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Minimally Invasive CABG Combined With Mitral Valve Repair and Left Ventricle Aneurysm Repair Through Left Anterior Thoracotomy

Tuesday, December 3, 2019

Babliak O, Demianenko V. Minimally Invasive CABG Combined With Mitral Valve Repair and Left Ventricle Aneurysm Repair Through Left Anterior Thoracotomy. December 2019. doi:10.25373/ctsnet.11310641.

A 53-year-old man was admitted with a two-month history of anterior myocardial infarction, congestive heart failure, and a New York Heart Association III classification. Echocardiography showed severe mitral insufficiency (Carpentier I, IIIb), left ventricle aneurysm, and left ventricle ejection fraction (EF) 35%. An angiogram showed severe triple vessel disease.

The authors performed coronary artery bypass grafting combined with mitral valve repair and left ventricle aneurysm repair using a minimally invasive approach through the left anterior thoracotomy in the fourth intercostal space. The left internal mammary artery and saphenous vein were harvested. The authors used peripheral cannulation (femoral) for cardiopulmonary bypass (CPB). The aorta was cross-clamped and cold blood cardioplegia was administered every 15-20 minutes. The following distal anastomoses were performed: vein to PDA, vein to OM, and left internal mammary artery to left anterior descending artery (LAD). Then, a 5 cm incision was made in the left ventricle anterior wall parallel to the LAD through the aneurysmal tissues. The mitral valve was exposed and an Alfieri stitch was done between the A2 - P2 segments of the mitral valve leaflets. Then, a left ventricle repair using two layers of endoventricular suture lines with polypropylene 3-0 was performed. The volume of the left ventricle was reduced and the shape was restored. Proximal anastomoses to the aorta with two vein grafts were completed using a side-biting aortic clamp. Cardiopulmonary bypass was weaned and the wound was closed.

The patient was discharged on the fifth postoperative day with EF 40% and no mitral regurgitation.

Comments

A couple of questions : Did you harvest the IMA on bypass, or is this an editing error? If so, how can you justify the extra pump time on a sick (ischemic MR) patient? Also, I couldn't see the aneurysm on the field - the LV wall appeared thick where you opened it and no scar was visible. In addition, the LAD was not occluded (although tightly diseased), so I am somewhat confused about the pathology. Finally, do you routinely perform stand-alone Alfieri stitches for IIIb mitral pathology? If so, how does it work in the mid- and long term. If you have good long term follow-up data, you should publish your work as this will revolutionize the treatment of ischemic MR.
1-the alfieri stitch is it enough to correct the ischemic mitral regurgitation? 2-the LV repair was as linear suturing in thr anterior territory where the circular repair using a patch(DOR) is recommended to preserve the LV geometry. Ur comments? Noting that the approach is amazing.
The video is amazing by complete misunderstanding of the pathology and ignorance in quidelines study. There are no indications for LV reconstruction as well as this type of repair of ischemic MR in this case.
Dear George Tolis. Thank you for your interest to our video. I am receiving too many questions now on this technique. The additional information on LV pathology (MRI), which will resolve your doubt, you may find on this link. https://youtu.be/XduUIFQxAJQ?t=12 The main message of our video is that even for complex surgery we can avoid the median sternotomy for patients’ needs. By the way, 99% of isolated CABG we operate though the left anterior thoracotomy and I believe this technique will change to future of cardiac surgery. We will have two presentations at ICC 2019 in New York and you are welcome for open discussion.
Dear Sarkis Ejbeh. This case perfectly solved the patient’s problem and let him safely go through the complex surgery with minimal trauma. MV - main jet on Echo was effectively corrected with stitch. LV - here we presented one of the techniques, that we use to restore the LV shape. As well, you are welcome to our Center to see this approach live, as this is a routine approach for multivessel CABG. https://www.babliak.com/mba
Dear Amir Kramer. We treat patients, not - guidelines. Re “… no indications for LV reconstruction …” you can find additional information on MRI of this patient link: https://youtu.be/XduUIFQxAJQ?t=12 You are welcome to follow my further publications and presentations.
I definitively love this case and the approach!! Congratulations! Nevertheless, I completely agree regarding the mitral valve repair. Alfieri stitch is not a good option for a 53-year-old man with ischemic mitral regurgitation...what about the mid and long term follow up? I truly think it´s going to fail and a mitral replacement will be needed in the near future. The CABG procedure itself was amazing, congratulations again! I´m pro-MICS, but, do we sacrifice the best mitral valve repair in order to perform the MICS approach anyway? Thank you for this well-documented case.
Dear Germán Fortunato Alfieri stitch is not the best procedure for ischemic MI and is not what we usually do. But we understand that no good treatment exists for ischemic MI, even MV replacement. So, in this situation we can not ignore the patient strong wish to get minimal invasion in his thick condition. Anyway, I appreciate your interest about our video and you are welcome to our Center.
Dear Germán Fortunato Alfieri stitch is not the best procedure for ischemic MI and is not what we usually do. But we understand that no good treatment exists for ischemic MI, even MV replacement. So, in this situation we can not ignore the patient strong wish to get minimal invasion in his thick condition. Anyway, I appreciate your interest about our video and you are welcome to our Center.
Who edited this content from CTSNet? Do we really want to advertise that just because a 53 year old patient comes to the office asking for “minimally invasive surgery” we will open their LV to put an Alfieri stitch on the mitral valve? How can a CTSNet editor not know that OM stands for obtuse marginal and not otitis media and that PDA - in this setting - stands for posterior descending artery and not patent ductus arteriosus? This is really disappointing. If this platform is to maintain any validity it needs to tighten up the editing process.
TERRIFIC !!! Thanks for sharing, I am learning more with your video than in a long time. Only two questions, 1) Why do you prefer the LIMA DA by pass on the lateral side and not the lateral terminal? and, 2) If you considered another access point and place a mitral ring? Thank you very much and I think your work is fantastic and the result is in sight.
Dear Marcos Loconte. 1) In this case LIMA was put on LAD, not diagonal. We usually do this anastomosis "side-to-side" and have good follow-up up to 20 years. 2) In case of sternotomy we would put rigid ring. The alternative approach that we also do in combined (CABG+MVR) procedures is do MIVR through the R minithoracotomy and to do CABG through the L minithoracotomy. But this procedure takes 1-2 hours longer and we considered not do it in this case. Feel free to contact me, if I didn't answer your question.
Amazing video, congratulations!!! I have couple of questions just for the CABG part. 1). How easy to access RCA/PDA from left anterolateral thoracotomy? 2). you did it on pump with cardiac arrest, have you tried it off pump? if so, is it still doable to bypass onto right side coronary ? Thanks
Amazing video, congratulations!!! I have couple of questions just for the CABG part. 1). How easy to access RCA/PDA from left anterolateral thoracotomy? 2). you did it on pump with cardiac arrest, have you tried it off pump? if so, is it still doable to bypass onto right side coronary ? Thanks
Dear Xingyi Que. 1) With this technique (TCRAT) and exposure maneuvers, that we described in Innovation (Innovations (Phila). 2019 Aug;14(4):330-341. doi: 10.1177/1556984519849126. Epub 2019 May 20.) and MMCTS (https://mmcts.org/tutorial/1338), the exposure of PDA or RCA became as easy as in sternotomy. 2) We do beating heart MICS CABG only with porcelain aorta. Exposure of PDA is much more difficult, but definitely possible.

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