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Vinzant NJ, Christensen JM, Yalamuri SM, Smith MM, Nuttall GA, Arghami A, LeMahieu AM, Schroeder DR, Mauermann WJ, Ritter MJ. Pectoral Fascial Plane Versus Paravertebral Blocks for Minimally Invasive Mitral Valve Surgery Analgesia. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00099-X. [PMID: 36948910 DOI: 10.1053/j.jvca.2023.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 01/24/2023] [Accepted: 02/06/2023] [Indexed: 02/13/2023]
Abstract
OBJECTIVES This study examined the postoperative analgesic efficacy of single-injection pectoral fascial plane (PECS) II blocks compared to paravertebral blocks for elective robotic mitral valve surgery. DESIGN A single-center retrospective study that reported patient and procedural characteristics, postoperative pain scores, and postoperative opioid use for patients undergoing robotic mitral valve surgery. SETTING This investigation was performed at a large quaternary referral center. PARTICIPANTS Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2016, to August 14, 2020, for elective robotic mitral valve repair who received either a paravertebral or PECS II block for postoperative analgesia. INTERVENTIONS Patients received an ultrasound-guided, unilateral paravertebral or PECS II nerve block. MEASUREMENTS AND MAIN RESULTS One hundred twenty-three patients received a PECS II block, and 190 patients received a paravertebral block during the study period. The primary outcome measures were average postoperative pain scores and cumulative opioid use. Secondary outcomes included hospital and intensive care unit lengths of stay, need for reoperation, need for antiemetics, surgical wound infection, and atrial fibrillation incidence. Patients receiving the PECS II block required significantly fewer opioids in the immediate postoperative period than the paravertebral block group, and had comparable postoperative pain scores. No increase in adverse outcomes was noted for either group. CONCLUSIONS The PECS II block is a safe and highly effective option for regional analgesia for robotic mitral valve surgery, with demonstrated efficacy comparable to the paravertebral block.
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Affiliation(s)
- Nathan J Vinzant
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Jon M Christensen
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Suraj M Yalamuri
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Mark M Smith
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Gregory A Nuttall
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Allison M LeMahieu
- Department of Quantitative Health Sciences, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Darrell R Schroeder
- Department of Quantitative Health Sciences, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - William J Mauermann
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Matthew J Ritter
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.
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Goto Y, Takagi S, Yanagisawa J, Nakasu A. Combination of endoscopic internal thoracic artery harvest and proximal anastomoses on the descending aorta in minimally invasive coronary artery bypass grafting. BMJ Case Rep 2022; 15:15/12/e251785. [PMID: 36593614 PMCID: PMC9730380 DOI: 10.1136/bcr-2022-251785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Minimally invasive coronary artery bypass grafting is less invasive. Proximal anastomoses at the ascending aorta, in contrast, are technically difficult to perform because of the limited field of view. A man in his 60s undergoing haemodialysis required minimally invasive coronary artery bypass grafting for left anterior descending artery and circumflex arterial restenosis. We successfully performed minimally invasive coronary artery bypass grafting with a proximal graft anastomosis of the descending aorta. A thoracotomy was performed to extend the lateral approach to the descending aorta. We performed a minithoracotomy using three-dimensional endoscopy for internal thoracic artery harvesting. Endoscopic internal thoracic artery harvesting minimises incision length. The combination of endoscopic and lateral thoracotomy incisions in minimally invasive coronary artery bypass grafting enabled small and lateral thoracotomy incisions.
