Thoracotomy For Obtuse Marginal Opcab

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.

Obtuse Marginal Artery
Fig. 9.6. Retractor and stabilizer positioned via a left posterolateral thoracotomy for off-pump grafting of the marginal artery in a redo setting.

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.

References

1. Roach GW, Kandruger M, Mangano CM, et al. Adverse cerebral outcome after coronary bypass surgery. NEJM 1996; 335:1857-1863.

2. Svensson LG, D'Agostino RS. Minimal-access aortic and valvular operations, Including the "J/j" incision. Ann Thorac Surg 1998; 66:431-5.

3. Buffolo E, de Andrade JCS, Branco JNR, Teles CA, Aguiar LFA, Gomes WJ. Coronary artery bypass grafting without cardiopulmonary bypass. Ann Thorac Surg 1996; 61:63-6.

4. Pfister AJ, Zaki MS, Garcia JM, et al. Coronary artery bypass without cardiopulmonary bypass. Ann Thorac Surg 1992; 54:1083-92.

5. Calafiore AM, Teodori G, DiGiammarco G, et al. Minimally invasive coronary artery bypass grafting on a beating heart. Ann Thorac Surg 1997; 63:S 72-5.

6. Subramanian VA. Less invasive arterial CABG on a beating heart. Ann Thorac Surg 1997; 63:S 68-71.

7. Baumgartner FJ, Gheissari A, Capouga ER et al. Technical aspects of total revascularization in off-pump coronary bypass via sternotomy approach. Ann Thorac Surg 1999; 67:1653-8

8. Yokoyama T, Baumgartner FJ, Gheissari A et al. Off-pump vs. on-pump coronary bypass in high-risk subgroups. Ann Thorac Surg 2000; 70: 1546-50

9. Baumgartner FJ, Yokoyama T, Gheissari A et al. Effect of off-pump coronary bypass on morbidity. Am J Cardiol 2000; 86:1021-2

10. Stamou SC, Jablonski KA, Pfister AJ et al. Stroke after conventional vs. minimally invasive coronary bypass.

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