Xiphoid Lower-Sternotomy Approach for Multivessel Revascularization of the Left Internal Mammary Artery to the Left Anterior Descending Artery and Right Internal Mammary Artery Inflow to the Other Vessels
Background: We describe the technical details and the preliminary results of a new surgical approach for multivessel disease that involves using a lower T sternotomy, grafting of the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) and use of the right internal mammary artery (RIMA) as inflow to the other vessels.
Operative Technique: The sternotomy was made from the xiphoid up to the fourth intercostal space and then was continued transversally (T incision). The LIMA was harvested for a length of approximately 8 cm, with preservation of the distal part. The vein was simultaneously taken from the leg. The RIMA was dissected for a length of approximately 5 cm, and the distal part was occluded. Then, 3 mg/kg heparin was given. The anastomosis between the vein and the RIMA was performed. The distal venous anastomoses were done either singly or sequentially. The anterior or posterior route was chosen according to the patient's anatomy. The LIMA was then anastomosed to the LAD. One drain was placed. The sternum was closed with 4 wires, 2 for the T incision and 2 for the sternum.
Results: Between September and December 2008, 9 patients underwent their operations with this technique. The mean age was 60 years (range, 55-68 years). The mean number of grafts was 2.8. The mean hospital stay was 5.2 days. Operative mortality was 0%. All patients were reevaluated with 16-slice multislice computed tomography, and all grafts were patent. At the 3-month follow-up, all patients were alive and free of symptoms.
Conclusion: This minimally invasive technique is a useful alternative for complete revascularization. The sternal mammary supply and the upper part of the sternum are preserved.
Al-Ruzzeh S, Nakamura K, Athanasiou T, et al. 2003. Does off-pump coronary artery bypass (OPCAB) surgery improve the outcome in highrisk patients? A comparative study of 1398 high-risk patients. Eur J Cardiothorac Surg 23:50-5.nAngelini CD, Taylor FC, Reeves BC, Ascione R. 2002. Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised trials. Lancet 359:1194-2000.nBenetti FJ. 1985. Direct coronary surgery with saphenous vein bypass without either cardiopulmonary bypass or cardiac arrest. J Cardiovasc Surg 26:217-22.nBenetti FJ. 1999. Minimally invasive coronary surgery (the xiphoid approach). Eur J Cardiothorac Surg 16(suppl 2):S10-1.nBenetti FJ, Ballester C. 1995. Use of thoracoscopy and minimally thoracotomy, in mammary-coronary bypass to left anterior descending artery, without extracorporeal circulation: experience in 2 cases. J Cardiovasc Surg (Torino) 36:159-61.nBenetti FJ, Ballester C, Barnia A. 1994. Uso de la toracoscopia en cirugia coronaria para diseccion de la arteria mamaria interna. Prensa Med Argent 81:877-9.nBenetti FJ, Rizzardi JL, Concetti C, et al. 2008. Xiphoid approach long term results [abstract]. Paper presented at: 18th World Congress - World Society of Cardio-Thoracic Surgeons; April 30 to May 3, 2008; Kos Island, Greece. Heart Surg Forum 11(suppl 1):175. Abstract OP-821.nBuffolo E, Andrade JC, Succi J, Leao LE, Gallucci C. 1985. Direct myocardial revascularization without cardiopulmonary bypass. Thorac Cardiovasc Surg 33:26-9.nJansen EW, Borst C, Lahpor JR, et al. 1998. Coronary artery bypass grafting without cardiopulmonary bypass using the Octopus method: results in the first one hundred patients. J Thorac Cardiovasc Surg 116:60-7.nLattouf OM, Puskas JD, Thourani VH, Noora J, Kilgo PD, Guyton RA. 2007. Does the number of grafts influence surgeon choice and patient benefit of off-pump over conventional on-pump coronary artery revascularization in multivessel coronary artery disease? Ann Thorac Surg 84:1485-95.nMagee MJ, Jablonski KA, Stamou SC, et al. 2002. Elimination of cardiopulmonary bypass improves early survival for multivessel coronary artery bypass patients. Ann Thorac Surg 73:1196-203.nMehran R. Long-term patency of LIMA-LAD beating heart anastomosis (POEM) trial. 2000. Paper presented at: The 6th Annual Cardiothoracic Techniques & Technologies meeting 2000; January 27-29, 2000; Bal Harbour, Fla.nParolari A, Alamanni F, Polvani G, et al. 2005. Meta-analysis of randomized trials comparing off-pump with on-pump coronary artery bypass graft patency. Ann Thorac Surg 80:2121-5.nPuskas JD, Edwards FH, Pappas PA, et al. 2007. Off-pump techniques benefit men and women and narrow the disparity in mortality after coronary bypass grafting. Ann Thorac Surg 84:1447-54.nPuskas JD, Williams WH, Duke PG, et al. 2003. Off-pump coronary artery bypass grafting provides complete revascularization with reduced myocardial injury, transfusion requirements, and length of stay: a prospective randomized comparison of two hundred unselected patients undergoing off-pump versus conventional coronary artery bypass grafting. J Thorac Cardiovasc Surg 125:797-808.nPuskas JD, Williams WH, Mahoney EM, et al. 2004. Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial. JAMA 291:1841-9.nSharoni E, Song HK, Peterson RJ, Guyton RA, Puskas JD. 2006. Off pump coronary artery bypass surgery for significant left ventricular dysfunction: safety, feasibility, and trends in methodology over time—an early experience. Heart 92:499-502.n[STS] Society of Thoracic Surgeons. 2007. Spring 2007 Report. Adult Cardiac Database Executive Summary. Available at: http://www.sts.org/documents/pdf/Report_Overview_-_General.pdf'>http://www.sts.org/documents/pdf/Report_Overview_-_General.pdfnSubramanian VA, Benetti FJ, Calafiore AM. 1995. Minimally invasive bypass surgery: a multi-center report of preliminary clinical experience [abstract]. Circulation 92(suppl):645.nTrehan N, Mishra M, Sharma OP, Mishra A, Kasliwal RR. 2001. Further reduction in stroke after off-pump coronary artery bypass grafting: a 10-year experience. Ann Thorac Surg 72(suppl):S1026-32n
