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[Pitfall of minimally invasive direct coronary artery bypass]
H Takemura1, M Kawasuji, N Sakakibara
1Department of Surgery (I) Kanazawa University School of Medicine, Japan.
Insights
Minimally invasive direct coronary artery bypass grafting (MIDCAB) using the left internal thoracic artery is feasible. Careful anastomosis site selection and monitoring are crucial for successful MIDCAB outcomes.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
- Coronary Artery Bypass Grafting
Background:
- Minimally invasive direct coronary artery bypass grafting (MIDCAB) offers a less invasive approach for coronary revascularization.
- The left internal thoracic artery (LITA) is a preferred conduit for bypass grafting to the left anterior descending artery (LAD).
Purpose of the Study:
- To evaluate the feasibility and early outcomes of MIDCAB using LITA.
- To assess the efficacy of ischemic preconditioning during MIDCAB.
- To identify potential challenges and considerations for MIDCAB procedures.
Main Methods:
- Six patients underwent MIDCAB via left thoracotomy, with LITA dissection and anastomosis to the LAD.
- Left ventricular function was monitored using transesophageal echocardiography.
- Ischemic preconditioning was induced and monitored using near-infrared spectroscopy to measure myocardial tissue oxygen saturation.
- Graft patency was confirmed by Doppler echocardiography and angiography.
Main Results:
- All grafts demonstrated patency on early postoperative assessment.
- One patient developed distal coronary artery stenosis, possibly due to coronary snaring.
- Anastomosis sites were consistently in the distal LAD, potentially missing proximal LAD disease.
- Ischemic preconditioning with two cycles of occlusion/reperfusion showed satisfactory effects.
Conclusions:
- MIDCAB using LITA is a viable procedure with confirmed graft patency.
- Accurate anastomosis site selection is critical, especially in cases of proximal LAD disease.
- Monitoring myocardial oxygen saturation can help ensure effective ischemic preconditioning and safe coronary occlusion.
Abstract:
Six thoroughly selected patients underwent minimally invasive direct coronary artery bypass grafting (MIDCAB). While monitoring left ventricular function with transesophageal echocardiography, MIDCAB was done by performing small left thoracotomy through the fourth intercostal space, dissection of the left internal thoracic artery without thoracoscopy, ischemic preconditioning, and grafting of the internal thoracic artery to the left anterior descending coronary artery with 8-0 polypropylene continuous suture. A home-made cardiac stabilizer and Visuflow enabled us to perform precise suturing of the internal thoracic artery. The patency of all grafts was confirmed by early transthoracic Doppler echocardiography and selective angiography. A new stenosis of the coronary artery distal to the anastomosis was detected probably due to coronary snaring in one patient. The anastomosis sites were confined to the distal segments of the left anterior descending coronary artery in MIDCAB patients. The optimal anastomosis site may be missed in the patients with proximal left anterior descending artery disease. An experimental study of myocardial tissue oxygen saturation using near infrared spectroscopy showed that two times of coronary occlusion and reperfusion provided satisfactory effects of ischemic preconditioning. Measurement of the myocardial tissue oxygen saturation may be helpful for confirming effective ischemic preconditioning and a safe coronary occlusion during MIDCAB. Although MIDCAB is an attractive procedure, we should consider the accuracy of anastomosis, the risk of possible incomplete revascularization, the indications, and long-term results.