Routine intraoperative angiography improves the early patency of coronary grafts performed on the beating heart

OBJECTIVES: The techniques of performing coronary revascularization without cardiopulmonary bypass are rapidly evolving. However, concern remains regarding the accuracy of coronary artery anastomoses performed on the beating heart. This report reviews the use of intraoperative angiography in the critical appraisal of "off-pump" coronary artery bypass graft (CABG) surgery. PATIENTS: Intraoperative angiography was performed in 24 consecutive patients undergoing CABG surgery without cardiopulmonary bypass. In all, 24 left internal mammary artery (LIMA) grafts and 18 saphenous vein bypass grafts were assessed for patency, anastomosis quality, distal and proximal runoff, and correct placement. RESULTS: All of the saphenous vein-to-coronary artery anastomoses were widely patent, although two patients (8%) required revision of their LIMA grafts on the basis of angiographic findings. CONCLUSION: Intraoperative angiography permits the surgeon to immediately appraise the CABG and to revise, if necessary, any graft abnormality, thus potentially eliminating the need for early repeated surgery. The practice of routine intraoperative angiography is likely to improve the outcome of CABG surgery on the beating heart.     

Hybrid revascularization

OBJECTIVE: To evaluate our initial experience in the combination of two less invasive procedures for myocardial revascularization, coronary artery bypass grafting without cardiopulmonary bypass and immediate posterior angioplasty, on untreated lesions (hybrid revascularization) as an alternative treatment to conventional surgery in selected patients. MATERIAL AND METHODS: From october 1996 to September 1998, 19 patients received hybrid revascularization. The mean age was 64 (47-76). Two patients underwent urgent surgery. Two patients had left main coronary disease, and 9 three-vessel disease. In general, we considered this procedure for patients with high-risk factors for cardiopulmonary bypass and two or more vessel disease. The internal mammary artery was connected to the left anterior descending artery in all 19 patients. All patients were moved to the hemodynamic ward immediately after surgery in 7 cases and before 48 h in the rest, 24 angioplasties were performed. A mean of 2.6 vessels per patient were revascularized and revascularization was complete in 15 patients (79%). RESULTS: One patient had perioperative myocardial infarction. There was no hospital mortality. Length of stay in the intensive care unit was 44 h (IQR = 49) and global postoperative stay was 8 days (IQR = 3.5). In the postoperative angiographic study, before the angioplasty, 95% of mammary arteries (CI 95% 74-100%) and 100% of saphenous grafts (CI 95% 59-100%) were patent. CONCLUSIONS: Combined revascularization allows almost complete revascularization, avoiding complications of cardiopulmonary bypass and minimizing surgical aggression. At the same time, it secures the graft of internal mammary artery to left anterior descending artery.     

Right coronary revascularization by coronary-coronary bypass with a segment of internal thoracic artery

In certain coronary artery bypass grafting operations, the internal thoracic artery is not by itself adequate for complete arterial revascularization. Which graft should be used for revascularization of the right coronary artery is still a matter of debate. From August 2000 through July 2005, we performed coronary-coronary bypass grafting on 48 patients (77.1% men, 22.9% women), whose mean age was 57.2 years (range, 40-75 yr). After completion of the internal thoracic artery anastomoses, we performed coronary-coronary bypass grafting with a remaining (distal) segment of the left (or, rarely, the full length of the free right) internal thoracic artery. The proximal and distal anastomoses of the internal thoracic artery to the right coronary artery were end-to-side. We preferred to use the right coronary ostium as the proximal anastomosis site where possible; otherwise, we used a disease-free segment of the right coronary artery. A total of 192 anastomoses were performed (mean, 4.15 per patient); all used the bilateral internal thoracic arteries as conduits. There were no in-hospital deaths or perioperative myocardial infarctions. The duration of follow-up ranged from 1 to 46 months (mean, 9.6 mo). Follow-up angiography was performed in 24 patients (50%). The mean time to coronary angiography was 16.5 months (range, 7 days-2 years). The patency rate was 100%. We conclude that coronary-coronary anastomosis by means of a distal segment of the internal thoracic artery can help to achieve complete arterial revascularization in selected patients.     

