Minimally Invasive Direct Coronary Artery Bypass (MIDCAB)

CHAPTER 1

My name is Marco Zenati. I’m a cardiac surgeon at VA Boston. Today we're going to perform a minimally invasive coronary bypass on a 72-year-old male. He's a very healthy and active gentleman with no other medical comorbidities. And he - about 6 months ago - during his workouts - he works out actually 6 days a week, and he alternates treadmill with weight lifting and he found out that he had to stop, and he had some chest pressure during exercise. It will go away after he would cease the activity, so he's sought medical attention he underwent the stress test, which was positive with EKG changes- he had ST depression in anterior leads. And he also had a nuclear medicine study - thallium test - it was both positive, so that triggered a left heart catheterization, which demonstrated a high-grade lesion of the proximal left anterior descending coronary artery without any other disease in the other vessels. The cardiologist determined that this lesion was not amenable to angioplasty or stenting, so it was referred to us for a minimally invasive bypass with a mammary to the left anterior descending coronary artery. And we perform this procedure through a 3-inch mini-thoracotomy on the left side without the use of the heart-lung machine on the beating heart. The patient is an excellent candidate for this procedure. His body habitus is very favorable. He's in good shape. He's thin, and he has wide interspaces. So we believe he is an excellent candidate for this operation. So the minimally invasive coronary bypass procedure is performed through a 3-inch mini-thoracotomy on the left side. It starts with a modified anesthetic approach using left side of the lumen tube that allows us to deflate the left lung and work in the left pleural space. The incision is usually in the fifth intercostal space and is followed by a pericardiotomy and exposure of the target to make sure the LAD is acceptable quality and it's not intramyocardial. Once that is assessed, we move to the harvest of the mammary artery, which is done using a special device we call the LIMA Lift that provides exposure of the mammary artery. Once the harvest is completed, we use a stabilization device and we perform the anastomosis between the mammary - to the LAD on the beating heart, using intracoronary shunt. Following the procedure, we are very careful about providing the best possible analgesia. The options are either an epidural approach or or an intercostal cryoablation. Our protocol is using a cryoprobe for 2 minutes at the level of the 5th intercostal space where we do the thoracotomy and then two spaces above and two spaces below for a total of 5 applications that we supplement with intercostal nerve block with Novocain. And the patient is usually extubated in the operating room. Average duration of procedures between 90 minutes and 2 hours - skin to skin from the surgical part. We have a standby system here available. The pump is in the room but has not been primed - will take us a few minutes to prime it, and this procedure is done off pump. This provides additional layers of safety. So the patient is a 72- year-old with a single-vessel coronary disease involving the left anterior descending coronary artery and a small diagonal branch, and this lesion was found not to be amenable to angioplasty, and it was referred for a minimally invasive bypass. Our plan is to perform a mammary artery to the left anterior descending coronary artery bypass and possibly also a composite graft to the diagonal. Decision would be made intraoperatively based on the size. So the patients is supine, as you can see. We prepped legs in case we need to have a segment of vein. And the positioning is with the left side of the chest slightly bumped and the arms are tucked on the side. The other thing to note is we have placed them - they not visible under the drapes - some defibrillating pads. There's adhesive on the chest, in case of the need for defibrillation. We won't be able to access using the internal pads, we use the external pads, so that's actually an important point to know when we prep this patient because we don't routinely use these external pads for sternotomy cases. So, Dr. Zorca, are we currently doing both lung ventilation or single lung? So the left lung has been deflated, and the saturation is fine, so looks like the patient is tolerating this well. Nice. So we already done our safety pause, the antibiotic is in the patient Perfect, and we have blood available in the room. So the next step is to perform the skin incision. So can we have a marking pen?

