title: Mammary coronary artery anastomosis without cardiopulmonary bypass through minithoracotomy: one year clinical experience.
abstract: OBJECTIVE
  The recent concept of minimally invasive coronary artery surgery in selected patients has dramatically affected surgical management of coronary artery disease. We explored the possibility of coronary artery bypass grafting of anterior coronary arteries with in situ internal mammary artery through a limited anterior thoracotomy on beating heart.
  
  
  METHODS
  Minithoracotomy and direct coronary artery surgery without cardiopulmonary bypass (CPB) was attempted in 116 patients. The procedure was completed in 108 cases while in eight cases minithoracotomy was converted to mid sternotomy. In 107 cases, left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery anastomosis was done through left anterior minithoracotomy and in one case LIMA to LAD and right internal mammary artery (RIMA) to right coronary artery (RCA) anastomosis was done through bilateral minithoracotomy. Left anterior minithoracotomy through 4th intercostal space and right anterior minithoracotomy through 5th intercostal space was used for left and right internal mammary artery dissection respectively. With this approach 4-8 cm length of mammary artery was easily dissected. Mammary coronary artery anastomosis were performed on a beating heart without CPB through window pericardiotomy. Two patients also underwent left carotid endarterectomy along with LIMA to LAD anastomosis. In two patients complementary percutaneous transluminal coronary angioplasty (PTCA) to circumflex artery was done 5 days after minithoracotomy and LIMA to LAD anastomosis.
  
  
  RESULTS
  Forty-two patients were extubated in the operating room and 66 in the intensive care unit 2-10 h after surgery. Blood transfusion was used in one case who was reexplored for postoperative bleeding due to a displaced hemoclip from the internal mammary artery branch. None of these patients required inotropic support. Postoperative predischarge check angiogram in 53 cases revealed adequate mammary coronary flow in 51 cases, the remaining two had anastomotic problems, one was subjected to PTCA and the other for redo coronary bypass grafting through mid sternotomy. Doppler flow assessment of anastomosis was done in 102 cases, of which two showed problems which was confirmed on check angiography. One-hundred and six patients are in our regular follow-up (mean follow-up 10+/-1.5 months), 98 of them are in functional class I.
  
  
  CONCLUSIONS
  In our experience mammary coronary artery anastomosis without CPB through minithoracotomy is a safe, simple and minimally invasive procedure. Favorable cost/benefit ratio, has been achieved due to no early/late mortality and minimal early morbidity. Postoperative check angiogram and Doppler flow study revealed excellent mid term results.
authors.affiliation: Escorts Heart Institute and Research Centre, New Delhi, India. ehirc@giasd1.01.vsnl.net.in
authors.forename: Y
authors.initials: Y
authors.lastname: Mishra
authors.forename: Y
authors.initials: Y
authors.lastname: Mehta
authors.forename: S
authors.initials: S
authors.lastname: Mittal
authors.forename: M
authors.initials: M
authors.lastname: Mairal
authors.forename: A
authors.initials: A
authors.lastname: Karlekar
authors.forename: A
authors.initials: A
authors.lastname: Seth
authors.forename: T S
authors.initials: TS
authors.lastname: Kler
authors.forename: N
authors.initials: N
authors.lastname: Trehan
mesh_terms: D002315:Cardiopulmonary Bypass; D016894:Endarterectomy, Carotid / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007387:Internal Mammary-Coronary Artery Anastomosis / Q000379:methods* / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology; D013249:Sternum / Q000601:surgery; D013908:Thoracotomy / Q000379:methods; D013997:Time Factors; D016896:Treatment Outcome