Concomitant Minimally Invasive CABG with LV Restoration and Mitral Valve Replacement

Experience with routine minimally invasive coronary artery bypass grafting makes it possible to successfully and safely perform more complex procedures through the same incision. This video presents the authors’ routine approach for minimally invasive left ventricle aneurysm repair and coronary artery bypass grafting through the left minithoracotomy.  

The patient was a fifty-nine-year-old woman with severe angina and heart failure. Six weeks ago she had a large myocardial infarction. Angio showed double vessel disease with total LAD occlusion. Echo showed severe mitral insufficiency with mitral valve leaflet restriction. Finally, MRI showed a large area of nonviable myocardium. 

Patient position and skin incision were the same as for minimally invasive isolated coronary artery bypass grafting. After the chest was entered in the fourth intercostal space, the LIMA was divided in the same intercostal space and LIMA was skeletonized under direct vision up to its origin. This procedure was done with peripheral cardiopulmonary bypass aortic cross-clamping and cold blood cardioplegia. Tape was put around the ascending aorta, which helped expose the aorta when doing proximal anastomosis and as well as putting the cannula for blood cardioplegia. Next, an aortic clamp was put through the second ICS, and the aorta was cross-clamped under direct vision. With the empty and arrested heart, it was easier to dissect the adhesions around the aneurysm. After that, came the coronary artery bypass grafting. 

To improve the exposure of coronary vessels and LV aneurysm, separate tapes were placed around left pulmonary veins and the inferior vena cava. This helped to bring all the targets closer to the surgeon. After these exposure maneuvers, the distance between the skin and all coronary vessels was less than 6 cm. All knots were then tied with the surgeons’ fingers. PDA anastomosis came first, and the last anastomosis was LIMA to LAD. Then LV aneurysm repair began. In this case, endoventricular circular patch repair technique was performed. The incision was made in the anterior wall of the left ventricle. All the thrombotic masses were removed from the left ventricle and all the remnants of the left ventricle wall were cut out.  
 

The surgeons decided the mitral valve wasn't suitable to repair. The anterior leaflet was divided in the A2 segment, and mitral valve replacement was performed with the preservation of both mitral valve leaflets. First, all stitches were put in the mitral valve prosthesis and then around the mitral valve annulus. There was a nice exposure of the mitral valve prosthesis. All nots were then tied with the surgeons’ fingers. Then, LV aneurysm repair was continued. A circular stitch was placed to restore the left ventricle cavity and a separate running suture was used to fix the dacron patch inside. Left ventricle wall was closed with several layers of continuous polypropylene sutures reinforced with pericardial strips. The aorta was unclamped, and proximal anastomosis was performed with the side-biting clamp. The sutures were also tied with fingers. The clamp was the removed. A post-op echo confirmed good mitral valve prosthesis function. 

References

1. Babliak O, Demianenko V, Melnyk Y, Revenko K, Babliak D, Stohov O, et al. Multivessel Arterial Revascularization via Left Anterior Thoracotomy. Seminars in Thoracic and Cardiovascular Surgery [Internet]. Elsevier BV; 2020 Feb; Available from: http://dx.doi.org/10.1053/j.semtcvs.2020.02.032
2. Babliak, O., Demianenko, V., Melnyk, Y., Revenko, K., Pidgayna, L., & Stohov, O. (2019). Complete Coronary Revascularization via Left Anterior Thoracotomy. Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, 14(4), 330–341. doi:10.1177/1556984519849126

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