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Early results with the minimally invasive thoracotomy for myocardial revascularization
F Alessandrini1, N Luciani, C Marchetti
1Department of Cardiac Surgery, A. Gemelli University Hospital, Catholic University, Rome, Italy.
Insights
Minimally invasive left anterior descending artery revascularization using a mini-thoracotomy shows early promise. Careful attention to technical aspects like artery harvesting and anastomosis is crucial for optimal outcomes in beating-heart surgery.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
- Interventional Cardiology
Background:
- Coronary artery disease remains a leading cause of mortality worldwide.
- Traditional coronary artery bypass grafting (CABG) involves significant invasiveness.
- Minimally invasive techniques offer potential benefits in reducing surgical trauma.
Purpose of the Study:
- To evaluate the early results of left anterior descending (LAD) artery revascularization.
- To examine the technical aspects of minimally invasive thoracotomy for LAD revascularization.
- To assess the feasibility of off-pump beating-heart surgery for LAD lesions.
Main Methods:
- Retrospective analysis of 51 patients undergoing LAD revascularization via mini-thoracotomy.
- Beating-heart surgery without cardiopulmonary bypass.
- Utilized left internal mammary artery (LIMA) graft and focused on anastomosis techniques.
Main Results:
- No intra-operative mortality observed.
- One postoperative myocardial infarction leading to death.
- Three patients experienced anastomotic stenosis requiring further intervention.
Conclusions:
- Minimally invasive LAD revascularization is technically feasible but presents challenges.
- Key technical areas include LIMA harvesting, temporary LAD occlusion, anastomosis construction, and intraoperative patency assessment.
- Addressing these critical points is essential for improving early outcomes and reducing failure rates.
Objective:
We report the early results of the left anterior descending artery revascularization through a minimally invasive thoracotomy, examining the main technical aspects of the operation.
Methods:
From January 1995 to September 1996, 51 patients underwent myocardial revascularization through a mini-thoracotomy on beating heart without cardiopulmonary bypass. The main indication to operation was limited lesions of the left anterior descending artery with contra-indications or high risk of failure of angioplasty. The position of the patient was the same than traditional surgery; the chest was opened on the fourth left intercostal space; the left internal mammary artery harvested under direct vision; temporary occlusion of the left anterior descending was obtained prevalently using 5-0 poliypropilene sutures; the anastomosis was performed with single or double 7-0 or 8-0 suture. In six patients the chest was closed and a conventional open-heart operation was performed due to internal mammary artery or left anterior descending unsuitability for minimally invasive revascularization. All the patients were submitted after operation to early angiographic control and/or a Doppler study of the mammary flow.
Results:
There was no intra-operative mortality. One patient had a postoperative myocardial infarction of the anterior-lateral wall of the left ventricle, and died after an emergency open-heart operation. In one case the patient was reopened after a few hours for a bleeding. Three patients showed various degrees of anastomotic stenosis at the angiographic control.
Conclusions:
Several technical difficulties can play an important role in the operative outcome because a single repeated technical error could not fully explain these heterogeneous observed failures. The technique of myocardial revascularization through a left anterior small thoracotomy might present several critical points, particularly: (1) the harvesting of LIMA, meaning the preservation of integrity of the arterial wall and adequacy of the length; (2) the method of the temporary closure of the LAD during of the anastomosis; (3) the stabilization of the LAD and the surgical technique of the anastomosis; (4) the methods for intraoperative control of the patency of the anastomosis. All points mentioned have been thought in our experience to be causes of early failure.