Dullum M K, Block J, Qazi A, Shawl F, Benetti F
Washington Hospital Center, Washington Adventist Hospital, Washington, DC, USA.
Heart Surg Forum. 1999;2(1):77-81.
Coronary bypass surgery on the beating heart has been in existence since the inception of coronary revascularization. The advent and evolution of the heart-lung machine and cardioplegia have greatly advanced and expanded the realm of bypass surgery, allowing surgeons to perform precise coronary anastomoses in a still field of the arrested heart. The minimally invasive direct coronary artery bypass (MIDCAB) has been used primarily for grafting the left internal mammary artery (LIMA) to left anterior descending artery (LAD) and is gaining acceptance as a less invasive option. Dr. Frederico Benetti in Argentina championed the resurgence of beating heart surgery in 1985, and pioneered the left anterior thoracotomy MIDCAB procedure, which he has further refined to a xiphoid approach. The xiphoid incision is a simpler, less painful approach than that through a left anterior thoracotomy.
An incision is made through the xiphoid and, if necessary, into the tip of the sternum allowing the left side of the chest to be elevated. The distal LIMA is identified and dissected proximally to about the third interspace to give enough distance for a tensionless anastomosis. The pericardium is opened and the heart positioned to expose the LAD. Local stabilization for the LAD is obtained and the LIMA-to-LAD anastomosis is performed.
The xiphoid MIDCAB approach was used for LIMA-to-LAD anastomosis in ten patients ranging in age from 52 to 86 years (mean age 73 years). Three patients underwent angioplasty of additionally obstructed vessels (so-called hybrid procedures) following initial MIDCAB. Despite high preoperative-risk profiles and Parsonnet scores, there were no deaths. However, two of the three hybrid patients had major complications resulting in a prolonged hospital stay.
Initial clinical experience with xiphoid MIDCAB proves it is a feasible alternative to intercostal MIDCAB with the possible advantages of reduced pain and chest wall complications. Further investigation into this surgical approach is warranted.
自冠状动脉血运重建术开展以来，不停跳冠状动脉搭桥手术就已存在。心肺机和心脏停搏液的出现与发展极大地推动并扩展了搭桥手术的领域，使外科医生能够在心脏停搏的静止视野中进行精确的冠状动脉吻合。微创直接冠状动脉搭桥术（MIDCAB）主要用于将左乳内动脉（LIMA）移植至左前降支动脉（LAD），并作为一种侵入性较小的选择而逐渐被接受。阿根廷的弗雷德里科·贝内蒂博士在1985年倡导了不停跳心脏手术的复兴，并率先开展了左前胸廓切开MIDCAB手术，他进一步将其改进为剑突下入路。剑突下切口比左前胸廓切开术更简单，疼痛更少。
通过剑突做切口，必要时延伸至胸骨尖端，使左侧胸部得以抬起。识别并向近端解剖LIMA远端至大约第三肋间，以获得足够距离进行无张力吻合。打开心包并调整心脏位置以暴露LAD。对LAD进行局部稳定后，进行LIMA与LAD的吻合。
剑突下MIDCAB入路用于10例年龄在52至86岁（平均年龄73岁）的患者进行LIMA与LAD的吻合。3例患者在初次MIDCAB术后对额外阻塞的血管进行了血管成形术（所谓的杂交手术）。尽管术前风险较高且Parsonnet评分较高，但无一例死亡。然而，3例杂交手术患者中有2例出现严重并发症，导致住院时间延长。
剑突下MIDCAB的初步临床经验证明，它是肋间MIDCAB的一种可行替代方法，可能具有减轻疼痛和减少胸壁并发症的优点。有必要对这种手术方法进行进一步研究。
