PORT-ACCESS CORONARY-ARTERY BYPASS-GRAFTING - A PROPOSED SURGICAL METHOD

Minimally invasive surgical methods have been developed to provide pat ients the benefits of open operations with decreased pain and sufferin g. We have developed a system that allows the performance of cardiopul monary bypass and myocardial protection with cardioplegic arrest witho ut sternotomy or thoracotomy. In a canine model, we successfully used this system to anastomose the internal thoracic artery to the left ant erior descending coronary artery in nine of 10 animals, The left inter nal thoracic artery was dissected from the chest wall, and the pericar dium was opened with the use of thoracoscopic techniques and single lu ng ventilation, The heart was arrested with a cold blood cardioplegic solution delivered through the central lumen of a balloon occlusion ca theter (Endoaortic Clamp; Heartport, Inc., Redwood City, Calif,) in th e ascending aorta, and cardiopulmonary bypass was maintained with femo rofemoral bypass, An operating microscope modified to allow introducti on of the 3.5x magnification objective into the chest was positioned t hrough a 10 mm port over the site of the anastomosis, The anastomosis was performed with modified surgical instruments introduced through ad ditional 5 mm ports, In the cadaver model (n = 7) the internal thoraci c artery was harvested and the pericardium opened by means of similar techniques, A precise arteriotomy was made with microvascular thoracos copic instruments under the modified microscope on four cadavers, In t hree other cadavers we assessed the exposure provided by a small anter ior incision (4 to 6 cm) over the fourth intercostal space. This anter ior port can assist in dissection of the distal internal thoracic arte ry and provides direct access to the left anterior descending, circumf lex, and posterior descending arteries, We have demonstrated the poten tial feasibility of grafting the internal thoracic artery to coronary arteries with the heart arrested and protected, without a major thorac otomy or sternotomy.