Minimally invasive direct coronary artery bypass procedure using a high thoracic epidural plus general anesthetic technique

Abstract

A NEW SURGICAL approach to coronary artery revascularization that avoids the use of extracorporeal circulation (ECC) is now available: minimally invasive direct coronary artery bypass (MIDCAB). The procedure is limited to patients with one-vessel or two-vessel coronary artery disease (CAD), and allows the heart to continue beating throughout surgery. 1,2 An additional advantage is that the size of the incision is reduced to a small submammary area (keyhole incision). However, the combination of the beating heart and the keyhole incision make this surgical approach more difficult for the surgeon. The increase in postoperative pain and the need for one-lung ventilation during the anastomosis are additional disadvantages of this technique. Incisional pain after the snbmammary incision is greater (especially during the postoperative period) than that associated with a median sternotomy. 3 There are also selected patient characteristics that exclude candidates for MIDCAB, such as severe chronic obstructive pulmonary disease (FEV 1 < 1,500 mL) and coagulation disorders (especially when epidural anesthesia will be used). In contrast to these problems, however, are the many beneficial effects, which include lack of ECC and, therefore, a decreased inflammatory reaction, faster patient recovery, and shorter hospital stay. Beginning in 1990 at Nijmegen University Hospital (The Netherlands), a combined anesthetic technique (high thoracic epidural plus general anesthesia [HTE/GA]) has been used for the patients undergoing coronary artery bypass grafting (CABG) surgery. The authors previously described and reported the beneficial effects of the HTE/GA technique compared with a general anesthetic. 4-6