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Affiliation(s)
- Yoshihiro Goto
- Cardiovascular Surgery, Toyohashi Heart Center, Toyohashi, Japan
| | - Sho Takagi
- Cardiovascular Surgery, Toyohashi Heart Center, Toyohashi, Japan
| | - Junji Yanagisawa
- Cardiovascular Surgery, Toyohashi Heart Center, Toyohashi, Japan
| | - Akio Nakasu
- Cardiovascular Surgery, Toyohashi Heart Center, Toyohashi, Japan
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Minimally invasive cardiac surgery: A systematic review and meta-analysis. Int J Cardiol 2016; 223:554-560. [PMID: 27557486 DOI: 10.1016/j.ijcard.2016.08.227] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 08/12/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Minimally invasive (MI) cardiac surgery was introduced to reduce problems associated with a full sternotomy. This meta-analysis aimed to investigate the effects of minimally invasive cardiac surgery on a range of clinical outcomes. METHODS To identify potential studies (randomised/prospective clinical trials) systematic searches were carried out. The search strategy included the concepts of "minimally invasive" OR "MIDCAB" AND "coronary artery bypass grafting" OR "cardiac surgery". This was followed by a meta-analysis investigating cross-clamp time, cardiopulmonary bypass (CPB) time, operation time, ventilation time, intensive care unit (ICU) stay, hospital stay, incidence of myocardial infarction and of stroke/neurologic complications. RESULTS Eight studies (9 intervention groups), totalling 596 participants were analysed. MI cardiac surgery was associated with a shorter ICU stay mean difference (MD) -0.7days (95% confidence interval (CI) -1.23 to -0.18, p=0.009) and longer cross-clamp MD 6.7min (95% CI 1.24 to 12.17, p=0.02), CPB MD 26.68min (95% CI 10.31 to 43.05, p=0.001), and operation times MD 55.03min (95% CI 22.76 to 87.31, p=0.0008). However no differences were found in the ventilation time MD -3.94h (95% CI -8.09 to 0.21, p=0.06), length of hospital stay MD -1.14days (95% CI -3.11 to 0.83, p=0.26) and in the incidence of myocardial infarction odds ratio (OR) 1.97 (95% CI 0.49 to 7.9, p=0.34) or stroke/neurologic complications OR 0.67 (95% CI 0.11 to 4.05, p=0.66). CONCLUSIONS Minimally invasive cardiac surgery is as safe as conventional surgery and could reduce costs due to a shorter period spent in ICU.
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Vieira de Melo RM, Hueb W, Rezende PC, Alves da Costa LM, Oikawa FTC, Lima EG, Hueb AC, Scudeler TL, Kalil Filho R. Comparison between off-pump and on-pump coronary artery bypass grafting in patients with severe lesions at the circumflex artery territory: 5-year follow-up of the MASS III trial. Eur J Cardiothorac Surg 2014; 47:455-8. [DOI: 10.1093/ejcts/ezu216] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Prapas SN, Tsakiridis K, Zarogoulidis P, Katsikogiannis N, Tsiouda T, Sakkas A, Zarogoulidis K. Current options for treatment of chronic coronary artery disease. J Thorac Dis 2014; 6 Suppl 1:S2-6. [PMID: 24672695 DOI: 10.3978/j.issn.2072-1439.2013.10.25] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Accepted: 10/30/2013] [Indexed: 11/14/2022]
Abstract
The primary issues must be discussed regarding the decision making of treating a patient with chronic coronary artery disease (CAD), are the appropriateness of revascularization and the method which will be applied. The criteria will be the symptoms, the evidence of ischemia and the anatomical complexity of the coronary bed. Main indications are persistence of symptoms, despite oral medical treatment and the prognosis of any intervention. The prognosis is based on left ventricular function, on the number of coronary arteries with significant stenosis and the ischemic burden. For patients with symptoms and no evidence of ischemia, there is no benefit from revascularization. If ischemia is proven, revascularization is beneficial. If revascularization is decided, the next important issue must be taken under consideration is the choice of the appropriate method to be applied, surgical or interventional approach. Current treatment options will be presented.
