RESUMO
OBJECTIVE: Introduction of the new method of videoassisted multiple direct revascularization of the heart muscle from left-sided minithoracotomy (LAST--Left Anterior Small Thoracotomy) using an automatic connector of central anastomoses Symmetry (St. Jude Medical ATG, Inc., St. Paul, MN) in patients indicated for re-operation of bypasses of the coronary arteries or with pathological conditions of the sternum and for the cosmetic effect of submammary incisions in women. METHOD: From September 2001 to the end of February 2002 15 patients with affections of three arteries had an operation from a LAST approach with videoscopic construction of central anastomoses by means of a Symmetry connector with portal entries and the use of extracorporeal circulation introduced from the groin without cardioplegic arrest. Nine men and six women were operated with a mean age of 68.7 years and a mean ejection fraction (EF) of 58.2%. In seven instances reoperation of aortocoronary bypasses was involved; two patients with multiple myelomas (morbus Kahler) had a brittle and cavernously altered sternum, all six women wanted a small skin incision below the breast. The criterion for ruling out the mentioned procedure was marked atherosclerotic affection of the ascendent aorta, affection of the arteries in the aortoiliac area and affection of one or two coronary arteries suitable for miniinvasive revascularization without extracorporeal circulation. Fourteen patients had an angiographic check up examination of the patency of grafts before they were discharged. RESULTS: The total number of distal anastomoses per patient was 3.13 +/- 0.6, the median period of extracorporeal circulation was 112 +/- 34 minutes and the mean time of operation 186 +/- 52 minutes. Blood losses were on average 425 ml/24 h without necessity of revision on account of haemorrhage. Eleven (73%) patients were subjected to an ultra fast track protocol with extubation on the operating table. The mean time spent in the postoperative department was 8.6 hours and the total hospitalization period 5.5 days. None of the operated patients died. Peroperative ischaemia of the heart muscle was not observed, in one instance the authors observed a newly developed atrial fibrillation. During an angiographic check-up the authors detected 6 (13.6%) stenoses and occlusions in 44 checked bridged vessels. CONCLUSION: The alternative approach reduces the risk of cardiac injury during reoperation and the danger of impaired healing of the sternotomical wound in patients with pathological conditions of the sternum, with contamination of the surrounding tissue (e.g. in tracheostomy) or malignant disease. The cosmetic effect of the submammary incision, the small inguinal incision and endoscopic saphenous vein harvesting should be considered in elective direct revascularization of the heart muscle in women. Bridging of the coronary arteries with optical assistance from minithoracotomy and with an automatic connector of central anastomoses seems to be a safe alternative of standard sternotomy only with methodological but not anatomical or functional restriction.