Early results with the minimally invasive thoracotomy for myocardial revascularization

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Abstract
OBJECTIVE: We report the early results of the left anterior descendingartery revascularization through a minimally invasive thoracotomy,examining the main technical aspects of the operation. METHODS: FromJanuary 1995 to September 1996, 51 patients underwent myocardialrevascularization through a mini-thoracotomy on beating heart withoutcardiopulmonary bypass. The main indication to operation was limitedlesions of the left anterior descending artery with contra-indications orhigh risk of failure of angioplasty. The position of the patient was thesame than traditional surgery; the chest was opened on the fourth leftintercostal space; the left internal mammary artery harvested under directvision; temporary occlusion of the left anterior descending was obtainedprevalently using 5-0 poliypropilene sutures; the anastomosis was performedwith single or double 7-0 or 8-0 suture. In six patients the chest wasclosed and a conventional open-heart operation was performed due tointernal mammary artery or left anterior descending unsuitability forminimally invasive revascularization. All the patients were submitted afteroperation to early angiographic control and/or a Doppler study of themammary flow. RESULTS: There was no intra-operative mortality. One patienthad a postoperative myocardial infarction of the anterior-lateral wall ofthe left ventricle, and died after an emergency open-heart operation. Inone case the patient was reopened after a few hours for a bleeding. Threepatients showed various degrees of anastomotic stenosis at the angiographiccontrol. CONCLUSIONS: Several technical difficulties can play an importantrole in the operative outcome because a single repeated technical errorcould not fully explain these heterogeneous observed failures. Thetechnique of myocardial revascularization through a left anterior smallthoracotomy might present several critical points, particularly: (1) theharvesting of LIMA, meaning the preservation of integrity of the arterialwall and adequacy of the length; (2) the method of the temporary closure ofthe LAD during of the anastomosis; (3) the stabilization of the LAD and thesurgical technique of the anastomosis; (4) the methods for intraoperativecontrol of the patency of the anastomosis. All points mentioned have beenthought in our experience to be causes of early failure.

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