MINI OPCAB Operation: Surgical Technique.

INTRODUCTION: We describe how to perform left internal mammary artery (LIMA) bypass to the left anterior descending (LAD) artery, the so-called MINI Off-pump Coronary Artery Bypass (MINI OPCAB). MATERIALS AND METHODS: We included patients with a demonstrated predominant ischemia related to the LAD territory. Of 70 patients who were operated upon at the Benetti Foundation, 10 received hybrid revascularization. SURGICAL TECHNIQUE: The patient is prepared as for a standard coronary bypass operation through sternotomy. The sternum is opened to the 3rd or 4th intercostal space depending on the anatomy, and a retractor is put in place. The left mammary artery is generally dissected to about 8 cm and isolated without the veins. Importantly, the angle of the superior part, where the mammary artery is attached to the sternum, needs to be below 20% to avoid any potential kinking. The pericardium is cleaned to identify the area of the pulmonary artery. The pericardium is opened to the apex and towards the right to around 5 to 6 cm initially. In most cases, the area of the LAD can be seen and the potential area of the anastomosis is defined. The patient is heparinized and the LAD is occluded with 5-0 Proline. A mechanical stabilizer is put in place and the anastomosis is performed. When the bypass is finished, and before sutures are tied, the stitches of 5-0 polypropylene around the artery are released, along with the clamp of the mammary artery; the anastomosis is then tied. The mechanical stabilizer is removed, the stitches of the pericardium are released and the flow of the graft is measured, while ensuring that there is no kinking. If the flow and Pulsatility and Resistance (PR) are acceptable, the mammary is fixed with 2 stitches of 7-0 polypropylene on both sides around 1 cm from the anastomosis. The heparin is reverted with protamine and a drain is put in place, while taking care to avoid any chance of touching the mammary artery or the anastomosis. The sternum is closed with 1 or 2 wires. RESULTS: Operative mortality in this series was 0%; one patient was converted to sternotomy off-pump (1.4%). None of the grafts were revised after measurement with a Medistim system (Medistim ASA, Oslo, Norway). Fifty five patients (79%) were extubated in the operating room The average hospitalization stay was 60 hours (SD 17, 95% CI). Sixteen patients who underwent the LIMA-to-LAD procedure were restudied, with 100% patency. At 144 months, 82% of the patients were alive and 68% were asymptomatic. CONCLUSION: Additional clinical experience is required to be able to reproduce this operation on a large scale and expand the MINI OPCAB operation in hybrid revascularization.

MINI-off-pump coronary artery bypass graft: long-term results.

In an effort to decrease the risks and costs associated with coronary artery bypass graft, in 1978 we repopularized off-pump coronary artery bypass graft (OPCABG) and expanded the technique, addressing lesions of the circumflex system and applying it to diverse clinical scenarios. In this article we describe our experience with 40 patients who received coronary revascularization through a MINI-OPCABG (Benetti technique) operation. Follow-up was achieved by direct communication with the patients or their family during 144 months. The interviews investigated survival, symptoms, long-term medical management and the need for reintervention. This group of patients had no operative mortality and 18 patients (45%) were extubated in the operating room. One patient (2.5%) experienced a perioperative myocardial infarction. During follow-up, two patients received percutaneous coronary intervention, one in the right coronary artery, the other in the circumflex system. A total of seven patients (17.5%) died. Overall, cumulative patient survival at 144 months was 82.5% (33 cases). Of the seven patients who died, four (10.0%) died of cardiac causes and 68.5% were free of symptoms. Technological advances will help to overcome the anatomical difficulties of this surgical technique, and when simplified, will allow it to be reproduced, offering patients a minimally invasive surgical alternative for the treatment of coronary disease, avoiding the limitations of percutaneous transluminal coronary angioplasty and coronary artery bypass graft.

Epicardial ablation of atrial fibrillation on the beating heart without cardiopulmonary bypass.

The Cox-Maze procedure is the gold standard in surgical treatment of atrial fibrillation. Alternative techniques using cryoablation, radiofrequency, or microwaves have been proven to be equally effective. However, up to now, all techniques require the opening of the atria and, hence, the use of extracorporeal circulation. We describe a technique to perform epicardial ablation of atrial fibrillation on the beating heart without the use of cardiopulmonary bypass.

Enfermedad de Kawasaki (patología de la infancia): aneurismas polifocales, tratamiento quirúrgico, revascularización miocárdica, revascularización renal / Kawasaki disease: child pathology

La enfermedad de Kawasaki, o síndrome linfoganglionar mucocutáneo, es una patología multiorgánica infantil, de afectación preferente por las arterias de mediano y pequeño calibre y, especialmente, las arterias coronarias. Se presenta en este trabajo la resolución quirúrgica secuencial de varios aneurismas coronarios, y un aneurisma de la arteria renal izquierda, en un paciente varón de 9 años, afecto de enfermedad de Kawasaki. Los procedimientos llevados a cabo, con 6 días de diferencia fueron: Primero - Triple bypass aorto-mamario-coronario sin circulación extracorpórea (puente mamario a la descendente anterior y puentes venosos a la coronaria derecha y la circunfleja). Segundo - Ligadura - exclusión del aneurisma renal izquierdo, y bypass aorto-renal con vena safena, por vía extraperitoneal. El paciente fue dado de alta al octavo día postoperatorio de la segunda intervención, y se halla en la actualidad, dos años después, asintomático y de retorno a su vida normal (AU)

Enfermedad de Kawasaki (patología de la infancia): aneurismas polifocales, tratamiento quirúrgico, revascularización miocárdica, revascularización renal / Kawasaki disease: child pathology

La enfermedad de Kawasaki, o síndrome linfoganglionar mucocutáneo, es una patología multiorgánica infantil, de afectación preferente por las arterias de mediano y pequeño calibre y, especialmente, las arterias coronarias. Se presenta en este trabajo la resolución quirúrgica secuencial de varios aneurismas coronarios, y un aneurisma de la arteria renal izquierda, en un paciente varón de 9 años, afecto de enfermedad de Kawasaki. Los procedimientos llevados a cabo, con 6 días de diferencia fueron: Primero - Triple bypass aorto-mamario-coronario sin circulación extracorpórea (puente mamario a la descendente anterior y puentes venosos a la coronaria derecha y la circunfleja). Segundo - Ligadura - exclusión del aneurisma renal izquierdo, y bypass aorto-renal con vena safena, por vía extraperitoneal. El paciente fue dado de alta al octavo día postoperatorio de la segunda intervención, y se halla en la actualidad, dos años después, asintomático y de retorno a su vida normal