Cardiac Stabilization
Innovation Workshop
Problem Statement:
During off-pump cardiac surgery the heart is constantly moving. The movement increases the difficulty
of the surgery which can in turn lead to longer surgical times and/or unfavorable patient outcomes.
Procedures like this have their benefits since the patient does not have to go on-bypass which can
introduce other possible problems. Currently there are cardiac stabilization instruments on the market,
however when they are used, particularly when manipulating the heart and fully inverting it can cause
the patient to lose systemic pressure and decrease the hearts performance. In summary, an instrument
that could stabilize the heart while not inhibiting the proper function of the heart could be
advantageous for both the physician and patient.
Anatomy:
<http://en.wikipedia.org/wiki/File:Mediastinum_anatomy.jpg>
Location of the heart in relation to the major blood vessels and lungs.
<http://www.heart-valve-surgery.com/surgeon-database/median-sternotomy.jpg>
Typical view of a heart through a medial sternotomy.
Currently Available Instruments:
The tools that are used currently have either one of two functions, 1) to position the heart, 2) to
stabilize the tissue. The former moves the heart into a position that is favorable for the physician and
the latter reduces the movement of the tissue at a particular location.
<http://www.ctsnet.org/graphics/experts/Adult/4165_13.gif>
A focal tissue stabilization device from Guidant. It can be seen in use in the next two images.
<http://www.ctsnet.org/graphics/experts/Adult/4165_7.jpg>
Tissue stabilizer that utilizes suction to hold tissue still.
<http://www.revespcardiol.org/ficheros/images/255/255v58n11/origen/255v58n1113081186fig02.jpg>
The tissue stabilization device used during cardiac bypass grafting surgery.
<http://cardiothoracicsurgeryservices.com/21.html>
Other available stabilization and positioning tools for cardiac surgery. The instruments on the right are
used to position the heart into a favorable location for the physician and utilize suction to achieve this
goal.
Both tissue stabilizer an positioned used to hold the heart during cardiac surgery.
Alternative methods for holding and stabilizing the cardiac tissue.
Most of the stabilizers on the market currently rely on suction to adhere to the epicardium and stabilize
or position the heart.
Minimally invasive cardiac surgery
Minimally invasive cardiac surgery
Minimally Invasive Cardiac Surgery, also known as MICS CABG (Minimally Invasive Cardiac
Surgery/Coronary Artery Bypass Grafting) or The McGinn Technique is heart surgery performed through several
small incisions instead of the traditional open-heart surgery that requires a median sternotomy approach. MICS
CABG is a beating-heart multi-vessel procedure performed under direct vision through an aterolateral
mini-thoracotomy.[1]
Minimally Invasive Heart Surgery is favored by surgeons and patients because of reduced post-operative discomfort,
faster healing times and lowered risk of infections or complications. This procedure makes heart surgery possible for
patients who were previously considered to be too at risk for traditional surgery due to age or medical history.[2][3]
Patients referred for this procedure may have Coronary Artery Disease (CAD); Triple Vessel Disease with median to
large posterior descending artery (PDA); or previous unsuccessful stenting.
The procedure
MICS CABG is performed through one window incision that stretches 5–7 cm in the 4th intercostal space (ICS). In
some cases the thoractomy may be necessary in the 5th ICS instead. A soft tissue refractor is used to allow for
greater visibility and access.
Two access incisions are also made at the 6th intercostal space and xphoid process to allow for operative
Medtronic® instruments to pass through.[4]
The McGinn Technique (Proximal Anastomoses)
The McGinn Proximal Technique is performed with blood pressure lowered to 90-100 systolic which reduces stress
to the aorta, reducing the risk of damage. A series of tools are used to position and stabilize vessels. The technique
uses devices developed by Medtronic® to support the surrounding heart tissues while vital surgery takes place. The
devices are managed externally and access the heart through small incisions between the ribs.
Pump-assisted beating heart bypass
A cannula with a pump and vacuum action is fed up through an artery in the groin to reduce the stress on the heart so
that it may still function during the operation. This pump flows at 2-3L per minute to support circulation and
eliminates the need for a heart-lung bypass machine.
After surgery
Using the McGinn Minimally Invasive technique, patients recover more quickly than from open-heart surgery and
suffer fewer complications. Most patients can expect to resume all everyday activities within a few weeks of their
operation. After surgery, patients are administered with a pain pump and drains that will be removed after one day.
Patients are encouraged to move around as much as possible after their operation to recover quickly. Once
discharged from hospital, patients require no further post-operative assistance.[5]
Minimally invasive heart surgery procedures are a safe and broadly applicable technique for performing a wide range
of complex heart procedures, including single or multiple heart valve procedures, bypass surgery, and congenital
heart repairs.
Minimally invasive heart surgery has been used as an alternative to traditional surgery for the following procedures:
• Mitral valve repair and replacement
• Aortic valve replacement
• Atrial septal defects
1
Minimally invasive cardiac surgery
• Coronary artery bypass
Benefits of MICS CABG/ The McGinn Technique
Eliminating the need for median sternotomy greatly reduces the trauma and pain associated with open-chest surgery
and improves quality of life for patients. In the hospital, reduced post-operative discomfort enables patients to more
quickly begin a much shorter recovery process with minimally invasive heart surgery. Most patients ambulate more
easily and participate more actively in their personal care. Additionally, this approach lowers risk of complications
such as bleeding and infection.
Minimally invasive heart surgery dramatically improves cosmetic scarring. Rather than a prominent 10-inch scar
down the middle of the chest, patients are left with smaller marks to the side of the ribs. For women, in many cases,
this scar is completely unnoticeable as it sits below the breast.
Benefits Include:
•
•
•
•
No splitting of the breastbone
Dramatic reduction in pain
Lower risk of infection
Lower risk of bleeding
•
•
•
•
•
Reduced ICU and hospital stay
Improved postoperative pulmonary function
Accelerated recovery/return to activity
Improved quality of life
Greatly improved cosmetic result
History
The Minimally Invasive Cardiac Surgery was invented by Dr Joseph T McGinn, Jr. The first minimally invasive
heart cardiac surgery was performed in the United States on January 21, 2005 at The Heart Institute at Staten Island
University Hospital in Staten Island, New York by a team led by Dr. Joseph T. McGinn. This technique is an
off-pump coronary artery bypass surgery. The procedure is much less invasive than traditional bypass surgery
because it is performed through three small incisions rather than the traditional sternotomy. Since its first procedure,
over 900 MICS CABG procedures have been performed at The Heart Institute amongst many more around the
world.[6]
References
[1]
[2]
[3]
[4]
[5]
[6]
"MICS CABG Technique Overview: Minimally Invasive CABG (MICS CABG) Procedure", " (http:/ / medtronicmics. com/ )", 2010, p. 1
"NYU Langone Medical Center", " (http:/ / cardiac-surgery. med. nyu. edu/ )", December 29, 2009
"The Heart Institute"," (http:/ / www. theheartinstituteny. com/ pdf/ THI_March_24th_Press_Release. pdf)", March 25, 2011
"MICS CABG Technique Overview: Minimally Invasive CABG (MICS CABG) Procedure", " (http:/ / medtronicmics. com/ )", 2010, p. 1
"Medtronic", " (http:/ / www. medtronic. com/ mics/ documents/ 200901133b_EN. pdf)", 2009
"The Heart Institute"," (http:/ / www. theheartinstituteny. com/ pdf/ THI_March_24th_Press_Release. pdf)", March 25, 2011
External links
• The McGinn Technique at The Heart Institute at Staten Island University Hospital (http://www.theheartinstitute.
com/)
• Mitral Valve Repair at NYU Langone Medical Center's Cardiac and Vascular Institute (http://cardiac-surgery.
med.nyu.edu/treatments-procedures/mitral-valve-repair)
• Minimally Invasive Cardiac Surgery at NYU Langone Medical Center (http://cardiac-surgery.med.nyu.edu/
minimally-invasive-heart-surgery)
2
Minimally invasive cardiac surgery
• Bypass technique is less taxing for patients- St. Louis Today (http://www.stltoday.com/lifestyles/
health-med-fit/fitness/bypass-technique-is-less-taxing-for-patients/
article_875cda99-ca34-578e-bb47-7185f1205e9b.html)
• Heart and Lung surgery clinic-Dr. Mazhar Ur Rehman (http://heartsurgery.com.pk/our-services.html)
3
Article Sources and Contributors
Article Sources and Contributors
Minimally invasive cardiac surgery Source: http://en.wikipedia.org/w/index.php?oldid=570263677 Contributors: Camwolf72, Delirium, Dlodge, Ebbrock, FifteendegreesWiki, Hertz1888,
Malcolma, Nono64, NuclearWarfare, Rd232, Rich Farmbrough, Richard Anthony Clarke, Richardaclarke, T. Canens, 11 anonymous edits
License
Creative Commons Attribution-Share Alike 3.0
//creativecommons.org/licenses/by-sa/3.0/
4
MICS
CABG
Technique Overview
:
Technique Overview:
Minimally Invasive CABG (MICS CABG) Procedure
thinking
forward
Caution: Federal law (USA) restricts this device to
sale by or on the order of a physician. For a listing
of indications, contraindications, precautions and
warnings, please refer to the Instructions for Use.
Medtronic is committed
to the development
of advanced technology
to support MICS CABG
with its multiple proven
benefits for patients,
surgeons, and hospitals.