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Affiliation(s)
- Sotirios N Prapas
- 1 Cardiac Surgery Department, Director of "Henry Dunant" Hospital, Athens, Greece ; 2 Cardiothoracic Surgery Department, "Saint" Luke Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 6 Pathology Department, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
| | - Kosmas Tsakiridis
- 1 Cardiac Surgery Department, Director of "Henry Dunant" Hospital, Athens, Greece ; 2 Cardiothoracic Surgery Department, "Saint" Luke Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 6 Pathology Department, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
| | - Paul Zarogoulidis
- 1 Cardiac Surgery Department, Director of "Henry Dunant" Hospital, Athens, Greece ; 2 Cardiothoracic Surgery Department, "Saint" Luke Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 6 Pathology Department, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
| | - Nikolaos Katsikogiannis
- 1 Cardiac Surgery Department, Director of "Henry Dunant" Hospital, Athens, Greece ; 2 Cardiothoracic Surgery Department, "Saint" Luke Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 6 Pathology Department, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
| | - Theodora Tsiouda
- 1 Cardiac Surgery Department, Director of "Henry Dunant" Hospital, Athens, Greece ; 2 Cardiothoracic Surgery Department, "Saint" Luke Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 6 Pathology Department, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
| | - Antonios Sakkas
- 1 Cardiac Surgery Department, Director of "Henry Dunant" Hospital, Athens, Greece ; 2 Cardiothoracic Surgery Department, "Saint" Luke Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 6 Pathology Department, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
| | - Konstantinos Zarogoulidis
- 1 Cardiac Surgery Department, Director of "Henry Dunant" Hospital, Athens, Greece ; 2 Cardiothoracic Surgery Department, "Saint" Luke Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 6 Pathology Department, "G. Papanikolaou" General Hospital, Thessaloniki, Greece
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Stamou SC, Kouchoukos NT. Reoperative coronary artery bypass grafting via left thoracotomy and hypothermic fibrillation. J Card Surg 2011; 26:34-6. [PMID: 21235625 DOI: 10.1111/j.1540-8191.2010.01178.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Left posterolateral thoracotomy approach for reoperative coronary artery bypass grafting (CABG) is a useful alternative to median sternotomy. We describe use of a left posterolateral thoracotomy and hypothermic fibrillation for reoperative CABG in a patient with patent bilateral internal thoracic artery grafts.
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Affiliation(s)
- Sotiris C Stamou
- Division of Thoracic and Cardiovascular Surgery, Missouri Baptist Medical Center, St Louis, Missouri, USA
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Minimally Invasive Direct Coronary Artery Bypass as a Primary Strategy for Reoperative Myocardial Revascularization. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2010; 5:22-7. [DOI: 10.1097/imi.0b013e3181cef8a6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective Conventional reoperative coronary artery bypass grafting is associated with risk of sternal re-entry, injury to patent grafts, and embolization from diseased grafts. Sternal sparing minimally invasive direct coronary artery bypass (MIDCAB) avoids such risks in cases where it is technically feasible. We sought to examine in-hospital outcomes of reoperative MIDCAB surgery. Methods We recorded prospective standardized data from the New York Cardiac Surgical Reporting System database of 369 reoperative MIDCAB cases from 1996 to 2006 and compared with 822 primary MIDCAB patients in the same time period. We compared the preoperative risk profile and postoperative in-hospital outcomes and length of stay for both groups. Results There was a significantly higher risk profile typical of the reoperative patient population (P < 0.001 for stroke, peripheral/cerebrovascular disease, extensive aortic calcification, renal failure, and left ventricular ejection fraction <40%) compared with the primary MIDCAB group. Despite this fact, there was no difference in the in-hospital outcomes and length of hospital stay between the two groups. Conclusions Reoperative MIDCAB provides targeted coronary revascularization and avoids hazards of sternal re-entry, graft injury and manipulation, and deleterious effects of cardiopulmonary bypass. This hastens recovery and provides excellent early outcomes equivalent to primary MIDCAB procedures.
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Balacumaraswami L, Patel NC, Gorki H, Jennings J, Plestis KA, Subramanian VA. Minimally Invasive Direct Coronary Artery Bypass as a Primary Strategy for Reoperative Myocardial Revascularization. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2010. [DOI: 10.1177/155698451000500106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Nirav C. Patel
- Department of Cardiothoracic Surgery, Lenox Hill Hospital, New York, New York USA
| | - Hagen Gorki
- Department of Cardiothoracic Surgery, Lenox Hill Hospital, New York, New York USA
| | - Joan Jennings
- Department of Cardiothoracic Surgery, Lenox Hill Hospital, New York, New York USA
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Sasaki H. Coronary artery bypass grafting without full sternotomy. Surg Today 2009; 39:929-37. [PMID: 19882313 DOI: 10.1007/s00595-009-3976-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Accepted: 04/05/2009] [Indexed: 10/20/2022]
Abstract
Coronary artery bypass grafting is performed without full sternotomy in selected patients because it is less invasive. Left internal thoracic artery-left anterior descending artery bypass (LITA-LAD bypass) via a small left anterior thoracotomy is a well established procedure, which achieves good graft patency with low mortality and morbidity rates. Multiple revascularization is possible with a limited lateral thoracotomy or L-figure approach. Axillary-coronary bypass and right gastroepiploic artery-right coronary artery bypass (RGEA-RCA bypass) are alternative methods, especially for redo surgery, in selected patients.
