title: Minimally invasive coronary bypass using internal thoracic arteries via a left minithoracotomy: "the Nambiar Technique".
abstract: OBJECTIVE
  Harvesting of the right internal thoracic artery (RITA) under direct vision, through a left minithoracotomy, without robotic or thoracoscopic assistance has never been done or described before. Bilateral internal thoracic arteries (BITAs) in coronary artery bypass grafting (CABG) have shown greater survival and freedom from reintervention. The aim was to develop a multivessel minimally invasive CABG technique in which the BITAs are harvested under direct vision and complete revascularization of the myocardium is done by the off-pump method, using only BITAs (left internal thoracic artery [LITA]-RITA Y) through a 2-in left minithoracotomy, without robotic/thoracoscopic assistance-the "Nambiar Technique."
  
  
  METHODS
  From August 2011 to December 2012, a total of 150 patients underwent off-pump minimally invasive multivessel CABG using BITAs, through a 2-in left minithoracotomy incision. Both internal thoracic arteries were harvested directly under vision, and complete revascularization of the myocardium was done using the LITA-RITA Y composite conduit, followed by flow study of the grafts. Coronary artery stabilization for anastomoses was done by using epicardial stabilizers introduced through the minithoracotomy.
  
  
  RESULTS
  One hundred fifty patients had minimally invasive total arterial myocardial revascularization using BITAs (LITA-RITA Y composite conduit) via a left minithoracotomy. The mean number of grafts was 2.8. A total of 81.6% of the patients had three grafts. Ejection fraction was 34.5 ± 5.2. There was one mortality but no major morbidity. The RITA and LITA harvest times were 39.5 ± 11.2 and 35.2 ± 8.6 minutes, respectively. The total time in the operating room (including extubation) was 331.5 ± 42.5 minutes, and operating time was 240.8 ± 24.6 minutes. One hundred twenty-six patients (87.7%) were extubated on the table. The mean hospital stay was 3.1 days. One patient (0.6%) had an elective conversion to sternotomy because the flow in the LITA-RITA Y composite conduit was inadequate and had saphenous vein grafts. Coronary angiograms were done in 37 patients (25%); and computed tomographic angiograms, in 33 patients (22%), and the grafts were patent. Stress test was done in 80 patients (53%), which had normal findings.
  
  
  CONCLUSIONS
  The Nambiar Technique encompassed using a 2-in left minithoracotomy incision through which the BITAs were conveniently harvested in a skeletonized manner under direct vision without robotic or thoracoscopic assistance. Multivessel total arterial revascularization was then done using the LITA-RITA Y composite conduit by the off-pump methodology. The early outcomes have been excellent, and coronary angiograms showed widely patent grafts. This technique is reproducible and can be done on an empty beating heart to aid in training.
authors.affiliation: From the *Max Superspeciality Hospital, New Delhi, India; and †Rockland Hospitals, New Delhi, India.
authors.forename: Pradeep
authors.initials: P
authors.lastname: Nambiar
authors.forename: Chandermohan
authors.initials: C
authors.lastname: Mittal
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D017023:Coronary Angiography; D001026:Coronary Artery Bypass / Q000379:methods*; D003324:Coronary Artery Disease / Q000000981:diagnostic imaging / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008323:Mammary Arteries / Q000637:transplantation*; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D012189:Retrospective Studies; D013908:Thoracotomy / Q000379:methods*; D016896:Treatment Outcome