Novel use of a magnetic coupling device to repair damage of the internal thoracic artery

At present, there is limited reported literature on the use of the magnetic anastomotic device Ventrica MVP in the coronary artery bypass surgery setting. The device has been primarily used to perform distal coronary anastomoses. We report for the first time the novel use of this magnetic coupling device as a technique to repair iatrogenic injury of the left internal thoracic artery conduit. Technical issues, advantages, disadvantages, and the use of computer tomography angiogram for assessment of the anastomosis are discussed.     

Comparative analysis of the patency of the internal thoracic artery in the CABG of left anterior descending artery: 6-month postoperative coronary CT angiography evaluation

Objective

To assess the patency of the pedicled right internal thoracic artery with an anteroaortic course and compare it to the patency of the left internal thoracic artery , in anastomosis to the left anterior descending artery in coronary artery bypass grafting by using coronary CT angiography at 6 months postoperatively.

Methods

Between December 2008 and December 2011, 100 patients were selected to undergo a prospective coronary artery bypass grafting procedure without cardiopulmonary bypass. The patients were randomly divided by a computer-generated list into Group-1 (G-1) and Group-2 (G-2), comprising 50 patients each, the technique used was known at the beginning of the surgery. In G-1, coronary artery bypass grafting was performed using the left internal thoracic artery for the left anterior descending and the free right internal thoracic artery for the circumflex, and in G-2, coronary artery bypass grafting was performed using the right internal thoracic artery pedicled to the left anterior descending and the left internal thoracic artery pedicled to the circumflex territory.

Results

The groups were similar with regard to the preoperative clinical data. A male predominance of 75.6% and 88% was observed in G-1 and G-2, respectively. Five patients migrated from G-1 to G-2 because of atheromatous disease in the ascending aorta. The average number of distal anastomoses was 3.48 (SD=0.72) in G-1 and 3.20 (SD=0.76) in G-2. Coronary CT angiography in 96 re-evaluated patients showed that all ITAs, right or left, used in situ for the left anterior descending were patent. There were no deaths in either group.

Conclusion

Coronary artery bypass grafting surgery involving anastomosis of the anteroaortic right internal thoracic artery to the left anterior descending artery has an outcome similar to that obtained using the left internal thoracic artery for the same coronary site.     

Clinical and six-month angiographic evaluation of coronary arterial graft interrupted anastomoses by use of a self-closing clip device: a multicenter prospective clinical trial

OBJECTIVES: To evaluate the safety and effectiveness of a self-closing surgical clip with an interrupted technique in left internal thoracic artery to left anterior descending artery bypass grafting. METHODS: Eighty-two patients were enrolled and treated (February 2000 through August 2001) in a prospective, nonrandomized, multicenter trial. Left internal thoracic artery to left anterior descending artery anastomoses were performed in 60 off-pump coronary artery bypasses (73%), 12 conventional coronary artery bypass grafting (15%), and 10 minimally invasive direct coronary artery bypass (12%) procedures. Angiograms (64 to 383 days, mean 200 days) were obtained on 63 patients (77%). Qualitative and quantitative angiographic assessment was performed by an independent core laboratory. RESULTS: The self-closing surgical clip was used for 82 left internal thoracic artery to left anterior descending artery interrupted anastomoses without the requirement for knot tying or primary suture management. Minimum left internal thoracic artery to left anterior descending artery anastomosis time was 3 minutes. There was one perioperative and one late death (both not heart related) and one reexploration for bleeding unrelated to the anastomotic site. FitzGibbon grades were as follows: A (n = 60, 95.2%), B (n = 3, 4.8%) including one kinked left internal thoracic artery, and O (n = 0, 0%). Quantitative analysis (n = 57) showed mean lumen diameters of left internal thoracic artery proximal to the anastomosis of 2.1 mm, at anastomosis of 2.0 mm, and in the left anterior descending artery distal to the anastomosis of 1.9 mm. The average ratio of the anastomosis to the left anterior descending artery diameter was 1.14 (0.45 to 1.93). Anastomotic stenosis as a percentage of average left internal thoracic artery to left anterior descending artery diameter was -2.3%, comparing favorably with results (23% to 24%) reported from the Patency, Outcomes, Economics, Minimally invasive direct coronary artery (POEM) bypass study. CONCLUSIONS: The interrupted technique, facilitated by a self-closing anastomotic clip, yields favorable 6-month angiographic results when compared with other published studies.     

