Off-Pump LIMA to LAD Coronary Artery Bypass Through Left Anterior Minithoracotomy

Minimally invasive approaches are slowly but surely entering the field of cardiac surgery. It is important to note that in this direction, the valvular pathology has developed first and an important experience through the years has been accumulated by the surgical community. Regarding coronary artery bypass surgery (CABG), minimally invasive accesses remain somehow confidential. Even though some authors have reported very interesting results in multiple arterial or venous bypasses (1,2), the spread of the technique remains limited. This can be explained in part by the surgical hesitation to change habits in a procedure that has otherwise very good results by sternotomy. That is why we think that one-vessel disease of the LAD represents the ideal pathology to start with. This is also supported by a recent publication of the Leipzig group, which shows excellent and very stable outcomes over almost twenty years (3).

Here we show our technique of doing LIMA to LAD off-pump CABG through a left anterior minithoracotomy. The patient is installed supine, with a lateral pad under the left side of the thorax. Intubation is done with a single-lumen tube. A 6 to 8cm minithoracotomy incision is done anteriorly between the nipple and the sternum at the level of the fourth intercostal space. For harvesting of the LIMA, we use a specially designed rib retractor (Delacroix-Chevalier instruments, France), which greatly improves surgical exposure. During this time, the lung is ventilated without PEEP, with a low tidal volume, and pulled away by a large surgical gauze inserted in the thorax. After harvesting of the LIMA, the pericardium is opened and the LAD is visible without any important pericardial traction. Usually, pericardial stay sutures are not needed. To improve surgical view of the heart, we use a special MIDCAB stabilizer (Fehling instruments, Germany) that has a distal removable head without suction. In some challenging cases where the stabilization must be improved, a distal head with suction from other manufacturers may be adapted. The anastomosis itself is done as usual in off-pump surgery with classic instruments. Closure and drainage are performed according to our standard procedure.

We think that this technique has shown reliable and excellent results (3) and may represent in the near future the gold standard for the LIMA to LAD CABG.

References

1. Babliak O, Demianenko V, Melnyk Y, Revenko K, Pidgayna L, Stohov O. Total coronary revascularization via left anterior thoracotomy: Practical aspects. Multimed Man Cardiothorac Surg MMCTS. 26 nov 2019;2019.

2. Babliak O, Demianenko V, Melnyk Y, Revenko K, Babliak D, Stohov O, et al. Multivessel Arterial Revascularization via Left Anterior Thoracotomy. Semin Thorac Cardiovasc Surg. Winter 2020;32(4):655‑62.

3. Davierwala PM, Verevkin A, Bergien L, von Aspern K, Deo SV, Misfeld M, et al. Twenty-year outcomes of minimally invasive direct coronary artery bypass surgery: The Leipzig experience. J Thorac Cardiovasc Surg. 17 févr 2021;S0022-5223(21)00343-3.

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