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J Thorac Cardiovasc Surg 1998;115:256
© 1998 Mosby, Inc.

LETTERS TO THE EDITOR

Minimally invasive coronary bypass grafting

To the Editor:

I commend Watanabe and associates for their work in minimally invasive surgery (J Thorac Cardiovasc Surg 1997;113:949-51).

In May of 1978 we began performing coronary surgery without the use of the heart-lung machine via a sternotomy approach. In 1988 we performed a quadruple coronary artery bypass graft operation, connecting the left internal thoracic artery (LITA) to the left anterior descending coronary artery (LAD) and three veins to perform complete revascularization of the beating heart through a small anterior thoracotomy. Kolessov was the first to perform an LITA anastomosis on a beating heart through an anterior thoracotomy. ¹

On the January 25, 1994, with the goal of continuing to simplify coronary operations and to perform coronary surgery as an ambulatory procedure, we ² used a small incision less than 10 cm in length without opening the pleura. With the assistance of a videoscope, we harvested the LITA and completed the procedure connecting a vein between the ascending aorta and the LAD extrapleurally in the beating heart of an 84-year-old woman. We further developed the procedure connecting the LITA to the LAD on a beating heart using the scope and without opening the pleura in two more patients. Both were restudied immediately, and the anastomoses between the LITA and LAD were patent. The first patient was discharged after 3 days and the second after 36 hours. Both are free of symptoms 3 years after the operation. ³

We then introduced the concept of minithoracotomy on beating hearts without opening the parietal pleura using a thoracoscope to harvest the LITA. In November of 1994, with Sani and Toscano in Sienna, Italy, we achieved total arterial revascularization in a patient with triple-vessel disease. We connected the LITA to the LAD and the radial artery between the LITA, the diagonal, and the circumflex arteries using the same concept. Various alternatives were published later, which included using LITA-LAD right gastroepiploic artery grafting to the right coronary artery. ⁴ A number of different accesses with arterial conduits have been in use in the past 3 years. We must remember that three potential native arterial conduits are available for use in a minimally invasive approach; the right and left internal thoracic arteries and the right gastroepiploic artery.

With the technology available in the field at this time and the contribution of many surgeons during the past few years, I have no doubt that in the next few years patients with multivessel disease will be treatable with one or more minimally invasive approaches. The critical factor with these procedures will be the review of patients who need more than LITA-LAD bypass for treatment of coronary artery disease with the correct functional and clinical evaluation of the coronary obstruction. Independent of the technical evolution of techniques, this will be the critical point with each patient.

Benetti Foundation, Buenos Aires, Argentina References

1. Kolessov VI, Potashov LV. Operations of the coronary arteries. Exp Chir (USSR) 1965;2:3-8.
   
2. Benetti FJ, Ballester C, Barnia A. Uso de la torasopia en cirugia coronaria para diseccion de la mamaria interna. Frensa Med Argent 1994;81:877-9.
   
3. Benetti FJ, Ballester C. Use of thoracoscopy and a minimal thoracotomy, in mammary-coronary bypass to left anterior descending artery, without extracorporeal circulation. J Cardiovasc Surg 1995;36:159-61.
   
4. Benetti FJ, Ballester C, Sani G, Boonstra P, Grandjean J. Video assisted coronary bypass surgery. J Card Surg 1995;10:620-5.