Table of Contents
What is a MICS CABG Procedure?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Potential Benefits of MICS CABG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Key Procedural Steps (with general recommendations)
1. Patient Selection/Inclusion Criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2. Contraindications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
3. Patient Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
4. Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
5. Thoracotomy/Incisions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
6. Access Portals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
7.Left Internal Mammary Artery (LIMA) Harvesting . . . . . . . . . . . . . . . . . . . . . 4
8.Pump-Assisted Beating Heart Bypass. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
9.Aorta Preparation for Proximal Anastomosis . . . . . . . . . . . . . . . . . . . . . . . . . . 5
10. Anastomoses (Distal). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
11. Chest Tube and Drains. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
12.Post-Op Pain Relief with a Pain Pump . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
13. Interdisciplinary Post-Op Guide. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
How Do I Begin?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
MICS CABG Instruments and Disposables. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
This technique overview is based on a compilation of the surgical techniques of:
Dr. Joseph McGinn, Staten Island University Hospital; Staten Island, New York
Dr. Marc Ruel, University of Ottawa Heart Institute; Ottawa, Canada
Dr. Mahesh Ramchandani, Methodist Hospital; Houston, Texas
Dr. Steven Hoff, Vanderbilt Heart Institute; Nashville, TN
Anesthesia techniques:
Dr. Scott Sadel, Staten Island University Hospital; Staten Island, New York
Dr. Ben Sohmer, University of Ottawa Heart Institute; Ottawa, Canada
Expand your reach. Advance your practice.
The views and teaching techniques expressed in this Technique Overview are those of medical professionals and not necessarily the views of Medtronic.
1
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Technique Overview: Minimally Invasive CABG (MICS CABG) Procedure
What is a MICS CABG Procedure?
MICS CABG is a beating heart, multi-vessel CABG procedure in which the anastomoses are performed under direct
vision through an anterolateral mini-thoracotomy. The internal mammary artery (IMA) harvest can be performed
under direct vision, with video assistance, or robotically. Additionally, in order to achieve complete revascularization,
a hybrid approach, or pump-assisted beating heart approach, can be employed.
Potential Benefits of MICS CABG:
» Improved satisfaction among patients and referring physicians1
» Complete revascularization can be achieved through a small
thoracotomy
» Surgeon differentiation
For the Patient:
» Shorter hospital stay2
» Faster return to daily living2
» Better cosmesis
» No sternotomy, no risk of a sternal wound infection
For the Hospital:
» Competitive differentiation
» Marketing opportunities
» Direct vision MICS CABG: Lower cost per procedure than
robotic cases
MICS CABG
MIDCAB
Complete IMA
Harvest
✔
—
Access to Ascending
Aorta for Proximal
Attachment
✔
—
Multi-Vessel
Revascularization
✔
—
Less Pain
✔
—
Ability to Bypass
Inferior & Lateral
Coronaries, i.e., PDA, PL
✔
—
Starfish® NS Heart Positioner
PRODUC T RISK STATEMENT
Not all patients are candidates for beating
heart procedures. Some patients require
cardiopulmonary support during surgery.
Octopus® Nuvo Tissue Stabilizer
Technique Overview: Minimally Invasive CABG (MICS CABG) Procedure
l
Key Procedural Steps (with general recommendations)
1. Patient Selection/Inclusion Criteria
3. Patient Positioning
» Coronary Anatomy
-Left main coronary artery disease (CAD) with
normal right coronary artery (RCA)
-Triple vessel disease with medium to large
posterior descending artery (PDA)
-Complex proximal left sided lesions with or
without large branch involvement
-Previous unsuccessful stenting
» Position patients in a 15° to 30° right lateral
decubitus position (supine), with the right arm
extended to allow harvest of the radial artery,
if applicable.
» Place a roll longitudinally between the left scapula
and spine.
» Drape the patient to allow access to the left
groin and right thigh/leg for femoral cannulation
(if needed) and saphenous vein harvest, respectively.
» Slightly drape the left elbow from the patient’s side
to expose the patient’s left lateral thoracic wall.
» The patient’s iliac crest (top of the hip bone) should
be near the flex break in the table, and the patient
is placed in a slightly reversed Trendelenburg
position.
» Comorbidities: Includes patients who are at a high
risk for problems with median sternotomy
- Long-term steroid use
-Severe chronic obstructive pulmonary disease
(COPD)
- Advanced age
-Need for other major operative procedure
- Severe deconditioning
- Patients with arthritic or orthopedic problems
-Patients who want the procedure, are active,
and seek out less invasive surgery options
2. Contraindications
» Contraindications
-Emergency cases
- Patients with hemodynamic instability
» Potential Contraindications:
- Previous CABG surgery
- Morbid obesity
- Patients with postero-lateral branch disease
-Ejection Fraction <20%
- Patients with peripheral vascular disease (PVD)
- Moderate to severe aortic insufficiency
4. Anesthesia
» Single-lung ventilation is required in off-pump
MICS CABG procedures.
» If pump assistance is used, both lungs can be
deflated. However, note that deflating both
lungs moves the heart away from the surgeon.
» Perform intubation with either a double or single
lumen oral endotracheal tube and a left bronchial
blocker to deflate the left lung. The single lumen
oral endotracheal tube and bronchial blocker are
placed under fiber-optic guidance.
TIP
If CPB is necessary and the surgeon is considering
using the right subclavian artery for arterial
cannulation, the arterial line should be placed
in the left radial artery or the femoral artery.
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3
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Technique Overview: Minimally Invasive CABG (MICS CABG) Procedure
4. Anesthesia (continued)
» Place one external defibrillator pad high over the
left scapula and one inferior to the right breast
extending medially to the nipple line.
» Vasopressors, such as phenylephrine and
norepinephrine, and vasodilators, such as
nicardipine and nitroglycerine, should be available
to control blood pressure during proximal
anastomosis.
» A standard IV drip setup that includes: nitroglycerine,
phenylephrine, norepineprine, vasopressin, insulin,
and nicardipine is recommended.
» An airway cart with a fiber optic bronchoscope
is recommended for placement of a bronchial
blocker.
» Lines are routine and include an arterial line and PA
catheter. If peripheral access is limited, at least a 16
gauge IV should be placed. A triple lumen catheter
is placed along with the PAC – “double stick”.
» After intubation, place a bronchial blocker into
the left mainstem bronchus with fiber optic
guidance. Place the proximal end of the balloon
approximately 1 cm to 2 cm below the carina.
TIP
Look beyond the blocker to be sure it is not pushing
on a secondary carina. This decreases the chance of
trauma to the bronchial mucosa that may result in
excessive bleeding after heparinization.
Fig. 1 MICS CABG incisions
4. Anesthesia (continued)
» Single-Lung Ventilation:
-Deliver approximately 10 cc/kg of tidal volume
prior to and during single-lung ventilation.
The tidal volume may need to be decreased
with single-lung ventilation because a large
tidal volume causes shifting of the mediastinum,
which may cause the MICS retractor to slip.
-Keep the O2 saturation greater than 90%. If the
saturation begins to decrease:
-Add CPAP of 5 cm H2O to the deflated lung.
This can be performed through the bronchial
blocker by inserting a 7 ETT connector into the
barrel of a 3 cc syringe. Insert the syringe tip
into the lumen of the bronchial blocker. Attach
the 7 ETT connector to a CPAP circuit.
-CPAP can be increased, but if it is increased
too much it will cause the lung to inflate and
obscure the surgeon’s view.
5. Thoracotomy/Incisions
T he "window incision" refers to the skin incision and the
intercostal incision together.
» The window incision is a 5 cm to 7 cm intercostal
incision in the 4th ICS
-Male patients: Over the 4th intercostal space (ICS)
-Female patients: Inframammary
-In some patients, this could be the 5th ICS,
depending on the location of the apex of the heart
-The medial two thirds of the window incision is
medial to the anterior axillary line
-Divide the intercostal muscles laterally to reduce
the risk of rib fracture, then divide them medially
to avoid damage to the left internal mammary
artery (LIMA)
-While making the window incision, deflate the
left lung
-A soft tissue retractor can be placed in the
window incision to maximize access
Technique Overview: Minimally Invasive CABG (MICS CABG) Procedure
6. Access Portals
» Two access incisions are recommend in multi-vessel
MICS CABG procedures
-An access incision at the 6th intercostal space
-An access incision below the xyphoid process
The incisions should be just large enough to allow
the shaft of the Octopus® Nuvo Tissue Stabilizer or
Starfish® NS Heart Positioner to enter the space.
No trocars are needed for the portals.
TIP
Hybrid Note
Anticoagulation Protocol* in Patients undergoing
simultaneous Hybrid Coronary Revascularization:
Anticoagulation should be modified for hybrid coronary
revascularization procedures to reduce the risk of
perioperative bleeding and maximize platelet inhibition.
-Give aspirin and a loading dose of 300 mg of
clopidogrel 30 minutes prior to the CABG procedure.
-Utilize routine heparinization during the
MICS CABG part of the hybrid procedure.
-Do not reverse the heparin and proceed to
completion arteriography and then percutaneous
revascularization.
-Generally, do NOT reverse protamine upon
completion of percutaneous revascularization.
-If bleeding is a concern, a half dose of protamine
can be considered.
- Administer 300 mg of clopidogrel in ICU.
-Give 75 mg clopidogrel daily post-op.
*Anticoagulation protocol utilized at Vanderbilt Heart Institute
7.Left Internal Mammary Artery
(LIMA) Harvesting
» Place a large Kelly clamp with a sponge in the 6th
intercostal space to assist with harvesting the LIMA.
