title: Anesthetic implications of subxiphoid coronary artery bypass surgery.
abstract: BACKGROUND
  Minimal invasive surgeries are carried out to benefit the patient with less pain, blood loss, mechanical ventilation and hospital stay; a smaller scar is not the aim. Minimal invasive cardiac surgeries are carried out via small sternotomy, small thoracotomy and via robotic arms. Subxiphoid route is a novel method and avoids sternotomy.
  
  
  OBJECTIVE
  This case series is an attempt to understand the anesthetic modifications required. Secondly, whether it is feasible to carry out subxiphoid coronary artery bypass surgery.
  
  
  METHODS
  Elective patients scheduled to undergo subxiphoid coronary artery bypass surgery were chosen. The surgeries were conducted under general anesthesia with left lung isolation via either endobronchial tube or bronchial blocker.
  
  
  RESULTS
  We conducted ten (seven males and 3 females) coronary artery bypass graft surgeries via subxiphoid technique. The mean EuroSCORE was 1.7 and the mean ejection fraction was 53.6. Eight patients underwent surgery via endobronchial tube, while, in the remaining two lung isolation was obtained using bronchial blocker. Mean blood loss intraoperatively was 300 ± 42 ml and postoperatively 2000 ± 95 ml. The pain score on the postoperative day '0' was 4.3 ± 0.6 and 2.3 ± 0.7 on the day of discharge. Length of stay in the hospital was 4.8 ± 0.9 days. There were no complications, blood transfusions, conversion to cardiopulmonary bypass. The modifications in the anesthetic and surgical techniques are, use of left lung isolation using either endobronchial tube or bronchial blocker, increased duration for conduit harvesting, grafting, requirement of transesophageal echocardiography monitoring in addition to hemodynamic monitoring. Other minor requirements are transcutaneous pacing and defibrillator pads, a wedge under the chest to 'lift' up the chest, sparing right femoral artery and vein (to serve as vascular access) for an unlikely event of conversion to cardiopulmonary bypass. Any anesthesiologist wishing to start this technique must be aware of these modifications.
  
  
  CONCLUSIONS
  Subxiphoid route is safe to carry out coronary artery bypass graft surgery using the minimal invasive cardiac surgery. It is reproducible and has undeniable benefits. We plan to conduct such surgeries in awake patients under thoracic epidural anesthesia thus making it even less invasive and amenable for fast tracking.
authors.affiliation: Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India.
authors.forename: Murali
authors.initials: M
authors.lastname: Chakravarthy
authors.affiliation: Department of Cardiac Surgery, Fortis Hospitals, Bengaluru, Karnataka, India.
authors.forename: Muralimanohar
authors.initials: M
authors.lastname: Veerappa
authors.affiliation: Department of Cardiac Surgery, Fortis Hospitals, Bengaluru, Karnataka, India.
authors.forename: Vivek
authors.initials: V
authors.lastname: Jawali
authors.affiliation: Department of Cardiac Surgery, Fortis Hospitals, Bengaluru, Karnataka, India.
authors.forename: Nischal
authors.initials: N
authors.lastname: Pandya
authors.affiliation: Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India.
authors.forename: Jayaprakash
authors.initials: J
authors.lastname: Krishnamoorthy
authors.affiliation: Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India.
authors.forename: Geetha
authors.initials: G
authors.lastname: Muniraju
authors.affiliation: Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India.
authors.forename: Antony
authors.initials: A
authors.lastname: George
authors.affiliation: Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India.
authors.forename: Jitumoni
authors.initials: J
authors.lastname: Baishya
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000768:Anesthesia, General / Q000379:methods*; D001026:Coronary Artery Bypass / Q000379:methods*; D005260:Female; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures / Q000379:methods*; D016896:Treatment Outcome