Hugo M. N. Issa MD, and Marc Ruel MD
University Ottawa Heart Institute, Ottawa, ON, Canada.
This chapter is a revision and update from what was included in the previous edition of the TSRA Operative Dictations
in Cardiothoracic Surgery written by M. Scott Halbreiner MD, and Joseph Sabik MD.
Essential Operative Steps
- Lines, monitoring and general anesthesia
- Selective right lung ventilation
- Intraoperative TEE
- External defibrillator pad placement
- Patient positioned in a right lateral decubitus orientation (approximately 25o to 35o)
- Left anterolateral thoracotomy
- Graft harvest
- Systemic heparinization (ACT > 280 seconds)
- Open the pericardium and identify the coronary targets
- Exposure of the aorta
- Side clamping of aorta under systolic blood pressure of 75-85 mmHg
- Perform proximal anastomoses
- Check hemostasis of the proximal anastomoses and the orientation of the grafts
- Systolic blood pressure rises to 130-140 mmHg
- Placement of epicardial stabilizers. For the LAD and diagonal artery exposure, usually just the Octopus Non-Sternotomy
Tissue Stabilizer (Medtronic) is required. For the OM, Rm, PL, and PDA, an armless Starfish Heart Positioner
(Medtronic) is usually also necessary to get adequate coronary exposure - Proximal coronary occlusion and/or shunt placement
- Perform distal anastomoses
- Doppler flow check of anastomoses
- Protamine administration
- Chest tube placement
- Assess hemostasis
- Reinflation of left lung (assess tension of graft with inflation)
- Rib approximation and soft tissue/skin closure
Potential Complications and Pitfalls
- Incorrect rib space for entry: adequate surgical exposure is a must. If necessary, do not hesitate to open the intercostal
space above or below according to your judgment to achieve good surgical exposure - Injury to LIMA: always have in mind that the LIMA may be injured during thoracotomy and during its harvest. Be very
focused to avoid LIMA injury as it is the graft which has best long-term patency. In case of injury, try to use it as an
isolated graft or substitute it with the RIMA, radial artery, or vein graft - Inadequate right lung isolation: be patient and ask the anesthesiologist to fix it. Use bronchoscopy if necessary. In most
cases, right lung isolation is achieved. A wet sponge may be place on the right lung to facilitate exposure. When not
achieved and/or if it compromises surgical exposure, usually it is necessary to go on CPB - Phrenic nerve injury when opening pericardium: this is a rare complication and attention when opening the pericardium
will decrease the risk of phrenic nerve injury to almost 0% - Kinking of graft: when kinking happens, reorientation of the graft must be done and usually the anastomosis needs to be
redone. To avoid such complications, mark the graft with Mytilene Blue - Fibrillation: external defibrillator pads must be used in such a scenario. In cases in which the external pads do not reverse
fibrillation, CPB support is mandatory - Need to go on CPB: CPB is a tool used in about 15-20% of the cases for minimally invasive CABG. If mobilization of
the heart leads to hemodynamic instability despite the use of vasopressors or if the exposure to a distal target is poor, the
femoral vessels are used to initiate CPB. Remember to achieve an ACT >400 seconds with an extra dose of heparin if
going on CPB - When faced by any other major complication and adverse scenario, such as uncontrolled bleeding or inability to achieve
good surgical exposure, remember that conversion to full sternotomy is always an option. The minimally invasive
approach should never jeopardize the security and safety of the patient
Template Dictation
Preoperative Diagnosis: Coronary Artery Disease
Postoperative Diagnosis: Same (with appropriate adjustments)
Procedure(s) Performed: Multi vessel minimally invasive coronary artery bypass. e.g. Coronary Artery Bypass x 3, off pump,
using the left internal mammary artery, the left radial artery, and one vein conduit, by small left thoracotomy, to LAD, OM1,
and PDA
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [SEX] with [DURATION] history of symptomatic coronary artery disease
and [COMPLAINT: e.g. increasing shortness of breath, angina, etc]. Preoperative coronary angiography
reveals [FINDINGS: e.g. 90% stenosis of proximal-LAD, 70% stenosis of RCA, 80% stenosis of OM1, and ejection fraction
of 50%].
Description of Procedure: The patient was thoroughly evaluated and consented for coronary bypass grafting after a full
explanation of the proposed procedure, the alternatives, the risks, and the potential benefits. The patient was taken to the
operating room on [DATE]. An appropriate review was performed verifying the patient’s identity and planned
procedure. While supine on the operating room table, general endotracheal anesthesia was administered without
difficulty. Single right-sided lung ventilation was achieved with a [double-lumen tube or bronchial blocker] and confirmed
by bronchoscopy. A [right/left] internal jugular central line and a [right/left] [radial/ femoral/brachial] arterial line were
placed. A pulmonary artery catheter [was/was not] placed. Preoperative transesophageal echocardiogram was performed to
evaluate cardiac and valvular function. A Foley catheter was inserted.
The patient was positioned to 25° right lateral decubitus and the left arm was folded above the patient’s head and carefully
supported. Defibrillator pads were placed.
The patient was thoroughly prepped and carefully draped as per our usual standard procedure, leaving the sternotomy area
accessible in case of conversion. We kept the groins, thighs, and legs prepped and exposed.
