Multiple minimally invasive direct CABG for the complete revascularization: the figure L approach

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.

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.

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.

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.