Assistive Techniques for Proximal Anastomosis in Minimally Invasive Coronary Artery Bypass Grafting

We introduce assistive techniques for proximal anastomosis in off-pump minimally invasive coronary artery bypass grafting (MICS CABG) to overcome difficult access to the ascending aorta in MICS CABG. An 8-cm left thoracotomy is made in the fifth intercostal space. ThoraTrak retractor (Medtronic Inc, Minneapolis, MN USA) is used to open the thoracotomy and is pulled to the cephalad and rightward direction toward to the ascending aorta. The pericardium is opened from the ascending aorta to the left ventricular apex and to the inferior vena cava. Two retraction sutures on the pericardial edge are used to laterally displace the heart. After dissecting between the ascending aorta and main pulmonary artery, the Octopus tissue stabilizer (Medtronic Inc, Minneapolis, MN USA), of which the suction tip is bent 60 degrees, is used to retract the pulmonary artery caudally. A flexible side-biting clamp (Vitalitec Inc.) is placed on the ascending aorta, and proximal anastomoses are handsewn on the ascending aorta. A total of 31 proximal anastomoses were completed with this technique between November 2013 and June 2015. All proximal anastomosis was completed without any difficulty. In MICS CABG, the technical challenges in proximal anastomosis due to difficult access to the aorta can be overcome safely by using this technique.