A timeout was performed. A [BLANK] cm anterolateral skin incision was made in the [4th/5th] intercostal space at the
inframammary fold. Dissection was carried down to the intercostal space with minimal division of the pectoralis muscle. The
thoracic cavity was then entered in the standard fashion with care to avoid injury to the LIMA. We took down the LIMA using
electrocautery and clips (Figure 1). During that time, our assistants harvested the greater saphenous vein from the left thigh
and the right radial artery from the right forearm. The whole surgical team ensured to maintain careful hemostasis and
minimization of tissue trauma throughout the operation. Prior to ligating the internal thoracic artery, we gave a dose of heparin
in order to achieve an ACT >280 seconds. The LIMA was marked with marking to help orientation and to avoid kinking the
graft. We performed a total of 3 bypasses. First, we performed two proximal anastomoses. The pericardium was then opened
at the right ventricular outflow tract level and extended toward the upper pericardium reflection between the aorta and the
pulmonary artery. Multiple pericardial retraction sutures were placed to bring the superior mediastinum toward the incision.
An unfolded 4×4 gauze was placed between the superior vena cava and the aorta, which made a leftward displacement of the
ascending aorta.
A 5mm incision was made below the main incision to allow the introduction of the Octopus Non-Sternotomy Tissue Stabilizer
(Medtronic), which was positioned over the RVOT to flatten it posteriorly and therefore expose the ascending aorta. After
bringing the systolic blood pressure to 75-85 mmHg, the ascending aorta was side clamped and two aortotomy holes of 3.6mm
were performed with a punch. We measured, tailored, and anastomotically attached the 2 future grafts (vein-PDA and radialOM1) proximally onto the ascending aorta, by using 6-0 prolene in continuous fashion (Figure 2). The vein and radial artery
were marked to help orientation and avoid kinking the graft.
The pericardium was then opened distally. The first distal graft was on the PDA branch of the RCA. It was positioned with a
combination of Starfish and Octopus exposure, all through the small left thoracotomy. An arteriotomy was performed with a
15 blade in the PDA and an [BLANK]mm intravascular shunt was used to prevent ischemia and to achieve hemostasis. The
distal end of a reversed SVG was successfully anastomosed to it, using continuous 7-0 prolene in continuous fashion.
The next distal was the OM1. We positioned the heart with the Starfish and Octopus. An arteriotomy was performed with a
15 blade in the OM1 and an [BLANK]mm intravascular shunt was used to prevent ischemia and to achieve hemostasis. The
distal end of the radial artery was successfully anastomosed to it, using continuous 7-0 prolene in continuous fashion (Figure 3).
Finally, the last distal graft was on the LAD which was opened with a #15 blade and extended to an opening size of about 6-
8mm. An [BLANK]mm intravascular shunt was placed to prevent ischemia and to achieve hemostasis. The distal end of the
LIMA was anastomosed to it by using continuous 7-0 prolene, in continuous fashion (Figure 4).
Protamine was administered to reverse the heparin effects. The flow down the bypass graft was checked and confirmed using
a doppler flow probe. The coronary stabilizing device was removed and hemostasis was achieved. A total of [BLANK] chest
tubes were placed in the left pleural space and [BLANK] chest tube(s) were placed in the mediastinum. [Atrial/Ventricular] pacing wires were placed in the standard fashion. The thoracotomy was reapproximated with rib sutures and, prior to closure, the left lung was observed to reinflate completely and imposed minimal tension on the LIMA graft. The subcutaneous tissues and skin were closed in the standard fashion and sterile dressings were applied. The patient tolerated the procedure well and was [extubated in the operating room and then] brought to the intensive care unit in stable condition.
All instrument, sponge, and needle counts were confirmed to be correct following skin closure.
Figure 1: Patient’s position for MICS-CABG
Figure 2: LIMA harvest from lateral approach and thought a small thoracotomy. Figure 3: Proximal anastomosis. Figure 4:
Distal anastomosis in the lateral wall. Figure 5: Distal anastomosis in the anterior wall
Multiple Choice Question(s)
About Multi Vessel Minimally Invasive Directed Coronary Artery Bypass, all the following sentences are correct, EXCEPT:
A. Side clamping for proximal anastomosis of aorta should be under low systolic blood pressure such as 75-85 mmHg
B. CPB is a tool used in about 40-50% of the cases for minimally invasive CABG.
C. The minimally invasive approach should never jeopardize the security and safety of the patient and conversion to full
sternotomy should be done when major a complication requires it
D. Patients with severe COPD are usually not good candidates for the minimally invasive approach as single right ventilation
is required
E. External defibrillator pads should be placed before starting the incision.
Answer: B. The rate of 40-50% for CPB is high. CPB is used in about 15-20% of the cases for Multi Vessel Minimally Invasive
Directed Coronary Artery Bypass. All the other choices are correct.
Sources
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Ruel M. Commentary: Sternotomy for every cardiac surgery patient ain’t the future, so let’s get going. J Thorac Cardiovasc
Surg. 2021 Jan 30:S0022-5223(21)00195-1.
Guo MH, Vo TX, Horsthuis K, Rahmouni K, Chong AY, Glineur D, Ruel M. Durability of Minimally Invasive Coronary
Artery Bypass Grafting. J Am Coll Cardiol. 2021 Sep 28;78(13):1390-1391.
Lapierre H, Chan V, Sohmer B, Mesana TG, Ruel M. Minimally invasive coronary artery bypass grafting via a small
thoracotomy versus off-pump: a case-matched study. Eur J Cardiothorac Surg. 2011 Oct;40(4):804-10.
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