Combined use of off-pump techniques and a sutureless proximal aortic anastomotic device reduces cerebral microemboli generation during coronary artery bypass grafting

OBJECTIVE: Intraoperative cerebral microemboli are associated with the development of postoperative stroke and neurocognitive decline in patients undergoing coronary artery bypass grafting. Although cardiopulmonary bypass is responsible for the generation of a significant number of such emboli, the elimination of cardiopulmonary bypass alone has not been conclusively shown to improve neurocognitive outcome. The current study was performed to determine the effects of combined off-pump coronary artery bypass grafting and sutureless proximal aortic anastomotic techniques on the generation of intraoperative cerebral microemboli compared with standard coronary artery bypass grafting techniques of cardiopulmonary bypass and hand-sewn proximal anastomoses. METHODS: Fifty-three patients underwent off-pump coronary artery bypass grafting by using the sutureless Symmetry aortic connector device (St Jude Medical, St Paul, Minn) for all proximal anastomoses. Eighteen of these patients received intraoperative transcranial Doppler ultrasonography to determine right- and left-sided cerebral microembolic counts. These results were compared with those obtained from a similar group of 17 patients undergoing standard coronary artery bypass grafting, in whom cardiopulmonary bypass and hand-sewn proximal anastomoses were used. RESULTS: Our use of the proximal anastomotic device in patients undergoing coronary artery bypass grafting was safe, with no aortic complications, postoperative strokes, or in-hospital deaths. Microembolic counts to both the right and left cerebral circulation were significantly reduced in the patients undergoing off-pump coronary artery bypass grafting (right = 21.9 +/- 20.7 emboli, left = 24.9 +/- 19.2 emboli) compared with those in patients undergoing standard coronary artery bypass grafting (right = 181.6 +/- 85.3, left = 189.9 +/- 60.401, P <.0001). CONCLUSIONS: Our use of a sutureless proximal anastomotic device during off-pump coronary artery bypass grafting is safe and significantly decreases cerebral microembolism when compared with standard coronary artery bypass grafting with cardiopulmonary bypass and hand-sewn anastomoses. Long-term follow-up is needed to determine the effects of this technical strategy on neurocognitive outcome.     

Facilitated endoscopic beating heart coronary artery bypass grafting using a magnetic coupling device

BACKGROUND: Suturing of a coronary anastomosis in totally endoscopic coronary artery bypass grafting on the beating heart is technically demanding. The potential benefits of the endoscopic Magnetic Vascular Positioner device (Ventrica, Inc, Fremont, Calif) to facilitate construction of a coronary anastomosis in a closed chest environment were evaluated. METHODS: Totally endoscopic coronary artery bypass grafting on the beating heart was performed in 8 foxhound-beagle inbred dogs with the da Vinci telemanipulation system (Intuitive Surgical, Mountain View, Calif). A prototype of the endoscopic Magnetic Vascular Positioner device was used to facilitate construction of the coronary anastomosis. One pair of magnets was inserted in the internal thoracic artery and left anterior descending artery using robotic instruments to guide and place the endoscopic delivery platform. All animals underwent angiography; gross inspection of the anastomotic site was performed after excision of the hearts. RESULTS: The procedure was accomplished in all animals in 169 minutes (155-190 minutes). Dissection of the left anterior descending coronary artery (6.5 minutes; 1-20 minutes), positioning of the stabilizer (8.5 minutes; 7-16 minutes), placement of occlusion tapes (6 minutes, 3-10 minutes), and arteriotomy 5.5 minutes (3-30 minutes) was achieved without problems. By use of the Magnetic Vascular Positioner device, the anastomosis at the graft site was performed with the graft still in situ. Except for 1 premature deployment, all other deployments were easily accomplished in 3 minutes (1-28 minutes). The following adverse events were encountered: bleeding from the right ventricle caused by occlusion tape (1), anastomotic leakage on reperfusion requiring repair stitches (2), and anastomotic occlusion as a result of thrombus (1). All except 1 animal with a patent graft and anastomosis survived the procedure. The overall patency was 7 of 8. DISCUSSION: The combination of robotic technology allowing for dexterous manipulation in a closed chest environment and a simple yet effective and timesaving technique for anastomotic coupling may facilitate beating heart totally endoscopic coronary artery bypass grafting.     