Use the sponge to push away tissue for better IMA
visualization.
» Insert the MICS retractor system into the
4th intercostal space incision; then hook the MICS
retractor system to the Rultract® to facilitate the
LIMA harvest.
» In order to prevent damage to the LIMA, make sure
the superior portion of the retractor is placed and
maintained in the lateral aspect of the incision.
» Care should be taken not to fracture a rib.
-The MICS retractor system should be cranked
slowly, which allows tissue and bone to acclimate
to the change in position to minimize the
potential for rib fracture and pain.
» The LIMA harvest is started at the 3rd intercostal space
using direct vision through the window incision.
» Use an extended electrocautery instrument,
endoscopic forceps, suction, endoscopic clip
applier, and small clips for the harvest.
» The harvest is completed up to the subclavian vein
and down past the left 5th intercostal space.
» Take care to identify and avoid the phrenic nerve.
» During the LIMA harvest, flexing the table may
facilitate access to the superior portion of the LIMA.
» The pedicle of the LIMA is anchored with silk ties to
maintain the proper orientation.
» Intravenous heparin is given prior to LIMA division.
TIP
An Army Navy placed at the inferior portion of the
window incision retracted by an assistant or attached
to the Rultract® may increase visibility when harvesting
the distal IMA.
Fig. 2 LIMA harvest
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Technique Overview: Minimally Invasive CABG (MICS CABG) Procedure
8. Pump-Assisted Beating Heart Bypass
» Left groin cannulation is performed with the
following cannulae: Bio-medicus® arterial cannula;
Bio-medicus® venous cannula.
» A reduced prime pump with vacuum-assist setup is
preferred
» Pump flow rate at 2-3 liters/minute should be
sufficient to support circulation
» A Perclose® A-T (auto-tie) Suture-Mediated Closure
(SMC) device may be used to close femoral artery
cannulation site
Fig. 3 Pump-assist approach
TIP
Considerations for pump assistance
9.Aorta Preparation for Proximal Anastomosis
» McGinn Proximal Technique
1.After placing the #1 or #2 MICS retractor blades in
the window incision, angle the retractor superiorly
and use the Rultract to pull the retractor cephalad
to gain better access to the ascending aorta (Fig. 4).
2.Remove thymus tissue over the aorta and
pulmonary artery.
3.Open the pericardium anterior to the pulmonary
outflow track and extend cephalad to the inominate
(brachiocephalic) vein.
4.Place pericardial retrection stitches on the right
side of the pericardium, and bring the stitches
out through separate parasternal stab wounds;
these stitches enable you to roll the aorta toward
the window incision.
5.Place the Octopus® Nuvo Tissue Stabilizer through
the subxyphoid incision to depress the pulmonary
artery and expose the ascending aorta.
6.Dissect around the aorta and place vaginal packing
or a 1½ inch penrose drain behind the aorta to pull
the aorta closer to the window incision.
7.After the blood pressure drops to 90-100 systolic,
the proximal anastamoses can be performed
by using U-Clip® anastomotic devices, proximal
connector, or hand-sewn anastomoses.
-A side-biting clamp can be placed on the ascending
aorta to facilitate up to 3 hand-sewn anastamoses.
Preparing the groin for cannulation at the beginning
of the procedure is recommended for the following
circumstances:
-Cardiomyopathies
-Difficult inferior and lateral vessels, i.e., PL and OM2
-Aortic Insufficiency
-Surgeons in the early phase of MICS experience
-If positioning of the heart causes hypotension
that is not responsive to position changes
and vasoactive medications, the surgeon can
try to reposition the heart to allow for better
hemodynamics. If all of these maneuvers
fail, it may be necessary to perform the distal
anastomoses with pump-assistance.
Consider axillary arterial cannulation when femoral
cannulation is a poor option, i.e., illiac disease (PVD).
Fig. 4 Aorta preparation
Technique Overview: Minimally Invasive CABG (MICS CABG) Procedure
TIP
Anesthesia Considerations for the
McGinn Proximal Technique
TIP
-Bring the systolic blood pressure down to
90 – 100 mm Hg. This makes the aorta more supple,
making it easier to pass the tape around the vessel
without damaging it.
-Occasionally the surgeon will ask to check the
superior vena cava (SVC) with the TEE during
placement of the umbilical tape around the aorta.
This is to be sure the SVC is not occluded by the strap.
-It is extremely important to keep the SBP low to
keep the side-biting clamp from slipping off, and to
prevent damage to the aorta i.e., aortic dissection.
-Keep control of the SBP by giving more anesthetics
and by using boluses of nicardipine along with an
infusion, if necessary.
Anesthesia Considerations for the
Ruel Proximal Technique
Ottawa technique: Minimalize distention of the
heart by decreased fluid administration; this keeps
the patient dry and assists in avoidancy overfilling
with CVP kept below 14 mm Hg. A concern with this
technique is patients with decreased renal function.
-Single-lung ventilation with left lung down
(bronchial blocker or double-lumen endotracheal
tube) during the proximal anastomosis
-During ascending aorta isolation, the following
maneuvers are taken:
-Increased tidal volume
-Decreased inspiratory/expiratory ratio
-Increased Peep
Be aware that these maneuvers can result in decreased
O2 saturation and shunting.
9.Aorta Preparation for Proximal Anastomosis
Note: Check RV pressure when completing proximal
anastomosis to ensure the RCA has not been clamped.
(continued)
» Ruel Proximal Technique
1.Place the MICS Retractor with #1 or #2 blades in
the window incision.
2.To expose the ascending aorta, the pericardium
is opened anteriorly and retracted inferolaterally
toward the thoracotomy by using several traction
sutures.
3.Position the MICS retractor in a cephalomedial
direction with the Rultract® Skyhook.
4.A 6-mm incision is made in the left 7th
intercostal space to allow introduction of an
Octopus ® Nuvo tissue stabilizer.
5.Position the Octopus ® Nuvo over the pulmonary
artery trunk or right ventricular outflow tract,
to gently depress it in a left postero-inferior
direction.
6.Pack an open gauze against the right lateral aspect
of the aorta, anterior to the superior vena cava.
7.Place a Kay-Lambert, side-biting clamp on the
ascending aorta, and up to 3 hand-sewn proximal
anastomoses can be performed by using 6-0
polypropylene sutures, under direct vision.
10. Anastomoses (Distal)
» Open the pericardium down to the diaphragm
and then toward the right pleura.
» Heart positioning is accomplished using the
Starfish® NS Heart Positioner placed through
the subxyphoid portal.
» Cases involving the left anterior descending
artery (LAD), Diagonal, 1st obtuse marginal (OM),
2nd OM, or ramus intermedius, require the
Starfish® NS Heart Positioner to be placed
through the subxyphoid portal.
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Technique Overview: Minimally Invasive CABG (MICS CABG) Procedure
10. Anastomoses (Distal) (continued)
» Divide the rectus fascia just prior to the Starfish® NS
Heart Positioner insertion.
» A red rubber catheter is placed through the
subxyphoid portal and pulled out through the
window.
» Attach the red rubber catheter to the Starfish® NS
Heart Positioner shaft.
» Pull the tip of the shaft through the window and
attach the Starfish® NS Heart Positioner head onto
the shaft.
» Next, attach the head of the Starfish® NS Heart
Positioner to the obtuse marginal side of the apex
of the heart, and apply suction.
TIP
In order to keep the heart midline for optimal
stabilization, during a left circumflex anastomosis,
use bilateral, low-tidal ventilation. Alternatively,
use lap pads to pack the left lung and achieve the
same result.
Helpful hint
-All distal anastomoses can be created using the
U-Clip® Anastomotic Device or standard suturing
techniques.
TIP
» Overall Positioning Guidelines
-Diagonal and ramus intermedius: Neutral
position of the Starfish® NS Heart Positioner
-LAD Position: Clockwise rotation of the Starfish®
NS Heart Positioner
-OM: Counterclockwise rotation of the Starfish® NS
Heart Positioner, while moving the heart medially
-PDA: Rotate and move the heart toward the
patient's left shoulder with the Starfish® NS
Anesthesia Considerations
for Distal Anastomosis
Staten Island technique: Prior to the distal
anastomosis, patients can be given a loading dose of
Milrinone (50μg/Kg) over approximately 20 minutes;
even if the cardiac index is adequate. This technique
has the effect of decreasing the cardiac size, allowing
the smaller heart to be more easily positioned in
the confined space of the closed chest. It also has
the effect of shifting the heart’s Frank-Starling curve
upward, allowing for better hemodynamics in the face
of decreased preload secondary to the positioning of
the heart for distal anastomoses.
TIP
For lateral coronary vessels, place the patient in the
Trendelenberg position and rotate the patient away
from the surgeon to better expose the left lateral
wall of the heart.
-Once the heart is positioned and visible through
the window, place the Octopus® Nuvo Tissue
Stabilizer through the 6th intercostal space
incision and stabilize the vessel using suction.
-Once the artery is stabilized, the artery is
occluded and bypass is created using routine
forceps, coronary scissors, and coronary needle
holders.
Optimal Stabilization
TIP
Re-inflate the left lung under direct vision to prevent
avulsion of the LIMA-LAD with the expanding lung tissue.
11. Chest Tube and Drains
» A chest drain can be placed through each of the
portals that have already been created for the
Starfish® NS Heart Positioner and Octopus® Nuvo
Tissue Stabilizer.
