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Grafting an internal thoracic artery to a coronary artery with moderate stenosis remains controversial. Competitive flow from the native coronary artery has been proposed as the cause of distal narrowing and ultimate failure of the internal thoracic artery graft. We investigated intraoperative phasic blood flow in internal thoracic arteries grafted to coronary arteries with various degrees of stenosis and the influence of stenosis on postoperative angiographic findings. One hundred patients who underwent coronary artery bypass grafting of an internal thoracic artery to the left anterior descending coronary artery were divided into three groups according to degree of coronary stenosis. Group 1 included 39 patients who had 75% or less stenosis, group 2 included 34 patients with stenosis from 76% to 90%, and group 3 included 27 patients with stenosis greater than 90%. Mean flow and peak systolic flow of internal thoracic artery graft in group 1 were lower than those in group 2 (p < 0.01, p < 0.05). Peak diastolic flow in group 1 showed no difference from flows in groups 2 and 3. In eight patients in group 1, internal thoracic artery flow showed a predominant diastolic peak with characteristic systolic reversal as a result of competitive flow from the native coronary artery. Angiography at 1 month showed that the internal thoracic artery graft was patent in every case. Relative contributions of native coronary artery and internal thoracic artery flow to distal perfusion differed among the three groups (p < 0.001). In group 1, 15% of patients showed native-dominant flow, 62% showed balanced flow, and 23% showed internal thoracic artery-dependent flow. In group 2, 9% of patients showed native-dominant flow, 29% showed balanced flow, and 62% showed internal thoracic artery-dependent flow. In group 3, 96% of patients showed internal thoracic artery-dependent flow. String sign of the internal thoracic artery graft developed in only three patients; in two of these patients internal thoracic arteries were grafted to coronary arteries with stenosis of 50% or less and in the other patient there was competitive flow from a diagonal vein graft. Eleven of 13 internal thoracic arteries grafted to coronary arteries with stenosis of 50% or less did not show string sign. Competitive flow from a moderately stenotic coronary artery did not predispose the patient toward string sign of the internal thoracic artery graft in the presence of substantial diastolic internal thoracic artery flow. We conclude that internal thoracic artery grafting is acceptable for a moderately stenotic coronary artery.

Objective The continuous suture technique has numerous advantages as simple, quick, and effective for aortic valve replacement; however, it is technically difficult. We have modified the continuous suture technique and evaluated our new technique in patients with aortic stenosis. Methods Between July 2007 and May 2010, 86 patients with aortic valve stenosis underwent aortic valve replacement alone or with other concomitant cardiac procedures including mitral valve surgery in our hospital. The patients were randomly divided into two groups: group A (n = 43) in which the continuous suture technique with some modifications was used and group B (n = 43) in which the conventional interrupted suture technique was used. There were no statistical differences between two groups in age, sex, body surface area, concomitant cardiac procedures, blood loss, and postoperative extubation time. Results The aortic cross-clamp time, cardiopulmonary bypass time, operation time, and hospital stay were significantly shorter in group A than that in group B, and the valve size was significantly larger in group A. No perivalvular leak was detected in postoperative echocardiograms. All patients recovered satisfactorily without complications associated with suture technique or prosthesis. During follow-up of 4 to 38 months, there were no clinically significant complications in group A, while one patient in group B developed perivalvular leakage requiring reoperation 3 months after surgery. Conclusions Our modified continuous suture method is useful for aortic valve replacement in patients with aortic stenosis and beneficial for the patients because the procedure is less invasive and a larger valve can be implanted.

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We have performed 12 cases of robotically assisted coronary artery bypass grafting (CABG) to accomplish less invasive revascularization. In this report, we describe a new method of robotically assisted internal thoracic artery (ITA) harvesting via subxiphoid approach, using the da Vinci surgical system. A 22-year-old man with three-vessel coronary artery disease due to Kawasaki disease was referred to our institution for coronary artery revascularization. A small subxiphoid incision was made, and the xiphoid process at the lower end of the sternum was excised. A U-shaped hook was inserted into the retrosternal space, and the lower sternum was lifted. A 30 degrees angle-up camera was inserted under the U-shaped hook, bilateral ITAs were harvested in a totally skeletonized fashion endoscopically. The required time for right ITA harvesting was 50 min, and that for the left was 20 min. After bilateral ITAs were harvested, composite grafts were made, and then the distal anastomoses were made. The patient was discharged six days after the operation. We performed a new robotically assisted bilateral ITA harvesting technique via sub-xiphoid safely and with excellent results. This method might be an evolutionary step of minimally invasive direct coronary artery bypass (MIDCAB) using the da Vinci surgical system.

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The aim of this study was to compare early and late graft patency in patients with and without previous successful PTCA. Of the 70 patients who received both early and late follow-up angiography, 13 patients who had received successful PTCA at the left anterior descending coronary artery (LAD) before CABG (group I) and 31 patients who had not received preoperative PTCA in any vessel (group II) were retrospectively reviewed. There were no significant differences in patient characteristics including major coronary risk factors. The mean duration between the operation and control angiography was 35+/-23 months in group I and 36+/-19 months in group II (P=0.90). Occlusions of the LITA graft were observed in four patients of group I and in four patients of group II. Cumulative patencies of the LITA graft were 54% in group I and 83% in group II (P=0.12). The late patency rate of the LITA graft bypassed to the LAD in patients that received previous successful PTCA in the coronary artery tended to be lower than in patients without previous PTCA. This result should be confirmed by further prospective studies.

This case report presents beating-heart totally endoscopic coronary artery bypass grafting (TECAB) for single-vessel coronary artery disease. A 72-year-old man with isolated left anterior descending (LAD) coronary artery disease was considered eligible for TECAB. Left internal thoracic artery (LITA) mobilization and subsequent off-pump revascularization applying the LITA to the LAD in a closed chest environment was performed using the da Vinci surgical system (Intuitive Surgical, Mountain View, CA, USA). The LITA was first harvested completely in a totally skeletonized fashion through three incisions 1-2 cm long in the left thoracic wall. The LAD was immobilized with the aid of a heart stabilizer. The LITA was then anastomosed to the LAD with 10 interrupted sutures of a Nitinol self-closing S15 U-clip device (Medtronic, Minneapolis, MN, USA) on the beating heart without the use of cardiopulmonary bypass. The time acquired to perform anastomosis was 20 min, and the total operative time was 5 h 34 min. The postoperative course was uneventful and the patient was discharged 5 days after the operation. Beating-heart TECAB was successfully performed for this patient with single-vessel LAD disease. This approach may be an evolutionary step toward beating-heart multivessel TECAB.