Multivessel Coronary Artery Bypass Grafting Without Cardiopulmonary Bypass  Mark W. Connolly, Valavanur A. Subramanian, Nilesh U. Patel  Operative Techniques in Thoracic and Cardiovascular Surgery  Volume 5, Issue 3, Pages 166-175 (August 2000) DOI: 10.1053/otct.2000.18228 Copyright © 2000 Elsevier Inc. Terms and Conditions

1 A full midline sternotomy incision is made extending inferior to the xiphoid, to enable wide lateral retraction of the sternum. As the retractor is opened, the right sternum is pulled anteriorly while the left sternum is pushed posteriorly. This allows for possible displacement of the apex of the heart under the right sternum during circumflex vessel grafting. The incision is extended inferiorly another 4 cm if right gastroepiploic artery harvesting is needed. The pericardium is opened widely along the diaphragm and extended down to the inferior vena cava to increase the laxity of the right pericardium. This decreases right heart compression when the heart is displaced to the right. The entire right pleural space may be opened to displace the heart into the right pleural space when grafting circumflex arteries or large hearts. No right-sided pericardial sutures are placed; these sutures would increase right pericardial tension and potential mechanical compression of the right heart, leading to hemodynamic deterioration. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 166-175DOI: (10.1053/otct.2000.18228) Copyright © 2000 Elsevier Inc. Terms and Conditions

2 Left superficial pericardial sutures are placed to pull the pericardium up to the left sternum. The apex of the heart is gently pulled right lateral and anterior to expose the left posterior pericardium. Deep pericardial sutures are placed in three positions: just medial to the inferior vena cava (IVC) in the diaphragmatic pericardium, between the IVC and the left inferior pulmonary vein under the posterior left atrium, and just anterior to the left inferior pulmonary vein below the left phrenic nerve. The heart is gently retracted and placed back into the pericardial well with each suture placed to prevent prolonged hemodynamic compromise. Having the anesthesiologist briefly hold mechanical ventilation will increase exposure for this step. These deep pericardial sutures are then pulled to varying degrees of tension, displacing the heart for exposure of the desired coronary artery. The surgeon must avoid taking deep bites through the pericardium with these sutures, as puncture of the left lung and hilar structures can occur. The sutures should remain below the left phrenic nerve to prevent injury. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 166-175DOI: (10.1053/otct.2000.18228) Copyright © 2000 Elsevier Inc. Terms and Conditions

3 LAD and diagonal anastomosis. The deep pericardial sutures are gently pulled to bring the LAD midline and up into the surgical field. The coronary artery is palpated and the anastomosis site inspected. Silastic tapes are placed proximal and distal to the anastomosis site. The retractor (CTS Access Ultima System; Guidant-CTS, Cupertino, CA) is slid into position to stabilize the coronary artery. Gentle compression around the LAD on the left ventricle can achieve stabilization without compromising hemodynamics. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 166-175DOI: (10.1053/otct.2000.18228) Copyright © 2000 Elsevier Inc. Terms and Conditions

4 Coronary anastomosis. The proximal Silastic tapes are gently crossed, and the distal tapes are gently pulled inferiorly (not crossed) to decrease coronary blood flow. Excessive crossing of distal tapes may injure the coronary artery. The epicardium over the vessel is dissected with a scalpel or scissors. The arteriotomy is performed with an iris blade. After the arteriotomy is extended with coronary scissors; lateral 6-0 silk retraction sutures may be used to open the arteriotomy and increase stabilization if necessary. The in-situ left internal mammary artery is anastomosed to the LAD or sequentially to the diagonal-LAD in the standard fashion. A CO2 mist blower is used to briefly blow away coronary blood and improve visibility during suture placement. An intracoronary shunt may be used to perfuse the distal artery during the procedure to prevent myocardial ischemia. Intracoronary shunts can also be used to improve visibility if excessive blood flow from collaterals or septal perforators occurs. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 166-175DOI: (10.1053/otct.2000.18228) Copyright © 2000 Elsevier Inc. Terms and Conditions

5 Circumflex anastomoses. The deep pericardial sutures are pulled to further displace the heart to the right. The apex of the heart may be placed into the right pleural space to improve exposure of the lateral wall. The site for anastomosis of the intermediate ramus or obtuse marginal vessel(s) is determined, Silastic tapes are placed, and the stabilizing arm is positioned. The arm is usually positioned as parallel to the vessel as possible, to minimize its movement. This is important with hypertrophied, hyperdynamic ventricles that exert outward force against the retractor. The anastomosis is completed as shown in 3. After sequential radial artery anastomoses are performed, the stabilizer is carefully backed out from the sequential segment, to prevent disruption and pulling on the anastomoses. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 166-175DOI: (10.1053/otct.2000.18228) Copyright © 2000 Elsevier Inc. Terms and Conditions

6 PDA and PLA anastomosis. The IVC deep pericardial suture is pulled inferiorly, and the patient is placed in Trendelenburg position to displace the apex of the heart toward the ceiling. Silastic tapes are placed, and the stabilizing arm is positioned around the desired posterior vessel, taking care to avoid excessive stabilizer compression that displaces the apex of the heart superiorly, which can cause hemodynamic compromise. This position is usually well tolerated even in patients with low ejection fraction. Sequential grafting to the PDA and PLA is commonly performed. The right gastroepiploic artery can also be brought through a diaphragmatic slit to access the PDA. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 166-175DOI: (10.1053/otct.2000.18228) Copyright © 2000 Elsevier Inc. Terms and Conditions

7 RCA anastomosis. The left deep pericardial sutures are loosened to position the heart in its normal anatomical position. Deep right inferior pericardial sutures are placed to pull up the right heart anteriorly. Silastic tapes are placed proximally and distally around the distal RCA. The proximal tape is pulled toward the surgeon, to bring the RCA upward. The distal tape is pulled (not crossed) inferiorly to flatten the RCA horizontally. The stabilizing arm is then placed around the RCA. The acute margin of the right ventricle may need to be retracted to the left with a pledgeted suture to increase exposure. In situ right internal mammary or vein grafting is then done in standard fashion. Proximal anastomoses are done in standard fashion with a partial occlusion clamp. Deairing of the aorta is performed after all proximal grafts are completed with retrograde radial artery flow before the partial occlusion clamp is released. Operative Techniques in Thoracic and Cardiovascular Surgery 2000 5, 166-175DOI: (10.1053/otct.2000.18228) Copyright © 2000 Elsevier Inc. Terms and Conditions