Ann Thorac Surg 2000;69:1276-1277
© 2000 The Society of Thoracic Surgeons
HOW TO DO IT
Mini-sternotomy for off-pump coronary artery bypass grafting
Artur Lichtenberg, MDa,
Uwe Klima, MDa,
Wolfgang Harringer, MDa,
Peter Y. Kim, MDa,
Axel Haverich, MDa
a Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, Hannover, Germany
Address reprint requests to Dr Lichtenberg, Division of Thoracic and Cardiovascular Surgery, Hannover Medical School, 30623 Hannover, Germany
e-mail: lichtenberg{at}thg.mh-hannover
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Abstract
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The number of off-pump coronary artery bypass grafting procedures without cardiopulmonary bypass is steadily increasing. We report on a new, minimally invasive surgical approach for off-pump coronary revascularization in multivessel disease. A distal sternotomy is performed to gain access to the left and right internal thoracic arteries and to reach the left anterior descending coronary artery, diagonal branches, and right coronary artery for off-pump revascularization.
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Introduction
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Coronary artery revascularization can be accomplished by full sternotomy, mini-sternotomy, thoracoscopically, or endoscopically with the use of computer-assisted telemanipulation technology, either with or without cardiopulmonary bypass [1–4]. We describe a minimally invasive surgical approach for coronary artery bypass grafting on the beating heart for multivessel disease. This approach consists of a distal sternotomy and permits the harvest of either internal thoracic artery (ITA) as well as excellent exposure and immobilization of the left and right coronary arteries. With this technique off-pump coronary artery bypass grafting (OPCABG) is possible.
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Technique
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Ten patients underwent OPCABG through a 10 cm midline skin incision extending from the third intercostal space to the xyphoid process. The sternum was divided vertically to the third intercostal space using a standard sternotomy saw. In cases of one-vessel disease only the left side (for the left anterior descending artery [LAD] or diagonal branch) or the right side (for the right coronary artery [RCA]) of the sternum was divided horizontally in an L-shaped manner. In multivessel disease a T-shaped partial sternotomy was performed in the third intercostal space using a small oscillating saw (Fig 1). In 10 patients the LAD, in 6 patients the diagonal branch, and in 2 patients the RCA were anastomosed with either the left ITA or the right ITA.
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Fig 1. Incision lines 1, 2, and 3 and anatomic relation of underlying heart. Incision 1 (L-shaped to the left) gives excellent access to the left coronary artery, as well as incision 2 (L-shaped to the right). Incision 3 (T-shaped) was used for total revascularization.
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A mechanical lift device was used to elevate the sternal edge thereby exposing the ITA, which was dissected to the level of the first intercostal space. Side branches were cut by electrocautery or clipped. Heparin was adminis-tered intravenously at a dose of 100 IU/kg upon completion of the dissection. A diluted papaverine solution was applied topically to the ITA. The pericardium was opened and several pericardial stay sutures were placed along the dorsal aspect of the pericardium to expose the target vessels. A mechanical U-shaped stabilizer was then placed parallel to the target vessel. In selected cases pharmacologic reduction of the heart rate was necessary and accomplished with ß-blockers (Esmolol, 0.5 to 2.0 mg/kg body weight; Gensia Europe Ltd, Berkshire, UK). After stabilization, the vessel was encircled with two 4-0 polypropylene sutures with tourniquets proximal and distal to the arteriotomy site. Temporary coronary shunts were not used. After closing the vessel proximally a longitudinal arteriotomy was made and the anastomosis performed with a running 8-0 polypropylene suture. The distal tourniquet was tightened only in cases with significant coronary back flow. The left ITA was grafted to the LAD or a diagonal branch or used as a sequential bypass for both vessels, and the right ITA was anastomosed to the RCA. Upon completion, one or two pleural chest drains were placed and the incisional site was closed in several layers. There were no perioperative or postoperative complications. All patients underwent a control-angiography between the 4th and 8th postoperative days, which revealed all anastomoses to be patent. All patients were free of angina postoperatively.
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Comment
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New techniques for coronary artery bypass grafting have been described and evaluated for potential reduction of perioperative morbidity and accelerated postoperative recovery. Complications may arise from the use of cardiopulmonary bypass and cardioplegic arrest as well as from full sternotomies. Potential advantages of the OPCABG procedure arise from the avoidance of cardiopulmonary bypass, which leads to reduced rate of postoperative complications such as bleeding, arrhythmia, stroke, renal failure, aortic injury, respiratory failure, and coagulation abnormalities [5, 6].
With this technique it is not only possible to reach the LAD as in minimally invasive direct coronary artery bypass grafting (MIDCABG) but the RCA and the diagonal branches as well. In addition, the posterolateral branches are also accessible. Even though we did not perform anastomoses to the circumflex artery in our series we were able to expose and stabilize for test reasons the circumflex artery in patients who received grafts to the peripheral RCA. A mini-sternotomy allows extension to a full sternotomy and avoids a second skin incision in emergency cases in which full access is necessary to establish CPB. As the sternal incision can be tailored individually to each patient’s and surgeon’s needs, the access allows a broad spectrum of variations from mini-incision to subtotal sternotomy.
Additional potential advantages include a decreased risk of sternal wound dehiscence and wound infection as the integrity of the thorax is not fully interrupted, less risk of traction injuries to the brachial plexus as the proximal aspect of the sternum is not distracted, improved cosmetic results, earlier extubation, and shorter intensive care and hospital stay. These advantages must be proved in future clinical trials. The technique was more tedious and took more time than our conventional coronary artery bypass grafting cases, however, with increasing experience the total operation time will certainly decrease.
Our minimally invasive technique using a T- or L-shaped distal sternotomy provides excellent access to all major coronary vessels. It is not only an alternative to other limited approaches or full sternotomies, but also provides the surgeon the opportunity to use this technique for off-pump cardiac revascularization. In addition, a rapid extension to a full sternotomy or central cannulation for extracorporeal circulation can be achieved if necessary.
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References
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Calafiore A.M., Di Giammarco G., Teodori G., et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996;61:1658-1665.[Abstract/Free Full Text]
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Mangano D.T. Perioperative cardiac morbidity. Anesthesiology 1990;72:153-184.[Medline]
Accepted for publication November 18, 1999.
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Abstract
Introduction
