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Multivessel Minimally Invasive Direct Coronary Artery Bypass Grafting Of The Lateral And Inferior Wall: Challenges And Solutions
Alaa Abd El Al, MD, Matteo Montagner, MD, Stephan Jacobs, MD, Falk Volkmar, MD, Jörg Kempfert, MD, Timo Z. Nazari-Shafti.
German Heart Center, Berlin, Germany.

BackgroundPatients with multivessel disease (MVD), high-risk profile for postoperative complications, and complex lesions of the coronary arteries may benefit from multivessel minimally invasive direct coronary artery bypass grafting (MV-MIDCAB). This procedure is technically demanding and requires excellent pre-operative planning. Here we present some of the technical challenges and mitigation strategies for performing anastomoses on the inferior and lateral wall in MV-MIDCAB.MethodAn 85-year-old Caucasian male presented with MVD and a heavily calcified ascending aorta. The patient was the primary care-giver for his disabled wife and requested a less invasive surgical solution for his MVD. After performing a pre-operative CT-scan, coronary arteries and their respective lesions were identified and optimal intercostal space (ICS) for lateral thoracotomy was determined. Multivessel MIDCAB with left internal thoracic artery (LITA) to left anterior descending (LAD) and venous graft with sequential anastomoses to the first obtuse marginal (OM1) and posterior interventricular ramus (RIVP) was performed. The saphenous vein, harvested endoscopically, was anastomosed to the LITA. For the lateral thoracotomy, a more medial incision over the 4th ICS was chosen to create optimal visualization of the inferior wall. The endoscopic stabilizer shaft was introduced via a subxyphoidal incision, 2 cm to the left of the midline. The pericardium was opened with extending the incision above the diaphragm to the right as far as possible to reduce compression of the right atrium and right ventricle during luxation. For visualizing the RIVP, the positive end expiratory pressure on the right lung was increased and the endoscopic stabilizer was used to push the heart cranially. To optimize exposure of the circumflex branches, ventilation was briefly interrupted to support luxation of the heart and the operating table was placed in a 45° Trendelenburg position. ResultsPostoperatively, the patient was transferred to the regular ward less than 24 hours after surgery. He had an uneventful postoperative course and was released from hospital nine days after surgery.ConclusionIn this case report we demonstrate that with optimal exposure of the posterior and lateral wall can be achieved in a MIDCAB setting. Additionally, the high-risk patient had an excellent postoperative outcome with no additional postoperative morbidities.


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