Chakravarthy Murali, Veerappa Muralimanohar, Jawali Vivek, Pandya Nischal, Krishnamoorthy Jayaprakash, Muniraju Geetha, George Antony, Baishya Jitumoni
Department of Anesthesia, Critical Care and Pain Relief, Fortis Hospitals, Bengaluru, Karnataka, India.
Department of Cardiac Surgery, Fortis Hospitals, Bengaluru, Karnataka, India.
Ann Card Anaesth. 2016 Jul-Sep;19(3):433-8. doi: 10.4103/0971-9784.185525.
Minimal invasive surgeries are carried out to benefit the patient with less pain, blood loss, mechanical ventilation and hospital stay; a smaller scar is not the aim. Minimal invasive cardiac surgeries are carried out via small sternotomy, small thoracotomy and via robotic arms. Subxiphoid route is a novel method and avoids sternotomy.
This case series is an attempt to understand the anesthetic modifications required. Secondly, whether it is feasible to carry out subxiphoid coronary artery bypass surgery.
Elective patients scheduled to undergo subxiphoid coronary artery bypass surgery were chosen. The surgeries were conducted under general anesthesia with left lung isolation via either endobronchial tube or bronchial blocker.
We conducted ten (seven males and 3 females) coronary artery bypass graft surgeries via subxiphoid technique. The mean EuroSCORE was 1.7 and the mean ejection fraction was 53.6. Eight patients underwent surgery via endobronchial tube, while, in the remaining two lung isolation was obtained using bronchial blocker. Mean blood loss intraoperatively was 300 ± 42 ml and postoperatively 2000 ± 95 ml. The pain score on the postoperative day '0' was 4.3 ± 0.6 and 2.3 ± 0.7 on the day of discharge. Length of stay in the hospital was 4.8 ± 0.9 days. There were no complications, blood transfusions, conversion to cardiopulmonary bypass. The modifications in the anesthetic and surgical techniques are, use of left lung isolation using either endobronchial tube or bronchial blocker, increased duration for conduit harvesting, grafting, requirement of transesophageal echocardiography monitoring in addition to hemodynamic monitoring. Other minor requirements are transcutaneous pacing and defibrillator pads, a wedge under the chest to 'lift' up the chest, sparing right femoral artery and vein (to serve as vascular access) for an unlikely event of conversion to cardiopulmonary bypass. Any anesthesiologist wishing to start this technique must be aware of these modifications.
Subxiphoid route is safe to carry out coronary artery bypass graft surgery using the minimal invasive cardiac surgery. It is reproducible and has undeniable benefits. We plan to conduct such surgeries in awake patients under thoracic epidural anesthesia thus making it even less invasive and amenable for fast tracking.
开展微创手术是为了让患者减少疼痛、失血、机械通气时间及住院时间；较小的疤痕并非目的。微创心脏手术通过小胸骨切开术、小开胸术及机器人手臂进行。剑突下路径是一种新方法，可避免胸骨切开术。
本病例系列旨在了解所需的麻醉调整。其次，探讨剑突下冠状动脉搭桥手术是否可行。
选择计划接受剑突下冠状动脉搭桥手术的择期患者。手术在全身麻醉下进行，通过支气管内导管或支气管封堵器实现左肺隔离。
我们通过剑突下技术进行了10例（7例男性和3例女性）冠状动脉搭桥移植手术。平均欧洲心脏手术风险评估系统（EuroSCORE）评分为1.7，平均射血分数为53.6。8例患者通过支气管内导管进行手术，其余2例使用支气管封堵器实现肺隔离。术中平均失血量为300±42毫升，术后为2000±95毫升。术后第0天的疼痛评分为4.3±0.6，出院当天为2.3±0.7。住院时间为4.8±0.9天。无并发症、输血情况，未转为体外循环。麻醉和手术技术的调整包括：使用支气管内导管或支气管封堵器进行左肺隔离、增加获取血管移植物及移植的时间、除血流动力学监测外还需经食管超声心动图监测。其他小的要求包括经皮起搏和除颤电极片、在胸部下方放置楔形物以“抬起”胸部、保留右股动脉和静脉（用作血管通路）以备不太可能发生的转为体外循环的情况。任何希望开展此技术的麻醉医生都必须了解这些调整。
剑突下路径用于微创心脏手术进行冠状动脉搭桥移植手术是安全的。该方法可重复且具有不可否认的益处。我们计划在胸段硬膜外麻醉下对清醒患者进行此类手术，从而使其创伤更小且更适合快速康复。
