Beating heart coronary artery bypass: operative strategy and technique

With beating heart techniques firmly established, coronary surgeons now have a variety of approaches from which to choose the best operation for each individual patient based upon their own personal and institutional experience. Selection of the best operative approach and combination of available techniques for each patient is a dynamic process and forms the basis of our operative strategy. We consider four basic alternative operative approaches in each patient based on specific physiologic and anatomic criteria. Success begins with a committed team and close collaboration between surgeon and anesthesiologist. Effective communication is essential to maintaining clinical stability and avoiding disaster. During beating heart surgery, global ischemia is eliminated and regional ischemia is managed by an individualized grafting strategy designed to minimize the area of regional myocardium that is ischemic during each anastomosis. Maneuvers are described that are designed to minimize compression, ischemia, and length of time that the heart is displaced and usually result in satisfactory exposure and hemodynamics. A proven successful operative strategy is outlined including 1) initial patient evaluation and preoperative procedure selection; 2) operative choreography; 3) incision and initial exposure; 4) an individualized revascularization strategy; and 5) target vessel exposure, stabilization, vascular control, and visualization. Most cardiac surgeons already possess the skills required to successfully adopt beating heart surgery. Knowing when to patiently wait, when to persist, and when to intervene is more important to the successful application of these techniques than any skill.