Off-pump myocardial revascularization. The single-suture technique: how to avoid any complication

Coronary artery bypass grafting without cardiopulmonary bypass (CPB) is now an accepted technique of complete myocardial revascularization. The technique was originally described by Kolesov [Kolesov 1967] and later abandoned when the CPB became the gold standard for cardiac operations on the arrested heart. In the late 1980s off-pump coronary grafting was reintroduced by Benetti and Buffolo with very encouraging results, especially for high-risk patients [Benetti 1985, Buffolo 1996]. This technique was limited to the grafting of left anterior descending (LAD) coronary artery and sometimes to the right coronary artery (RCA) [Benetti 1985, Buffolo 1996]. In recent years, technical advantages in coronary exposure and mechanical stabilization have come from the industry, leading to the possibility of a complete off-pump myocardial revascularization. The exposure of coronary arteries in the circumflex territory has been described by Ricardo Lima from Brazil. He described a series of four sutures on the pericardium, which allowed a good exposure of such surgically difficult territory. Tomas Salerno simplified the "Lima sutures" with a technique using a single suture placed in the oblique sinus of the posterior pericardium, which allowed a good exposure of the circumflex territory and less heart manipulation. [Bergsland 1997, Salerno 1999, Ricci 2000]. This deep pericardial suture may injure the organs situated just behind the pericardium, such as the esophagus and thoracic aorta [Ricci 2000], and several complications have been reported in literature: injury of the left lower pulmonary vein has resulted in post-operative bleeding and dangerous hematoma behind the left atrium [Fukui 2002]; and subcutaneous emphasema has been detected in several cases in our experience. We report a different way to pose the single lima suture in order to avoid any damage to the structures behind the posterior pericardium.