Reversed-J inferior sternotomy for beating heart coronary surgery

Median sternotomy or combined multiple minimally invasive approaches are currently used to revascularize patients with multivessel coronary artery disease on the beating heart. We present here a new alternative approach for minimally invasive coronary surgery on the beating heart: the reversed-J inferior sternotomy. Through this approach, the left anterior descending, diagonal, and right coronary arteries can be revascularized via a single minimally invasive approach.

 Minimally invasive approaches for beating heart coronary surgery are currently growing in acceptance. However, minimally invasive approaches generally permit the exposure of a single coronary artery [1] [2] [3] [4] . When multiple vessel revascularization is required, full midline sternotomy is generally preferred [5] . Recently, combined minimally invasive approaches have been also described for patients with multivessel disease [4] . The reversed-J inferior sternotomy is an alternative minimally invasive approach that is especially suited for patients with two-vessel disease involving the left anterior descending (LAD) and the right coronary artery (RCA).

The reversed-J inferior sternotomy provides an optimal exposure of the anastomotic site and of the left internal mammary artery (LIMA). With the reversed-J inferior sternotomy, pedicled arterial grafts can be used in patients with LAD, diagonal branches, and RCA disease.

The patient is positioned as for the standard sternotomy. A midline skin incision is made from the third intercostal space down to the xiphoid process; then, the lower part of the sternum is divided up to the third intercostal space beginning from below . [Figure 1] At this level an oscillating saw is used to transect obliquely the left half of the sternum. A mammary retractor is used to harvest the LIMA, which can be easily exposed and harvested. A long-tip electrocautary can be used to harvest the proximal portion of the LIMA. After the harvesting of the LIMA is completed, a Finocchietto-like pediatric retractor is positioned to spread the sternum. The right gastroepiploic artery (RGEA) is harvested as previously described [1] . The heparin is given (1.5 mg/kg), and the pedicles of the arterial conduits are divided . [Figure 2] A 0.1−mg/mL papaverine solution is injected into the graft and in the pedicle. The spreader, endowed with a coronary artery stabilizer (OPCAB Midline Multi-Vessel Set; CardioThoracic Systems, Cupertino, CA), is introduced. The stabilizer is positioned and fixed on the LAD, which is centered between the tines. The anastomotic site of the LAD is chosen, and two looping 5−0 polypropylene sutures surround proximally and distally the anastomotic site of the coronary vessel. The LAD is briefly occluded by means of the looping sutures to evaluate the tolerance to ischemia. The LAD is opened longitudinally and the looping sutures are pulled for hemostasis. The LIMA-LAD anastomosis is done with a running 7−0 or 8−0 polypropylene suture. The stabilizer is removed and the LIMA is secured to the epicardium by two 5−0 prolene stitches to avoid kinking of the pedicle. For the anastomosis on the RCA, two stay sutures are used to pull the diaphragm caudally. The RGEA is routed anterior to the pylorus and left liver lobe into the pericardium through a hole made in the diaphragm anteriorly to the inferior vena cava. The acute margin of the heart is then displaced cranially by means of a 3−0 prolene buttressed with a felt to provide a good exposure of the inferior wall. Then, the anastomotic site of the RCA or the right posterior descending is chosen and prepared as described above. The anastomosis is performed with a running 8−0 polypropylene suture, and the RGEA pedicle is sutured to the epicardium. No protamine is given at the end of the procedure. The peritoneum is closed in layers, and two drains are positioned in the pericardial cavity and the substernal space. The lower sternotomy is then closed with sternal wires.

From February to June 1998, 6 patients were operated on for a primary myocardial revascularization on the beating heart through a reversed-J sternotomy. The characteristics of the patients are showed in . [Table 1] Neither hemodynamic changes nor transient S-T segment changes occurred during the procedures. No patients had perioperative myocardial infarction. The mean duration of intubation was 9.6 h and the mean stay in the postoperative intensive care unit was 14.6 h. Neither sternal dehiscence nor wound infections occurred. The postoperative period was uneventful in all cases, and the mean hospital stay was 4.8 days.

Minimally invasive coronary surgery (MICS) has become an accepted procedure because it avoids the disadvantages of cardiopulmonary bypass (CPB) and cardioplegic arrest [5] . The expansion of the indication of beating heart surgery to larger groups of patients with multi-vessel disease has renewed interest in the median sternotomy [6] . Combined multiple approaches [4] have been proposed as an alternative to the full median sternotomy to revascularize patients with multivessel disease.

We believe that the reversed-J inferior sternotomy can be a less invasive approach in patients with a stenosis of the LAD, diagonal, and RCA. This approach can be used as an alternative to median sternotomy, especially in the presence of risk factors such as diabetes and female gender. With the reversed-J inferior sternotomy, the exposure of the diseased vessels is as good as in conventional full sternotomy, but the procedure is less traumatic for the thoracic wall. Therefore, the patient receives most of the advantages of a minimally invasive technique in the postoperative period. In fact, the upper part of the chest wall remains intact, providing beneficial effects on postoperative recovery.

 

In conclusion, the reversed-J inferior sternotomy can be an alternative minimally invasive approach for patients with LAD and RCA disease.

 

 References

 

1.Grandjean J.G., Mariani M.A., Ebels T.. Coronary reoperation via small laparotomy using right gastroepiploic artery without CPB. Ann Thorac Surg 1996;61:1853−1855.

2.Boonstra P.W., Grandjean J.G., Mariani M.A.. Improved method for direct coronary grafting without CPB via anterolateral small thoracotomy. Ann Thorac Surg 1997;63:567−569.

3.Calafiore A.M., Di Giammarco G., Teodori G.. Midterm results after minimally invasive coronary surgery (LAST operation). J Thorac Cardiovasc Surg 1998;115:763−771.

4.Voutilainen S., Verkkala K., Jarvinen A.. Minimally invasive coronary artery bypass grafting using the right gastroepiploic artery.