Clampless arterial coronary artery bypass grafting with the use of magnetic coupling devices

BACKGROUND: The aim of our study was to evaluate the feasibility of using the Ventrica MVP device to perform proximal anastomoses as part of the clampless off-pump coronary artery bypass (OPCAB) arterial revascularization procedure. METHODS: We present our preliminary experience of these first nine coronary artery cases performed in the UK from April 2003 to December 2004. RESULTS: The device was used in eight patients for the proximal anastomosis of a radial artery (n = 8) or right internal thoracic artery (n = 1) graft as a Y-graft from the left internal thoracic artery to the circumflex territories. One patient died in this series although the autopsy showed that the device was intact and free of clots and the reported cause of death was an acute cardiac event due to myocardial ischemia. Anastomotic patency was confirmed in five patients with the use of multidetector row computed tomography coronary angiogram. The anastomosis time in our series was 6.3 +/- 2.1 minutes and the blood loss 814 +/- 245 mL. The mean length of stay was 5.2 +/- 1.2 days. No other significant major morbidity events were observed postoperatively (neurological complications, renal failure, and reopening for bleeding). The assessment of quality of life at 6 months postoperatively using SF-36 questionnaires revealed improvement. CONCLUSION: The versatile use of Ventrica MVP distal anastomotic device is feasible in clinical practice allowing surgeons to perform proximal anastomoses and arterial OPCAB surgery with short learning curve and without compromising the clinical outcome and quality of life.     

Is the GraftConnector a valid alternative to running suture in end-to-side coronary arteries anastomoses?

BACKGROUND: An animal study was carried out to compare long-term patency rates of coronary anastomoses performed with the GraftConnector versus running suture technique. METHODS: 10 sheep, 45 to 55 kg, underwent off-pump coronary artery bypass grafting (right internal mammary artery to left anterior descending artery). In 5 animals, the anastomosis was performed with a GraftConnector and in 5 animals with 7-0 running suture. Intraoperative fluoroscopy and a fluoroscopic control at 6 months were performed. After 6 months, the animals were sacrificed and the anastomoses were examined histologically. RESULTS: All animals survived at 6 months with 100% anastomosis patency rates in both groups. In the GraftConnector group, the anastomosis diameter at 6 months fluoroscopy was 118% of native left anterior descending artery versus 97% of the control group. Luminal anastomotic width at histology was 1.7 +/- 0.2 mm in the device group versus 1.6 +/- 0.1 mm in the control group. Mean intimal hyperplasia thickness was 0.21 +/- 0.1 mm in the device group versus 0.01 mm in the control group. CONCLUSIONS: The GraftConnector provides a consistent and reproducible coronary artery anastomosis and reduces technical demand and manual dexterity in coronary operations. Long-term results demonstrate that off-pump coronary artery bypass grafting performed with the GraftConnector had the same patency rate and luminal width as those performed with running suture.     

Early experience of coronary artery bypass grafting with a new self-closing clip device

