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OBJECTIVE: Background: Off-pump minimally invasive coronary artery bypass grafting (MICS CABG) for multivessel disease via a small left thoracotomy requires extensive surgical experience and skill. Lateral and inferior territories are difficult to expose, consequently requiring the use of cardiopulmonary bypass at times. Maximizing exposure may help surgeons complete off-pump multivessel MICS CABG safely. As a result, more surgeons may perform this operation with comfort so that patients will benefit from this less invasive strategy. For a better exposure, we initiated a stepwise approach with a multisuction cardiac positioner
METHODS: Methods: A 6-9cm left thoracotomy is made in the fifth intercostal space. After the left internal thoracic artery is taken down, proximal anastomoses are made onto the ascending aorta with a side-clamp. For distal anastomoses, a stepwise approach is performed. Firstly, a rib-retractor is placed in the small thoracotomy and pulled cephalad and leftward. Secondly, several retraction sutures attached to the lateral pericardial edge are held on the skin for optimizing exposure of the lateral and inferior area. Thirdly, two of three suction cups of a multisuction cardiac positioner are put on the sides of the target vessel through the same thoracotomy, and pulled directly towards the incision. Finally, a distal anastomosis is performed with an epicardial stabilizer via the thoracotomy as in standard off-pump CABG.
RESULTS: Results: We recently initiated MICS CABG program, and completed 20 cases, including 9 multivessel MICS CABG with a multisuction cardiac positioner. In these cases, the average number of distal anastomoses was 2.8±0.9. Two cases were off-pump quadruple bypass grafting .All patients were discharged, and remain well to this day.
CONCLUSIONS: Conclusions: Despite the time of initiation, off-pump multivessel MICS CABG is feasible with the use of a multisuction cardiac positioner. Thus, this approach is easy and helpful in providing good exposure of target vessels during MICS CABG without additional incisions for an epicardial stabilizer or apical positioner.