LATERAL MIDCAB GRAFTING VIA LIMITED POSTERIOR THORACOTOMY

Objective: Minimally invasive direct coronary artery bypass (MIDCAB) i s a technique for coronary artery bypass grafting performed under dire ct vision without sternotomy or cardiopulmonary bypass. The approach h as been used principally for primary single vessel grafting of the ant erior or inferior coronary circulation. This initial experience presen ts a new lateral technique for patients with isolated circumflex coron ary disease which can be used for both primary and reoperative revascu larization with either saphenous vein or a free radial artery conduit. Methods: Lateral MIDCAB grafting of the circumflex coronary circulati on was accomplished over a 33 month period at a single center using sa phenous vein or free radial artery as the bypass conduit. Through a li mited posterior thoracotomy, the lung is deflated and reflected superi orly. The pericardium is opened below the phrenic nerve to expose an o btuse marginal branch of the circumflex coronary artery. After heparin ization, the coronary artery is temporarily occluded proximally and di stally with local immobilization and an arteriotomy is performed. The distal anastomosis with running suture is followed by the proximal ana stomosis on the descending aorta below the hilum of the lung using a s ide-biting clamp and radiopaque marker. Intraoperative transit time ul trasound how measurements confirm adequate graft how before wound clos ure. Results: To date, 19 patients have undergone this procedure with a mean follow-up of 12 months. A total of 12 patients received sapheno us vein grafts and 7 patients received radial artery grafts. There was one death from arrhythmia on postoperative day 9. There was one elect ive conversion to conventional sternotomy due to inadequate exposure. Graft hows averaged 33.3 cc/min (range 5-87) and the mean postoperativ e length of stay was 4.5 days; 4 patients underwent recatheterization; 1 had graft occlusion and 2 received late postoperative catheter-base d interventions. All patients are currently free of symptoms. Conclusi ons: Lateral MIDCAB grafting provides focused revascularization to the circumflex distribution in both primary and reoperative settings. Thi s approach avoids the hazards of resternotomy, eliminates cardiopulmon ary bypass, and hastens postoperative recovery. These early results su ggest the technique is effective at relieving symptoms and minimizing perioperative morbidity. Further experience at multiple centers will s erve to define the ultimate capabilities of this new approach. (C) 199 7 Elsevier Science B.V.