Thorac Cardiovasc Surg 2003; 51(1): 28-32
DOI: 10.1055/s-2003-37271
Original Cardiovascular
Original Paper
© Georg Thieme Verlag Stuttgart · New York

Multiple Minimally Invasive Direct CABG for the Complete Revascularization: The Figure L Approach

G.  Watanabe1 , H.  Takemura1 , S.  Tomita2 , T.  Misaki2 , K.  Kotoh2
  • 1Department of General and Cardiothoracic Surgery, Kanazawa University School of Medicine
  • 2Department of Surgery, Toyama Medical and Pharmaceutical University, Toyama, Japan
Further Information

Publication History

Received June 4, 2002

Publication Date:
14 February 2003 (online)

Abstract

Background: Coronary artery bypass grafting on the beating heart via median sternotomy causes significant hemodynamic compromise during displacement of the heart, especially in patients with low ejection fraction or those who have potential catastrophic sternal reentry injuries. We have developed an innovative minimally invasive surgical approach (figure L Approach) for the treatment of multi-vessel coronary artery disease; especially in cases with huge hearts (> CTR 50 %) including tracheostomy requiring COLD, and redo cases. The objective of this study was to assess the efficacy and safety of this alternative surgical incision. Methods: From January 1998 to March 2001, 22 patients underwent complete revascularization using this figure L Approach. Left submammary anterior thoracotomy incisions are made with the medial part of the incision vertically extending downward to the upper abdomen. The costal margin was divided. The pleural and peritoneal spaces were then entered. A chest retractor was placed to elevate the chest wall, exposing the heart and stomach. Two to four arterial grafts including LIT A, RGEA, RA and IEA were harvested. Revascularization of the LAD, LCX and distal RCA were performed in 22 patients without cardiopulmonary bypass on complex performed arterial grafts using this approach. In four patients, triple and quadruple vessel grafting was performed. Results: No early deaths or postoperative complications occurred. The mean coronary clamp time was 12.5 ± 5.1 minutes for the LAD, 10.8 ± 1.8 minutes for diagonal branch, 14.1 ± 2.9 minutes for the LCX and 16.0 ± 5.1 minutes RCA time. There were no late deaths or angina during the mean follow-up of 37.3 ± 9.0 months. Postoperative coronary angiography demonstrated widely patent grafts in all but one patient. Hemodynamics did not change significantly during the distal anastomoses. No wound-healing problems were experienced. Conclusions: Multiple MIDCABG using the figure L Approach represents a novel way of approaching both the LAD, CX and distal RCA in patients with multi-vessel disease, especially in those with low ejection fraction, huge heart (> CTR 50 %), or hemodynamically unstable patients, without any hemodynamic deterioration or sternal related complication.

References

  • 1 Calafiore A M, Giammarco G D, 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
  • 2 Grundeman P F, Borst C, van Herwaarden J A, Verlaan C W, Jansen E W. Vertical displacement of the beating heart by the octopus tissue stabilizer: influence on coronary flow.  Ann Thorac Surg 1998. May;  65 (5) 1348-1352
  • 3 Mathison M, Edgerton J R, Horswell J L, Akin J J, Mack M J. Analysis of hemodynamic changes during beating heart surgical procedures.  Ann Thorac Surg. 2000;  70 (4) 1355-1360; discussion 1360-1361
  • 4 Takahashi M, Yamamoto S, Tabata S. Immobilized instrument for minimally invasive direct coronary artery bypass: MIDCAB doughnut.  J Thorac Cardiovasc Surg. 1997;  114 680-682
  • 5 Benetti F J, Ballester C, Sard G, Boonstra P, GTandjean J. Video assisted coronary bypass surgery.  J Cardiac Surg. 1995;  10 620-625
  • 6 Sabramanian V A, McCabe J C, Geller C M. Minimally invasive direct coronary artery bypass grafting: Two-year clinical experience.  Ann Thorac Surg. 1997;  64 1648-1655
  • 7 Follis F M, Pett S B, Miller K B, Wong R S, Temes R T, Wernly J A. Catastrophic hemorrhage on sternal reentry: still a dreaded complication?.  Ann Thorac Surg 1999. Dec;  68 (6) 2215-2219
  • 8 Spanos P K, Bisbos A D, Arditis I I. Treatment of internal thoracic artery steal syndrome with supraclavicular approach.  J Thorac Cardiovasc Surg. 1998;  115 464-465
  • 9 Watanabe G, Misaki T, Kotoh K, Kawakami K, Yamashita A, Ueyama K. Multiple minimally invasive direct coronary artery bypass grafting for the complete revascularization of the left ventricle.  Ann Thorac Surg. 1999;  68 (1) 131-136
  • 10 Calafiore A M, Giammarco G D, Luciani N. et al . Composite arterial conduits for a wider arterial myocardial revascularization.  Ann Thorac Surg. 1994;  58 185-190
  • 11 Suma H, Wanibuchi Y, Terada Y. et al . The right gastroepiploic artery graft. Clinical and angiographic mid-terra results in 200 patients.  J Thorac Cardiovasc Surg. 1993;  105 615-623
  • 12 Suma H, Amano A, Fukuda S. et al . Gastroepiploic artery graft for anterior descending coronary artery bypass.  Ann Thorac Surg. 1994;  57 925-927
  • 13 Subramanian V A. Less invasive arterial CABG on a beating heart.  Ann Thorac Surg. 1997;  63 S58-71
  • 14 Boonstra P W, Grandjean J G, Mariani M A. Local immobilization of the left anterior descending artery for minimally invasive coronary bypass grafting.  Ann Thorac Surg. 1997;  63 S76-78

Dr. G. Watanabe

Department of General and Cardiothoracic Surgery, Kanzawa University School of Medicine

Takaramachi 13-1

Kanazawa

Japan 920-8641

Phone: +81 (76) 265-23 55

Fax: +81 (76) 222-68 33