Beating heart multi-vessel minimally invasive direct coronary artery bypass grafting: techniques and pitfalls

Coronary artery bypass grafting (CABG) has been changing since its initial reports. There has been a shift from standard CABG, which uses sternotomy and a single left internal mammary to the left anterior descending artery (LAD) grafting, plus vein grafts to other targets, and performed on bypass with aortic cross -clamping. We now have CABG using multiarterial grafts, avoiding manipulation of the aorta, and through a minimally invasive approach. Beating heart Multi -vessel Minimally Invasive Coronary Artery Bypass (Multi -vessel MICS CABG) has emerged as an attractive alternative in coronary revascularization. The minimally invasive approach mitigates some of the risks and long recovery associated with the more invasive standard full sternotomy approach. It decreases the rates of wound infection, transfusion, postoperative pain, time of recovery and sternal dehiscence, while maintaining the same outcomes as the standard approach with full sternotomy. There are multiple centers around the world that have reported safe and good outcomes with Multi -vessel MICS CABG, including the initial report from our center joint with Staten Island, NY. The aim of this paper is to describe the technique and pitfalls of Multi -vessel MICS CABG as used at our center and go over patient selection and outcomes. A video and several pictures are shown to facilitate the understanding and learning of this technique.