EARLY RESULTS WITH THE MINIMALLY INVASIVE THORACOTOMY FOR MYOCARDIAL REVASCULARIZATION

Objective: We report the early results of the left anterior descending artery revascularization through a minimally invasive thoracotomy, ex amining the main technical aspects of the operation. Methods: From Jan uary 1995 to September 1996, 51 patients underwent myocardial revascul arization through a mini-thoracotomy on beating heart without cardiopu lmonary bypass. The main indication to operation was limited lesions o f the left anterior descending artery with contra-indications or high risk of failure of angioplasty. The position of the patient was the sa me than traditional surgery; the chest was opened on the fourth left i ntercostal space; the left internal mammary artery harvested under dir ect vision; temporary occlusion of the left anterior descending was ob tained prevalently using 5-0 poliypropilene sutures; the anastomosis w as performed with single or double 7-0 or 8-O suture. In six patients the chest was closed and a conventional open-heart operation was perfo rmed due to internal mammary artery or left anterior descending unsuit ability for minimally invasive revascularization. All the patients wer e submitted after operation to early angiographic control and/or a Dop pler study of the mammary flow. Results: There was no intra-operative mortality. One patient had a postoperative myocardial infarction of th e anterior-lateral wall of the left ventricle, and died after an emerg ency open-heart operation. In one case the patient was reopened after a few hours for a bleeding. Three patients showed various degrees of a nastomotic stenosis at the angiographic control. Conclusions: Several technical difficulties can play an important role in the operative out come because a single repeated technical error could not fully explain these heterogeneous observed failures. The technique of myocardial re vascularization through a left anterior small thoracotomy might presen t several critical points, particularly: (1) the harvesting of LIMA, m eaning the preservation of integrity of the arterial wall and adequacy of the length; (2) the method of the temporary closure of the LAD dur ing of the anastomosis; (3) the stabilization of the LAD and the surgi cal technique of the anastomosis; (4) the methods for intraoperative c ontrol of the patency of the anastomosis. All points mentioned have be en thought in our experience to be causes of early failure. (C) 1997 E lsevier Science B.V.