Ministernotomy in myocardial revascularization without cardiopulmonary bypass: technical aspects and early results

This study attempts to evaluate the feasibility of ministernotomy in beating heart coronary surgery, with special emphasis on technical aspects.

From September 1997 to September 1999, 137 patients were scheduled for off-pump coronary surgery in our institution. In 61 cases requiring revascularization of the left anterior descending artery (LAD) and right coronary artery (RCA) systems, the approach was either a reversed "L-shaped " ministernotomy (56 patients) or a "T-shaped " ministernotomy (five patients). Mean age of the ministernotomy patients was 64 +/- 10 years, and 17 of the patients were female. The mean left ventricular ejection fraction (LVEF) was 60 +/- 11% (<35% in four patients), and 32 patients (52.5%) had one-vessel disease while 29 (47.5%) had 2-vessel or 3-vessel diseases. There were seven (11.4%) urgent procedures. For these procedures, we used devices that we designed ourselves for sternal retraction and coronary stabilization.

Five patients (8.2%) needed conversion to another method due to hemodynamic instability or ischemia, while 56 of the patients completed the procedure. Fifty-one patients (91.1%) had a single graft on the LAD, four (7.1%) had a double graft on the LAD and the right or diagonal coronary artery, and one (1.8%) had a triple graft on the LAD and two diagonal branches. Mean coronary occlusion times and operative times were 12.1 +/- 2.7 and 152 +/- 33 minutes, respectively. Mean creatine kinase value was 29.8 +/- 24.6. One patient died of acute myocardial infarction, and one patient had temporary acute renal failure. Mean in-hospital stay was 5.2 +/- 1.9 days. Of the 18 patients (32.1%) who had postoperative angiographic control (range of 1 to 13 months), 17 showed patent anastomoses, and one required percutaneous transluminal coronary angioplasty (PTCA) of the anastomosis on the LAD. Mean follow-up time for all patients was 10.8 +/- 6.4 months. Freedom from any kind of repeat procedure was 98.2%.

Ministernotomy is a safe approach for patients not requiring grafts on the circumflex system. The possibility of multiple grafting and the easy conversion to a conventional surgical method make ministernotomy a preferable approach for minimally invasive coronary surgery.