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Ann Thorac Surg 2001;72:664-665
© 2001 The Society of Thoracic Surgeons
a Division of Cardiothoracic Surgery, Buffalo General Hospital @ Kaleida health, 100 High St, Buffalo, NY 14203, USA
b Department of Surgery, State University of New York at Buffalo, 100 High St, Buffalo, NY 14203, USA
c Tokai University School of Medicine, Bohseidai, Isehara, Kanagawa 259-1193, Japan
To the Editor
We enjoyed the recent report by the Tokyo group regarding coronary revascularization of the left anterior descending artery or right coronary artery, or both, via a lower ministernotomy without a transverse extension [1]. The authors should be commended for performing multivessel revascularization using this approach with a safety net for conversion to midline sternotomy. Agreeably, several satisfactory methods exist to approach the coronary arteries during off-pump coronary artery bypass (OPCAB) with smaller incisions. The method described avoids unnecessary injury to the sternum without compromising optimal exposure.
We have performed this technique for combined revascularization of the left anterior descending artery and circumflex arteries. Using a similar lower sternal splitting technique employed by the Tokyo group, we place a stitch (0-silk) in the posterior pericardium and place traction on the suture by passing it through a vaginal pack. This is a variation of the technique we have described earlier for revascularization of the circumflex vessels during OPCAB via a full sternotomy approach [2–5]. When a lower sternal splitting approach is used, however, the pericardial stitch is placed in a more caudal position. Whereas the "Lima" stitch is placed in the oblique sinus when a full sternotomy approach is used [2–5], the modified "Lima" pericardial traction stitch is placed more caudally in the posterior pericardium by gently pushing the posterior surface of the heart away from the diaphragm. Traction on this suture readily visualizes the circumflex territory and enables revascularization without cardiopulmonary bypass. We have successfully used a saphenous vein graft that is connected proximally to the LIMA-to-LAD graft as a "T" graft in 2 patients. In another 2 patients, we have bypassed the circumflex artery with the LIMA and bypassed the LAD with the RIMA.
In conclusion, the lower sternal approach described by the Tokyo group is an excellent one in patients with LAD and RCA disease. As the authors have described, the LAD can be revascularized with the LIMA and the RCA with either RIMA or right gastroepiploic artery. Our modification of the Tokyo technique has allowed us to revascularize the LAD with the LIMA or RIMA and the circumflex territory using the LIMA or saphenous vein graft using a "T" connection to the LIMA. For all of these cases, the modified "Lima" traction suture has allowed us to expose the lateral territory of the heart without hemodynamic compromise [5]. Stabilization is a secondary issue and was achieved by a pressure-type mechnical stabilizer. Stabilization could similarly have been achieved using a suction device [5].
References
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