Ann Thorac Surg 2004;77:731-733
© 2004 The Society of Thoracic Surgeons
How to do it
Optimizing use of the octopus system for off-pump total arterial myocardial revascularization with the TY graft
Calin Vicol, MDa*,
Georg D. A. Nollert, MDa,
Helmut Mair, MDa,
Bruno Reichart, MDa
a Clinic of Cardiac Surgery, Clinic of the University of Munich, Munich, Germany
Accepted for publication April 8, 2003.
* Address reprint requests to Dr Vicol, Herzchirurgische Klinik, Klinikum der Ludwig-Maximilians Universität München, Marchioninistr. 15, D-81377 München, Germany
e-mail: cvicol{at}helios.med.uni-muenchen.de
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Abstract
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Rapid developments in interventional cardiology for the treatment of coronary artery disease ask for further evolution of surgical revascularization techniques with improved short-term and long-term results. Off-pump bypass grafting, total arterial revascularization, and use of composite arterial grafts are innovative operative procedures that are already established in many centers. We describe our technique to combine all three procedures in a single operation.
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Introduction
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| Dr Vicol discloses that he has a financial relationship with Medtronic, Inc.
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Off-pump coronary artery bypass (OPCAB) reduces myocardial ischemia, avoids the inflammatory response to cardiopulmonary bypass (CPB), and thereby reduces morbidity [1]. Arterial grafts—exclusively used during total arterial revascularization—demonstrate high patency rates, which may translate into reduced mortality and improved quality of life [2]. The TY graft is a composite graft made of the proximal "in situ" left internal thoracic artery (LITA) and several segments of a free graft of various lengths. Either the radial artery (RA) or right internal thoracic artery serve as a free graft. Manipulation of the aorta is unnecessary for production of a TY graft [3]. The LITA is anastomosed distally with the left anterior descending artery (LAD). The longest segment of the free graft connects the LITA with the most distal coronary artery of the lateral or posterior wall. Short free graft segments connect the long segment with the other coronary arteries (Fig 1).
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Fig 1. Total arterial revascularization with the TY graft. The left internal thoracic artery is connected with the left anterior descending artery. The long and small segments of the radial artery bypass the right posterior descending branch of the right coronary artery, the circumflex, marginal, and diagonal branches of the left coronary artery.
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Off-pump total arterial coronary artery bypass grafting with the TY graft combines these three innovative new concepts of myocardial revascularization in a single operation to improve short-term and long-term results.
To perform this surgically challenging procedure in a safe and precise fashion, optimal positioning and stabilization of the coronary arteries is of paramount importance. After some experience with different methods and stabilizer systems we developed a technique with the Octopus 3-0 Tissue Stabilizer (OTS) and the Starfish Heart Positioner (SHP) (Medtronic, Minneapolis, MN).
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Technique
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After median sternotomy the bypass material is harvested. The LITA is dissected in "no-touch" technique with a pedicle of 1 cm width. After administration of heparin (10,000 IU), 2 mL of a solution consisting of 50 mg papaverine and 5,000 IU heparin in 100 mL 0.9% NaCl solution is injected intraluminally. The second graft is treated analogously.
The pericardium is opened vertically and the cut is caudal lengthened to the left up to the apex and to the right into the pleural cavity. To allow a displacement of the heart to the right, the mediastinal pleura is generally opened.
With two sutures the left pericardial edge is lifted and the SHP is inserted on the surgeon's side to inspect the topography of the coronaries. One cup of the suction element is placed on the diaphragmatic wall and the two others on both sides of the distal LAD ideally in a fat-free region to avoid tissue tearing. The heart is elevated up and right by progressive traction from the flexible arm of the SHP without shortening the long axis of the heart. To avoid pressure on the right heart, the patient is tilted to the right and the heart displaced toward the right pleural cavity. The surgeon localizes the coronaries, suitable sites for anastomoses, and measures the distances between the anastomoses. Subsequently the heart is brought back into its native position in a stepwise fashion and released from the SHP.
