Eur J Cardiothorac Surg 1999;16:478-479
© 1999 Elsevier Science NL
Off pump coronary bypass grafting of the circumflex artery
Antonis A. Pitsis,
G.D. Angelini
Bristol Heart Institute, Bristol Royal Infirmary, Bristol BS2 8HW, UK
Corresponding author. Tel.: +44-0-117-928-3145; fax: +44-0-117-929-9737
e-mail: g.d.angelini{at}bristol.ac.uk
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Abstract
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The circumflex artery is the most challenging vessel to be grafted off pump, since it requires lifting and rotating of the heart. A method of exposure and stabilisation of the circumflex during construction of the anastomosis is described. The technique, which is routinely used in our institution, is effective, simple and safe.
Key Words: Coronary bypass • Circumflex artery • Grafting
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1. Introduction
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The last few years have seen a surge of interest in off pump coronary artery bypass grafting [1,2]. It initially started with the minimally invasive left internal mammary artery to left anterior descending coronary artery revascularization, to expand soon after to off pump multiple grafting via a median sternotomy [3,4]. Grafting of the circumflex system remains, however, the major technical limitation to a wider use of the off pump technique. Here we describe the method routinely used in our institution for grafting of the circumflex artery.
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2. Technique
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Following median sternotomy the pericardium is opened longitudinally. Traction sutures are not applied since those lift the whole pericardial cavity towards the surface of the wound, reducing the freedom of movement of the heart which is necessary for the subsequent manipulation. The operating table is then positioned at 20° trendelenburg to increase the preload of the heart, but also to assist the tilting and twisting of the heart towards the right. The table is then rotated to the right towards the surgeon as far as possible. These two simple manoeuvres produce anti-clockwise rotation of the heart and facilitate access to the circumflex system. The heart is then lifted upwards and towards the right by the surgeon and two folded cotton tapes (2 cm wide and 80 cm long) are stitched to the posterior pericardium using an 0-silk suture. The first tape is stitched halfway between the inferior vena cava and the left inferior pulmonary vein, as close as possible to the AV groove, and the second at the level of the left inferior pulmonary vein. One limb of each tape is pulled to the left towards the assistant side to lift the posterior pericardium as much as possible, and then clipped to the surgical towel. The two remaining limbs of the tapes are then crossed around the branch of the circumflex artery to be grafted and fixed to the towel on the side of the surgeon. In this way the apex of the heart is rotated upwards and to the right, facing the surgeon (Fig. 1). If the heart is compressed between the sternal retractor and the tapes we open the right pleura in an attempt to created additional space. A stabiliser is then used, positioned on the right side of the retractor. At the beginning of our experience we used a CTS Stabiliser (Access Plus Cardiothoracic Systems, Cupertino, CA). More recently we have used a reusable stabiliser (Abbey Surgical Limited, Mitcham, Surrey, UK) which can be screwed tight on to any sternal retractor. Once the vessel to be grafted has been appropriately exposed and stabilised, we open the artery without using vessel loops either proximally or distally, and with the aid of a humidifier air blower (Visuflo Research Medical Inc., Midvale, UT) we insert an appropriate size intraluminal shunt (Flothru Biovascular Inc., St Paul, MN). The anastomosis can then be performed using any venous or arterial conduit of choice. On completion of the anatomosis, the shunt is removed just prior to tying the knots, following which the stabiliser is also removed and the two ends of the tapes are repositioned onto the next coronary artery to be grafted or simply removed.
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Fig. 1. The two limbs of the tape on the assistant side have been fixed to the surgical drapes whereas the other two ends have been crossed to the right and fixed to the surgeon's side to hold the heart in position. A reusable stabiliser screwed tight to the sternal retractor to facilitate exposure and stabilisation of the circumflex artery to be grafted is also used.
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This technique has been successfully used in our institution for the last 18 months in approximately 140 cases where it has proved particularly valuable in facilitating exposure and stabilisation to all the branches of the circumflex system and also when grafting the posterior descending coronary artery. The technique allows the use of any arterial or venous conduit, and indeed we have used mammary artery and radial artery as single or sequential grafts, as we would have done if the surgery had been conducted on cardiopulmonary bypass. The patients in whom this technique were used were part of a large prospective, randomised study comparing coronary revascularization with or without cardiopulmonary bypass [5]. With this technique we have not noticed any major cardiovascular instability and the use of bradycardic or vasoconstrictors pharmacological agents is very rare.
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3. Discussion
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Coronary surgery without the use of cardiopulmonary bypass is becoming increasingly popular because of the potential beneficial effects in terms of morbidity, reduced length of stay and cost savings [3,5]. The main restraint to the wide application of the technique is the difficulty in exposing and stabilising the circumflex system. Steady positioning and stabilisation of the coronary arteries to be grafted are essential for performing a technically precise anastomisis on a beating heart. The method described here fulfils this criteria, is easy to use, is effective and safe, and is now routinely used in our institution for patients requiring grafting of the circumflex artery system.
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References
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Ascione R., Lloyd C.T., Lotto A.A., Pitsis A., Angelini G.D. Determinants of perioperative economic outcomes in beating coronary heart surgery: a prospective randomised study. Ann Thorac Surg 1999 in press.
Received February 15, 1999;
received in revised form July 26, 1999;
accepted August 4, 1999.
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Top
Abstract
1. Introduction
