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MMCTS
(May 12, 2006). doi:10.1510/mmcts.2004.000810 Copyright © 2006 European Association for Cardio-thoracic Surgery
Procedure Anterolateral thoracotomy for myocardial revascularizationCentro Médico Guerra Mendez, Calle Rondón c.c. 5 de Julio Venezuela, 2001- Valencia, Venezuela * Corresponding author: * Tel.: +01158-2 418 596571; fax: +01158 -2418 596326, E-mail: m120159{at}telcel.net.ve
Off pump coronary artery bypass is commonly performed through a full median sternotomy, however, the tendency to reduce surgical trauma has stimulated cardiac surgeons to use less invasive techniques for single vessels disease (MIDCAB). The use of thoracotomy for reoperative and valvular surgery has also been reported. But its application in primary revascularization is still uncommon. We report here a series of consecutive patients, who underwent complete myocardial revascularization on the beating heart via antero-lateral thoracotomy (ALT-CAB).
Key Words: Antero-lateral thoracotomy • Complete myocardial revascularization • Off pump
In the last ten years, the trends in cardiac surgery had the purpose to reduce surgical trauma, sometimes avoiding extracorporeal circulation [1,2,3,4,5,6], sometimes avoiding median sternotomy [7,8,9], and sometimes avoiding both [10,11]. The advantage of the off-pump coronary surgery has also been reported [12,13,14], as well as the good results obtained with the anterior thoracotomy for single vessels disease and postero-lateral thoracotomy for the RE-DO coronary surgery [15,16,17]. Our technique has the aim to perform a complete myocardial revascularization using an antero-lateral thoracotomy approach without CPB as a routine, even for a total arterial bypass grafting.
The patients were operated under general anesthesia using selective right lung ventilation when possible. The incision was carried out on the fourth or fifth intercostal space from the left parasternal line to the anterior-middle axillary line (Video 1). The left internal thoracic artery (LITA) was harvested under direct vision in a skeletonized fashion using a Finocchietto retractor starting from the lower space of the incision until the origin of the first intercostal branch (Video 2).
The right internal thoracic artery (RITA) also can be dissected from this approach after the pericardial fat and the thymus are carefully removed (Video 3).
Systemic heparin, 2 mg/kg of body weight, was given to maintain an ACT over 350 s. The LITA and, when used, the RITA were transected distally and a warm papaverine solution administered topically. It is possible to take down the RIMA in all patients. We have only dissected the mammaries in skeletonized fashion because it is our common practice since 1995 and maybe it is a little more difficult than the pedicled technique. We believe that the RIMA dissection is still demanding but definitely possible in all patients. Perhaps some long instruments or technique changes would make this more comfortable for the initiating surgeons. The pericardium was then incised from the pulmonary artery towards the ascending aorta and then towards the right atrial appendage. Traction sutures were positioned on the pericardium to rotate the ascending aorta to the left side. The tissue between the aorta and the pulmonary artery was dissected and three or four further traction sutures were placed on the pulmonary adventitia to expose the lateral wall of the aorta. When proximal graft anastomoses were required (i.e. saphenous vein or radial artery), these were performed first using a side bite clamp in a conventional fashion (Video 4).
In order to extend the pericardial incision as posteriorly as possible, the phrenic nerve was carefully dissected from the pericardium. The pericardium was then tractioned with traction sutures to facilitate the exposure of the posterior and lateral wall vessels of the heart (Video 5).
The distal anastomosis was performed on the beating heart using a pressure stabilizer and intracoronary shunt whenever possible. The sequence of the coronary artery anastomosis was left anterior descending first (Video 6), followed by diagonal, obtuse marginal branch of circumflex and right coronary or posterior descending last (Video 7).
For grafting of the left anterior descending and diagonal, no additional mobilization of the heart was required, only the table was rotated towards the right side to facilitate displacement of the heart and visualization of the vessels. For grafting the circumflex and right coronary territory, the heart was lifted out of the pericardium using an apical suction device (Video 8).
At the end of the procedure, the pericardium was partially closed taking care not to compress or twist the grafts. The heparin was reverted with protamine and haemostasis carefully checked. Before closing the chest wall, a small catheter was placed between the ribs for postoperative pain control with bupivacaine infusion.
From November 2002 to June 2005, two hundred and fifty-five consecutive patients underwent an ALT-CAB approach. Complete revascularization was achieved in all scheduled patients with 3.3±1.1 mean number of grafts. The overall mortality was 1.2%. There were no conversions to on pump or median sternotomy. Two hundred and thirty-seven patients (93.3%) were extubated on the operating table and one hundred and sixty-four (65.1%) were discharged home within 48 h postoperatively. Two patients (0.8%) experienced stroke and five (2%) needed re-exploration for bleeding. There was one peri-operative myocardial infarction (0.4%) and fourteen patients (5.5%) experienced postoperative atrial fibrillation. Few patients experienced the phrenic nerve injury and we have classified these patients into two groups: I. Asymptomatic II. Symptomatic In group I we followed with the chest X-ray and the left diaphragm elevation observed was mild to moderate. All of them normalized the diaphragm position level after 6 to 8 weeks. Group II was divided into three grades: mild, moderate and severe according to the respiratory function and the left diaphragm elevation. We also considered the phrenic nerve palsy as transitory when resolved spontaneously and permanent if persisting after 8 weeks. In our series of patients, we have 11 (4.4%) with phrenic nerve palsy; 7 patients (63.6%) from group 1, 4 patients (36.5%) from group 2 and no one in the moderate or severe subgroup. All resolved spontaneously with no permanent limitations. Now we are using the harmonic scalpel for the phrenic nerve dissection with a very important improvement because the temperature generated is much lower than the usual diathermia. The mean follow up was 14.6±9.7 months with a 97.6% survival rate.
The antero-lateral thoracotomy technique (ALT-CAB) is an effective alternative approach to the median sternotomy conventional route for coronary artery bypass surgery when the off-pump method is used. The technique is safe and feasible in the majority of the patients.
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