Minimally Invasive Coronary Artery Bypass Grafting: A New Method Using an Anterior Mediastinotomy

Abstract

The benefit of internal mammary artery (IMA) grafting as a long-lasting intervention for coronary artery disease is well recognized. However, largely because they are less invasive, catheter based alternatives are frequently chosen, particularly to treat single or double vessel disease. To retain the advantages of the IMA graft, and to offset the invasiveness of conventional coronary artery bypass grafting, we developed a new minimally invasive method using an anterior mediastinotomy for treating left anterior descending (LAD) or right coronary artery disease, or both. Feasibility studies using 16 pigs and a human cadaver led to approval by the Institutional Review Board for use of this procedure to treat six patients (four men, two women; mean age, 63.8 +/- 13.6 [SD] yrs) who granted informed consent. Pedicle dissection of the IMA, using video assisted thoracoscopy if necessary, was made through a 2- to 3-inch horizontal anterior mediastinotomy. The underlying LAD artery was grafted during femoral vessel cardiopulmonary bypass, with cooling to 30 degrees C, induced ventricular fibrillation, and left ventricular venting if required. Transesophageal echocardiography performed after bypass showed that two patients maintained normal wall motion and four had improvement from the original impairment. One patient suffered a recurrence of angina 4 weeks after the procedure; recatheterization showed an acutely angled IMA, subsequently corrected by balloon angioplasty. The results of follow-up dobutamine echocardiographic stress tests were negative in all patients. With this minimally invasive approach, the procedure should provide the benefits of IMA grafting with shorter hospital stay, more rapid recovery, and less overall cost.

Técnica de revascularização miocárdica com uso de toracoscopia

“…(18), em publicação recente , descrevem uma técnica com mediastinotomia anterior com ressecção de cartilagem costal permitindo, ao mesmo tempo, a dissecção parcial da ATI e o acesso à AIA . O método foi utilizado em 6 pacientes com CEC e fibrilação, tendo como complicações uma hérnia da parede torácica em 1 caso e a estenose da ATI em outro .…”

Revascularização do miocárdio minimamente invasiva videoassistida

“…After this operation technique had been well-established and mastered with a beating heart, reports were made of coronary bypass surgery performed through a small left anterolateral thoracotomy [5][6][7][8] , which aroused great interest among cardiovascular surgeons. However, the location where the incision was performed made it difficult to remove the left internal thoracic artery, presented low mobility of the intercostal space, which led to rib fracture, in some cases with severe pain in the postoperative period, and mainly limited this type of revascularization procedure to the anterior interventricular artery.…”

“Keyhole” Coronary Artery Bypass Surgery

“…Proximal and distal vascular control of the target coronary artery is accomplished at this point by looping silastic sutures (Quest Medical, Inc., Dallas, TX) or similarly placed 5-0 polypropylene pledgeted sutures about the vessel. [13][14][15][16] One hundred milligrams of lidocaine and 10,000 U heparin then are administered intravenously. Test occlusion of the coronary artery then is performed.…”