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Affiliation(s)
- Hideki Sasaki
- Department of Cardiothoracic Surgery, The University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390, USA
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Subramanian VA, Loulmet DF, Patel NC. Minimally Invasive Coronary Artery Bypass Grafting. Semin Thorac Cardiovasc Surg 2007; 19:281-8. [DOI: 10.1053/j.semtcvs.2007.11.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2007] [Indexed: 01/08/2023]
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Elahi MM, Khan JS, Matata BM. Deleterious effects of cardiopulmonary bypass in coronary artery surgery and scientific interpretation of off-pump's logic. ACTA ACUST UNITED AC 2007; 8:196-209. [PMID: 17162546 DOI: 10.1080/17482940600981730] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Cardiopulmonary bypass (CPB) has been suggested to be a cause of complex systemic inflammatory response that significantly contributes to several adverse postoperative complications. In the last few years, off-pump coronary artery bypass grafting (OPCAB) has gained widespread attention as an alternative technique to conventional on-pump coronary artery bypass grafting (ONCAB). However, a degree of uncertainty regarding the relative merits of ONCAB and OPCAB continues to be a significant issue. Surgeons supporting off-pump surgery, state that the avoidance of the CPB leads to significantly reduced myocardial ischemia-reperfusion injury, postoperative systemic inflammatory response and other biological derangements, a feature that may improve the clinical outcomes. However, perfection in perioperative care, surgical technique and methods of attenuating the untoward effects of CPB has resulted in better clinical outcome of ONCAB as well. Possible reasons of these controversial opinions are that high-quality studies have not comprehensively examined relevant patient outcomes and have enrolled a limited range of patients. Some studies may have been too small to detect clinically important differences in patient outcomes between these two modalities. We present a review of the available scientific interpretation of the literature on OPCAB with regard to safety, hemodynamic changes, inflammation, myocardial preservation and oxidative stress. We also sought to determine from different reported retrospective and randomized control studies, the initial and the long-term benefits of this approach, despite the substantial learning curve associated with OPCAB.
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Affiliation(s)
- Maqsood M Elahi
- Wessex Cardiothoracic Centre, General Hospital/BUPA, Southampton, UK
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Suzuki T, Okabe M, Yasuda F, Miyake Y, Handa M, Nakamura T. Our experiences for off-pump coronary artery bypass grafting to the circumflex system. Ann Thorac Surg 2003; 76:2013-6. [PMID: 14667632 DOI: 10.1016/s0003-4975(03)01326-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Complete revascularization has been difficult in off-pump coronary artery bypass grafting (OPCAB). Hemodynamic deterioration often prevents access to the circumflex territory. This study presents instrumentation for accessing the circumflex territory, and our clinical experience. METHODS From August 1999 through December 2002, 140 patients underwent OPCAB via sternotomy in our institution. The 114 requiring reconstruction of the circumflex artery are the subjects of this study. There were no exclusion criteria. A series of techniques and instruments were developed to provide access to the circumflex area while hemodynamic stability was preserved, including the left pericardial traction technique, compression of the right pericardium, a right sternal retractor, and a type of shunt tube. RESULTS Patients received an average of 3.2 grafts (range, 2 to 6). Complete revascularization was achieved in 95% of the cases. Complications included respiratory insufficiency (0.8%), renal dysfunction (7%), and sternal wound infection (0.8%). Blood transfusions were required in 10 patients (8%). No patient suffered perioperative myocardial infarction or stroke. No operation was converted to cardiopulmonary bypass. There was no operative death. Predischarge angiography demonstrated a 99% patency rate. CONCLUSIONS With our techniques and instruments, off-pump coronary revascularizaion of the circumflex area may be performed safely to achieve complete revascularization. Early clinical results are excellent, but long-term longitudinal follow-up is required to assess the future effectiveness of OPCAB procedure with our techniques.
