1. History
Beating heart anastomosis
Alexsis Carrell on dog
Kolessov 1967 first LIMA to LAD (6 pts)
Banned/ Buffalo 1990/1991
Subramanian/Acuff/Mack/Calafiore - MIDCAB
2. Port Access Cardiac Surgery
CABG -- Stevens 1996 (Stanford)
MVR -- Schwartz, Ribakove (NYU)
MIDCAB --
Exposure thru 4th ICS
1 or 2 vessel bypass
5-20% stenosis rate
Anterior wall revascularization only
Less use of resources
Eliminates CPB and sternotomy
3. OPCAB
Exposure median sternotomy
Bypass multiple targets
Patency unknown
No CPB
Port access
4th ICS
Femoral cannulation CPB
Still heart
Total revascularization
Can use SVG for proximals
Over 2000 cases done similar results as open
4. Endoscopic CABG
LIMA taken down with scope only
Then conventional MIDCAB or Port Access
5. MIDCAB or OPCAB
Use in patients you might not want to use CPB
Calcified aorta, poor LVEF, severe PVD
Severe COPD, CRF, coagulopathy
Transfusion issues, i.e., Jehovahs witness
Good target vessels not diffuse disease
Anterior/lateral wall revascularzation
Target revascularzation in older sicker patients
6. Port Access
More universal use
Multi-vessel revascularization
Redo cases
Where sternum healing is problem
Obese, DM, steroids
7. Aortic Valve surgery
Approach
1) Right parasternal first used by Cosgrove
2nd and 3rd costal cartilages removed
try to preserve RIMA
2) Mini sternotomy (Gundry)
upper sternotomy T off to the right 3rd or 4th ICS
better for homograft root replacement
3) Transected sternum (Cosgrove)
transect at 3rd ICS level
both RIMA and LIMA divided
8. Mitral Valve Surgery
Approach
Right parasternal
Lower mini sternotomy
Right anterior lateral thoracotomy
CPB has been accomplished with Heartport system
Fem-fem CPB
Direct cannulation of aorta and atrium
9. Advantages
Decreased length of stay (average 4 days)
Decreased blood transfusions (Cohn, et al)
Return to activity sooner
Less atrial fibrillation (5-10% incidence vs 20-30% open CPB)
10. Pediatric Cardiac Surgery
Ligation of PDA and division of vascular rings via thorascopic technique (Burke)
Open procedures VSD, Tetralogy via mini-sternotomy (Gundry)
ASD closure with Heartport port access
Mini L-Shaped Sternotomy
Mini T-sternotomy
Mini- Parasternal & Mini-Thoracotomy
Graphs
AF Incidences
Patency Rates
Long-Term Results
Angiographic Results
Postoperative AF
Decision Grid
Sternotomy vs No Sternotomy
Off-Pump Indications
11. Future robotics
3-D imaging
Total closed chest still experimental
What to do?
All will become tools to be used
Each will find a niche
How to define role for each tool
Balance co-morbidities with complete revascularization
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