Reoperative coronary surgery in patients with patent IMA grafts may be hazardous. If such a patient only requires grafting of the circumflex system, a thoracotomy approach with single-lung ventilation may be useful to avoid cardiac injury from sternal reentry. This thoracotomy approach (usually 4th interspace) may be combined with OPCAB instrumentation to provide local stabilization for obtuse marginal grafting (Fig 9.6). The proximal anastomosis should be done to the descending thoracic aorta or, alternatively, the splenic or subclavian arteries in the case of a heavily calcified descending thoracic aorta. It is important to keep the pelvis corkscrewed and the left groin in clear view in case femoro-femoral CPB becomes necessary. Preoperative lung function tests to ensure that the patient can tolerate a thoracotomy is important. Off-pump thoracotomy grafting of the obtuse marginal targets is technically more difficult than other MIDCAB or OPCAB grafting. This relates to the distance of the lateral heart vessels from the lateral chest wall, resulting in a deeper hole within which the surgeon must maneuver, and less steady stabilization by the foot plate.
In summary, OPCAB, by sternotomy or thoracotomy, should not be done if it cannot be done safely or if the quality of the anastomoses is felt to be inferior to those performed on-pump. It requires a level of intensity and cooperation from both surgeon and anesthesiologist that differs from most routine pump cases. Long-term graft patency with OPCAB using stabilizing devices is not yet available, but early results appear encouraging.
It is important, as with any new procedure, to ensure that reason and sound ethical principles apply. This has not necessarily been followed in the past 30 years of modern medicine in matters of life, death, faith, and morals. In the case of cardiothoracic surgery, historically steep "learning curves" when there were no alternative treatments were acceptable, as it was ethically not only justified, but necessary to relieve human suffering. The same type of learning curve is not acceptable today. "Learning curves" can justify some surgical experiences, but it is our duty to ensure that the end is worth the means required to achieve it.
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