Handsewn Proximal Anastomoses Onto the Ascending Aorta Through a Small Left Thoracotomy During Minimally Invasive Multivessel Coronary Artery Bypass Grafting: A Stepwise Approach to Safety and Reproducibility

Minimally invasive coronary artery bypass grafting (MICS CABG) is a nonrobotic, nonthoracoscopic operation that achieves complete anatomical graft similarity with conventional CABG, while avoiding sternotomy and cardiac anoxia. We describe the stepwise approach to perform proximal anastomoses directly off the ascending aorta and also early results of this operation. All myocardial territories are accessed via a 4- to 6-cm left fifth intercostal thoracotomy. After takedown of the left internal thoracic artery, the ascending aorta is progressively brought into view by the following maneuvers: (1) administration of cardiac inotropes to minimize right ventricle filling, (2) increase in right lung positive end-expiratory pressures and tidal volumes, (3) placement of multilevel pericardial retractions, (4) leftward displacement of the ascending aorta with a gauze anterior to the superior vena cava, and (5) left posteroinferior displacement of the right ventricular outflow tract with an epicardial stabilizer. Handsewn proximal anastomoses can then be performed on the ascending aorta with a side-biting clamp. In the first 100 patients who underwent multivessel MICS CABG with proximal anastomoses directly off the aorta, the mean age was 62.6 ± 10.2 years, and median operative time was 3.5 hours. The mean number of grafts was 2.3 ± 0.5, and there were 3 conversions to open sternotomy. There were no preoperative deaths, 2 reoperations for bleeding, and 2 superficial wound infections. The median length of hospital stay was 4 days. MICS CABG is a safe alternative to conventional CABG, with excellent short-term results.