Minimally invasive direct coronary artery bypass (MIDCAB) surgery: Technical aspects

Minimally invasive direct coronary artery bypass surgery without cardiopulmonary bypass is gaining popularity for the surgical revascularization of patients with selected coronary artery disease. The most frequent procedure is left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery bypass graft using left anterior small thoracotomy (LAST) incision. The LIMA can be dissected under direct vision or through video-assisted device. Recently, we used minimally invasive direct coronary artery bypass (MIDCAB) surgery on the beating heart without cardiopulmonary bypass for single- or double- vessel coronary artery disease patients. Twelve patients with symptomatic coronary artery disease were included in this study. These patients underwent attempted MIDCAB surgery. A LAST incision, about 8 cm long, was made in the fourth intercostal space and the fourth intercostal cartilage was excised (third cartilage also, if needed). The LIMA was mobilized for about 6 cm under direct vision. End to side, LIMA to LAD coronary artery anastomosis was performed for nine patients with single vessel LAD disease and median sternotomy with a vein graft was performed for one patient with double-vessed disease. These ten patients all underwent MIDCAB on beating hearts without cardiopulmonary bypass. Of the twelve study patients, two required converion to traditional approach median sterotomy with cardiopulmonary bypass, one patient for intramyocardial and the other because of calcified LAD. In conclusion, MIDCAB surgery can be performed with success under careful patient selection.