Concomitant Minimally Invasive Surgical Approach: Minimally Invasive Direct Coronary Artery Bypass and Minimally Invasive Endoscopic Resection of Cardiac Tumor

Case Presentation
A 46-year-old man with a history of stroke and permanent atrial fibrillation was referred to the authors’ institution with the diagnosis of an LV mass. During preoperative study, catheterization revealed an 80% stenosis of the mid portion of the left anterior descending artery (LAD), and echocardiography showed a PFO. As the authors’ institution has experience with both minimally invasive mitral valve repair (MIMVR) and minimally invasive direct coronary artery bypass (MIDCAB), they opted for a no bone cut procedure by applying both of these techniques concomitantly.

Operative Technique
The patient was placed in the dorsal position with external defibrillator paddles and transesophageal echocardiography (TEE). The groin was used for cannulation for cardiopulmonary bypass.

A 3 cm lateral thoracotomy was performed in the right fourth intercostal space and another port was placed in the right third intercostal space for the video camera. Small pleural adhesions were dissected and the pericardium was opened parallel and 2 cm anterior to the left phrenic nerve. An ordinary aortic root cannula for antegrade cardioplegia was placed and the aorta was clamped using the deployable Glauber™ clamp (Sorin Group®). The atrium was opened, the PFO closed with a continuous suture, and the Valve XS Atrium retractor™ (Braun®) was positioned. The LV mass was adherent to the LV wall, not interfering with the mitral valve or its apparatus. The mass was resected at its base using a blade. The atrium was closed.

Concomitantly, a 7 cm anterolateral thoracotomy was performed in the left fourth intercostal space. A ThoraGate™ (Geister®) rib retractor was used to elevate the rib for LIMA harvesting. The artery was mobilized in a skeletonized fashion. The pericardium was opened at the level of the interventricular groove and a stabilization device exposed the LAD. A longitudinal incision was made in the coronary artery and continuous stitches were used to construct the LIMA to LAD anastomosis. Transit time flow showed an excellent result. Additionally, after positioning the articulated endoscopic stapler at the base of the LAA, the entire LAA was resected.

After unclamping, TEE confirmed complete removal of the LV mass and the LAA, no mitral valve dysfunction, and no remaining PFO, thus allowing the authors to get out of cardiopulmonary bypass. All incisions were closed after positioning one thoracic tube on each thoracotomy.

The postoperative course was uneventful, and the patient was discharged on postoperative day five.

Conclusion
This case demonstrates that MIERCT and MIDCAB procedures can be done concomitantly with safety and success. It also clearly indicates that, if necessary, CMISA will be feasible for MIDCAB and MIMVR.

References

1. Kotowicz V, Posatini R, Fortunato G, Battellini R. How to Perform a MIDCAB Procedure Step-by-Step in Single Vessel Disease. CTSNet. July 2018. doi:10.25373/ctsnet.6713054.
2. Monteiro JP, Pereira R, Fernandes P, Guerra M, Miranda J, Vouga L. Laqueation of a Giant Aneurysm of the Left Atrial Appendage Using VATS Approach. CTSNet. May 2019. doi:10.25373/ctsnet.8160179.
3. Günther T, Kehl V, Voss B, Lange R. Video-assisted right mini-thoracotomy versus full sternotomy for isolated mitral valve repair: a propensity-matched comparison. Interact Cardiov Th. 2014 Oct;19(1): 27.

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