CHAPTER 2

The tip of the xiphoid, and we're marking the costal margins here. And jugular notch will be here. So we identify the nipple and based on the size of the heart, which we evaluated on the chest x-ray, we would like to make an incision about 3 inch, and we'll center the incision about 2/3 medial and 1/3 lateral to the nipple. Something like this. Okay, so... I'll take a knife. Okay, incision. You want to do your rakes to lift the skin? You have rakes? Please. Do you have a Weitlander? Yeah, there's not much subcutaneous tissue in this patient. Okay, so we're going to enter - Robby, it's either fifth or sixth space. We have to make a decision here. Most likely I will try to go in the in the 5th space so we go between - separate the belly of the pectoralis muscle. Okay, so we're in the pleural space. The left lung looks like it's nicely deflated, thank you, Susanna. The incision is done and we have opened the intercostal space, so we now use the MIDCAB retractor. The operation goes by the acronym MIDCAB which stands for Minimally Invasive Direct Coronary Artery Bypass, and this is a MIDCAB retractor - it’s designed for this procedure. Now mount the blades So this next phase is confirming the targets and we're going to open the pericardium - open the pericardium, and then finalize our revascularization plan. Maybe the table up a little bit, please. Thank you. So what I'm doing right now, I'm mobilizing the fat pad that is laying over the heart and as I do that, you will start seeing pericardium and underneath the pericardium you’ll see the heart. So we’re going to mobilize more of this pericardial fat on the side, and we'll use this eventually for - to close the pericardium. Again, the Bovie that I’m using is on a very low setting because we're operating in proximity to the heart, so there is the potential of triggering some arrhythmias, so we have to be cognizant of that. Moving this laterally. So I keep peeling this - then I gently use this retractor. Try to minimize the muscle incision and… So we’re… Okay, so I’ll take a tonsil, please. So we're ready to open the pericardium. and assess our target. If I have done a good job, the left anterior descending coronary artery, which is our main target, will lie right in the middle of my incision. We grab the pericardium with this instrument. Ory, please hold it for us And Voila. This is the left anterior descending coronary artery. So I think we, we, we made a good choice in terms of the location of this thoracotomy in relationship to the target. That is a very important component of this procedure. If this patient had a cardiomegaly and the costal - the heart margin would have been more lateral - this incision would have been more lateral in order to center on the LAD. So it's really important for the rest of the procedure that we have the target in the center of the field so I'm happy about this. So I’m going to extend the incision cranially, and we are now able to appreciate this very nice target. Is it visible on the screen? It is. It's a beautiful target - I'm guessing between 1.75 to 2 millimeter in diameter, so very nice target. I'm going to gently palpate, and the site that I'll choose for the anastomosis is- it's right here and just proximal to that, I feel a calcification. Ory, you're going to put your finger over, you'll feel a calcification - yeah - but if you if you slide distally, you’ll see that's nice and soft. So this is exactly what we want. We want the location of the anastomosis to be free from disease, and leave the disease proximal.

CHAPTER 3

So the next step here, we have established that our main target, the LAD, is suitable for anastomosis. The next question is whether the diagonal branch that was identified as having a lesion is of a size that’s at least 1.5 mm or greater, and so far I have not really been able to appreciate it so I'm going to open this subpericardial incision a little more. And what I'm going to do, I'm going to lift the pericardium on the right side and try to identify the diagonal branch. In my opinion, oversize - it is not amenable to a bypass, so I will plan at this point, to stay with the original single-vessel bypass with a left internal mammary internal to the left anterior descending coronary artery. So this is the first step of the operation. It has to be done prior to any harvest. You have to make sure that the target for revascularization is available and is a suitable. So we checked all those. So the next step in this procedure is the harvest of the mammary artery, and we do that under direct vision through this small incision. So this first part - I need a sitting stool, please.

