Technique of bilateral internal thoracic artery minimally invasive coronary artery bypass grafting with double-lung ventilation

摘要

Central MessageAnaortic off-pump MICS-CABG allows for minimally invasive revascularization with both internal thoracic arteries by means of double-lung ventilation even in patients with impaired lung function.See Commentary on page XXX. Anaortic off-pump MICS-CABG allows for minimally invasive revascularization with both internal thoracic arteries by means of double-lung ventilation even in patients with impaired lung function. See Commentary on page XXX. Minimally invasive coronary artery bypass grafting (MICS-CABG) is as safe as off-pump CABG (OPCAB) via sternotomy while allowing for superior cosmetics, wound healing, and recovery.1Lapierre H. Chan V. Sohmer B. Mesana T.G. Ruel M. Minimally invasive coronary artery bypass grafting via a small thoracotomy versus off-pump: a case-matched study.Eur J Cardio Thorac Surg. 2011; 40: 804-810PubMed Google Scholar,2Davierwala P.M. Verevkin A. Sgouropoulou S. Hasheminejad E. von Aspern K. Misfeld M. et al.Minimally invasive coronary bypass surgery with bilateral internal thoracic arteries: early outcomes and angiographic patency.J Thorac Cardiovasc Surg. 2021; 162: 1109-1119.e1104Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar MICS-CABG with conventional single-lung ventilation is limited by a variety of chronic lung diseases as well as technique-inherent pathomechanisms such as missing left lung ventilation that results in intrapulmonary shunting and consecutive hypoxemia, left lung hypoxic pulmonary vasoconstriction leading to pulmonary hypertension, and right lung enhanced airway pressure promoting acute lung injury. Recently, we demonstrated that patients with severely impaired lung function are eligible for MICS-CABG when using a pulmonary fan.3Assmann A.K. Lichtenberg A. Assmann A. Bilateral internal thoracic artery minimally invasive CABG management in COPD.Thorac Cardiovasc Surg Rep. 2022; 11: e14-e16Crossref Google Scholar Here, we present in detail our bilateral internal thoracic artery (BITA)-MICS-CABG technique with double-lung ventilation. BITA-MICS-CABG requires thorough planning considering several contraindications (Table 1). A computed tomography chest scan reveals the patients' intrathoracic anatomy and thus eligibility. Institutional review board approval was not required. An informed written consent for publication of study data was obtained from the patient in the video.Table 1Contraindications for bilateral internal thoracic artery minimally invasive cardiac surgery coronary artery bypass graftingEmergency operationHemodynamic instabilitySeverely impaired ventricular function/dilated ventriclesCardiac redo operationSeverely stenotic or occluded subclavian arterySevere obesity (relative contraindication)Chest deformity (relative contraindication) Open table in a new tab An anesthesiologist team with profound experience in MICS and OPCAB is mandatory. We routinely use pulmonary artery catheters to continuously monitor pulmonary arterial, central venous, and left ventricular filling pressure and cardiac output. Adequate volume management and differentiated catecholamine use are of utmost importance. Patients are placed in the supine position with the left thorax lifted up by 30°. After a submammary skin incision (5-8 cm along the fifth intercostal space) and extrathoracic preparation, the parietal pleura is widely opened to reduce the risk of costal fractures (Video 1). Double-lung ventilation is achieved by our pulmonary fan technique as previously described.3Assmann A.K. Lichtenberg A. Assmann A. Bilateral internal thoracic artery minimally invasive CABG management in COPD.Thorac Cardiovasc Surg Rep. 2022; 11: e14-e16Crossref Google Scholar In brief, the mediastinal pleura is incised 1 to 2 cm anterior of the phrenic nerve, and 6 to 12 sutures are stitched along the pericardio-pleural margin and pulled laterally through the third or fourth intercostal space. Thus, the constructed fan retracts the left lung to enable continuous double-lung ventil