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J Thorac Cardiovasc Surg 1998;115:486-487
© 1998 Mosby, Inc.

LETTERS TO THE EDITOR

Minimally invasive coronary artery surgery

To the Editor:

My colleagues and I enjoyed the editorial, "Minimally Invasive Coronary Artery Surgery—A Word of Caution" (J Thorac Cardiovasc Surg 1997;114:419-20) and have voiced similar concerns. ¹ We agree wholeheartedly with the authors that accurate anastomosis and long-term patency are critical for the success of minimally invasive coronary artery surgery.

Professor Reardon had concerns about teaching the technique to residents. We have developed some techniques to facilitate the teaching of minimally invasive surgery that might be helpful to Professor Reardon and his colleagues and to others in a similar situation.

Trainees should probably start with redo bypass surgery to the left anterior descending or diagonal coronary artery. In this situation, the adhesions from previous operations hold the target area steady, and the use of a platform (United States Surgical Corporation, Norwalk, Conn.) adds to the stability so that the target area of the coronary artery literally does not move. It is as stationary as the coronary artery in conventional coronary artery surgery.

Placing a coronary artery perfusion cannula inside the lumen of the coronary artery after arteriotomy ensures that there is no ischemia in the area of the myocardium perfused by the coronary artery. Thus hypotension and arrhythmias are not a problem. The cannula consists of a 2 mm olive-tipped DLP arteriography catheter (DPL Inc., Walker, Mich.) attached to a 30-inch B-D (Franklin Lakes, N.J.) roentgenography set tubing which is, in turn, attached to the Luer side port on a femoral artery DLP cannula. ² Long-term studies have shown no evidence of trauma to the coronary arteries cannulated in this way. ³ The suturing can then proceed at a leisurely pace with each suture precisely placed and corrections made if necessary. Another advantage of the cannula is that the placement of the critical sutures at the apex of the arteriotomy is facilitated by gentle sideways traction on the perfusion cannula. The presence of the cannula also prevents errors, such as inadvertently catching the back wall or the other side of the artery with the needle. Prolene snares (Ethicon, Inc., Somerville, N.J.) around the coronary artery and the use of a carbon dioxide blower ensure a totally bloodless field with identical working conditions to those of conventional coronary bypass surgery.

It is probably best if the trainee starts by suturing saphenous vein to the coronary artery and bringing the vein up to the subclavian or axillary artery as the inflow vessel. ⁴ The vein is more forgiving than the internal thoracic artery, and segments of vein are easier to swing around from side to side and maneuver so as to ensure accurate suturing on the medial side of the anastomosis. The vein length should be assessed carefully to avoid the risk of stretching or avulsion when the patient coughs in the postoperative period. This measurement should be made with the lung fully expanded and with the pericardial traction sutures relaxed.

The use of a thoracoscopy camera held by a nurse a few inches from the anastomosis enables faculty to watch the suturing on the screen and monitor the placement of every suture and record it for critical analysis afterward. Intraoperative arteriograms can be used to document the status of the anastomosis between the saphenous vein and the coronary artery. Intraoperative flow probes are useful to demonstrate good graft function after completion of the anastomosis of the vein to the subclavian or axillary artery.

We agree with Professor Reardon that minimally invasive coronary artery surgery is not necessarily something that all community surgeons might want to undertake. In our community, two surgeons have concentrated on minimally invasive techniques, and it is probably better presently if one or two surgeons in a group are delegated to being the "minimally invasive surgeons."

Cardiovascular and Thoracic Surgery
Linacia Building420 West Acacia St., Suite 12, Stockton, CA 95203 References

1. Coulson A. Minimally invasive heart surgery—caveat emptor. Contemp Surg 1997;50:309-10.
   
2. Borges MF, Spohn P, Coulson A. A novel approach to arrhythmia management during minimally invasive cardiac surgery. Ann Thorac Surg 1997;64:843-4.[Abstract/Free Full Text]
   
3. Coulson AS, Bakhshay SA. The use of a coronary artery cannula during minimally invasive coronary artery surgery. Chest. In press.
   
4. Coulson AS, Bakhshay SA. Clinical concepts: subclavian artery origin for a coronary bypass graft. Contemp Surg 1997;50:65-6.
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Alan Coulson Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Coulson, A. Search for Related Content PubMed PubMed Citation Articles by Coulson, A.