Dual inflow, total-arterial, anaortic, off-pump coronary artery bypass grafting: how to do it

Coronary surgery performed on an arrested heart, using one internal mammary artery and a saphenous vein carries two main potential drawbacks: the known failure rate of vein grafts and the relatively high rate of neurologic injury. To address these concerns, we describe a technique that achieves complete revascularization without manipulating the ascending aorta (anaortic, off-pump) and utilizing total arterial grafts. All patients undergo thorough preoperative investigation, including bilateral carotid, vertebral and subclavian artery Duplex ultrasounds. A pulmonary artery catheter, transoesophageal echocardiography, and point-of-care coagulation testing are used in each case. The left and right internal mammary arteries and non-dominant radial artery are harvested using a fully skeletonised technique. Wide bilateral extrapleural retrothymic tunnels are developed and the pericardium is opened widely to facilitate cardiac positioning. A tandem graft is constructed with the right internal mammary artery (RIMA) and radial artery using an end-to-end anastomosis. This graft is brought into the pericardium and through the transverse sinus in order to graft the lateral and inferior walls with multiple sequential distal anastomoses. The left internal mammary artery (LIMA) is used to graft the anterior wall. Four main cardiac positions (high and low lateral walls, inferior and anterior walls) are obtained using a combination of off-pump stabilizer positioning, alternate tension on pericardial 'heart-strings', table tilting and folded wet sponges. All distal anastomoses are performed using silastic intracoronary shunts and an off-pump myocardial stabilizer. All grafts are checked using transit-flow time measurements. Milrinone is continued overnight and dual antiplatelet therapy is continued for 3 months postoperatively.