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Affiliation(s)
- Robert A Lancey
- Bassett Heart Care Institute, Mary Imogene Bassett Hospital, Cooperstown, New York, USA
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Semrad M, Stritesky M, Vondracek V, Lindner J, Vanek I, Kristof J, Aschermann M. Port access video-assisted proximal anastomosis with the symmetry aortic connector in MIDCABG procedure. Ann Thorac Surg 2003; 76:919-21. [PMID: 12963230 DOI: 10.1016/s0003-4975(02)04774-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We present an alternative way to create a video-assisted port access proximal anastomosis in the ascending aorta with the Symmetry Bypass System Aortic Connector (St. Jude Medical ATG, St. Paul, MN). This technique was successfully used in a patient undergoing urgent minimally invasive direct coronary artery bypass grafting (MIDCABG), in whom the left internal mammary artery was not harvested owing to subtotal occlusion of the left subclavian artery. Port access use of mechanical anastomotic devices may increase the indications for minimally invasive coronary artery surgery.
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Affiliation(s)
- Michal Semrad
- Department of Cardiovascular Surgery, Charles University Teaching Hospital, 1st Medical Faculty, Prague, Czech Republic.
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Semrád M, Bodlák P, Stríteský M, Vondrácek V, Urban T, Vyhnalová P, Holm F, Vanek I. Video-assisted multivessel revascularization through a left anterior small thoracotomy approach with the Symmetry Aortic Connector System. J Thorac Cardiovasc Surg 2003; 125:129-34. [PMID: 12538996 DOI: 10.1067/mtc.2003.79] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We sought to demonstrate the applicability of video-assisted multivessel revascularization through a left anterior small thoracotomy approach with the use of the Symmetry Aortic Connector System (St Jude Medical Anastomotic Technology Group, Inc, St Paul, Minn) as an alternative to the standard median sternotomy approach and to evaluate predischarge angiographically documented graft patency. METHODS From October 2001 through February 2002, a total of 15 patients with triple-vessel disease were operated on through a left anterior small thoracotomy approach with video-assisted port-access construction of proximal aorta-to-saphenous vein anastomoses with the Symmetry Aortic Connector System and cardiopulmonary bypass with femoral cannulation and without cardioplegic arrest. There were 9 male and 6 female subjects with a mean age of 68.3 +/- 3.6 years and an average ejection fraction of 55.8% +/- 19.6%. Subject inclusion criteria consisted of female sex (initially but not throughout the study), coronary artery reoperations, and sternal bone disease. Subject exclusion criteria consisted of an age younger than 65 years, extensive atheromatous plaques in the ascending aorta, and aortoiliac occlusive disease. All but 1 patient underwent angiographic patency evaluation before discharge. RESULTS Fifteen operations were performed successfully without any deaths. Twenty-nine sutureless proximal anastomoses were performed, with an average of 3.13 +/- 0.62 distal anastomoses per patient. Eleven (73%) patients underwent a fast track protocol with extubation in the operating room. We did not observe any instances of low cardiac output syndrome, stroke, renal insufficiency, wound complication, or perioperative myocardial infarction. A single episode of atrial fibrillation occurred in this group. Angiographic assessment of 44 bypass grafts and target arteries was performed, and 86% of those examined were widely patent (FitzGibbon score A). CONCLUSIONS We have demonstrated a potential advantage of the sutureless Symmetry Aortic Connector System as a suitable approach that affords minimal access. Video-assisted multivessel revascularization through a left anterior small thoracotomy approach with an automated mechanical anastomosis device is particularly useful in patients undergoing coronary artery bypass reoperations or those at risk of poor sternal healing or infection. This approach seems to be a safe alternative to standard median sternotomy.