CHAPTER 4

This part can be done the way I'm doing, under direct vision, or it can be done also endoscopically with with the - the robot so it can be done be done with the DaVinci robot as well, but we're doing it direct vision. So I need that the metal tip sucker. Connect it here. So we use a Bovie extender and the setting is is low at about 20 joules. And so what I'm doing here is moving medially - until I identify the mammary artery, so you have to be very careful here as you do this maneuver that you don’t injure the mammary. So the first step it will be the mammary vein - the lateral mammary vein - I will encounter, and after that I will I will identify the mammary artery. And if you look on the screen - you probably are you can start seeing the mammary vein. And I'm dividing the fascia as I move medially, and the artery is probably laying in this plane. It's right here, so you can see the fascia underneath here. See the endothoracic fascia, which actually I'm going to divide. This is the lateral vein and then the mammary artery is the white structure right underneath here. Slightly below the sixth rib here. You see the artery there. That’s the medial vein, and I'm just creating some space in the section of the distal part of the mammary, so... Again very careful here that in this process you don't injure the mammary. So the next step is we - we trade this retractor, which we will use later, for the LIMA lift. So LIMA is acronym for the left internal mammary artery and LIMA Lift is a device that is designed specifically for harvesting the mammary under direct vision. This is one of the vendors that we use, and we - we have a choice of the the upper blade, so - I think we can try, well, let’s try it with the smaller one for the upper blade and then we need to choose another blade for the lower and then the retractor. So this is the retractor. We mount the upper blade and requires a little bit of assembly, and we have choices here. And this will be the lower blade. This retractor again as two components This blade will go inside the chest and as we spread, will create a degree of offset. It will allow us to see between the ribs and follow the mammary course. And this hook here will be connected to the rule tract and and by adjusting also patient positioning, we'll- we should be able to have a good exposure. So we place this blade inside the chest careful not to engage the inside of the pericardium so it has to stay outside the pericardium and we start spreading as you - as you see, as spreading, you can see the exposure improves. Throughout this part of the procedure the left lung is deflated, so the patient is relying on the right lung. So this is where, if we are not able to visualize, we could add a scope here for a side view. And incise the fascia medially. So the harvest is a little bit of a mirror image of the LIMA harvest that we performed through the sternotomy. Also, can you rotate table away from me a little bit. Stop, thank you. So, the beginning of the exposure is - for those who have not done this procedure often can be intimidating, but as we progress, it will get better. So again, the paramount is not to damage the mammary, so be watchful for potential for any undue traction. So, you see we followed the this pedicle that we have identified earlier. So see the mammary artery there? And we’re going to follow north. This is the endothoracic fascia and muscle. And... So every branch that we encounter this is one branch is here - we're going to place a clip. And then use the Bovie. So this is a very important part of procedure, so we want to really take our time, have adequate exposure, and do a good job. Dr. Zenati, what will be the optimal length you will dissect on the LIMA? That's a very good question - that’s now debated among those that perform this procedure. Some surgeons actually perform a short harvest, but I believe - I have used a harvest as high as possible definitely above the first rib. Okay. Because that provides flexibility, provides the ability to reach distal location on the LAD. And also, you have to keep in mind that we are performing this bypass with the lung deflated, but at the end of procedure, the lung will be re-inflated. And especially in patient with emphysema, COPD, the expansion of the lung, especially the right upper- left upper lobe will potentially cause tension on the mammary and that’s something that is very dangerous, and we try to avoid it at all possible. So the length prevents potential tension, so I believe it in a harvest that is more complete than what others would do. So that's that's my philosophy. So you can see now that I'm able to to protect my pedicle, and I have now incised the fascia both proximally and - more - both medially and laterally and by using gentle traction, I’m able to progress cranially. So the ideal patient for this procedure would be somebody with actually some degree of emphysema because they usually have wider interspaces and that's actually makes this procedure easier. So at this point, I'm going to start the following the mammary north, and actually, I am noticing that the traction on the my LIMA Lift is preventing me from having a good exposure of the mammary, so I'm going to take this down and then add that extension. So I will obtain a more favorable pull on the lift, so I'm going to modify my set up a little bit. So this will allow me to have retraction that is more toward the left of the patient because the mammary as you go north kind of curves a bit, so, I need to… Well, let’s see if this adjustment has helped me with that. I have this suction device around the mammary. See, we are- we're making progress. Every branch I encounter, I'm going to put a clip. Like this. You see the exposure actually is pretty nice. Yeah. Okay, so always make sure there's no tension on this pedicle that you're developing and you see that dividing the fascia both laterally and medially like this allows a nice progression. Microclip. i see- a branch - a perforating branch - so place the clip right at the base, and then we