Perioperative management in minimally invasive coronary surgery

It is important to apply the same rules used for classical coronary revascularization to beating heart coronary surgery. The surgeons must have a strategy, and be prepared for adverse events, and complications.

A careful analysis of the coronarography is essential to predict eventual contraindications or causes of possible operative difficulties. All the team must be involved in the surgical protocol. Three main problems need to be solved: the prevention of ischemia during the procedure, good stabilization of the anastomotic site and arterial occlusion. The first goal is reached by using a pre-conditioning technique or an intracoronary shunt. Vessel stabilization may be obtained by several methods: pressure adhesion devices, patch technique or suction devices. The final problem is to have a blood free field, this requires arterial occlusion which may be achieved in several ways: silastic Snares or sutures, aclan clamps, coronary occluder.

We have developed at la Pitié a protocol to apply all these principles. From February 1997 to November 1998, multiple revascularization was performed on 167 patients. A total of 344 coronary anastomosis were carried out (mean: 2.05 graft/patient).

Some simple rules had to be applied to reduce the rate of complications to the minimum: a good clinical case selection, use of a routine protocol, and recognize the need to adapt the indications to the learning curve of the operator.