Technique Overview: Minimally Invasive CABG (MICS CABG) Procedure
12. Post-Op Pain Relief with a Pain Pump
13. Interdisciplinary Post-Op Guide (continued)
» After protamine administration, 2 soaker
catheters can be placed:
-One subpleura
-One subcutaneous
» Unless contraindicated, resume antihypertensive
medications on the first postoperative day.
» Patients undergoing MICS CABG with a radial
artery graft are prescribed dihydropyridine
calcium channel blockers for 6 months.
» Catheters remain in place per pain pump instructions.
» Administer Marcaine® in a .25% dosage level.
13. Interdisciplinary Post-Op Guide
» Extubation is usually achieved 2-6 hours
after surgery.
» Pain management: Pain pump
» Start patients on daily enteric-coated 325 mg
aspirin on the day of the operation.
» Resume clopidogrel, 75 mg, in patients with
coronary stents.
TIP
All patients are treated with medical therapy as with
conventional CABG via sternotomy, including aspirin,
beta-blockers, ace inhibitors, and statin therapy.
» Post-op Day 1
-Patient ambulating and all drains out
-Evaluate discharge needs and prepare for
discharge
-Transfer to telemetry
-Bedside exercise, ambulate with assistance
» Post-op Day 2 and Beyond
-Ambulate with minimal or no assistance
-Evaluate for discharge
-Ad-lib activities
-Visiting nurse referral
» At Home
-No physical restrictions
-Remove pain pump as instructed
These are recommendations based on optimal
patient recovery.
How do I begin?
Medtronic offers peer-to-peer education for surgeons interested in learning how to do a MICS CABG procedure.
Please contact your CardioVascular sales representative for more information.
l
8
MICS CABG Instruments and Disposables
1. ThoraTrak® MICS Retractor System
2. Octopus® Nuvo Stabilizer
3. Starfish® NS Positioner
4. U-CLIP® Anastomotic Device
5. Mounting System for Octopus® Nuvo and
Starfish® NS
6.Rultract® with Skyhook Retractor
7.Optional Rotating Extender Bar with Cross Square
(Rultract®)
8. Small and Medium Endoscopic Clip Appliers
9. Knot Pusher
10. Minimally Invasive (MI) Needle Holder
11. Minimally Invasive Curved Scissors
12. Minimally Invasive Debakey Forceps
13. 14"Chest Tube Passer w/ Lock
14.Tangential Occlusion Clamp - 34 mm w/ DeBakey
Atraumatic Jaws, Slightly Curved
15.DeBakey Aorta Clamp - Full Curved DeBakey
Atraumatic Jaws, Curved Shanks, Stainless Steel,10.5 inch
16. Soft Tissue Retractor
17. 16 and 18 Fr Red Rubber Catheter
18.Extended Bovie Blade
19. Biomedicus® Femoral Cannula - Arterial
20. Biomedicus® Femoral Cannula - Venous
21. Pain Pump
22. Standard Off-Pump CABG tray
* Medtronic products in bold.
** T he instruments/disposables listed are in addition to essential instruments necessary to perform surgery. Refer to MICS CABG
instrumentation list for complete details.
*** Cannula sizing should be determined by the surgeon.
Caution: Federal law (USA) restricts this device to sale by or on the order of a physician. For a listing of
indications, contraindications, precautions and warnings, please refer to the Instructions for Use.
References:
1. Poston R, Tran R, Collins M, Reynolds M, Connerney I, et al. Comparison of economic and patient outcomes
with minimally invasive versus traditional off-pump coronary artery bypass grafting techniques. Ann Surg. 2008:248: 638-646.
2. M
cGinn JT, Usman S, Lapierre H, Pothula VR, Mesana TG, Ruel M. Minimally invasive coronary artery
bypass grafting: dual center experience in 450 consecutive patients. Circulation. 2009; 120:S78-S84.
Rultract is a registered trademark of Rultract. Used without permission.
Marcaine is a registered trademark of AstraZeneca. Used without permission.
Perclose is a registered trademark of Abbott Vascular. Used without permission.
Bio-Medicus, Starfish, Octopus, ThoraTrak, and U-Clip are registered trademarks of Medtronic, Inc.
www.medtronicMICS.com
www.medtronic.com
World Headquarters
Medtronic, Inc.
710 Medtronic Parkway
Minneapolis, MN 55432-5604
USA
Tel: (763) 514-4000
Fax: (763) 514-4879
LifeLine
CardioVascular Technical Support
Tel: (877) 526-7890
Tel: (763) 526-7890
Fax: (763) 526-7888
E-mail: rs.cstechsupport@medtronic.com
Medtronic USA, Inc.
Toll-free: 1 (800) 328-2518
(24-hour technical support for
physicians and medical professionals)
UC200901133b EN © Medtronic, Inc. 2009, 2010. All Rights Reserved. Printed in USA
Octopus Nuvo Setup Guide
®
De vice Se tup
1.Attach the rail clamp to the surgical table. Position the
rail clamp and mounting rail at the patient’s hip.
4. Transfer the Octopus ® Nuvo and vacuum line extension
to the sterile field using aseptic technique.
2.Attach the mounting rail to the rail clamp.
5. Connect the vacuum line extension to the luer connector
of the canister tubing set and attach the canister tubing
set to the regulated vacuum source. Set the regulated
vacuum to (–)400 mm Hg.
3.If using a Medtronic mounting rail, insert the flex-arm
post into the mounting rail. Secure the flex arm in the
mounting rail by locking the mounting rail lever.
Whale tail Flex-arm post Flex arm
Flex-arm clamp
Whale tail
Blunt
tip
Stabilizer
headlink
Blunt tip
Stabilizer
headlink
Shaft
Placement
1.Loosen the Octopus® Nuvo whale tail by turning it counterclockwise
to the out position. (Figure 1.)
2.Tether the blunt tip of the Octopus® Nuvo with a suture to prevent accidentally dropping the blunt tip in the thoracic cavity.
3.Press the whale tail forward, hold and connect the blunt tip to the shaft
of the Octopus® Nuvo.
4.Release pressure on the whale tail then turn the whale tail clockwise
to fully tighten and prevent the blunt tip from becoming dislodged.
5.Insert the shaft of the stabilizer with the blunt tip through the port incision.
6.Loosen the whale tail by rotating it counterclockwise until reaching
a stop while grasping the blunt tip with a surgical instrument.
7.Press the whale tail forward and remove the blunt tip.
11.Release pressure on the whale tail, then turn the whale tail
counterclockwise until you feel resistance. This attaches the headlink
to the shaft of the device, but still allows for movement and flexibility in order to position the headlink.
12.Make sure the headlink is attached to the shaft. There should not be a gap
between the headlink and the shaft. (Figure 2.)
13.Position the headlink on the desired coronary target and then fully tighten
the whale tail.
4. When the Octopus® Nuvo is properly positioned, fully tighten the flex arm 1
whale tail in order to lock the stabilizer in that position.
15.Turn suction on to (-)400 mm Hg.
In position
Out position
Connected
Not connected
8.Grasp the headlink at the plastic overmold with a surgical instrument.
9.Place the headlink in the thoracotomy incision, bring the suction line out
through the stabilizer shaft incision or through the thoracotomy.
10.Pressing the whale tail forward, insert the collet of the headlink into
the shaft of the Octopus® Nuvo.
(Figure 1)
(Figure 2)
Inserting the headlink
Ball joint
Plastic
overmold
Repositioning
1.Loosen the flex arm whale tail.
O rd er in g informat i on
TSMICS1
Octopus® Nuvo Tissue Stabilizer
2. Loosen the Octopus® Nuvo whale tail.
3. Turn suction off.
4.Manipulate the headlink as desired
and fixate again as in steps 13–15.
Removing
Caution: Federal law (USA) restricts this device to sale by or on the order
of a physician. For a listing of indications, contraindications, precautions
and warnings, please refer to the Instructions for Use.
Octopus, Starfish and ThoraTrak are registered trademarks of Medtronic, Inc.
1.Loosen the flex arm whale tail and remove the flex arm.
2. Loosen the Octopus ® Nuvo whale tail.
3.Turn suction off.
4.While grasping the headlink with a surgical instrument, press the
whale tail forward to release the headlink.
5.Remove the headlink through the thoracotomy and then remove
the shaft of the device from the thoracic cavity.
LifeLine
CardioVascular Technical Support
Tel: (877) 526-7890
Tel: (763) 526-7890
Fax: (763) 526-7888
E-mail: rs.cstechsupport@medtronic.com
www.medtronicmics.com
UC201003673 EN © Medtronic, Inc. 2010. All Rights Reserved. Printed in USA
Collet
clampless beating heart surgery
| 2 | CLAMPLESS BEATING HEART | Cardiovascular |
A comprehensive solution designed
To optimize outcomes
ACROBAT Mechanical, ACROBAT SUV, and ACROBAT V
HEARTSTRING III Seal Loader and Delivery Device, Aortic
Cutter, and Seal
HEARTSTRING ® III PROXIMAL SEAL SYSTEM
ACROBAT ® OFF-PUMP SYSTEMs
Do more—clamp less. HEARTSTRING III brings proximal
Suture with ease. The ACROBAT Off-Pump System provides
anastomotic technology into the future. A hemostatic seal
the strength, visibility, and stability necessary in a variety
enables surgeons to eliminate partial occlusion clamps and
of surgical situations.
minimize aortic manipulation that can lead to complications.