OBJECTIVE: We are in the midst of development of several new anastomotic devices for use in coronary artery bypass grafting surgery. This study was designed to examine one of these devices (a new self-closing clip) for left internal thoracic artery-left anterior descending coronary artery anastomosis. Its feasibility and the quality of anastomosis were evaluated. METHODS: Fourteen patients who underwent first-time elective coronary artery bypass surgery were enrolled between July and December 2000. The left internal thoracic artery was anastomosed to the left anterior descending coronary artery in an interrupted manner with Coalescent U-clips (Coalescent Surgical, Inc, Sunnyvale, Calif). Immediate patency was checked with a transit-time flowmeter. Selective angiography was performed 6 months after surgical intervention. RESULTS: Five patients underwent on-pump coronary bypass grafting, 9 on the beating heart. One patient was excluded from the study intraoperatively because of a poor target site necessitating a 2-cm-long anastomosis. Left internal thoracic artery-left anterior descending artery anastomoses were created with an average of 11.8 clips in 15.9 minutes. Mean graft flow was 45.6 mL/min. Neither conversion to standard suture technique nor revision of anastomosis was necessary. There tended to be a learning curve in the anastomosis on the beating heart. Postoperative lengths of stay in the intensive care unit and the hospital were 20.7 hours and 3.9 days, respectively. Neither death nor major complication was seen, except for temporary atrial fibrillation in 2 patients. Graft patency at 6 months was 100% (FitzGibbon grade A). CONCLUSION: Left internal thoracic artery-left anterior descending artery anastomoses can be created safely and effectively with new self-closing clips on the beating, as well as the arrested, heart. Midterm patency was shown to be perfect by means of angiography.     

Initial United States clinical trial of robotically assisted endoscopic coronary artery bypass grafting

OBJECTIVES: With traditional instruments, endoscopic coronary artery bypass grafting has not been possible. This study was designed to determine the clinical feasibility of using a robotically assisted microsurgical system to create endoscopic coronary anastomoses. Methods And Results: Ten patients underwent endoscopic coronary artery bypass grafting of the left internal thoracic artery to the left anterior descending artery. Subxiphoid endoscopic ports (2 for instruments, 1 for a camera) were placed, and a robotic system was used to perform the left internal thoracic artery-left anterior descending artery bypass graft. Conventional techniques were used to perform the other grafts. Blood flow through the left internal thoracic artery graft was measured in the operating room and was adequate in 8 of 10 patients. The 2 inadequate grafts were revised successfully by hand. Six weeks after the operation, selective coronary angiography demonstrated a graft patency of 100% (8/8). There were no technical failures of the robotic system. The only postoperative complication was mediastinal hemorrhage in 1 patient. CONCLUSIONS: This pilot study demonstrates the feasibility of robotically assisted endoscopic coronary artery bypass grafting.     

Coronary artery bypass grafting without cardiopulmonary bypass for high-risk patients

Between January 1991 and June 1993, coronary artery bypass grafting was performed without either cardiopulmonary bypass or cardiac arrest in 23 patients. Most patients had several surgical risk factors, including age ⩾ 70 years, poor left ventricular function, left main coronary artery stenosis, chronic renal failure, and aortic aneurysm. Distal anastomoses were made under temporary interruption of coronary flow. A total of 37 distal anastomoses to the left anterior descending coronary artery and/or right coronary artery (mean 1.6 per patient) were made, 24 of which were internal thoracic arteries. The coronary occlusion time ranged from 7–14 min (mean 9.8 min). Combined cardiac or vascular operations were carried out in six patients (abdominal aortic aneurysm repair, thoracic aortic aneurysm repair, carotid endarterectomy, and coronary endarterectomy). There was one hospital death. Postoperative angiography was performed in 22 patients and showed a patency rate of 89%. In summary, coronary artery bypass grafting without cardiopulmonary bypass may improve the postoperative outcome of high-risk patients.     

Reoperative off-pump coronary revascularization via left thoracotomy using the PAS-Port system to the descending thoracic aorta: report of a case

We performed redo-off-pump coronary artery bypass grafting( OPCAB) via a left thoracotomy using the PAS-Port system for proximal vein graft anastomoses in a patient with posterolateral myocardial ischemia. The patient was a 76-year-old man who had undergone coronary artery bypass grafting (CABG)[ left internal thoracic artery( LITA)-left anterior descending artery( LAD), saphenous vein graft(SVG)-posterior descending artery( 4PD), and SVG-postero-lateral branch( PL)] 14 years previously. Coronary angiogram showed that the LITA-LAD graft was patent but that the SVG-PL, left main trunk( LMT) and proximal right coronary artery(RCA) were occluded, and that there were 90% stenoses of LAD #7 and SVG-4PD anastomotic site. With catheter intervention therapy, stenosis of the SVG-#4PD was dilated. We then performed revascularization from the descending aorta to the second diagonal (D2) and PL with a saphenous vein graft via left thoracotomy using off-pump technique. To avoid descending aortic clamping, we used the PAS-Port system for proximal anastomosis. The postoperative course was uneventful and the patient was discharged on postoperative day 28. A redo-CABG is thought to be with high risk. Our procedure, however is safe and useful and can be an option for redo-CABG in the posterolateral area.     

