Journal of cardiac surgery
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Comparative Study
Minimally invasive direct coronary artery bypass: technical considerations and instrumentation.
Minimally invasive coronary artery bypass is defined as any maneuver or modification of conventional coronary bypass that decreases adverse effects. These adverse effects fall into three broad categories, which are access trauma, consequences of cardiopulmonary bypass, and aortic manipulation. In the minimally invasive direct coronary artery bypass (MIDCAB) approach, coronary revascularization is performed via a limited access incision, usually a left anterior thoracotomy, through which a left internal mammary artery is anastomosed under direct vision to the left anterior descending artery on a stabilized beating heart. ⋯ Graft patency data from early series of stabilized MIDCAB procedures and published series of left internal mammary artery graft patency with conventional bypass grafting appear to be comparable. Current indications for MIDCAB include restenosis of the left anterior descending artery after catheter-based therapy and the necessity for target vessel revascularization in elderly high-risk patients with multivessel disease. Limitations of the MIDCAB procedure include mostly single vessel revascularization of the anterior aspect of the heart.
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Left anterior descending artery grafting using the left internal mammary artery via a left anterior small thoracotomy (LAST) gained new popularity in 1994. We review our experience in 250 of 512 patients who underwent a LAST in single vessel left anterior descending artery disease from November 1994 to October 1997. ⋯ New instrumentation has made the operation easier and has contributed to its spread, along with increased experience and the end of the learning curve. At the moment we consider the LAST a more anatomical and physiological surgical approach to single vessel coronary disease.
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Most patient concerns and demands for less invasive surgery are focused on comfort, cosmesis, and rehabilitation that are all related to the degree of invasiveness. The degree of invasiveness of cardiac surgery depends on two factors: the surgical approach--the length of the skin incision, the degree of retraction and aggression to the tissue, and the loss of blood--and the use of cardiopulmonary bypass. ⋯ Minimally invasive cardiac surgery is undergoing an explosive evolution, and although the indications and best strategies for the different categories are yet to be determined, the trend cannot be stopped. We try to distinguish between "fashionable" strategies and those that are truly revolutionary and investments in the future.
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In Ebstein's anomaly, the septal and posterior tricuspid leaflets are plastered to the endocardium. We postulated that tricuspid valve function could be corrected by restoring mobility of these leaflets. (Feasibility of such repair was explored by anatomical and clinical studies.) ⋯ Repair of the septal and posterior tricuspid leaflets was found to be feasible and effective as tricuspid valvuloplasty for Ebstein's anomaly.