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Single and multivessel port-access coronary artery bypass grafting with cardioplegic arrest: technique and
D S Schwartz1, G H Ribakove, E A Grossi
1Department of Surgery, New York University Medical Center, NY 10016, USA.
Insights
Minimally invasive coronary artery bypass grafting using port-access technology demonstrated high anastomotic patency in canine models. This technique ensures myocardial protection and reproducible results for internal thoracic artery grafts.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Techniques
- Surgical Technology
Background:
- Minimally invasive coronary artery bypass grafting (CABG) offers potential benefits but faces challenges in achieving optimal graft patency compared to traditional open techniques.
- The use of cardioplegic arrest is crucial for standard CABG, but its application in beating-heart minimally invasive procedures requires advanced technology.
Purpose of the Study:
- To evaluate the feasibility and anastomotic reproducibility of a novel port-access coronary artery bypass system.
- To assess the efficacy of this system in performing internal thoracic artery-coronary artery anastomoses with myocardial protection.
Main Methods:
- The study involved 19 dogs undergoing thoracoscopic takedown of internal thoracic arteries followed by minimally invasive CABG using the port-access system with cardioplegic arrest.
- Anastomotic technique modifications were implemented, transitioning from microscope to operative loupes via an oval port.
- Assessment included cardioplegic solution delivery, ventricular decompression, and anastomotic patency.
Main Results:
- Crossclamp and bypass times were 50 ± 15 and 87 ± 28 minutes, respectively.
- Myocardial temperature was maintained at 17 ± 1°C with low hemodynamic pressures throughout the procedure.
- Successful thoracic artery takedown and anastomotic patency were achieved in 18 of 19 animals, with 100% patency after technique refinement.
Conclusions:
- A reproducible technique for minimally invasive CABG using port-access technology has been established.
- This method provides effective myocardial protection, precise anastomoses, and predictable graft patency for internal thoracic artery grafts.
- The findings support the indication for clinical trials to translate this technique to human patients.
Objectives:
Although minimally invasive coronary artery bypass grafting is now feasible, using this technique to perform anastomoses on the beating or fibrillating heart may yield poorer graft patency than the standard open techniques that use cardioplegic arrest. This study tested the feasibility and anastomotic reproducibility of minimally invasive coronary bypass using newly developed port-access coronary artery bypass technology (Heartport, Inc., Redwood City, Calif.), which allows endovascular cardiopulmonary bypass, cardiac venting, aortic occlusion, and cardioplegic arrest for internal thoracic artery-coronary artery anastomoses.
Methods:
Nineteen dogs had thoracoscopic takedown of either single (n = 14) or bilateral (n = 5) internal thoracic arteries followed by minimally invasive coronary bypass with cardioplegic arrest, done by means of the port-access system. The anastomotic technique was modified after the fourth animal by switching from a microscope to a 2.5 cm oval port and performing a conventional anastomosis with operative loupes. The adequacy of delivery of cardioplegic solution, ventricular decompression, and anastomotic patency was assessed.
Results:
The crossclamp and bypass times were 50 +/- 15 minutes and 87 +/- 28 minutes (mean +/- standard deviation), respectively. The mean myocardial temperature after cardioplegia was 17 degrees +/- 1 degree C and the aortic pressure (-3 +/- 9 mm Hg) and pulmonary artery pressure (4 +/- 1 mm Hg) were low throughout the procedure. All animals were weaned from bypass without inotropic agents. Angiograms and autopsies demonstrated successful thoracic artery takedown and anastomotic patency in 18 of 19 animals, with 100% anastomotic patency after the technique had been modified after the fourth animal.
Conclusion:
This study describes a reproducible technique for minimally invasive coronary bypass that allows myocardial protection, anastomotic precision, and predictable thoracic artery graft patency. Clinical trials are indicated.