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.