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J Thorac Cardiovasc Surg 1997;114:868-869
© 1997 Mosby, Inc.

LETTERS TO THE EDITOR

Extravascular aortic clamping for minimally invasive coronary artery bypass surgery

Department of Cardiovascular Surgery^a
Anesthesia Postoperative Care Unit^b
Department of Cardiology^c
Hôpital Cardiologique
Lyon, France

To the Editor:

We read with much interest the brief communication on video-assisted minimally invasive valve surgery by Chitwood and associates. ¹ We were particularly interested in the technique of transthoracic aortic crossclamping, which allowed them to perform video-assisted mitral valve replacement under safe and cost-effective conditions. With the intention of performing minimally invasive coronary artery bypass grafting (CABG) on the arrested heart, we developed a technique using peripheral cardiopulmonary bypass (CPB), similar transparietal extravascular aortic crossclamping, and antegrade cardioplegia, with the anastomosis being performed on a decompressed and arrested heart.

The left and/or right internal thoracic artery (LITA or RITA) is first harvested by means of a video-assisted technique. ² A left anterior minithoracotomy (2.5 inches long) is made in the fifth intercostal space. The pericardium is opened longitudinally and suspended. The site for the future anastomosis is identified on the coronary arteries. After initiation of peripheral CPB, a purse-string suture is placed in the ascending aorta under thoracoscopic vision, and an aortic catheter (Medtronic Inc.) is introduced through it for later antegrade delivery of crystalloid cardioplegic solution. A specially designed transparietal aortic crossclamp is introduced through the port previously used for LITA dissection, the posterior jaw being guided in the transverse sinus under thoracoscopic control. After cardioplegic arrest, the distal anastomoses are performed under direct vision.

Ten consecutive patients (mean age 58.07 ± 13.6 years, range 36 to 77 years) underwent a minimally invasive CABG procedure by means of this technique. Seven patients had stable angina, three had unstable angina, and four patients had previously had a myocardial infarction. On preoperative coronary angiograms, seven patients had isolated stenosis of the left anterior descending coronary artery (LAD) (previous angioplasty in three patients) and three had two-vessel disease. The mean ejection fraction was 47.8% ± 15.6% (range 20% to 70%). The operative procedure included nine LITA-LAD grafts and one double LITA-LAD and RITA–right coronary graft through only one incision. One patient underwent a right coronary artery angioplasty 3 days later. The mean aortic crossclamp time was 22 ± 12.7 minutes (range 12 to 54 minutes) and the mean CPB time was 49.9 ± 30 minutes (range 18 to 114 minutes). The mean duration of assisted ventilation was 17.9 ± 12.9 hours (range 6 to 52 hours) and the mean intensive care unit stay was 26 ± 8 hours (range 12 to 96 hours). In each case, the electrocardiogram remained unchanged and the troponin level stayed within normal limits (2.7 ± 1.5 IU, range 0.9 to 5.2 IU).

Minimally invasive procedures were first developed to allow CABG to be performed through a minithoracotomy on the beating heart without extracorporeal circulation. ² However, in the presence of intramyocardial, calcified, small, or inaccessible arteries, anastomoses cannot be safely performed on the beating heart and multiple revascularizations are limited. Another technique linking peripheral CPB and endovascular aortic crossclamping ³ was recently proposed, allowing minimally invasive coronary surgery on the vented and arrested heart. Similarly, the endovascular clamp, necessitating fluoroscopic or echographic guidance, creates a potential risk of aortic valve injury and occlusion of the head vessels related to improper placement of the balloon. To our knowledge the technique presented in this letter has not been previously described for CABG. Coronary anastomoses can be performed safely once the heart is decompressed during CPB and cardioplegic arrest. This type of aortic crossclamping and cardioplegia provides myocardial protection similar to that obtained with a conventional approach. Contrary to other reports, ⁴ multiple coronary anastomoses are feasible through a single incision without a T-graft technique, ² which may compromise the long-term patency of the LITA. The technique is simple, safe, and cost-effective. Results are qualitatively similar to those observed after a conventional approach with the advantages of limited chest wall trauma, limited postoperative bleeding, and improved esthetic appearance.

Peripheral CPB, thoracoscopic extravascular aortic clamping, and cardioplegic arrest may be used safely during mini-CABG. This approach represents an alternative either to beating heart procedures or endoaortic occlusion techniques.

View larger version (45K): [in this window] [in a new window]   Fig. 1. Introduction of the transparietal extravascular aortic clamp through the port previously used for LITA dissection. An aortic catheter is placed under thoracoscopic vision on the ascending aorta for antegrade delivery of cardioplegic solution.

References

1. Chitwood WR, Elbeery JR, Chapman WH, Moran JM, Lust RL, Wooden WA, et al. Video-assisted minimally invasive mitral valve surgery: the "micro-mitral" operation. J Thorac Cardiovasc Surg 1997;113,2:413-4.
   
2. Benetti F, Mariani MA, Sani G, Boonstra PW, Grandjean JG, Giomarelli P, et al. Video-assisted minimally invasive coronary operations without cardiopulmonary bypass: a multicenter study. J Thorac Cardiovasc Surg 1996;112:1478-84. [Abstract/Free Full Text]
   
3. Stevens JH, Burdon TA, Siegel LC, Peters WS, Pompili MF, St Goar FG, et al. Port-access coronary artery bypass with cardioplegic arrest: acute and chronic canine studies. Ann Thorac Surg 1996;62:435-41. [Abstract/Free Full Text]
   
4. Watanabe G, Misaki T, Kotoh K, Abe Y, Yamashita A, Ueyama K. Bilateral minimally invasive direct coronary artery bypass grafting with the use of two arterial grafts. J Thorac Cardiovasc Surg 1997;113,5:950-1.
   

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