Bilateral Thoracoscopic Minimally Invasive Direct Coronary Artery Bypass Grafting Using Internal Thoracic Arteries

Background. Single-vessel coronary artery bypass grafting of the left internal mammary artery (ITA) to the left anterior descending coronary artery using a minithoracotomy has been shown to produce excellent results with a very low mortality. However, this procedure cannot be used in patients with double- or triple-vessel disease. Our goal was to develop a minimally invasive direct coronary artery bypass grafting procedure without cardiopulmonary bypass for patients with multivessel disease.

Methods. Both ITAs were thoracoscopically harvested using video imaging. Limited bilateral anterior thoracotomies were performed in the fourth intercostal spaces, thus exposing the right coronary artery and the left anterior descending coronary artery. The right ITA–right coronary artery and ITA–left anterior descending coronary artery anastomoses were performed without cardiopulmonary bypass using 8-0 polypropylene sutures.

Results. This procedure was successfully performed in 3 patients. The patients were extubated in the operating room. Postoperative angiographic studies showed patent left ITA and right ITA grafts.

Conclusions. Bilateral thoracoscopic minimally invasive direct coronary artery bypass grafting can be used to treat patients with a proximally diseased left anterior descending coronary artery and right coronary artery. Bilateral thoracoscopic ITA harvesting is a less invasive surgical technique that may become an option for the management of multivessel coronary artery disease.     

Intraoperative Angiography During Minimally Invasive Direct Coronary Artery Bypass Operations

Background. The technical demands of beating heart operations raise concerns about anastomotic patency. This feasibility study tested the usefulness of intraoperative angiography during minimally invasive direct coronary artery bypass grafting (MIDCABG).

Methods. Ten patients underwent intraoperative angiography of the internal thoracic artery (ITA) after MIDCABG. Minimally invasive direct coronary artery bypass grafting was performed on a beating heart through the fourth or fifth intercostal space. Angiography was performed through the right or left femoral artery with a 7F introducer system placed before the operation. Views were obtained in the right and left anterior oblique and straight anterior projections.

Results. There were no deaths or intraoperative morbidities related to MIDCABG or angiography. Seven patients demonstrated widely patent MIDCABG anastomoses with obliteration of all intercostals, widely patent ITA pedicles, good distal runoff, and placement of the ITA into the proper native coronary artery. Two patients had revisions of their ITA pedicles, which on repeated angiography showed correction. One patient’s procedure was converted to a sternotomy because of poor distal runoff and haziness at the level of the MIDCABG anastomosis.

Conclusions. This feasibility study demonstrates the utility of intraoperative ITA angiography in identifying problems after MIDCABG. Intraoperative angiography may facilitate MIDCABG by documenting proper placement of conduits, obliteration of intercostal vessels, and patency of the MIDCABG anastomosis and ITA pedicle.     

Early experience with minimally invasive direct coronary artery bypass grafting with the internal thoracic artery

OBJECTIVE: Minimally invasive direct coronary artery bypass is performed under direct vision without sternotomy or cardiopulmonary bypass. The technique can be used in both primary and reoperative cases by employing the internal thoracic artery to perform arterial revascularization of the anterior surface of the heart. METHODS: Patients were selected who had significant coronary artery disease limited to 1 or 2 coronary distributions on the anterior surface of the heart. Coronary target vessels were grafted with the internal thoracic artery through a small anterior thoracotomy. After partial heparinization the anastomosis was facilitated by local coronary occlusion and handheld stabilization. RESULTS: Between August 1994 and July 1997, 162 patients underwent minimally invasive direct coronary artery bypass grafting with the internal thoracic artery. The left and right internal thoracic arteries were used for grafting of the left anterior descending artery in 142 patients (88%), the proximal right coronary artery in 7 patients (4%), existing saphenous vein grafts in 5 patients (3%), and diagonal branches in 2 patients (1%). Sequential grafting with the left internal thoracic artery was performed in 2 patients (1%) and bilateral internal thoracic artery grafting was performed in 4 patients (3%). Eight patients (4.9%) died within 30 days after the operation, 3 of cardiac causes. Seven additional patients died during the follow-up period. Nine patients (5.6%) required reintervention for graft stenosis or occlusion during follow-up. Of 141 patients seen 2 or more weeks after the operation, 135 (96%) had resolution of their anginal symptoms at a mean follow-up of 12 months (range 0-31 months). CONCLUSIONS: Anterior minimally invasive direct coronary artery bypass grafting with the internal thoracic artery avoids the risks of repeated sternotomy, aortic manipulation, and cardiopulmonary bypass. There was a low rate of reintervention, and patients had excellent resolution of anginal symptoms. Postoperative length of stay was comparatively short, and continued follow-up will be essential to evaluate long-term graft patency and patient survival.     

