The way to carry out an aortocoronary bypass has remained relatively unchanged during the last decades. The introduction of the beating heart surgery technique 10-15 years ago originated several technical and technological innovations, which made the procedure easier and safer. These developments created the potential for further approaches.
The latest evolution is performing the operation through a small incision under the left breast (mini-thoracotomy), also called MICS-CABG (minimally invasive cardiac surgery – coronary artery bypass grafting).
The most important graft, the left internal mammary artery, is taken down from the chest wall using specially designed surgical instruments. It serves as bypass to the anterior branch of the left coronary artery. Other grafts (“bypasses”) are the arm arteries (radial arteries) or segments of the legs’ saphenous veins. These conduits are connected centrally to the aorta and then to the sick coronary arteries: same as in the classic coronary bypass grafting surgery.
Special devices inserted in the chest through minimal incisions are used to move the beating heart without disturbing its activity too much, so that the targeted coronary artery can be brought to the mini-thoracotomy incision and stabilized safely. The surgeon can then suture the graft to the coronary artery (Fig. 1). Sometimes the use of the heart-lung-machine can facilitate the exposure of difficult accessible coronary arteries.
At the end of the surgery two thin catheters are inserted in the wound, keeping the post-operative pain contained by constantly supplying a local anesthetic. This kind of surgery requires a thorough preparation, a high level of technical expertise and patience. An excellent teamwork between surgeons and anesthesiologists is also required: many well coordinated maneuvers between surgeon and anesthesiologist are needed throughout the procedure and play a key role for its final success.
Recovery from surgery is fast, the restrictions and risks usually linked to the classical approach (sternal opening) are lacking (Fig. 2).
Mini-invasive aortocoronary bypass can be offered to those patients whose anatomy and distribution of coronary lesions appear favourable. The cautious application of this new technique has so far brought excellent results both short and mid term and its evolution will allow a growing number of patients to profit from it.