use the Bovie to divide the branch toward the chest wall. Yeah, I could probably get even a better exposure than the one that are showing, but I rather not do that, because this is good enough for me to harvest, and I don't want to overspread the ribs as the spread is associated with postoperative pain, and we're trying to minimize that, so it's one of our concerns. We try to minimize the - the ribs spreading. Clip again. You see a vein branch there, so I'm going to again place a clip at the base and then Bovie on the chest wall side. You see, we’re - we’re making nice progress. Our heavily-calcified targets will be difficult. But this procedure is the basis in order for hybrid revascularization to be performed, so you need to know this procedure in order to work with your cardiologist performing hybrid revascularization. So the mini- mini MIDCAB, LIMA to LAD is really a main stay of that approach as well, so... Yes, so the hybrid approach consists of LIMA to the LAD and a stent for known LAD target, so either - either circumflex or a right branch. So we're moving to the second intercostal space here. I need the table down a little bit more, please. More Trendelenburg. And I'm going to try to just get a little extra lift on this retractor to see the last part of the mammary and table toward me a little bit - so again combination with small adjustments. The positioning hopefully will allow me, table up also, sorry so we're just doing a little small, little adjustments. Perfect, no we’re good thank you. Clip. So some surgeon will stop here and call it. I like to go higher for the reason I mentioned. Specifically because I like the line of the mammary to to be a straight line from the take off from the axillary subclavian as opposed to take a curve medially and then curve back laterally. And I also - I really want to avoid at all costs, potential tension from the left upper lobe of the lung once it's inflated. So at this point you really want to advance millimeter by millimeter and... and carefully identify the structures and - keep a dry field as much as possible. So if you can appreciate them, the tip of my sucker actually is showing you under the pleura, the mammary artery. And that's - that's where I would like to reach. So I still have a little bit to go from where I am to where I would like to be. Are you able to see that mammary down here tip of my sucker? I can see. Tip of the sucker right there? This is where I am, and this is where I want to be. And I need the table little higher. Clip. Some surgeons would have stopped already, but I like to go as high as possible and as comfortable, and hopefully today, this patient has very nice anatomy, I may be able to show you even the subclavian vein which is really the highest really we - we want to go. It will be above the first rib, so I'll take a clip again. Nicely placed clip back there. I'm going to divide that branch towards the chest wall. I’ll allow this to drop medially. And actually, you can see already the vein there at the end of this pocket - I’ll show you better in a second. Rotate table toward me. So again at this point, we're very high - we’re between the first and second rib - so I need to go more laterally. The mammary doesn't follow straight course but tends to curve, so for me to follow it now, I have to rotate the table towards - towards me. And then again, I'm pointing with the tip of my Bovie the mammary and I'll show you where it - where I am, so I have a little bit more to go, but you see how the anatomy is opening up nicely for us. You can see a nice pedicle there. They developed it very nicely. Each branch that we divide, we obtain a better exposure. A clip - another branch there. So now we're really reaching the physical limit of this long clip applier. You really need the entire length of this device to place a clip there. Again, there's nothing wrong with somebody choosing to do a partial harvest. This is the way I do it, and I think it pays off in the end if you do - if you have some experience with this procedure. So I'm really, really reaching the end of the harvest here, see? First rib here I'm cleaning up. You'll see in a second better, and we should actually be able to visualize the subclavian vein shortly. Yeah, a LIMA to LAD under tension is probably one of the worst things that can happen to you, so with a complete harvest, you eliminate that possibility. That - we’re clearly above the first rib. Make sense? So we have complete harvest of our conduit. So, I’m very happy. I'm going to give you another - another view of the entire mediastinum so can you see that the phrenic nerve over here? Yes. Phrenic nerve is clearly seen. We’re clearly away from phrenic nerve. Phrenic nerve. The lung is deflated there inside of the chest wall. This is our mammary - clearly, nicely harvested above the first rib, which is right here. And we are following down and it looks looks really good for us. So we're very happy with this harvest. And we're going to free this from some adhesion and at this point Suzanna, I think we are ready for Heparin, and I would say let's give him 7000 units. Okay so I'll take a large clip. So we're going to divide in the mammary now, so we put the clip distally here. And we put a second clip, and you have the Bulldog. The yellow with the sutures, so we going to now clamp the mammary pedicle proximally. And what we do, we use this type of Bulldog and we have a suture here. And the reason for the suture is that we don't want to for reason lose - exactly - lose this clip in the chest, so we have a mosquito - we can lift it with a tether, and this allows us easily to retrieve this device in case it's lost in the chest. And then we're going to divide the mammary. So the memory is now divided. And- you have a dog catcher? So we're going to test the flow of this conduit. Do you have a tenotomy again. An Allis again. Allis. So this flow is excellent. So this is a- we are very happy with the flow from this mammary. And, do you have some Papain? So we actually put some local Papain here on this pedicle.