Construction of the TY graft is the next surgical step. If three distal anastomoses with the free graft are planned, two 2-cm long segments are cut off the free graft and connected with the remaining long segment by end-to-side anastomoses. The distances between the anastomoses in this so-called double Y-graft are equivalent to the distances between the coronaries and are measured by a pair of dividers on the filled beating heart. End-to-side implantation of the proximal end of this graft into the proximal third of the LITA results in the so-called TY graft with a total of four distal connections for the coronary arteries. All anastomoses are performed with 8-0 polypropylene (Ethicon, Cornelia, GA) running sutures.
For revascularization (Fig 2)
we prefer to start bypassing a diagonal branch and subsequently the LAD. Focusing the lateral wall is performed by moving the apex with the SHP right, top, and caudal. Tilting the operating table to the right further simplifies the access. The coronary is immobilized with the OTS, dissected, and surrounded by a 5-0 Gore-Tex suture (W.L. Gore and Assoc, Flagstaff, AZ) armed with a Gore-Tex pledget. During 2 minutes of ischemic preconditioning a second Gore-Tex suture is placed distal to the planned anastomosis site. After short reperfusion the coronary is occluded, cut open, and connected with the distal end of the first short free graft segment. CO2 is insufflated by a blower to achieve a bloodless operating field. After release blood flow is immediately electromagnetically measured.
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Fig 2. Positioning of the posterior heart wall with the Starfish Heart Positioner and stabilization of the distal circumflex artery with the Octopus 3-0 Tissue Stabilizer. (Large circle = T anastomosis; small circles = Y anastomoses; LITA = left internal thoracic artery; RA1 and RA2 = short segments of the radial artery serving as a free graft; RA3 = long segment of the radial artery.)
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For positioning of the anterior wall, the apex is pulled only slightly right and caudally with the SHP. Revascularization of the LAD with the LITA is performed in the above-described technique. The posterior wall is positioned by lifting the apex with the SHP stepwise to the top, right, and cranial. The OTS is inserted after a few minutes when the mixed venous O2 saturation is stable. The posterior wall is revascularized with the remaining endings of the short and long segments. To avoid vasospasm, 0.2 µg · kg-1 · min-1 milrinone is administered continuously throughout the operation.
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Comment
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Modern surgical revascularization aims to reduce the operative trauma and to increase bypass patency rates with consecutive superior quality of life and survival. Bypass material and CPB are the most important factors for improvement [4]. Renunciation of CPB and cardioplegic cardiac arrest leads to decreased organ dysfunction and associated morbidity [1]. Due to excellent patency rates of arterial conduits there is a growing trend toward total arterial revascularization [2]. Construction of composite grafts for total arterial revascularization offers many possibilities; most commonly the classic T graft is used.
We use a modified T graft, the TY graft, which is in our opinion better suited for OPCAB. Using this technique the coronaries are not connected by side-to-side (classic T grafting) but by end-to-side anastomoses with the grafts. The disadvantage is that the total number of necessary anastomoses is higher with TY grafting. However, end-to-side anastomoses are surgically less challenging and offer improved patency rates compared with side-to-side anastomoses [5]. Another advantage of TY grafting is the possibility to perfuse each coronary vessel immediately after performing the anastomoses.
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References
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- Patel N.C., Grayson A.D., Jackson M., et al. The effect off-pump coronary artery bypass surgery on in-hospital mortality and morbidity. Eur J Cardiothorac Surg 2002;22:255-260.[Abstract/Free Full Text]
- Barner H.B. The continuing evolution of arterial conduits. Ann Thorac Surg 1999;68(Suppl):S1-8.
- Prapas S.N., Anagnostopoulos C.E., Kotsis V.N., et al. A new pattern for using both thoracic arteries to revascularize the entire heart: the
-graft. Ann Thorac Surg 2002;73:1990-1992.[Abstract/Free Full Text]
- Loop F.D. Coronary artery surgery: the end of the beginning. Eur J Cardiothorac Surg 1998;14:554-571.
- Lev-Ran O., Paz Y., Pevni D., et al. Bilateral internal thoracic artery grafting: midterm results of composite versus in situ crossover graft. Ann Thorac Surg 2002;74:704-711.[Abstract/Free Full Text]
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Abstract
Introduction
