A low cost, low stress method for minimal access coronary artery bypass surgery
SS Shah, S Bennett, S Griffin
Castle Hill Hospital, Hull, East Yorkshire
Background: A major concern between conventional and minimal access coronary artery bypass surgery (MIDCAB) is the quality of the distal anastomosis. Various techniques have been utilised to improve the operative conditions during MIDCAB including myocardial stabilisers, heart rate reduction and drug induced asystole, all with varying degrees of success. The Heart Port system is said to allow near perfect conditions offering a bloodless field and a still heart however this system is prohibitively expensive costing an extra £2500-00 per case. We have developed an alternative system for use in patients with single artery disease.
Method: A small anterior thoracotomy is perfomed and the pericardium is opened. The heart is inspected and if the distal left anterior descending artery is suitable for grafting the left internal mammary artery (LIMA) is dissected under direct vision with video assistance used only for the most proximal dissection. A special IMA retractor is used for this procedure. Femero-femoral cardiopulmonary bypass is established via the femoral vessels using a long venous cannula with active drainage via a centrifugal pump. Transoesophageal echo is used to check both the position of the venous cannula and to ensure adequate emptying during bypass. The core temperature is allowed to drift to 340C. The pericardium is lifted and a left ventricular vent is inserted. The heart is then electrically fibrillated. The left anterior descending artery is isolated and opened, an intra-coronary occluder is inserted and the IMA is anastomosed end-to-side in the routine fashion.
Results: We have performed 12 MIDCAB procedures using this technique. There have been no deaths and all patients have reported resolution of angina. In 2 patients percutaneous angioplasty was performed to other vessels.
Conclusions: In the small number of cases we have performed, this technique provides a bloodless field with a safely vented fibrillating heart, enabling a satisfactory vascular anastomosis to be performed. The extra cost per case is £160-00. We believe that this is a low cost, low stress method for single vessel coronary artery bypass surgery.