Safety: Helps avoid embolic release and reduces the potential
for neurologic complications
Patency: Allows use of the surgeon’s own hand-suturing
technique for optimal anastomotic quality and procedural
flexibility
Ease of use: The innovative loading device makes
HEARTSTRING III Seal placement fast and easy
Excellent stabilization: Malleable feet provide ideal
stabilization and superb vessel presentation; tri-slot socket
wrist design provides access to difficult vessels in “toes-up”
position, for maximum visibility
Strength and flexibility: Low-profile arm is designed for
increased strength, and innovative FlexLink™ technology
features interlocking links that enable greater maneuverability
PRODUCT ORDERING INFORMATION
Offer more patients the proven benefits of clampless
beating heart surgery: reduced mortality, improved
cognition, and more rapid recovery.1-3 MAQUET
Cardiovascular offers an integrated system that
complements a range of surgical approaches.
Description
Code
HEARTSTRING® III Proximal Seal System
HEARTSTRING III Seal, Delivery Device, Loader, and 4.3 mm Aortic Cutter
HEARTSTRING III Seal, Delivery Device, Loader, and 3.8 mm Aortic Cutter
HEARTSTRING III Seal, Delivery Device, and Loader
HSK-3043
HSK-3038
HS-3045
XPOSE® Access Device
XPOSE 3 Device
XPOSE 4 Device
XP-3000
XP-4000
ACROBAT ® Off-Pump Systems and ULTIMA OPCAB™ System
HEARTSTRING® Proximal Seal System
allows clampless anastomoses, easy
use with hand-suturing, and reduced risk
of embolic release4
ACROBAT® Off-Pump System offers
uncompromising strength and stability
AXIUS Blower/Mister. CO blower with mist, 16.5 cm malleable shaft and IV set
AXIUS Coronary Shunt
Tip diameter (mm)
Standard length (mm)
Long length (mm)
1.00
16.25
1.25
16.25
1.50
16.25
20.25
1.75
17.50
2.00
18.00
22.00
2.25
18.50
2.50
19.00
2.75
19.50
3.00
20.00
3.50
24.00
2
hemodynamics while providing a simple
way to position target vessels
AXIUS® Beating Heart Accessories
help optimize operative conditions
and maintain perfusion
MAQUET Cardiovascular strives to be the gold
standard in surgical technology, delivering
exceptional stability, flexibility, and visibility. For
more information about the HEARTSTRING III
®
Proximal Seal System and the complete line
of clampless beating heart surgery devices,
www.maquet.com.
D = deep
OM-9000S
OM-9100S
OM-6000S
OM-2001S
OM-2001D
OM-2003S
XO3-9000S
XO4-9000S
XO3-9100S
XO4-9100S
XO3-6000S
XO4-6000S
XO3-2001S
XO3-2001D
XO4-2001S
XO4-2001D
XO3-2003S
XO4-2003S
AXIUS® Beating Heart Accessories
XPOSE® Access Device maintains
contact a MAQUET representative or visit
S = standard
ACROBAT SUV Stabilizer
ACROBAT V Vacuum Stabilizer
ACROBAT Mechanical Stabilizer
ULTIMA Mechanical Stabilizer
ULTIMA Mechanical Stabilizer
ULTIMA Mechanical Stabilizer*
XPOSE 3 + ACROBAT SUV Stabilizer
XPOSE 4 + ACROBAT SUV Stabilizer
XPOSE 3 + ACROBAT V Stabilizer
XPOSE 4 + ACROBAT V Stabilizer
XPOSE 3 + ACROBAT Mechanical Stabilizer
XPOSE 4 + ACROBAT Mechanical Stabilizer
XPOSE 3 + ULTIMA Mechanical Stabilizer
XPOSE 3 + ULTIMA Mechanical Stabilizer
XPOSE 4 + ULTIMA Mechanical Stabilizer
XPOSE 4 + ULTIMA Mechanical Stabilizer
XPOSE 3 + ULTIMA Mechanical Stabilizer*
XPOSE 4 + ULTIMA Mechanical Stabilizer*
CB-1000
Code
OF-1000
OF-1250
OF-1500/OF-1500L
OF-1750
OF-2000/OF-2000L
OF-2250
OF-2500
OF-2750
OF-3000
OF-3500
* With offset wide foot.
References: 1. Diegeler A, Hirsch R, Schneider F, et al. Neuromonitoring and neurocognitive outcome in off-pump
versus conventional coronary bypass operation. Ann Thorac Surg. 2000;69:1162-1166. 2. Murkin JM, Boyd WD,
Ganapathy S, Adams SJ, Peterson RC. Beating heart surgery: why expect less central nervous system morbidity?
Ann Thorac Surg. 1999;68:1498-1501. 3. Puskas JD, Wright CE, Ronson RS, Brown WM, Gott JP, Guyton RA.
Clinical outcomes and angiographic patency in 125 consecutive off-pump coronary bypass patients. Heart Surg
Forum. 1999;2:216-221. 4. Wolf LG, Abu-Omar Y, Choudhary BK, Pigott D, Taggart DP. Gaseous and solid
cerebral microembolization during proximal aortic anastomoses in off-pump coronary surgery: the effect of
an aortic side-biting clamp and two clampless devices. J Thorac Cardiovasc Surg. 2007;133:485-493.
| Cardiovascular | CLAMPLESS BEATING HEART | 4 |
INSTRUCTIONS FOR USE
HEARTSTRING® III Proximal Seal System
CAUTION
Federal (USA) law restricts the use of this device to sale, distribution, and use
by or on the order of a physician.
INDICATIONS
The HEARTSTRING® III Proximal Seal System is intended for use by cardiac
surgeons during CABG procedures to maintain hemostasis and to facilitate the
completion of a proximal anastomosis without application of an aortic clamp.
CONTRAINDICATIONS
1. Do not use the HEARTSTRING® III Proximal Seal System in the portion of the
aorta where conventional surgical anastomoses would typically not be created due
to the presence of palpable disease. Such determination may also be based upon
echocardiograms. 2. Do not use the HEARTSTRING® III Proximal Seal System
on patients with aortas less than 2.5 cm in diameter.
WARNINGS AND PRECAUTIONS
1. Physicians should be properly trained prior to using the HEARTSTRING® III
Proximal Seal System. 2. Physicians should not use the HEARTSTRING® III
Proximal Seal System on portions of the aorta where a partial occlusion clamp
cannot be applied, to prevent patient compromise due to hemorrhage. 3. The
HEARTSTRING® III Proximal Seal System should not be used in patients with
thin-walled aortas due to the potential risk of the tether lacerating the side of the
aortotomy. 4. When performing multiple anastomoses, ensure that all anastomotic
sites are at least 1.5 cm apart to ensure hemostasis. 5. Do not reuse or resterilize
the HEARTSTRING® III Proximal Seal System or any of its components. 6. Do not
use the HEARTSTRING® III Proximal Seal System if the packaging is damaged
or opened. 7. Inspect the devices to ensure no damage has occurred during
transit. 8. The Aortic Cutter is a single use (one aortotomy) device. Any attempt
to reuse the Aortic Cutter may result in the introduction of air emboli into the aorta.
9. The Aortic Cutter is for use on unaltered tissue only. Use on altered tissue
(eg, cardioplegia hole, aortotomy incision) may cause the aortic plug to not be
captured by the device and result in the introduction of emboli into the aorta.
are supplied nonsterile and must be cleaned and sterilized prior to each use.
Never use saline solution for cleaning surgical instruments. 8. Steam sterilization
is recommended to sterilize the Activator Drive Mechanisms. Other methods of
sterilization have not been demonstrated as effective and are not recommended.
9. The maximum vacuum setting for the Acrobat SUV Vacuum Stabilizer is 400 mm Hg.
XPOSE® Access Device
CAUTION
Federal (USA) law restricts the use of this device to sale, distribution, and use
by or on the order of a physician.
INDICATIONS
The XPOSE Access Device is intended to expose coronary arteries during minimally
invasive, off-pump cardiac surgery through a sternotomy incision approach with
a Stabilization System.
CONTRAINDICATIONS
Do not engage the XPOSE Access Device over a coronary artery, or newly infarcted
or aneurysmal tissue. If hemodynamic instability is experienced, gently return the
heart to its resting position.
WARNINGS AND PRECAUTIONS
Physicians should be properly trained to perform cardiac surgical procedures with
instruments prior to use. Many variables, including patient anatomy, pathology, and
surgical techniques, may influence procedural outcomes. Patient and procedure
selection is a responsibility of the medical professional. Care should be taken
to ensure that mount and mount lever are clear of tissue when device is positioned
on sternal retractor.
AXIUS® Blower/Mister
CAUTION
Federal (USA) law restricts the use of this device to sale, distribution, and use
by or on the order of a physician.
INDICATIONS
ACROBAT® Off-Pump System
CAUTION
The AXIUS Blower/Mister is intended to clear an anastomotic site for improved visibility.
Federal (USA) law restricts the use of this device to sale, distribution, and use
by or on the order of a physician.
1. DO NOT set flow at a rate greater than 8 liters per minute (l/min). 2. Use caution
when moving the tip of the AXIUS Blower/Mister closer than 3 cm to the surgical site.
Do not allow tip to contact tissue. 3. DO NOT USE OXYGEN WITH THIS DEVICE.