CHAPTER 5

So for this procedure really, we’re very grateful to have an assistant like Dr. Quinn. It makes a big difference. Another one? Another 5-0 CV silk. And a microclip as well. See, so, the mammary is in the center of the field here. We're providing traction, so the mammary stays exposed without us holding it. We put this - this is a 5-0 cardiovascular silk. We use it to just tack the mammary to the edge of the mini-thoracotomy incision. This way my assistant Dr. Quinn has free hand- both hands free to assist me with anastomosis. These additional tissue retractors here are useful in males, but even more useful in females, holding the breast out of the way. You can imagine this incision will be below the breast fold and this retractor will allow to have the breast out of the way. Okay, so we again are - Jackie, you want to feel again? Our target, I think, we assessed it. It looks pretty good with this calcification up here. You want to put the finger here. So but - where we are going to do the anastomosis it looks very good target. Okay, so the next step, is we're going to prepare the mammary. So- so I'll take a Jacobson please, Jamal. Can you keep this vein out of my way for a second. Yeah. I'll take a micro clip. And Jacobson. Going to go here. Okay. So we're going to prepare this - this mammary. Okay, we're looking good. So the mammary is already spatulated and looks good for our anastomosis. And give some Papain just to- Papain, since we're going to irrigate. So you can see that that the - the harvest all the way up to the takeoff allows us to really have a nice length of mammary. And I anticipate that the end-to-side anastomosis will be free from tension, which is a critical component of this procedure, avoiding tension. So, the next step, crucial, is I need to provide a proximal occlusion of the left anterior descending coronary artery. And we'll do that using a 4-0 Prolene with an SH needle. Sure. And I'm going to take a relatively large bite with tissue around the left anterior descending coronary artery. Again, there are several ways to obtain a proximal occlusion. There are Silastic tapes, but in my opinion they come with a needle- let me do it, let me do it. That it's too large and creates a potential for bleeding so I like to use a Prolene with an SH needle. And the key as you can see here is to have 4-5 mm of buffer between the artery itself and and the suture. Again, you have to be cognizant that you are working around the LAD so any undue traction here could be dangerous. So, we are still trying to achieve our target ACT. We have given additional Heparin and we're, again, targeting between 280 and 300 of ACT - so cut this, please. And then we use this slider around. Again, we have to at all costs try to avoid tension here, so let go, please. We have to slide this. Again, no tension on the LAD. So we call this component a bumper, and this bumper will provide us with control of the proximal blood flow. I'm going to try to put some tension on this bumper, so this will provide some degree of narrowing of the blood flow to the LAD. And we are at the point now keeping an eye on the EKG. So, with two leads on the EKG, and we have the ST segment is - is monitored by the our anesthesiology colleagues, Dr. Licener here. So if there is any elevation of the ST, you will let me know, but we’re not going to try to achieve a complete occlusion of the flow. We just kind of finger tight, like this. And then - and then we'll tack this to the side. The next step is to provide stabilization of our target, so this is beating heart surgery. We’re now using the heart-lung machine, and we need to stabilize this LAD. So I need the tray for the MIDCAB retractor. and we're going to use a pressure stabilization device. There are two categories: one is a suction stabilization, most well-known is the octopus device, but this works well together with this retractor, and it's a pressure-stabilization device. So by applying gentle pressure on the surface of the left ventricle, we can stabilize this area of tissue including the coronary, and we'll be able to perform