Anesthetic implications of subxiphoid coronary artery bypass surgery.
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Date
2016-07
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Abstract
Background: Minimal invasive surgeries are carried out to benefit the patient with less pain, blood loss,
mechanical ventilation and hospital stay; a smaller scar is not the aim. Minimal invasive cardiac surgeries
are carried out via small sternotomy, small thoracotomy and via robotic arms. Subxiphoid route is a
novel method and avoids sternotomy. Aim: This case series is an attempt to understand the anesthetic
modifications required. Secondly, whether it is feasible to carry out subxiphoid coronary artery bypass
surgery. Methods: Elective patients scheduled to undergo subxiphoid coronary artery bypass surgery
were chosen. The surgeries were conducted under general anesthesia with left lung isolation via either
endobronchial tube or bronchial blocker. Results: We conducted ten (seven males and 3 females) coronary
artery bypass graft surgeries via subxiphoid technique. The mean EuroSCORE was 1.7 and the mean
ejection fraction was 53.6. Eight patients underwent surgery via endobronchial tube, while, in the remaining
two lung isolation was obtained using bronchial blocker. Mean blood loss intraoperatively was 300 ± 42 ml
and postoperatively 2000 ± 95 ml. The pain score on the postoperative day ‘0’ was 4.3 ± 0.6 and 2.3 ± 0.7
on the day of discharge. Length of stay in the hospital was 4.8 ± 0.9 days. There were no complications,
blood transfusions, conversion to cardiopulmonary bypass. The modifications in the anesthetic and surgical
techniques are, use of left lung isolation using either endobronchial tube or bronchial blocker, increased
duration for conduit harvesting, grafting, requirement of transesophageal echocardiography monitoring in
addition to hemodynamic monitoring. Other minor requirements are transcutaneous pacing and defibrillator
pads, a wedge under the chest to ‘lift’ up the chest, sparing right femoral artery and vein (to serve as vascular
access) for an unlikely event of conversion to cardiopulmonary bypass. Any anesthesiologist wishing to start
this technique must be aware of these modifications. Conclusions: Subxiphoid route is safe to carry out
coronary artery bypass graft surgery using the minimal invasive cardiac surgery. It is reproducible and has
undeniable benefits. We plan to conduct such surgeries in awake patients under thoracic epidural anesthesia
thus making it even less invasive and amenable for fast tracking.
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Keywords
Minimal invasive coronary artery bypass surgery, Off‑pump coronary artery bypass surgery, Subxiphoid coronary artery bypass graft
Citation
Chakravarthy Murali, Veerappa Muralimanohar, Jawali Vivek, Pandya Nischal, Krishnamoorthy Jayaprakash, Muniraju Geetha, George Antony, Baishya Jitumoni. Anesthetic implications of subxiphoid coronary artery bypass surgery. Annals of Cardiac Anaesthesia. 2016 July; 19(3): 433-438.