Minimally Invasive Direct Coronary Artery Bypass Grafting and Transcatheter Aortic Valve Implantation

This video presents an associated procedure of a coronary bypass grafting and a transapical aortic valve replacement through a left anterior minithoracotomy.

The patient was an 83-year-old man with a known aortic stenosis and a hystory of persistent atrial fibrillation. He complained of a syncopal episode and was admitted to the authors’ center. A cardiac ultrasound showed a severe aortic stenosis with a good left ventricular ejection fraction. A coronary angiography revealed significant stenosis of the left main coronary artery and of the proximal left anterior descending, and a suboccluded right coronary artery. In view of the severe comorbidities with which the patient was affected, the authors decided to limit the surgical invasiveness.

The operation was performed through a left anterior minithoracotomy in the fourth intercostal space. One-lung ventilation was achieved by a double lumen tube. The left internal thoracic artery was harvested by means of a Delacroux Chevalier retractor and with the use of thoracoscopic instruments. At the end of Lima harvesting, it was irrigated with papaverine solution. The pericardium was opened and the anastomosis on the left anterior descending was performed by means of Medtronic Octopuss stabilizer. Transit time flow measurement was used to test graft patency.

To avoid an adjunctive thoratomy in the fifth intercostal space, normally used to access the left ventricular apex, a gauze was positioned behind the heart to lift the apex and two concentric purse-string sutures were applied. A guidewire from the left ventricular apex was advanced through the aortic wall in the ascending aorta and a Sapien 29 mm valve was delivered under fluoroscopy and transesophageal ultrasound check.

At the end of the procedure and after device removal, the purse-string sutures were tied and closed. The pericardium was partially closed and a drainage was positioned in the left pleura. The operation was completed in the usual manner. At the end of the operation, postoperative analgesia was enhanced by slow continuous anesthetic delivery of bipuvacaine of 5% through small catheters positioned inside the wound.

After an uneventful postoperative period, the patient was discharged home on the seventh postoperative day.

References

1. Repossini A, Di Bacco L, Nicoli F, Passaretti B, Stara A, Jonida B, et al. Minimally invasive coronary artery bypass: Twenty-year experience. J Thorac Cardiovasc Surg. July 2019;158(1):127–138.
2. Schymik G, Würth A, Bramlage P, Herbinger T, Heimeshoff M, Pilz L, et al. Long-term results of transapical versus transfemoral TAVI in a real world population of 1000 patients with severe symptomatic aortic stenosis. Circ Cardiovasc Interv. 2014 Dec 31;8(1):e000761.
3. Pibarot P, Salaun E, Dahou A, Avenatti E, Guzzetti E, Annabi MS, et al. Echocardiographic results of transcatheter versus surgical aortic valve replacement in low-risk patients: the PARTNER 3 trial. Circulation. 2020 May 12;141(19):1527-1537.

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