4. This product is for single use only. DO NOT RESTERILIZE. DO NOT REUSE.
INDICATIONS
Each ACROBAT Vacuum Stabilizer System is intended for use during performance of
cardiac surgical procedures through a sternotomy incision approach. The AccessRail®
Platform, in combination with an Activator ® Drive Mechanism, is used to spread
the sternum, providing access and direct visualization to the thoracic cavity. The
AccessRail Platform also allows for the organization of pericardial sutures. The stabilizer
isolates and provides local immobilization of the target vessel on the beating heart.
WARNINGS AND PRECAUTIONS
AXIUS® Coronary Shunts
CAUTION
Federal (USA) law restricts the use of this device to sale, distribution, and use
by or on the order of a physician.
CONTRAINDICATIONS
INDICATIONS
Do not position the stabilizer foot over a coronary artery, or newly infarcted
or aneurysmal heart tissue.
The AXIUS Coronary Shunt is designed to help reduce blood in the operative
field by temporary occlusion of the artery and to provide blood flow distal
to the arteriotomy during the anastomosis. The AXIUS Coronary Shunt is not
an implant and is removed prior to completion of the anastomosis.
WARNINGS AND PRECAUTIONS
1. Physicians should be properly trained to perform cardiac surgical procedures
with instruments prior to use. 2. As with all surgical retractors, care should be
taken to use only as much retraction as necessary to provide adequate access
and visualization. 3. Perform the anastomosis only when the stabilizer foot is
properly seated on the epicardium and adequate stabilization of the surgical site
is achieved. 4. When removing the stabilizer from the epicardium, care should be
taken not to disrupt the anastomotic site. 5. Take care not to adjust or move the
AccessRail Platform while pericardial sutures are engaged in the platform. 6. Suture
holder features are designed for “0” size sutures. 7. The Activator Drive Mechanisms
WARNINGS AND PRECAUTIONS
1. Use care during insertion and removal of the shunt to avoid tearing of the vessel
wall and/or intimal dissection. 2. During insertion of the shunt, avoid engaging shunt
in septal or side branches. 3. Discontinue use and remove if significant resistance
is felt during insertion of the shunt. 4. Care should be exercised upon removal
of the shunt to prevent the shunt from getting entangled in sutures. 5. Take care
not to stitch the shunt while suturing anastomosis. 6. Once shunt has been
removed, do not reinsert as residual blood may remain in the lumen.
| Cardiovascular | CLAMPLESS BEATING HEART | 5 |
XPOSE 4 and XPOSE 3
AXIUS Blower/Mister and Coronary Shunts
XPOSE ® ACCESS DEVICE
AXIUS ® BEATING HEART ACCESSORIES
Reach target vessels easily. The XPOSE Access Device
See more clearly. The AXIUS Coronary Shunt and Blower/
is designed for apical or nonapical placement, and securely
Mister help to optimize operative conditions during coronary
lifts the heart for access to vessels in any location.
revascularization procedures.
Maintain stable hemodynamics: Active suspension
technology allows normal cardiac motion
Ensure secure contact: Tissue-conforming suction
cup uses gentle vacuum to stay in place
Reveal hard-to-reach vessels: Low-profile arm makes
it easy to see and gain access to any target vessel
Create a clear work area: Shunt provides a bloodless field
at the anastomotic site
Minimize ischemia: Shunt helps maintain distal perfusion
Maintain moisture: Blower/Mister helps prevent
dessication of graft
Increase visibility: Blower/Mister gently displaces blood
with a controlled flow of saline and CO2
Copyright MAQUET Cardiovascular LLC or its affiliates. All rights reserved. 04/08
•
® MAQUET Registered Trademark of MAQUET GmbH & Co. KG
MAQUET Cardiovascular LLC
170 Baytech Drive
San Jose, CA 95134
Phone: 1-888-880-2874
Fax: 1-888-899-2874
www.maquet.com
GETINGE Group is a leading global provider of equipment and
systems that contribute to quality enhancement and cost efficiency
within healthcare and life sciences. Equipment, service and technologies are supplied under the brands ArjoHuntleigh for patient
handling and hygiene, disinfection, DVT prevention, medical beds,
therapeutic surfaces and diagnostics, GETINGE for infection control
and prevention within healthcare and life science and MAQUET for
Surgical Workplaces, Cardiovascular and Critical Care.
LT7900243
392
NEW TECHNOLOGY
IN CARDIAC SURGERY
Techniques of Exposure and
Stabilization in Off-Pump Coronary
Artery Bypass Graft
Paulo Soltoski, M.D., Jacob Bergsland, M.D., Tomas A. Salerno, M.D.,
Hratch L. Karamanoukian, M.D., Giuseppe D'Ancona, M.D., Marco Ricci,
M.D., Ph.D., and Anthony L. Panos, M.D.
Division of Cardiothoracic Surgery, Kaleida Health and VA Medical Center, State University of New York at Buffalo, Buffalo, New York
ABSTRACT Recent advances in techniques of coronary artery exposure and myocardial stabilization in off-pump myocardial revascularization have provided cardiac surgeons with a
wide variety of new devices and techniques. Until recently, the main obstacle t o performing
complete myocardial revascularization without using cardiopulmonary bypass (CPB) has
been the technical difficulties of exposing and stabilizing coronary targets, especially those
located on the lateral and inferior wall of t h e heart. The extraordinary cardiac tolerance t o
nonconstrictive anterior elevation and lateral displacement, however, has allowed t h e development of new strategies of coronary exposure. These advances, in combination with the
development of new techniques of mechanical myocardial stabilization, have impacted on
the feasibility and safety with which coronary anastomoses on the beating heart can be constructed. The aim of this article is t o describe the technical aspects involved in off-pump
coronary revascularization, focusing primarily on the most recent strategies of cardiac elevation and coronary exposure, t h e various techniques of myocardial stabilization, and some
of t h e technical details of constructing distal anastomoses on the beating heart. (J Card Surg
7 999; 14:392-400)
Myocardial revascularization on the beating
heart was introduced in the late 194Os, when Dr.
Vineberg first reported on the implantation of the
left internal mammary artery directly on the myocardium in an attempt to improve its perfusion.l,* The importance of coronary artery occlusion as a key element in the pathogenesis of
ischemic heart disease, however, was recogAddress for correspondence: Tomas A. Salerno, M.D., Department of Cardiothoracic Surgery, Kaleida Health-Buffalo General Hospital Site, 100 High Street, Buffalo, NY
14203. Fax: (716)859-4697; e-mail sur237@pol.bgh.edu
Dr. Sclerno is a consultant for CTS, Cupertino, California.
nized and investigated in experimental studies
only in the early 1950s by Murray and coworkers.3 A few years later, Bailey et al. reported on a
successful case of coronary endarterectomy performed in the setting of coronary artery occlusive
d i ~ e a s e It. ~was not until the early 1960s, however, that many of the most significant contributions to coronary artery surgery were made, primarily as a result of the revolutionary approach to
cardiac surgery determined by the introduction of
the cardiopulmonary bypass circuit by Dr. Gibbon
in Philadelphia.5,6 Using such innovative techniques, Dr. Sabiston at Johns Hopkins pioneered
the initial development of coronary surgery, and
J CARD SURG
1999;14:392-400
in 1962 performed the first human coronary
artery bypass grafting using the extracorporeal
circulation, which consisted of a saphenous vein
graft from the aorta to the right coronary artery.'
The following two decades were characterized by
the most important advances in the field of extracorporeal circulation, which significantly contributed to the popularization of coronary artery
revascularization. Not surprisingly, the attractiveness of a bloodless and perfectly motionless operative field largely overshadowed the risks associated with the use of CPB, until initial reports on
the adverse neurological events resulting from
the use of extracorporeal circulation were published by Rosenblum and coworkers.8 Despite
the growing enthusiasm for the new techniques
of extracorporeal circulation and its widespread
popularization in cardiac surgery, attempts were
made a t performing coronary surgery without
CPB. This innovative approach was pioneered by
Kolessov in 1967,9 who reported on a patient in
whom the left internal mammary artery (LIMA)
was anastomosed to the left anterior descending
coronary artery (LAD) through a left thoracotomy,
without using CPB. The technique of coronary
revascularization without CPB was subsequently
adopted and refined by DeBakeylO and Favalorol
in the late 1960s and early 1970s. During the
years following, as a consequence of the technical difficulties related to the initial experience
with off-pump myocardial revascularization and
the refinements of techniques of extracorporeal
circulation and myocardial preservation, the offpump approach was largely abandoned in favor of
CPB. Nevertheless, in the 1980s two independent groups of investigators lead by Benetti in Argentina12-14and Buffolo in Brazill5,l6 relentlessly
continued their work on off-pump coronary revascularization and reported favorable outcomes
from their large series of patients. Not surprisingly, those reports determined a remarkable
resurgence of interest for techniques of off-pump
CABG in an attempt to eliminate the untoward
systemic effects of CPB. Despite the growing enthusiasm, however, this technique was initially
adopted predominantly, and perhaps almost exclusively, for revascularization of the LAD territory
for the technical difficulties of exposing coronary
arteries located on the lateral and inferior wall of
the heart. Only during the last decade have the innovative techniques of myocardial elevation,
coronary exposure, and mechanical stabilization
SOLTOSKI. ET AL.
EXPOSURE AND STABILIZATION IN OFF-PUMP CABG
393
lead to the widespread use of this approach and,
more importantly, have allowed the development
of complete revascularization of all coronary territories, including those on the "topographically difficult" areas. As such, this new approach to minimally invasive CABG without CPB has been
recently proposed as a new alternative to conventional myocardial revascularization.
