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Objectives: Atherosclerotic disease often prohibits the use of an endoaortic occlusion balloon in patients undergoing robotically assisted totally endoscopic coronary artery bypass grafting (TECAB). Although a transthoracic clamp is easily applied from the right side through the transverse sinus, application from the left is more challenging. Use of a transthoracic clamp generally necessitates the delivery of antegrade cardioplegia, which poses additional challenges in the totally endoscopic setting as compared to a small thoracotomy.

Methods: Between January and June 2011, 6 patients (age 65 [26 - 81], 33.3% male) underwent arrested heart TECAB (3 single, 3 double vessel bypasses) with application of a transthoracic aortic crossclamp from the left. The aorta and pulmonary artery were separated and an antegrade cardioplegia was administered via a cardioplegia catheter inserted totally endoscopically through a double 4-0 Goretex pursestring suture using a modified Seldinger technique under echocardiographic guidance. Cardiopulmonary bypass was established with left axillary and percutaneous femoral venous cannulation.

Results: Cardiac arrest was successfully induced in all six patients although in one case the cardioplegia catheter required repositioning after the crossclamp had been applied as it had turned distally in the aorta. In another patient, an additional stich was required in one case to attain hemostasis at the cardioplegia site. No patients required conversion to an open incision and there were no 30-day mortalities.

Conclusions: Application of a transthoracic crossclamp from the left side in patients undergoing TECAB is feasible when the use of an endoaortic occlusion balloon is contraindicated.