AANA journal course: update for nurse anesthetists--anesthetic considerations for minimally invasive direct vision coronary artery bypass grafting.

A recently developed procedure known as MIDCAB (minimally invasive direct vision coronary artery bypass) offers a select group of patients with coronary artery disease an alternative to coronary artery bypass grafting with cardiopulmonary bypass. Compared with customary coronary artery bypass graft surgery, the MIDCAB procedure has a smaller modified incision, requires less operative time, eliminates the risk of cardiopulmonary bypass, and is, as the name implies, far less invasive. Single or multiple vessels are revascularized while the heart remains warm and beating. Movement of the beating heart is dampened in the area of the targeted bypass vessel with the use of mechanical stabilizers by the surgeon. The heart rate may be pharmacologically slowed by the anesthetist. The combination of slowed heart rate and mechanical tamponade by the stabilizers may lead to profound hemodynamic and ischemic changes that may be poorly tolerated in a patient with multiple vessel disease and concurrent disease processes. Extubation and recovery times are far shorter for MIDCAB procedures, leading to earlier discharge and substantial cost savings. The surgical techniques for cardiac bypass surgery have evolved dramatically during the past few years. It is the unique combination of anesthetic monitoring, quick response to hemodynamic changes, and manipulation of physiologic parameters that makes providing anesthesia for minimally invasive cardiac bypass surgery exceptionally challenging.