Bilateral internal thoracic artery T grafting for coronary artery revascularization

OBJECTIVES: We studied the early outcome of bilateral internal thoracic artery T grafting. METHODS: Coronary artery bypass grafting was studied retrospectively using bilateral internal thoracic artery T grafting in 51 patients. The T graft was made by anastomosing the free right internal thoracic artery to the in-situ left internal thoracic artery. Average patient age was 63.5 +/- 9.9 years, and the average number of anastomoses per patient was 3.6 +/- 0.9. In 35 patients, the right gastroepiploic artery (21 anastomoses in 20 patients), radial artery (1 anastomosis), free left internal thoracic artery (1 anastomosis) and saphenous vein graft (14 anastomoses in 13 patients) were used as additional bypass conduits. RESULTS: Hospital mortality was 0%. The morbidity of stroke was 1.9% (1 patient) and deep sternal infection 0%. Patency of the in-situ left internal thoracic artery was 49/50 anastomoses (98%) and that of the free right internal thoracic artery 81/84 anastomoses (96.4%). Mid-term coronary angiography in 7 patients demonstrated patent anastomosis of the T graft. Acute myocardial infarction unrelated to graft failure occurred in 2 patients during follow-up. Other patients were evaluated by exercise stress tests every year and none exhibited myocardial ischemia in the areas of T graft coronary revascularization. Three-year actuarial survival rate was 100% and freedom from cardiac events 96%. CONCLUSIONS: The bilateral internal thoracic artery T graft provides satisfactory early and mid-term outcomes in properly selected patients.     

Standard coronary artery bypass grafting and beating heart bypass. Indications and long-term results.

OBJECTIVES AND METHOD: We have performed 225 cases of coronary artery bypass grafting (CABG), between October 15 1995 and September 8 1999. We have evaluated the operative results of 121 cases (53.8%) of conventional CABG and 104 cases (46.2%) of minimally invasive coronary artery bypass grafting performed during this period. The average numbers of bypassed grafts was 3.45 for conventional CABG, and 1.41 for minimally invasive coronary artery bypass grafting. Sixty-seven right internal thoracic arteries, 145 left internal thoracic arteries, 71 gastroepiploic arteries, 38 radial arteries and 12 saphenous veins were used for conventional CABG, and 29 right internal thoracic arteries, 81 left internal thoracic arteries, 18 gastroepiploic arteries, 3 radial arteries, 10 saphenous veins and 2 inferior epigastric arteries were used for minimally invasive coronary artery bypass grafting. The total number of 303 grafts were anastomosed to 417 coronary arteries for conventional CABG, and 143 grafts were anastomosed to 147 coronary arteries for minimally invasive coronary artery bypass grafting. RESULTS: Although two saphenous veins were occluded, the early postoperative patency rate was 100% for conventional CABG using right internal thoracic arteries, left internal thoracic arteries, gastroepiploic arteries and radial arteries. Three site of stenosis in 18 left internal thoracic arteries and 2 in 16 right internal thoracic arteries were recognized in minimally invasive coronary artery bypass grafting without the use of stabilizers. One site of stenosis in 63 left internal thoracic arteries was recognized in minimally invasive coronary artery bypass grafting with the use of stabilizers. CONCLUSION: The use of stabilizers enables adaptation of the minimally invasive coronary artery bypass grafting procedure to a wider range of coronary artery bypass procedures, and a higher graft patency can be expected.     