How to Cite
Author Disclosure & Copyright Transfer Agreement
In order to publish the original work of another person(s), The Heart Surgery Forum® must receive an acknowledgment of the Author Agreement and Copyright Transfer Statement transferring to Forum Multimedia Publishing, L.L.C., a subsidiary of Carden Jennings Publishing Co., Ltd. the exclusive rights to print and distribute the author(s) work in all media forms. Failure to check Copyright Transfer agreement box below will delay publication of the manuscript.
A current form follows:
The author(s) hereby transfer(s), assign(s), or otherwise convey(s) all copyright ownership of the manuscript submitted to Forum Multimedia Publishing, LLC (Publisher). The copyright transfer covers the exclusive rights to reproduce and distribute the article and the material contained therein throughout the world in all languages and in all media of expression now known or later developed, including but not limited to reprints, photographic reproduction, microfilm, electronic data processing (including programming, storage, and transmission to other electronic data record(s), or any other reproductions of similar nature), and translations.
However, Publisher grants back to the author(s) the following:
- The right to make and distribute copies of all or part of this work for use of the author(s) in teaching;
- The right to use, after publication in The Heart Surgery Forum, all or part of the material from this work in a book by the author(s), or in a collection of work by the author(s);
- The royalty-free right to make copies of this work for internal distribution within the institution/company that employs the author(s) subject to the provisions below for a work-made-for-hire;
- The right to use figures and tables from this work, and up to 250 words of text, for any purpose;
- The right to make oral presentations of material from this work.
Publisher reserves the right to grant or refuse permission to third parties to republish all or part of the article or translations thereof. To republish, such third parties must obtain written permission from the Publisher. (This is in accordance with the Copyright Statute, United States Code, Title 17. Exception: If all authors were bona fide officers or employees of the U.S. Government at the time the paper was prepared, the work is a “work of the US Government” (prepared by an officer or employee of the US Government as part of official duties), and therefore is not subject to US copyright; such exception should be indicated on signature lines. If this work was prepared under US Government contract or grant, the US Government may reproduce, royalty-free, all or portions of this work and may authorize others to do so, for official US Government purposes only, if the US Government contract or grant so requires.
I have participated in the conception and design of this work and in the writing of the manuscript and take public responsibility for it. Neither this manuscript nor one with substantially similar content under my authorship has been published, has been submitted for publication elsewhere, or will be submitted for publication elsewhere while under consideration by The Heart Surgery Forum, except as described in an attachment. I have reviewed this manuscript (original version) and approve its submission. If I am listed above as corresponding author, I will provide all authors with information regarding this manuscript and will obtain their approval before submitting any revision. I attest to the validity, accuracy, and legitimacy of the content of the manuscript and understand that Publisher assumes no responsibility for the validity, accuracy, and legitimacy of its content. I warrant that this manuscript is original with me and that I have full power to make this Agreement. I warrant that it contains no matter that is libelous or otherwise unlawful or that invades individual privacy or infringes any copyright or other proprietary right. I agree to indemnify and hold Publisher harmless of and from any claim made against Publisher that relates to or arises out of the publication of the manuscript and agree that this indemnification shall include payment of all costs and expenses relating to the defense of any such claim, including all reasonable attorney’s fees.
I warrant that I have no financial interest in the drugs, devices, or procedures described in the manuscript (except as disclosed in the attached statement).
I state that the institutional Human Subjects Committee and/or the Ethics Committee approved the clinical protocol reported in this manuscript for the use of experimental techniques, drugs, or devices in human subjects and appropriate informed consent documents were utilized.
Furthermore, I state that any and all animals used for experimental purposes received humane care in USDA registered facilities in compliance with the “Principles of Laboratory Animal Care” formulated by the National Society for Medical Research and the “Guide for the Care and Use of Laboratory Animals” prepared by the Institute of Laboratory Animal Resources and published by the National Institutes of Health (NIH Publication No. 85-23, revised 1985).