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J Thorac Cardiovasc Surg 1997;114:680-682
© 1997 Mosby, Inc.

BRIEF COMMUNICATIONS

IMMOBILIZED INSTRUMENT FOR MINIMALLY INVASIVE DIRECT CORONARY ARTERY BYPASS: MIDCAB DOUGHNUT

Masao Takahashi , MD, Shinichiro Yamamoto , MD, Shigeki Tabata , MD


Fukui, Japan

From the Department of Cardiovascular Surgery, Fukui Prefectural Hospital, Fukui, Japan.

Received for publication Feb. 26, 1997 accepted for publication May 13, 1997. Address for reprints: Masao Takahashi, MD, Department of Cardiovascular Surgery, Fukui Prefectural Hospital, 2-8-1 Yotsui, Fukui, 910, Japan.

So that satisfactory vessel immobilization can be achieved, enabling consistently accurate grafting during off-pump coronary artery bypass grafting (CABG), mechanical immobilizing devicesGo Go 1-3 have been developed along with immobilization methods including pharmacologic control of heart rate to produce bradycardiaGo 2 and induction of transient ventricular asystole with adenosine. Even with heart rates of about 40 beats/min, however, the technical demands of suturing are often difficult. In this report, we describe a new immobilizing instrument for use during minimally invasive CABG on the beating heart. With this instrument, a motionless and bloodless operative field can be achieved without occlusion of the distal coronary artery. The use of this instrument facilitates the new techniques of operating on the beating heart.

Techniques.
The instrument, called a MIDCAB doughnut, consists of a double-bottomed silicone rubber dome and a suction tube that is supported with a handle. It has a simple structure, and its elastic firm material is thought to be safe and secure. The elastic dome has a small hole (14 to 16 mm in diameter) at the center through which the coronary artery that is being anastomosed can be positioned. The dimensions of the dome are 36 mm in diameter and 10 mm in depth. The mechanism of fixation to the heart is negative pressure by air suction (Fig. 1).



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  		Fig. 1. Schema of the MIDCAB doughnut. ITA, Internal thoracic artery.

 
After preliminary studies using four dogs and a pig, we have used the MIDCAB doughnut in three patients who underwent traditional CABG. The heart was exposed through a median sternotomy. The MIDCAB doughnut was fitted over the epicardium around the anastomotic site of the left anterior descending artery (LAD) by air suction with a wall sucker. Stable immobilization of the LAD could be achieved on the beating heart. The epicardium and adipose tissue on the LAD were dissected by means of this technique. Pressure in the instrument was –400 mm Hg. The instrument could be easily removed by releasing the negative pressure. Cardioplegic arrest was obtained in the ordinary way with the use of extracorporeal circulation, and the LAD was then incised for grafting. The MIDCAB doughnut was applied again around the LAD. Bothersome bleeding from the anastomotic site was easily controlled without aortic venting. After removal of the instrument, the traces on the heart surface disappeared in a few minutes. Hemorrhagic lesions was never found in the suction sites. The instrument was easy to handle when being placed over and removed from the heart surface.

The instrument has been applied in seven patients at other institutes during minimally invasive CABG without the support of extracorporeal circulation. In all seven patients, the LAD was bypassed with a left internal thoracic artery (LITA) bypass graft. Through a small left anterior thoracotomy incision, the MIDCAB doughnut was fitted over the anastomotic site of the LAD by air suction. Through this minimal access approach, stable immobilization of the LAD could also be achieved on the beating heart. The LAD was occluded proximally with a tourniquet and then incised with a knife. The distal LAD was not occluded with a looping suture; however, bothersome back bleeding from the distal coronary artery was almost completely controlled by this technique. The anastomotic site could be firmly stabilized, and the LITA-LAD anastomosis could be precisely completed, just as with cardioplegic arrest (Fig. 2). After completion of the anastomosis, negative pressure was released and the MIDCAB doughnut was cut off and removed from the LITA graft. Postoperative coronary angiography showed that all the grafts were widely patent, and there were no stenotic lesions at the suction sites. In two patients, percutaneous transluminal coronary angioplasty to the circumflex artery was performed simultaneously. All seven patients were discharged uneventfully from the hospital and are doing well. In conclusion, this technical procedure can stabilize the artery and control bleeding, making the anastomosis easier.



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  		Fig. 2. The instrument was fixed to the heart by air suction. Both a motionless and bloodless operative field could be obtained with the use of this instrument.

 
Comment.
A new instrument called a MIDCAB doughnut has been developed for immobilization of the anastomotic site and control of bleeding during minimally invasive CABG. The instrument can make the operative field both motionless and bloodless without snaring. The mechanism of the instrument is based on a negative pressure with fixation to the heart surface around the anastomotic site. Potential problems of encircling snares, such as septal artery injury, atheromatous embolism, coronary artery transection, ventricular tear, or late stenosis of the native coronary, are avoided by use of this instrument. Negative pressure of the instrument occludes the coronary vessels to reduce or interrupt bothersome bleeding from the proximal or distal coronary artery. The need for the proximal encircling suture to be pulled up firmly for immobilization is lessened. An Octopus device (Medtronic, Inc., Minneapolis, Minn.) reported by Borst and associatesGo 4 is based on a principle similar to ours; the device consists of hard multiple suction domes. In their study, light microscopy showed small hemorrhagic suction lesions and intact endothelium of the coronary vessels, which traversed suction lesions, with a negative pressure under –400 mm Hg. We believe that negative pressure fixation of the instrument to the heart may be superior to local myocardial compression methods.

References

  1. Westaby S, Benetti FJ. Less invasive coronary surgery: consensus from the Oxford meeting. Ann Thorac Surg 1996;62:924-31. [Free Full Text]
  2. Subramanian VA, Sani G, Benetti FJ, et al. Minimally invasive coronary bypass surgery: a multi-center report of preliminary clinical experience. Circulation 1995;92(Suppl):I645.
  3. Boonstra PW, Grandjean JG, Mariani MA. Improved method for direct coronary grafting without CPB via anterolateral small thoracotomy. Ann Thorac Surg 1997;63:567-9. [Abstract/Free Full Text]
  4. Borst C, Jansen EWL, Tullenken CA, et al. Coronary artery bypass grafting without cardiopulmonary bypass and without interruption of native coronary flow using a novel anastomosis site restraining device ("Octopus"). J Am Coll Cardiol 1996;27:1356-64.[Abstract]



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