an anastomosis. So there are two choices. I think I would like to have the other configuration with the arm coming off the other side and then - this is a little bit of like an erector set So we have a small space here, and we're going to try to make the best use as possible of this small environment. Also trying to provide enough space for Dr. Quinn to do first assist. Okay. So you see this device? We're going to lower into the wound. Again, I could try to make this incision bigger by cranking up the retractor. I choose not to. I try to provide a retractor with- provide exposure but no more than that. I need a forceps, please. So, I'm going to actually move this out of the way like this. Now we’re gonna lower, lower this stabilizer in place. And place it across on the LAD. So we don't really- our goal is not to eliminate motion, but to minimize it. So this is our LAD. 2-0 pop-off. So we have our mammary here. We have the Bulldog clamping proximally, and we have the LAD immediately below. So this is the setup is pretty much as good as it gets for this procedure. We are approaching the point where we going to go through our final checklist. So we want to have an ACT about- between 280 and 300. I think we are there. Right? We were going to wait for another ACT, but we already - we were already good in terms of... I’m going to occlude here proximally one more time. That's actually the next on the checklist, so I think the shunt here will be - I will start with a 2-mm shunt, and you can open that and have a 1.75 available next. So again I re-snared the proximal LAD. Okay, I'll take another forceps and a beaver blade. So my assistant Dr. Quinn here will use this device which is a blower mister. We flow about 3 liters per minute of CO2 and also we have saline. So again, we're exposing our target and this LAD looks looks very good. We’re confirming a size of approximately 2 millimeter. So we're starting with a 2-millimeter shunt and- we’ll then decide. I need a 5-0 CV silk next. So, mammary’s ready. Our target - we're doing the final preparations. Our ACT is fine, we're happy with this degree of stabilization, and you can appreciate how the myocardium outside of the stabilization is moving quite a bit. While the myocardium within the jaws of this stabilizer are relatively still. Doesn’t have to be completely still. I going to put a stay suture again to improve my exposure so cut here, please. I need a mosquito. So this is our small field. You have a ruler for second? Just give you a sense of the size of this field, so we’re- so this is this is 2 inches. 1 and 2 inches, so this is about 5 cm. So this is how big it is - this field here. But you can see you know if we organize it well, we have the LAD, the mammary, control of the proximal stabilizer. So this 8-0 has to be loaded backhand and I need a rubber shod on the end - and I will need a second 8-0 to follow. So I preload this before my first bite. So the plan here is to do a separate heel-and-toe anastomosis. So I am right above the coronary. So I have to modify my technique, so the surgical technique will be outside-in bite on the mammary. Outside-in. Followed by an inside-out on the coronary. And then repeat it two times, and finally, I’ll tack the suture for the heel up here. And then I'll use a separate suture, and I will do three bites running on the toe. Following that, we will parachute the mammary down and then complete the anastomosis on both sides. So the mammary- this- is ready, and I need that the shunt, please. So I’ll demonstrate the shunt. This is an intracoronary shunt. And the 2 millimeter refers to the size of this. So this will be placed inside the coronary after I do the arteriotomy. And then the proximal snare will be released and the channel will allow perfusion of distal LAD while I perform the anastomosis. So this is 2 millimeter - is my best guess, but we have sizes above and below that will match the artery. So this will minimize ischemia of the myocardium, also the blood loss. So I think we're ready to proceed. Anybody has any questions at this point? Okay, thank you. So I'll take a