Myocardial revascularization using both internal mammary arteries. Clinical results and surgical strategy

To improve the benefits from coronary artery grafting with internal mammary artery (IMA) several technical manoeuvres and methods have been developed to increase the number of coronary arteries and their branches that can be bypassed with internal mammary arteries. Between November 1985 and December 1986, 50 patients underwent a surgical myocardial revascularization procedure using both internal mammary arteries by single or sequential anastomoses and supplemental saphenous vein graft. In 42% of these patients complete revascularization was achieved employing only internal mammary artery grafts. One hundred and twenty-six internal mammary artery grafts (77% of the total coronary bypass performed), were placed. One patient developed perioperative myocardial infarction. Reparative surgery to control immediate post-operative bleeding was required in two patients. Post-operative coronary angiography performed in 30 patients showed all patent internal mammary artery grafts but one. No late deaths occurred. Mean follow-up of 10 months was complete in 50 patients, of whom 94% are symptom free. We conclude that bilateral internal mammary artery grafting can be performed with low operative risk and can provide excellent long-term functional improvement and survival employing only high patency arterial conduit. Moreover, it doesn't significantly increase surgical morbidity.     

Coronary-subclavian steal syndrome. A case report.

Coronary-subclavian steal is an unusual clinical syndrome after successful internal mammary-coronary artery bypass grafting. Proximal subclavian artery (SA) stenosis is present and atherosclerotic disease is the underlying pathophysiologic mechanism in the majority of cases. The authors report a case of a sixty-two-year old man with angina and ventricular fibrillation soon after myocardial revascularization with left internal mammary artery (LIMA) to left anterior descending coronary (LAD). Dobutamine stress echocardiography showed ischemia in the anterior myocardial territory with patent LIMA-LAD bypass in the angiographic evaluation. This procedure showed occlusion of the proximal SA with reversal of flow in the LIMA. The best therapeutic approach was discussed and a carotid-subclavian bypass was performed with restoration of antegrade blood flow and reversal of the clinical setting.     

One-year clinical outcomes after complete arterial coronary revascularization

BACKGROUND: Conventional coronary bypass surgery applies single internal mammary arteries and saphenous vein graft conduits for revascularization of occluded coronary arteries. While the use of saphenous vein grafts is limited by early graft occlusion, little data exist on clinical experiences with complete arterial revascularization. PATIENTS AND METHOD: From January 2003 to July 2004, 390 patients were transferred from Red Cross Hospital Cardiology Center to the Rotenburg Cardiovascular Center for coronary bypass operation. From these patients, 200 were selected for complete arterial revascularization. Mean age of the patients was 66.7+/- 8.0 years; 80.5% were male; 68.5% had triple-vessel disease, 31% had two-vessel disease, and 0.5% had single-vessel disease; 32% were diabetic; and 6.5% had a previous bypass operation. Left ventricular ejection fraction was >50% in 85.5% and 30-50% in 14.5%. Double internal mammary artery grafts were used in 98% and single internal mammary artery grafts in 2%. In 51%, the right internal mammary artery was connected with the left internal mammary artery as a T-graft and in 17%, it was used as a free aortocoronary graft. Radial artery grafts were used in 4%. The average number of anastomoses per patient was 3.4. RESULTS: During the primary in-hospital stay, 1.5% of the patients had to undergo reoperation, 3.5% had myocardial infarctions, 3.5% had wound healing complications, 1.0% experienced an ischemic stroke, and 1 patient died following an acute myocardial infarction. At 12 months, 1.0% underwent percutaneous reinterventions, 0.5% had to be reoperated, 0.5% had a myocardial infarction, and 1.0% died. The actuarial survival rate at 12 months was 99%. CONCLUSION: When both the internal mammary arteries are used as the preferred surgical strategy, complete arterial revascularization can be performed with excellent clinical results over 12 months.     

Hybrid coronary revascularization in high-risk patients

From January 2002 through June 2004, 17 patients (2% of all coronary cases) were treated with off-pump coronary artery bypass grafting combined with percutaneous coronary intervention. There were 13 men and 4 women, whose ages ranged from 54 to 78 years (mean, 63.1 +/- 20.9 yr). Preoperative angiography revealed 2-vessel coronary artery disease in 12 patients and 3-vessel disease in the remaining 5 patients. In all patients, extensive lesions (>50%) in the circumflex and right coronary arteries were treated first with a percutaneous intervention, followed by beating-heart coronary artery bypass grafting within 3 hours to treat the remaining obstructed vessels. Coronary angiography was performed 12 months after the operation to evaluate the effectiveness of the procedure. Procedure-related complications did not occur, and there was no in-hospital death. All patients underwent a successful left internal mammary artery-left anterior descending artery anastomosis with the exception of 1 patient, in whom we used a saphenous vein because of previous chest radiotherapy. The postoperative courses were uneventful, and no deterioration of preoperative organ dysfunction was noticed in any patient. There was no cardiac-related death or myocardial infarction. In follow-up angiography, all left internal mammary artery-left anterior descending artery anastomoses were patent. Three patients with restenosis were treated medically, which resulted in substantial reduction of angina. Hybrid coronary revascularization enables complete revascularization and may be an alternative method of treating selected patients who have concomitant disease.     

