Surgical technique:
The procedures were conducted in a hybrid operating room. Our technique
for multi-vessel anaortic OPCAB has been described in
detail[22,23] and a representative illustration of
the most common vessel arrangements is reproduced in Figure 1 with
permission from Seco et al. Eight patients underwent a no-touch anaortic
OPCAB via median sternotomy. One patient with isolated LAD disease
received a no-touch anaortic OPCAB using a Da Vinci assisted MIDCAB
approach, via a left anterior mini-thoracotomy and an in situ LIMA
graft. Internal mammary arteries were harvested as in-situ conduits
using skeletonized technique. The left internal mammary artery (LIMA)
was used to graft the LAD in all cases. The remaining vessels were
grafted using a composite arrangement, either using a “T” graft from
the LIMA or a tandem graft from an in-situ right internal mammary
artery. The radial artery or saphenous vein were harvested in cases of
multi-vessel disease using an endoscopic technique to use as free
conduits in a composite graft format, with IMA in-flow as described
above. The anaortic OPCAB was performed using the Medtronic Octopus
stabilizer and silastic intracoronary shunts were used for all
anastomoses. The Medistime MiraQ TTFM flow probe was used to assess all
grafts at the completion of the anastomoses. Following completion of the
operation, protamine was given to fully reverse the heparin. The
patient’s chest was closed and the patient was moved to the angiography
bed. All patients then had an Edwards Sapien 3 TAVR placed
percutaneously via the common femoral artery.
Assessment of valvular and ventricular function were evaluated using
transesophageal echocardiography intra-operatively. Postoperative
evaluation of valvular and ventricular function was performed using
transthoracic echocardiography prior to hospital discharge. Patients
received outpatient follow up within 30 days of the procedure.