Ministernotomy in myocardial revascularization without cardiopulmonary bypass: Technical aspects and early results

Objective: This study attempts to evaluate the feasibility of ministernotomy in beating heart coronary surgery, with special emphasis on technical aspects. Methods: From September 1997 to September 1999, 137 patients were scheduled for off-pump coronary surgery in our institution. In 61 cases requiring revascularization of the left anterior descending artery ( LAD) and right coronary artery (RCA) systems, the approach was either a reversed "L-shaped" ministernotomy (56 patients) or a "T-shaped" ministernotomy (five patients). Mean age of the ministernotomy patients was 64 +/- 10 years, and 17 of the patients were female. The mean left ventricular ejection fraction (LVEF) was 60 +/- 11% ( < 35% in four patients), and 32 patients ( 52.5%) had one-vessel disease while 29 (47.5%) had 2-vessel or 3-vessel diseases. There were seven (11.4%) urgent procedures. For these procedures, we used devices that we designed ourselves for sternal retraction and coronary stabilization. Results: Five patients (8.2%) needed conversion to another method due to hemodynamic instability or ischemia, while 56 of the patients completed the procedure. Fifty-one patients (91.1%) had a single graft on the LAD, four (7.1%) had a double graft on the LAD and the right or diagonal coronary artery, and one (1.8%) had a triple graft on the LAD and two diagonal branches. Mean coronary occlusion times and operative times were 12.1 +/- 2.7 and 152 +/- 33 minutes, respectively. Mean creatine kinase value was 29.8 +/- 24.6. One patient died of acute myocardial infarction, and one patient had temporary acute renal failure. Mean in-hospital stay was 5.2 +/- 1.9 days. Of the 18 patients (32.1%) who had postoperative angiographic control ( range of 1 to 13 months), 17 showed patent anastomoses, and one required percutaneous transluminal coronary angioplasty (PTCA) of the anastomosis on the LAD. Mean follow-up time for all patients was 10.8 +/- 6.4 months. Freedom from any kind of repeat procedure was 98.2%. Conclusion: Ministernotomy is a safe approach for patients not requiring grafts on the circumflex system. The possibility of multiple grafting and the easy conversion to a conventional surgical method make ministernotomy a preferable approach for minimally invasive coronary surgery.