Coronary Artery Bypass Grafting after Pneumonectomy

When open-heart operations are necessary in patients who have undergone pneumonectomy, the unavoidable shift of mediastinal structures should be carefully considered. Surgical access, revascularization procedures, and the institution of cardiopulmonary bypass can all require approaches that differ from the usual. In particular, no general recommendations exist regarding the management of patients who undergo coronary artery bypass grafting after pneumonectomy.We successfully performed coronary artery bypass grafting in a 57-year-old man who had undergone a left pneumonectomy 7 years previously. Because the patient''s heart was completely displaced into the left posterior hemithorax, access via a left posterolateral thoracotomy was chosen. Saphenous vein grafts were chosen over the internal mammary artery. The distal anastomoses were performed with use of the off-pump technique; for the proximal anastomosis, 2 venous grafts were implanted into the descending aorta. The patient''s postoperative course was uneventful, and postoperative angiography revealed patent grafts. Herein, we discuss the case of this patient, and we present some considerations that can influence surgical approaches in similar circumstances.Key words: Angina, unstable/surgery; cardiopulmonary bypass; coronary artery bypass/methods; coronary disease/surgery; pneumonectomy; respiratory insufficiencyA 57-year-old man, who had undergone left pneumonectomy 7 years earlier, presented with symptoms of unstable angina. Examination revealed triple-vessel disease, respiratory dysfunction, and complete displacement of the heart and the great vessels to the posterior wall of the left pleural cavity. Here, we discuss the case of this patient and the management of coronary artery bypass grafting (CABG) when the heart is completely displaced after pneumonectomy.     

Total arterial revascularization and concomitant aortic valve replacement

The safety of total arterial revascularization with a left internal thoracic artery-radial artery T-graft was evaluated in patients with at least two-vessel coronary artery disease and aortic valve stenosis requiring concomitant aortic valve replacement. From June 2001 to January 2005, 18 patients underwent aortic valve replacement and total arterial revascularization, while 101 had aortic valve replacement and conventional grafting. By matching age, sex, left ventricular ejection fraction, and number of distal anastomoses, 1:2 matched groups were generated: 15 patients with a left internal thoracic-radial artery T-graft, and 30 with left internal thoracic artery and additional vein grafts. Aortic cross clamp and cardiopulmonary bypass times were similar in both groups. There were no significant differences in postoperative data between the groups. Early mortality was 0% in the T-graft group and 2% in those with conventional grafts. Follow-up ranged from 2 to 50 months. Event-free survival was 100% in the T-graft group and 90% in the conventional graft group. Total arterial grafting with a left internal thoracic-radial artery T-graft can be performed in selected patients with aortic valve stenosis requiring simultaneous aortic valve replacement.     

Robotically enhanced coronary artery bypass surgery

BACKGROUND: Robotically enhanced telemanipulation surgery is a fast developing technique which allows totally endoscopic cardiac surgery with utmost precision and perfection on both beating heart as well as arrested heart. METHODS AND RESULTS: Between December 2002 and February 2004, 125 patients underwent robotically enhanced coronary artery bypass surgery using the da Vinci telemanipulation system (Intuitive Surgical Inc., California). Eleven patients underwent totally endoscopic coronary artery bypass surgery. Of them 9 were done on beating heart while 2 were done on arrested heart. One hundred and fourteen patients had endoscopic takedown of internal mammary artery followed by minimally invasive direct coronary artery bypass in 63 patients and left anterolateral thoracotomy in 51 patients. The internal mammary artery mobilization time was 42 min (35-74 min) while the left internal mammary artery to left anterior descending artery anastomosis time ranged from 20 to 36 min for the totally endoscopic coronary artery bypass patients. In 1 patient, the right internal mammary artery was anastomosed to diagonal artery totally endoscopically. The mean internal mammary artery flow by Doppler measurement done in patients undergoing minimally invasive direct coronary artery bypass was 64 ml/min. Seven patients required conversion to median sternotomy and coronary bypass surgery on beating heart. The mean intensive care unit stay was 1.2 days and the mean hospital stay 4.5 days. There was 1 in-hospital mortality. All 11 patients who underwent totally endoscopic bypass surgery had coronary angiography done at 3 months interval which showed 100% patency in 10 patients while one patient had 50% anastomotic narrowing for which coronary angioplasty was done in the same sitting. CONCLUSIONS: Using telematic technology, a complete endoscopic anastomosis is possible in both single vessel and suitable double vessel disease patients. The use of robotics is now extended to achieve complete myocardial revascularization by harvesting both the internal mammary arteries and making a small thoracotomy for direct anastomosis as well.     