beaver. And also Dr. Quinn is going to be careful to use this blower aiming toward the bumper as opposed to distally. We try not to introduce any air into the coronary. So we’re ready to perform the arteriotomy. Have a Jacobson ready. Okay, so, we performed the arteriotomy. We’re going to extend this a little bit. Proximally and distally. Sorry. Here, hang on a second. Hang on a second. Then I'll take the shunt. So here's our shunt. We’ll introduce the shunt into the coronary artery. So a 2-millimeter shunt is a little bit snug here, so can you please open this 1.75 shunt? Okay, don't blow just - just give me a second. Can I have a Jacobson again, one more time? I’ll take a 1.75 shunt. Are you able to see the shunt being introduced in the artery? On the screen? Okay, so the shunt is in place. So next I'm going to release the proximal snare on the LAD so we’ll provide flow again through the LAD. You see, I am releasing the bumper here and the suture so now there is flow through the LAD. We have visualization of the heel and toe in order to perform the anastomosis. So as I indicated earlier, our first bite will be an outside-in on the mammary. You see that the way we set it up, we don't have any need for an assistant to hold the mammary. So this is a convenient way, and then we place the rubber shod over here. Try to cover this so they don't get caught. And now the next bite will be an inside-out at the heel. Thank you, Jackie, that exposure’s very nice. We also use the blower very sparingly - only when I'm working on the artery. So again, outside-in. So, this is the last bite for the heel. Outside-in. And the last bite is going to be inside-out on the coronary. You’ve got be careful not to catch the shunt with our suture. I’ll take a rubber shod. And a new 8-0, loaded forehand. And we’re going to place this here, Jackie. Okay, blow. So now we're going to do the toe. See the coronary visualization is excellent. Our shunt is working well - there's no blood loss. Let go, please. Actually, you don't need to follow. And we're going to move toward me. Okay - very good. So at this point, I need a tenotomy suture. I'm going to release these two sutures that I used to hold the mammary in place. 1 and 2. And now we're going to parachute the mammary down so so I will need that. Actually, give me that rubber shod. Let go of that one - just drop it. Okay then I'll… Here's a- this one's in a shod and that one's free. This-this guy's free. Needle holder. So, I'm going to do your side of the anastomosis. I'm going to complete the- I don't need that exposure - so I can expose myself. I don't need to follow your- just- can you put some saline on that blower? If there's no saline, I need some saline, otherwise we’re desiccating the vessel. That should do it. We’re going to tie on this side. You cut this needle for me? And squirt in my hand? The right hand. So we’re getting there. Probably need another minute or so. See the stabilization is really excellent. Every bite was a high-quality and we're very happy with exposure here. I will take the scissor, please. So for the home stretch, so this will be the final side of the anastomosis. Gotta get this. How about I try to grab it this way? Let go of the artery? All right. Yes. I can hold the shunt. Here, let me just grab this shunt and try to pull it south. Gently towards you. Okay, now switch to the other side. Wait - let go. At this point, I like to flush the mammary just to make sure we de-air it and we confirm that we have a good flow, that we have excellent flow. And clamp again. So pretty soon, we’ll have to retrieve the shunt from the incision to the arteriotomy. So at this point we’re going to pull the shunt. Do you want me to follow you now, or are you okay? Here's the shunt. And we're going to do one more superficial bite to complete the anastomosis. And we're done. So, squirt my hand. So at this point the LAD is open. We're completing this last knot on the anastomosis, and next we’re going to open the mammary. And we're going to open the mammary next. And the anastomosis is now working. I’ll take Papain and we’re done.