In this perspective, the aim of this article is to
describe some of the technical details of off-pump
coronary revascularization, focusing predominantly, but not exclusively, on recent advances in
coronary artery exposure and mechanical myocardial stabilization. In addition, pitfalls and strategies
commonly adopted are described.
TECHNICAL ASPECTS OF
OFF-PUMP REVASCULARIZATION
As previously described,17the feasibility of myocardial revascularization without CPB is largely
dependent on the ability to expose all target vessels, minimize their motion during construction of
distal anastomoses, and preserve visualization by
maintaining a bloodless operative field.
Surgical approaches in off-pump CABG
A variety of different approaches may be used in
the setting of myocardial revascularizationwithout
CPB. These include median sternotomy, partial
sternotomy, left anterior small thoracotomy
(LAST),I8 left posterolateral thoracotomy, s u b
xyphoid access, and "hybrid approaches" (such as
the LAST procedure in combination with the s u b
xyphoid access). While some of these may be useful, especially during redo operations, complete myocardial revascularization in the setting of primary
operation is most commonly performed through a
median sternotomy. In our experience, however,
complete revascularization also can be accomplished through a partial sternotomy (only the distal
two thirds of the sternum are divided), although the
operative time may be slightly prolonged. This a p
proach still allows complete access to the great
vessels in a few patients in whom cardiopulmonary
bypass is required, and it may decrease the risk of
wound complications in the postoperative period.
More importantly, it may be particularly advantageous in patients with severe emphysema, COPD,
and impaired respiratory mechanics in whom the
improved stability of the chest wall and the reduc-
394
SOLTOSKI, ET AL.
EXPOSURE AND STABILIZATION IN OFF-PUMP CABG
tion in postoperative pain may beneficially affect
ventilation and respiratory function.
Exposure of the coronary targets
Adequate exposure of the coronary arteries
identified as potential targets on preoperative
coronary angiography cannot be obtained without
a combination of variable degrees of elevation
and lateral displacement of the heart. Obviously,
the degree of cardiac elevation and displacement
necessary to obtain adequate visualization are primarily determined by the location of the target
coronary artery on the surface of the heart, although other factors such as size of the cardiac
chambers and morphology of the chest wall may
play a role. In this regard, the principles of vessel
exposure do not differ significantly from those
used in conventional coronary operations on the
electromechanically arrested heart. However, in
"off-pump" revascularization this has to be accomplished while the heart is beating, thereby
maintaining cardiac function and preserving hemodynamics.
In our experience, exposure is best accomplished by placing several stitches in the posterior
pericardium and connecting them to a "vaginal
tape," which can them be manipulated and pulled
in various directions, thus lifting the heart and exposing the areas where the targets are located.
This technique, originally described by Ricardo
Lima from Brazil and never published, initially consisted of placing four stitches at the level of the
aorto-pericardial reflection, right superior and inferior pulmonary veins, and half-way between the
left inferior pulmonary vein and the inferior vena
cava. Alternatively, in an attempt to simplify this
approach, we have described and currently use a
modification to this technique that essentially
consists of placing a single suture in the oblique
sinus of the posterior pericardium ("single suture" technique) (Fig. l ) . 1 9
After the sternum is divided and the heart is exposed, the surgeon, standing on the right side of
the patient, uses his left hand to rapidly elevate
the heart and expose the posterior pericardium.
Then the "single suture," usually a O-silk, is placed
on the oblique sinus of the pericardium, situated
between the right and left, superior and inferior
pulmonary veins. Care must be taken to place the
stitch only through the pericardial layers, because
the esophagus and descending thoracic aorta are
J CARD SURG
1999;14:392-400
commonly located in close proximity. As soon as
the suture is placed, the heart is rapidly relocated
within the pericardial cradle and the silk suture is
secured to a "vaginal tape," which is pushed
down with a snare to the posterior pericardium.
This is commonly performed because the vaginal
tape, in contrast to the silk suture, does not traumatize the heart ("sewing effect") once it is used
to obtain cardiac elevation. Only a few seconds of
cardiac lifting usually are necessary to place the
suture in the posterior pericardium. As a result,
any drop in blood pressure is usually transient and
of no clinical relevance. Once the "single suture"
is placed, manipulation and traction on the vaginal
tape allow cardiac elevation and lateral displacement, which allows proper visualization of all coronary targets, including those located on the lateral
and inferior wall of the heart, which are the most
difficult to expose. The vaginal tape is gently secured under tension to the left blade of the sternal
retractor, only slightly lifting the heart upward and
toward the right, if the LAD system has to be exposed. Alternatively, just by opening the vaginal
tape in two arms, the apex of the heart can be elevated toward the ceiling and laterally displaced
toward the left shoulder, thereby exposing the
posterior descending coronary artery or the posterolateral branches of the right coronary artery. In
addition, exposure of the circumflex system can
be obtained by brining the two arms of the vaginal
tape to the left of the heart and securing them to
the right blade of the sternal retractor. Although
adequate exposure of the circumflex system may
be the most difficult to obtain, opening the right
pleuropericardial space may considerably facilitate
exposure by allowing the heart to herniate into the
right chest.
Hemodynamic consequences of cardiac
elevation and displacement
Concerns have been raised regarding the possibility of deterioration of the hemodynamic parameters during cardiac elevation and manipulation,
which may be more pronounced in the case of exposure of the circumflex territory. A significant decrease in systolic, and particularly diastolic arterial
pressure would invariably determine a significant
reduction in coronary perfusion pressure, particularly detrimental in patients affected with underlying coronary artery disease. Furthermore, suboptimal myocardiac perfusion during cardiac
J CARD SURG
1999;14:392-400
elevation and manipulation, in theory, may further
decrease left ventricular performance, thereby
further aggravating hemodynamics. However, in
our experience20,21
as well as those reported by
others,22 alteration of left ventricular geometry
with deterioration of hemodynamic parameters
even during maximal cardiac elevation is usually
an uncommon event if some principles are followed. In this regard, we have observed that cardiac elevation should be accomplished progressively, occasionally over several minutes, to
obtain adequate exposure, allowing the heart to
hemodynamically adjust to the new position.
Moreover, suboptimal exposure for limited cardiac elevation or lateral displacement may be
compensated for by changing the position of the
operating table (Trendelenburg position, inclination toward one side or the other). Not surprisingly, positioning of the patient in the Trendelenburg position considerably facilitates exposure of
the inferior wall of the heart. Similarly, rotation of
the table toward the right side of the patient (surgeon's side) improves exposure of the circumflex
territory. Moreover, as reported by other^,^^,^^ the
Trendelenburg position may significantly improve
systemic venous return and preload to the rightsided heart chambers, thus maintaining adequate
cardiac output.
In the very few patients in whom cardiac elevation and adequate exposure cannot be accomplished avoiding hemodynamic instability, in spite
of additional administration of volume and inotropic support, conversion to cardiopulmonary
bypass is promptly undertaken and generally does
not adversely affect perioperative outcomes.21
Preserving hemodynamics
during cardiac elevation
In recent years, the advances made in the field
of mechanical stabilization have lead to the popularization of strategies of coronary grafting without
CPB. Similarly, the introduction and development
of mechanical stabilizers of the new generation
have rendered pharmacologicaltechniques of stabilization virtually obsolete, so that the use of betablockers, calcium channel blockers, and adenosine,
previously used by some investigators to reduce
-- ,motion by reducing inotropism and chronotropisrn,
is no longer required. In this perspective, because
a motionlessfield can be obtained effectively by using the new stabilizers, pharmacological manipula-
SOLTOSKI, ET AL.
EXPOSURE AND STABILIZATION IN OFF-PUMP CABG
395
tion of the cardiovascular system using drugs that
may adversely affect cardiac performance is
avoided. Conversely, various strategies are frequently used to improve contractility and
chronotropism in an attempt to maintain hemodynamics during maximal cardiac elevation. These primarily include the use of temporary pacing wires,
volume administration, and thoughtful inotropic
support. Not surprisingly, their use may be particularly important when exposing the coronaryarteries
located on the inferior and lateral wall of the heart
because this commonly results in deformation of
the right-sidedcardiac chambers and impaired right
ventricular diastolic filling. As a result, temporary
epicardial pacing wires may be used advantageously in the patients in whom bradycardia is
thought to adversely affect cardiac performance.
Placement of temporary epicardial atrial and ventricular pacing wires is also recommended when
revascularizingthe right coronary artery, particularly
in its proximal portion. In this setting, transient ischemia due to right coronary manipulation may result
in hypoperfusion of the AV node, which may lead
to transient complete AV block. Similarly, in the
vast majority of patients, fluctuations of the systemic arterial pressureoften can be managed by increasing preload administering volume. lnotropic
support (dopamine or neosynephrine) may be required in a minority of patients who display refractory hypotension despite fluid administration.
Mechanical stabilizers
Optimal target stabilization remains the most
important technical aspect of off-pump coronary
revascularization. Mechanical stabilization, in contradistinction to the pharmacological stabilization
no longer used, can be accomplished by direct
pressure or suction. The pressure-type stabilizers
originally introduced were hand-held by an assistant. Newer types of pressure stabilizers can be
connected to one of the arms of the sternal retractor. In both cases, mechanical stabilization is
effectively accomplished by the pressure on the
epicardium surrounding the coronary target by
adjusting a U-shaped footplate (Figs 2 and 3). We
currently use the CTS Access Ultima System
(CTS, Cupertino, CA, USA), which is the latest
version of the CTS stabilizers. This device combines a sternal spreader-type retractor that can be
connected to an adjustable arm and horseshoe-
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SOLTOSKI, ET AL.
