisting of video-thoracoscopic harvesting of the internal mammary arteries (IMAs) and coronary artery bypass grafting through a limited left anterior thoracotomy.

Two male patients aged 76 and 55 years who had undergone total laryngectomy 10 and 5 years previously were referred for surgical revascularization. Significant proximal stenosis of the left anterior descending coronary artery and circumflex artery, and occlusion of the right coronary artery was noted on the coronary angiogram of the first patient. The other patient had a significant stenosis of the left main coronary artery.

Because of the presence of the tracheostomy an approach by anterolateral thoracotomy was chosen. The first stage of the procedure consisted of the harvest of the right and left internal mammary arteries (RIMA, LIMA) by thoracoscopy. After induction of anesthesia a double-lumen endotracheal tube was passed through the tracheostomy to allow alternative collapse of the right and left lung. The patient was placed in the dorsal position with the arms above the head. Inflatable pillows were placed laterally under the right and left thorax. By alternate inflation and deflation of these pillows, the patient may be placed in a right or left anterolateral position with an incline of 30°. The technique of thoracoscopic IMA harvesting is similar for each side. Trocars were introduced through three thoracic incisions of less than 15 mm at the level of the fourth and sixth intercostal spaces along the mid-axillary line and at the level of the fifth intercostal space on the anterior axillary line. Technique and pitfalls of thoracoscopic harvesting of the IMA have been described elsewhere [2]. After harvesting of the RIMA, two clips were placed on its distal extremity after intravenous administration of heparin. The graft was cut between these clips and then placed in the pericardium on the anterior surface of the right ventricle after fashioning a large pericardial window extending from the right atrium to the pericardial reflection of the superior vena cava. In this way, the RIMA graft may be delivered through the left thoracotomy. The LIMA was then dissected by thoracoscopy.

The second stage of the operation consisted of performing the left anterior thoracotomy and the two bypasses. A 12-cm left anterior thoracotomy was performed. The distal segments of the IMAs were withdrawn from the thoracotomy to correctly prepare them for anastomosis to the coronary arteries. A cardiopulmonary bypass was instituted by cannulation of the ascending aorta and the right atrium. This is believed to be necessary because of the hemodynamic instability caused by the manipulation necessary for the approach to the left marginal artery. Deviation of the heart in the left pleural cavity by exclusion of the left lung and the fashioning of a large left pericardial window allow a good visualization of the ascending aorta and the right atrium through the left thoracotomy and facilitate cannulations. After aortic clamping and administration of cardioplegia, the RIMA graft was anastomosed onto the left anterior descending coronary artery and the LIMA onto the marginal artery.

The duration of cardiopulmonary bypass was 40 minutes in the first patient and 46 minutes in the second patient, and the duration of aortic clamping was 32 and 42 minutes, respectively. The postoperative outcome was uneventful in these 2 patients.

	Comment

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Median sternotomy in patients with a tracheostomy may pose major operative and postoperative problems [1]. This approach through a small thoracotomy allows an arterial revascularization of the left coronary artery. The videoscopic approach avoids all sternal complications of bilateral IMA harvesting. Thoracoscopic harvesting of the LIMA for revascularization of the left anterior descending coronary artery by minithoracotomy on the beating heart has already been described [2]. This minimally invasive technique is especially appropriate in the case of single-vessel disease. To graft an artery other than the left anterior descending coronary artery, the videoscopic techniques may allow the possibility of a second IMA graft while limiting the thoracic opening. Although this technique offered the potential for off-pump coronary artery bypass grafting, the installation of a cardiopulmonary bypass was necessary in our patients because of hemodynamic instability during exposition of the circumflex artery. Aortopulmonary cannulation techniques or especially aortoatrial cannulation requires no special material and may be performed by anterior thoracotomy. Ascending aorta and right atrial cannulations are facilitated by luxation of the heart in the left pleural cavity, which is possible by exclusion of the left lung and the fashioning of a large left pericardial window.

In conclusion, revascularization in the territory of the left coronary artery using IMA grafts is possible by small left anterior thoracotomy in association with thoracoscopic harvesting of the IMA. In the particular case of patients with a tracheostomy, this approach is of real interest. The advantage of this technique compared with a classic sternotomy in certain categories of patients (obesity, diabetes) needs to be evaluated in term of functional recovery and the prevention of mediastinal sepsis.

	References

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1. Kaiser L.R., Salerno T.A. Coronary artery bypass in patients with total laryngectomy. Ann Thorac Surg 1985;39:481-482.[Abstract/Free Full Text]
2. Nataf P., Lima L., Regan M., et al. Thoracoscopic internal mammary artery harvesting: technical considerations. Ann Thorac Surg 1997;63:S104-S106.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map 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): Patrick Nataf Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nataf, P. Articles by Gandjbakhch, I. Search for Related Content PubMed PubMed Citation Articles by Nataf, P. Articles by Gandjbakhch, I.