Robotic totally endoscopic coronary artery bypass: program development and learning curve issues

BACKGROUND: The introduction of new procedures in heart surgery is a critical phase that includes learning curves and the risk of increased mortality or morbidity. Totally endoscopic coronary artery bypass grafting using robotic techniques represents such an innovative procedure. The aim of this report is to demonstrate the safe introduction of totally endoscopic coronary artery bypass grafting using a stepwise and modular approach. METHODS: From June 2001 until December 2002, 50 procedures were performed using the da Vinci telemanipulator system. After baseline training the following procedure modules were carried out in a stepwise manner: robotically assisted endoscopic left internal thoracic artery harvesting and completion of the procedure as conventional coronary artery bypass grafting, minimally invasive direct coronary artery bypass, or off-pump coronary artery bypass (n = 19), robotically assisted suturing of left internal thoracic artery to left anterior descending anastomoses during conventional coronary artery bypass grafting (n = 15), totally endoscopic coronary artery bypass grafting on the arrested heart using remote access perfusion and aortic endocclusion coronary bypass grafting (n = 15). One patient was excluded intraoperatively from a robotic procedure due to pleural adhesions. RESULTS: A significant learning curve was observed for left internal thoracic artery takedown time, y(min) = 181 - 39 x ln(x) (x = procedure number) (P <.001), and total operative time in totally endoscopic coronary artery bypass grafting, y(min) = 595 - 87 x ln(x) x = (procedure number) (P =.028). The conversion rate in totally endoscopic coronary artery bypass grafting was 2/15. Intensive care unit stay correlated significantly with total operative time (r =.427, P =.002). There was no hospital mortality. CONCLUSION: Totally endoscopic coronary artery bypass grafting can be safely implemented into a heart surgery program. Learning curves are steep for robotic left internal thoracic artery takedown and for performance of totally endoscopic coronary artery bypass grafting. Long operative times translate into prolonged intensive care unit stay in specific cases but not into increased mortality.     

Coronary artery bypass grafting without cardiopulmonary bypass: MIDCAB and OPCAB

Minimally invasive direct coronary artery bypass grafting via left anterior small thoracotomy (MIDCAB) and coronary artery bypass grafting without cardiopulmonary bypass (OPCAGB) are accepted technique as less invasive than conventional coronary artery bypass grafting (CABG). We reported our experience with these procedures. From 1996 to December 1999, 176 patients underwent MIDCAB or OPCAB with the internal thoracic artery. The left internal thoracic arteries were used for grafting of the left anterior descending artery (LAD) in 131 patients, LAD and diagonal branches sequentially in 8 patients, using free radial artery conduits for grafting of the right coronary artery (RAC) or left circumflex (LCx) in 7 patients, using radial artery conduits as Y-graft from LAD for grafting of the RAC or LCx in 24 patients, and bilateral internal thoracic artery grafting was performed in 4 patients. One patient (0.6%) died in the hospital. One patient (0.6%) had perioperative myocardial infarction. No patient had cerebrovascular accident and sever wood infection. One-hundred-seventy-four patients (98.8%) had resolution of their angina symptom.     

Mini-sternotomy for off-pump coronary artery bypass grafting

The number of off-pump coronary artery bypass grafting procedures without cardiopulmonary bypass is steadily increasing. We report on a new, minimally invasive surgical approach for off-pump coronary revascularization in multivessel disease. A distal sternotomy is performed to gain access to the left and right internal thoracic arteries and to reach the left anterior descending coronary artery, diagonal branches, and right coronary artery for off-pump revascularization.     

Total arch replacement through re-median sternotomy after coronary surgery

We report the case of 78-year-old-man who required graft replacement of an aortic arch aneurysm. He previously had undergone off-pump coronary artery bypass grafting with the right internal thoracic artery bypassed to the left anterior descending artery. For this difficult case, we successfully performed total arch replacement using selective antegrade cerebral perfusion through a re-median sternotomy without injuring the right internal thoracic artery, which was the only blood source for the left and right coronary arteries.