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Composite bilateral internal thoracic artery grafts via standard sternotomy for lateral wall revascularization in conscious patients.

BACKGROUND
A new technique has been developed that permits complete arterial revascularization of the lateral wall of the heart using in situ bilateral internal thoracic artery grafts in awake patients. This technique, performed without cardiopulmonary bypass or mechanical ventilation, creates the least invasive revascularization method for the lateral wall of the heart yet described.


METHODS
In 4 patients, double or triple vessel coronary artery bypass grafting was performed without general anesthesia. A high thoracic epidural anesthesia was started 1 hour before surgery. Bilateral internal thoracic arteries were harvested and all anastomoses were performed with the off-pump technique via standard median sternotomy. Circumflex branches were anastomosed with the left internal thoracic artery via a heart positioner.


RESULTS
All patients remained awake throughout the whole procedure. There was no perioperative myocardial infarction or mortality. Pneumothorax was observed in only 1 patient and did not hinder the procedure. There were no hemodynamic changes during lateral wall revascularization. Two patients required unexpected coronary endarterectomy during circumflex and right coronary artery anastomoses.


CONCLUSIONS
Complete arterial revascularization via median sternotomy using in situ bilateral internal thoracic artery grafts without general anesthesia is a feasible and safe procedure for multivessel disease. This approach allows for complete coronary artery revascularization in patients with contraindications for general anesthesia with or without cardiopulmonary bypass.