Off-Pump Minimally Invasive Coronary Artery Bypass Grafting With a Heart Positioner Direct Retraction for a Better Exposure

Objective: Lateral and inferior territories are difficult to expose during off-pump minimally invasive coronary artery bypass grafting (MICS CABG). The use of cardiopulmonary bypass is required at times. We initiated a direct retraction method by using a cardiac positioner for a better exposure, in order to complete off-pump, multivessel MICS CABG safely. Methods: We recently initiated multivessel MICS CABG, performed via a 6- to 9-cm left thoracotomy. For distal anastomoses, the lateral pericardial edge was pulled to the chest wall to optimize exposure of the lateral and inferior area. Next, a single- or multisuction cardiac positioner was put on the sides of the target vessel through the small thoracotomy and pulled directly toward the incision. Finally, a distal anastomosis was made with an epicardial stabilizer via the thoracotomy, as in standard off-pump CABG. Results: There was no mortality or conversion to sternotomy. A total of 10 cases were targeted for off-pump multivessel MICS CABG with this approach. Nine were completed, while 1 still required pump assist. The average number of distal anastomoses was 2.8 +/- 0.8. Two were successful off-pump quadruple bypass grafting with sequential anastomoses. All patients were discharged and remain well to this day. Conclusions: Most multivessel MICS CABG was feasible without pump assist even at the initiation period. This approach is easy and helpful in providing good exposure of target vessels without requirement of additional incisions.