Myocardial revascularization in dextrocardia with situs inversus]

BACKGROUND: The incidence of coronary artery disease in patients with dextrocardia associated with situs inversus is similar to that of the general population: Nevertheless, there are few papers regarding surgical myocardial revascularization in these patients. METHODS: We report two patients with dextrocardia and situs inversus who underwent myocardial revascularization by means of coronary artery bypass grafting, with the right internal mammary artery to the left anterior descending coronary artery in one case and with the left internal mammary artery as a free graft to the left anterior descending coronary artery associated with the repair of an aneurysm of the right coronary sinus of Valsalva in the second patient. RESULTS: There were no surgical complications; the patients were discharged on the 4th and 7th postoperative days, respectively. They are alive and well after 24 and 60 months of follow-up respectively. CONCLUSIONS: This report suggests that durable myocardial revascularization in dextrocardia with situs inversus can be successfully achieved with right or left mammary artery bypass grafting to the left anterior descending coronary artery. The advantage of using an in situ mammary artery is discussed.     

Evaluation of flow reserve in internal mammary artery in situ bypass

The internal mammary artery, when used as a conduit for coronary artery bypass, offers a better long-term patency and survival rate than the saphenous vein. However, concern exists that the flow through the internal mammary artery may be inadequate during periods of peak myocardial demand. This flow was investigated in 18 consecutive patients who were selected for coronary bypass of the left anterior descending artery using the internal mammary artery. All patients were evaluated post-operatively within 12 months by means of graded maximal stress test, cardiac catheterization and exercise thallium-201 scintigraphy. Significant improvement in work capacity, maximal rate-pressure product, effort angina and ECG abnormalities during exercise stress testing were observed following internal mammary artery myocardial revascularization. The patency rate for internal mammary artery grafts was 100% (vs 85% for vein grafts); during the followup period, occlusion of a saphenous vein bypass or development of a new stenosis in a native coronary artery was noted in five patients, and two patients were classified as having partial revascularization. Ischemia, demonstrated by perfusion deficits at peak stress which disappeared in the 3-hour delayed film, was documented in 7.4% (4/54) of the areas supplied by internal mammary artery grafts, compared to 31% (13/42) of the regions revascularized using saphenous vein conduits. Although this result was not statistically significant, a definite trend is suggested. We conclude that ischemia demonstrated by stress thallium scintigraphy in the post-operative period is uncommon when an internal mammary artery graft has been used. This suggests that adequate coronary flow exists at peak myocardial demand during exercise.     

Comparative assessment of the use of skeletonized and un-skeletonized internal thoracic artery for myocardial revascularization

BACKGROUND: Skeleting of internal thoracic artery widens possibilities of a surgeon during mammary-coronary bypass grafting but this procedure is associated with augmented risk of damage of internal thoracic artery (ITA). MATERIAL AND METHODS: ITA was used for creation of anastomosis with anterior interventricular artery in 151 patients. It was harvested on pedicle in 82 (group 1) and subjected to skeleting in 69 (group 2) patients. All operations were performed with cardiopulmonary bypass. In group 2 ITA conduits were more frequently used for grafting distal anterior interventricular artery. RESULTS: There were 3 and 0 deaths in groups 1 and 2, respectively. Rates of nonfatal postoperative complications were similar in both groups. Spasms of ITA grafts were more frequent in group 1. CONCLUSION: Skeleting of ITA for mammary coronary bypass grafting compared with its harvesting on pedicle was not associated with increased risk of complications or elevated mortality in early postoperative period.     