CHAPTER 6

So this is the Bulldog retrieved, so we don't have anything left in the chest. We're going to put some Papain on the anastomosis. There's no bleeding. And there's no tension, you see the mammary is nice and loose. So this is really important - microclip. We're going to next we're going to remove the clip here. Sorry, I can't see it - I'm assuming you can see it okay. And a microclip. Another microclip. I’ll take a flowmeter. So we're going to release this stabilizer. You have to be careful it doesn't - nah! I'm okay. Just make sure I don't get caught with the mammary. It’s a small space, so we're done with the stabilizer. And I'll take a scissor again. And this is the last thing - left over, this is our snare. And that’s it. This is a completed operation. It's a beautiful mammary to the LAD - working. We're going to scrutinize a little bit here. So I can fit a flow probe. We're going to confirm patency. So we're looking for the flow. That is, you know - I’m doing 20 mL per minute or so. What are we reading? It's uh... Uh... Are you on it? You're not - you're reading a... So the flow is excellent. It's about 50, 60, 70, 80, mL per minutes. So approaching 100, actually. And push print, please. The flow is biphasic diastolic dominant, so that's what we're looking for. So we’re happy. The flow is approaching 100 mL per minute - for single-coronary is very high, and we have a positivity index of 1.3, so we- we're relatively confident that we have a high-quality anastomosis that’s patent for this patient. Okay, so basically we’re - we’re satisfied with everything here. The operation is done, and now we need to close and provide perioperative analgesia. So we are going to use cryoablation as well as an intercostal nerve block. I’ll take a 2-0 Vicryl. So I will use here the fat pad that I mobilized earlier to to close and cover my anastomosis. See this is the fat that we mobilized earlier and we going to move it over to protect the mammary make sure it doesn't get stuck on the chest wall. 2-0 vicryl. And you’re going to open the cryoprobe for us? The chest tube will be a 28, straight. Yeah - no - it’s going to be relatively anterior and we're going to go posterior to the chest tube - yes. We need a narrow malleable as well, please. Okay. Knife's out. So we're going to use a cryoablation, and the purpose is to provide several weeks of stunning of the intercostal nerves, provide numbness on the anterior chest area for pain control, so I'm going to go on the opposite side, we're going to expose- it provides a linear cryoablation. So, the nerves along this line will be temporarily ablated but they will regenerate within weeks of the procedure. The purpose here is to go as lateral as possible to intersect the intercostal nerve as close as possible to the spine. At this point cryoablation, intercostal block, we're going to place a chest tube, and then we going to close the wound, and the next step will be hopefully the extubation of the patient in the operating room. So this is at the level of the 5th intercostal space, so we’re gonna freeze for 2 minutes. That’s the protocol. The probe is positioned just below the ribs to catch the intercostal nerve. So this is not a, you know, irreversible ablation of the nerve it's a temporary ablation, and the nerve regenerates within six, seven weeks. We will do a total five of these ablations: one at this level and then 2 above, 2 below. And we’ll supplement that with short-term coverage with injection of intercostal block with marcaine. So the two work together- should provide a good perioperative analgesia. So 15 more seconds for the second ablation. This is liquid nitrogen. It goes to minus 70. Saline. Okay, so I’ve done the space and two above, so I need to go below next. Okay, so come down this way? Let me see if I can toe in somehow. Yeah, freeze. I’ll take a chest tube guys. Tonsil. I don’t care - I mean I'll take the chest tube if you got it but… Tonsil. Chest tube. Oh this is an Argyle. Okay, you want a straight, right? Okay. Yeah. Okay. Okay, I'll take a pericostal. I'll tell you what, then I'll take the skin stitch. You want it- I want to aim it a little towards the back. Pericostal. And you want to get ready for re-expanding the lung. Hey can you cut that, Chris? I'll deal with that in a second. Let me just see if I can - I got a needle on the driver there. Guy's, I'll take another Army-Navy if you’ve got one. Yeah, I know, here - hang on - I'm trying to stay still. Stay still. Here, I'm gonna steal that. You have a forceps, please. Here, I’ll tell you what. Let me just... Forceps. Pick up please. See it? Okay. Okay, let's take a stitch. Can you connect the chest tube?

CHAPTER 7

As you can see, we just completed the procedure. The skin is being closed and our anesthesiology colleagues are in the process of waking up and extubating the patient on the table. We believe the operation was very successful. We encountered very favorable anatomy for this procedure. So, we are pleased that patient selection was was correct. The isolation of the left lung was textbook thanks to Dr. Zorca. We had excellent exposure of the mammary artery bed, and the harvest was uneventful. The target for bypass was very good quality, about 1.75 millimeter. And the anastomosis, we believe, it was high-quality. We confirmed patency using a transthoracic flowmeter, and the flow through the graft immediately after anastomosis was approaching 100 mL per minute, which is excellent. And the positivity with the index was the 1.3, which also is associated with long-term patency of the graft. And the flow pattern was actually diastolic dominant, demonstrating the widely-patent anastomosis. We were very careful and spent a good 15 minutes performing high-quality analgesia using cryoablation, so we're confident that we provided a very good perioperative pain control for this pleasant gentleman, so overall we were very satisfied with this procedure.