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Affiliation(s)
- Michal Semrád
- Department of Cardiovascular Surgery and Internal Department, Charles University Teaching Hospital, First Medical Faculty, Prague, Czech Republic
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Fuster RG, Montero JA, Gil Ó, Hornero F, Cánovas SJ, Dalmau MJ, Bueno M. Ventajas de la revascularización miocárdica sin circulación extracorpórea en pacientes de riesgo. Rev Esp Cardiol 2002. [DOI: 10.1016/s0300-8932(02)76618-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Fonger JD, Subramanian VA, Connolly MW. Limited-access surgical coronary artery revascularization. Semin Thorac Cardiovasc Surg 2002; 14:58-69. [PMID: 11977019 DOI: 10.1053/stcs.2002.31898] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The continued evolution of surgical revascularization has resulted in much less invasive alternatives for patients undergoing coronary artery bypass grafting. In particular, techniques and technologies have been developed to allow for the grafting of coronary arteries through limited access incisions without the circulatory support of cardiopulmonary bypass. The conduits are generally arterial rather than the venous alternatives used originally, and the harvesting of these conduits is performed through limited access incisions described in another article in this review. The result of these efforts is sternal-sparing solutions for the off-pump coronary artery bypass grafting of all the various coronary locations on the heart. This is accomplished through a spectrum of small incisions that can directly expose any specific area of interest for focal bypass grafting. The surgical insult is greatly reduced and the patient's recovery is significantly enhanced. These efforts continue to bring us closer to the ultimate goal of 24-hour hospital stays for coronary artery bypass grafting patients.
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Affiliation(s)
- James D Fonger
- Section of Cardiovascular Surgery, Lenox Hill Hospital, 130 East 77th Street, 4th Floor, New York, NY 10021, USA
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Azoury FM, Gillinov AM, Lytle BW, Smedira NG, Sabik JF. Off-pump reoperative coronary artery bypass grafting by thoracotomy: patient selection and operative technique. Ann Thorac Surg 2001; 71:1959-63. [PMID: 11426774 DOI: 10.1016/s0003-4975(01)02617-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Reoperative coronary artery bypass grafting (CABG) in patients with contraindications to sternotomy or cardiopulmonary bypass (CPB) presents a technical challenge. In this study we reviewed patient selection, operative technique, and early results in patients having redo-CABG to the circumflex artery system by a thoracotomy without CPB. METHODS From January 1996 through December 1999, 21 patients with contraindications to conventional redo-CABG had target vessel revascularization off-pump by thoracotomy. A posterolateral thoracotomy approach was used. RESULTS No patient required sternotomy or CPB. There was no hospital mortality. Postoperative cardiac morbidity included non-Q wave myocardial infarction (5%), need for intraaortic balloon pump support postoperatively (5%), and atrial fibrillation (5%). Two grafts were studied early and two were studied late (more than 6 months later). One venous graft was found to be occluded early. Survival at 2 years was 95%. Ninety percent of surviving patients were in New York Heart Association functional class I or II. CONCLUSIONS This approach was associated with no mortality, low morbidity, and favorable early symptomatic improvement. This is the approach of choice in cases of reoperative CABG to the circumflex system when resternotomy or CPB are undesirable, and the culprit coronary vessels are accessible through a thoracotomy.
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Affiliation(s)
- F M Azoury
- Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Ohio 44195, USA
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Stamou SC, Corso PJ. Coronary revascularization without cardiopulmonary bypass in high-risk patients: a route to the future. Ann Thorac Surg 2001; 71:1056-61. [PMID: 11269437 DOI: 10.1016/s0003-4975(00)02325-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Previous reports have demonstrated that reoperative coronary revascularization, advanced age, female sex, and impaired left ventricular dysfunction are independent predictors of operative mortality after coronary artery bypass grafting (CABG). CABG without cardiopulmonary bypass (off-pump CABG) has been proposed as a potential therapeutic alternative in these high-risk patient groups. Despite the substantial learning curve associated with off-pump CABG, early outcomes of off-pump CABG in high-risk patients are better than those associated with the conventional on-pump CABG approach. These results suggest that off-pump CABG is a safe alternative to on-pump CABG in high-risk patients. Randomized prospective studies are needed to validate the results of these initial retrospective reports and to demonstrate the long-term benefits of this approach.
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Affiliation(s)
- S C Stamou
- Department of Surgery, Washington Hospital Center, DC 20010, USA
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