Mitral valve annuloplasty and myocardial revascularization in the treatment of ischemic dilated cardiomyopathy

The aim of this study was to examine perioperative mortality and morbidity and midterm results in patients undergoing coronary bypass graft and mitral valve annuloplasty with advanced dilated cardiomyopathy. Sixty-one patients with ischemic dilated cardiomyopathy underwent coronary artery bypass grafting and mitral valve annuloplasty between January 1998 and December 2003. Patients eligible for revascularization that presented a mild or more severe mitral valve regurgitation at echocardiography (effective regurgitant orifice > 0.2 cm²) were considered for annuloplasty with a Cosgrove ring. New York Heart Association class (NYHA) III/IV was present in 40 patients (66%) and Canadian Cardiovascular Society class III–IV in 19 (31%). A previous acute myocardial infarction was reported in 48 patients (79%). The mean number of graft anastomoses was 2.5 ± 0.7 and the left internal mammary artery was used in 49 patients (80%). In-hospital mortality was 4.9% (3 patients), due to unsuccessful weaning from cardiopulmonary bypass, multiple organ failure, and stroke, respectively. Left ventricle ejection fraction improved from 28.9% ± 5.2% preoperatively to 35.4% ± 8.1% at follow-up (P = 0.0001) and a significant reduction in NYHA III/IV was detected: from 40 patients preoperatively (66%) to 14 (31%) at follow-up (P = 0.031). Midterm cardiac-related mortality rate was 3.4%. In our experience combined coronary artery bypass grafting and ring annuloplasty for ischemic dilated cardiomyopathy can be performed with acceptable risks for in-hospital mortality and morbidity. Midterm results show a good survival rate and a durable functional improvement in this subset of patients.     

Pedicled right internal mammary artery for reoperative off-pump revascularization of left anterior descending coronary artery

In situ right internal mammary artery is the graft of choice in reoperative off-pump coronary artery bypass grafting, as well as in primary on-pump coronary artery bypass grafting, unless the vessel has been used previously. However, there are not enough data about postoperative angiographic findings of the in situ right internal mammary artery in reoperative coronary artery bypass grafting with the off-pump technique. From September 1993 through January 2004, we reviewed the postoperative course and the graft patency of 12 selected patients who underwent off-pump coronary artery bypass grafting reoperation only for revascularization of the left anterior descending artery, by means of a pedicled right internal mammary artery graft. All patients were evaluated clinically and by postoperative coronary angiography. There were no early or late deaths during the mean follow-up period of 33.08 +/- 30.05 months (range, 1-77 months). The mean interval from the 1st operation to the 2nd operation was 74.1 +/- 57.01 months (range, 4.5-171 months). Postoperative coronary angiograms of all patients showed a 100% patency rate for both in situ grafts and composite grafts. We suggest that use of the in situ right internal mammary artery in off-pump coronary artery bypass grafting is a safe and reliable option for revascularizing the left anterior descending artery, especially in reoperation.     

First Italian robot-enhanced coronary bypass.

This case report presents the first totally endoscopic coronary artery bypass performed with a robotic system in Italy at the Department of Cardiovascular Surgery of Padua University in December 2001. A 66-year-old male, with an indication to a single bypass of the left anterior descending coronary artery using the left mammary artery, was considered eligible for a robot-assisted myocardial revascularization using the da Vinci robotic system. The left internal mammary artery takedown was performed through three 1 cm ports on the thoracic wall. The "end-to-side" anastomosis between the mammary artery and the target coronary artery was totally performed endoscopically on a beating heart by means of a stabilizing device introduced through an additional subxiphoid port. Angiographic follow-up at 1 year showed patency of the graft. Since September 2001, robot-enhanced left mammary artery harvesting has been performed in another 18 patients without complications.     

Hybrid-Verfahren zur Myokardrevaskularisation: Stellenwert der Kombination von minimal-invasiver Bypasstechnik (MIDCAB) mit interventioneller Therapie (PTCA)

BACKGROUND: Minimally invasive direct coronary artery bypass (MIDCAB) grafting without cardiopulmonary bypass (CPB) through an anterolateral minithoracotomy has become a promising therapeutical option especially in multimorbid, elderly and reoperative patients with single vessel disease. However, this procedure precludes complete revascularization in multivessel disease because the minithoracotomy limits the surgical access either to anterior or lateral or posterior vessels of the beating heart. To expand the benefits of the MIDCAB concept to patients with multivessel disease, new interdisciplinary approaches have recently been introduced. METHODS: Since December 1996, 26 patients (21 male, 5 female, mean age 56.6 +/- 18.8 years) underwent a "hybrid" revascularization performed as a primary MIDCAB procedure for grafting of the left anterior descending artery (LAD) with the left internal mammary artery (LIMA) followed by staged angioplasty and stenting of additional coronary lesions. RESULTS: After MIDCAB grafting, the postoperative course was uneventful in all patients. Coronary re-angiography after a median of 7 days revealed patent and functioning LIMA grafts in all patients. Applying subsequent percutaneous transluminal coronary angioplasty (PTCA) and occasional stenting (n = 8), a total of 31 lesions were treated successfully. Procedure related complications did not occur. All patients remained angina-free and no stress electrocardiographic changes were recorded. CONCLUSION: Our preliminary results of a "hybrid" approach to myocardial revascularization suggest that this concept is a safe and effective approach of complete revascularization for selected patients with multivessel involvement. Especially elderly and reoperative patients with significant comorbidity may benefit from hybrid procedures avoiding cardiopulmonary bypass and midsternotomy.     