EXPOSURE AND STABILIZATION IN OFF-PUMP CABG
J CARD SURG
1999:14:392-400
shaped stabilizing platform. This platform can be
articulated in a tridimensional fashion (alongthe x,
y, and zaxes) to reach any target vessel. Optimal
stabilization is accomplished securing the arm
and footplate into position.
The most popular suction-type mechanical stabilizer available is the Medtronic Octopus 2
(Medtronic Inc., Minneapolis, MN, USA), which
was originally introduced and then developed by
Borst and Grundeman from the Netherlands
(Figs. 4-7). This device consists of two paddles
with 4 or 5 small (6 mm) suction cups on each
paddle.*5 The paddles are connected to two different arms that can be held in position by securing them to the operating table rail or, the arms of
the sternal retractor. A negative pressure of approximately 400 mmHG within the cups can then
Figure 3. Exposure of the posterolateral vessels of the
heart with a pressure stabilizer.
Figure 1. The posterior pericardial stitches combined
with proper positioning of the patient provide adequate
exposure of all cardiac vessels.
Figure 4. Medtronic Octopus 2, suction-type stabilizer.
Figure 2. CTS Access Ultima System pressure-type
stabilizer.
Figure 5. Equipment required for stabilization using
the Octopus 2.
SOLTOSKI, ET AL.
EXPOSURE AND STABILIZATION IN OFF-PUMP CABG
J CARD SURG
1999:14:392-400
Figure 6.
tion stabilizer.
of the Same
using a sue-
397
required, is frequently accomplished after all other
distal anastomosis have been completed, in offpump CABG revascularization we generally construct the distal anastomosis of the LIMA-to-LAD
graft first. There are several reasons for this strategy. First, exposure of the LAD territory requires
only minimal cardiac elevation and displacement,
so that hemodynamics are usually well preserved
while the distal LAD anastomosis is constructed.
Second, this strategy allows expeditious revascularization of the anterior wall of the left ventricle.
Accordingly, this may confer additional ischemic
protection to the anterior wall of the left ventricle
when more drastic cardiac elevation to expose
other territories is used. Furthermore, early revascularization of the left ventricle may theoretically
improve cardiac performance during maximal elevation. Last, we have noted that constructing the
LIMA-to-LAD graft first does not adversely affect
the ability to manipulate, elevate, or laterally displace the heart provided that care is taken not to
damage the LIMA-LAD graft during cardiac manipulations. After revas,cularizationof the LAD is
accomplished, the circumflex and right coronary
territories can be revascularized if needed.
The use of the coronary "snare"
After a target coronary has been identified and
adequate exposure along with mechanical stabilization have been accomplished, we routinely
place a 4-0 Prolene suture around the coronary
Figure 7. Exposure of the posterolateral vessels of the
heart with a suction-type device.
be created to accomplish effective immobilization. No significant complications have been observed at the suction cup sites. Visualization and
exposure of various coronary territories can be accomplished by adjusting and optimizing the position of the flexible arms.
In our experience, both devices described can
accomplish epicardial stabilization efficiently, and
the decision as to whether one or the other
should be used is based on surgeons preference.
Sequence of coronary grafting
In contrast to conventional coronary surgery,
during which revascularization of the LAD, when
Figure 8. Photograph illustrating proximal and distal
snares used for hemostasis and ischemic preconditioning. In this case, adequate exposure is obtained using a pressure stabilizer in combination with a 6-0 Prolene suture to retract the perivascular tissues.
398
SOLTOSKI, ET AL.
EXPOSURE AND STABILIZATION IN OFF-PUMP CABG
artery, proximally to the area where the distal
anastomosis will be constructed (Fig. 8). To avoid
injury to the coronary artery, care is taken to place
the stitch deep into the myocardium surrounding
the vessel. In addition, the technical detail of placing a deep bite into the myocardium could also
eliminate, or at least reduce, the likelihood of injuring the artery when this Prolene "loop" is
snared, because a greater portion of myocardium
would be interposed between the suture and the
artery. In our experience, the advantages of using
such a technique (the "snare") overshadow the
theoretical disadvantages. The Prolene suture
can be easily snared down so that the coronary
target can be gently occluded, thereby gaining
proximal control and improving visualization as
the coronary artery is entered. This strategy also
permits a brief period (3-5 minutes) of ischemic
preconditioning,2"28which may improve myocardial tolerance to ischemia and may allow detection of ischemic electrocardiographic changes or
ventricular dysfunction as the coronary artery is
occluded, thus allowing modification of the strategy of revascularization. Intermittent occlusion of
the native coronary may be particularly advantageous during graft flow assessment of Dopplerbased techniques (Transit Time Flow Measurement [TTFMI),as described later in this article.
The theoretical disadvantages of inadvertent injury to the target coronary artery during placement
of the stitch can be easily avoided, and the possibility of dislodgment of atherosclerotic material
within the coronary artery once the Prolene suture
is snared may also be prevented by properly choosing the site where the "snare" is applied. Accordingly, this technique should not be used in the presence of heavily calcified coronary arteries because
it may fail to completely occlude the lumen of the
heavily calcified vessel and may increase the risk of
distal embolization. In addition, placement of the
snare may not provide any advantage in the presence of a totally occluded native coronary artery. In
this case it may be advantageous to place the Prolene suture distal to the site of construction of the
anastomosis, particularly if there is angiographic evidence that the target coronary artery is perfused
by collaterals in a retrograde fashion.
J CARD SURG
1999;14:392-400
Figure 9. Assortment of intraluminal shunts. Different
models are commercially available. The major benefit
is usually obtained using shunts of 2-mm diameter or
larger.
during construction of distal anastomoses has
been introduced as a method for improving distal
perfusion while the vessel is grafted. As a result,
this approach could prevent ischemia and preserve regional contractility of the territory supplied
by the coronary artery, although its importance
would invariably diminish in the face of total occlusion of the native coronary. In addition, the use
of intracoronary shunts may also improve visualization as the distal anastomosis is constructed,
thereby improving accuracy during suturing and
reducing the possibility of technical errors.
Improving visualization: The CO,
blower/saline aerosolizer
The CO, blower/saline aerosolizer has been introduced in an attempt to improve visualization
during construction of distal an as tor nose^.^^ In our
experience, this device along with the intracoronary shunt contributes remarkably to maintaining a
bloodless field. It should be noted, that such a device is not entirely harmless, because it may result
in inadvertent injury to the target coronary artery
and intimal dissection if used too close to the area
where the anastomosis is being constructed.
lntracoronary shunts
Coronary graft hemodynamic assessment
by Transit Time Flow Measurement (TTFM)
The use of intracoronary shunts (FloCoil, CTS)
(Fig. 9) inserted within the target coronary arteries
Doppler-based techniques of coronary graft
flow measurement recently have been intro-
SOLTOSKI, ET AL.
EXPOSURE AND STABILIZATION IN OFF-PUMP CABG
J CARD SURG
1999:14:392-400
duced and popularized as a method to intraoperatively assess graft patency during coronary
revascularization. This technical aspect may be
particularly important in the setting of myocardial
revascularization without CPB, because it was
originally believed that the technical challenge of
performing distal anastomoses on the beating
heart may increase the risk of technical failure. Although advances in techniques of mechanical
stabilization and target visualization have considerably circumvented this problem and facilitated
construction of distal anastomoses on the beating heart, we believe that flow measurement of
the coronary grafts may play an important role in
decreasing the risk of early graft occlusion due to
technical error. Although there has been evidence that even Doppler-based techniques of
flow measurement, more reliable than electromagnetic-based techniques, may fail to detect
mild or moderate graft stenosis of up to 75% of
the cross-sectional area.30,31
The correct interpretation of graft hemodynamics allows early intraoperative detection and immediate correction of
graft dysfunction in all patients with severe graft
stenosis or occlusion without considerably delaying the operation or increasing costs. As previously described,32a patent coronary graft usually
presents a predominantly diastolic flow pattern in
combination with a pulsatility index (PI) of < 5. In
contrast, a systolic flow pattern along with PI figures > 5 are often associated with severe graft
dysfunction or occlusion. In this regard, the appropriate use of the snare during graft flow measurements may allow further investigation exclusion of distal runoff obstruction, and evaluation of
the proportion of competitive flow in the native
coronary artery.28
CONCLUSION
Historically, one of the main obstacles to complete myocardial revascularization without CPB
has been represented by the inability to adequately expose the coronary targets and minimize their motion, preserving cardiac function
and hemodynamic stability. However, the introduction of the stabilizers of the new generation
in combination with the refinements in techniques of coronary revascularization on the beating heart have improved the feasibility and reliability with which distal anastomosis to all
coronary arteries can now be constructed. In this
399
perspective, we believe that the only absolute
contraindication to off-pump coronary grafting is
represented by the inability to preserve hemodynamics while obtaining exposure and stabilization of the target vessels. Accordingly, although
a variety of other factors such as left main disease, acute myocardial infarction, or the presence of an intramyocardial LAD have been considered as contraindications to off-pump CABG,
we believe that they do not represent absolute
contraindications, although their presence may
require modification of the operative strategies
used and may be associated with a higher rate of
conversion to CPB.
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