Sequential internal mammary artery bypass for multiple coronary stenoses

Long-term studies (10 years) show a 50 per cent patency rate of saphenous vein autograft and 95 per cent patency rate of internal mammary artery coronary bypass grafts. In some situations (after saphenous vein stripping, varicose and fibrotic veins) it is not possible to use venous grafts and the internal mammary artery has to be used. However, the internal mammary artery is usually only used for revascularisation of the left anterior descending artery. Sequential internal mammary artery bypass is a technique which can be used for revascularizing the left anterior descending artery. Seven men aged 44 to 68 years (average 55 years) were operated between November 1983 and February 1985. These patients had clinically stable (4 cases) or instable (3 cases) angina. Two patients had previously undergone bilateral saphenous vein stripping and one patient a terminal anastomosis on the left anterior descending and a latero-lateral anastomosis on the diagonal artery. Three patients had an associated venous bypass graft and one patient also underwent aortic valve replacement. There were no cases of postoperative myocardial infarction. Five control angiographies were carried out during the first postoperative month. In 4 patients the internal mammary graft ant the latero-lateral and termino-lateral anastomoses were patent. In the other case, the latero-lateral anastomosis and the diagonal artery was occluded but the internal mammary graft and the termino-lateral anastomosis on the left anterior descending artery were patent. The average follow-up period is now 18 months: there have been no recurrences of chest pain or any ECG changes. These results show that internal mammary artery bypass grafting is a delicate procedure.(ABSTRACT TRUNCATED AT 250 WORDS)     

胸腔镜辅助微创单支冠状动脉旁路移植术8例

目的 研究胸腔镜辅助下经胸壁小切口非体外循环冠状动脉旁路移植术的应用及效果。方法 8例患者在胸腔镜电视系统监测下经第4肋间前外侧小切口采集乳内动脉。并经此小切口直视下切开心包,显露左前降支,进行非体外循环不停跳冠状动脉旁路移植。结果 第2肋间至第6肋间节段的乳内动脉可顺利游离,时间平均为38min,吻合完成后检测旁路血管流量满意,无围术期心肌梗死及手术死亡。患者均于术后9～12d出院。随访3～23个月所有患者均无心绞痛症状。结论 胸腔镜电视系统监视提供了良好的视野,明显降低了经第4肋间小切口游离第2、6肋间乳内动脉的难度,可以获取足够长度的血管,通过小切口即可完成旁路移植。手术近期效果良好。     

Off-pump coronary artery bypass grafting using a bilateral internal mammary artery Y graft

Objectives To evaluate the outcome of off-pump coronary artery bypass grafting (OPCABG) using a bilateral internal mammary artery (BIMA) Y configuration graft to achieve total arterial myocardial revascularization. Methods From October 2002 to December 2008, 208 patients (196 males and 12 females) underwent OPCABG using a BIMA Y configuration graft. The average age of the patients was 56.5 ± 11.3 years, with an age range of 33–78 years. A total of 167 (80.2%) cases had triple-vessel disease. Left main stem disease was found in 33 (15.9%) cases, and double-vessel disease was found in 8 (3.9%) cases. The semi-skeletonization technique was used to harvest the two internal mammary arteries (IMAs), and then the free right internal mammary artery was connected end-to-side to the left internal mammary artery (LIMA) in situ to complete the Y configuration graft. Off-pump and sequential anastomosis methods were used to perform coronary artery bypass surgery in all patients. Graft patency was assessed intra-operatively with the HT311 transit time flowmeter. Results A total of 728 distal anastomoses were performed in 208 patients, with the average being 3.5 ± 1.3 per person. No one died or experienced recurrent angina within 30 days after the operation. Conclusions OPCABG using the BIMA Y graft was safe and effective to achieve total arterial revascularization. This method avoids surgical operation on the ascending aorta and other incisions.