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Journey through midcab,Tyro to virtuoso

BACKGROUND: - MIDCAB CABG in triple vessel disease is remained dream to many Cardiac surgeons. Difficulties and short comes exist. How to overcome and accomplish a complete and satisfactory revascularization is the most important goal of a Bypass surgery. Technical difficulties and its solution are described.

METHOD: - Since 1997, we started sternal sparing MIDCAB CABG. Till 2009 we have done 159 patients.70 patients were operated for SVD (58 CABG, 12 redo CADG), 32 cases for DVD (29 CABG, 3 redo CABG), 57 cases of TVD (55 CABG, 2 redo CABG). For initial two yrs. it was limited to SVD, mostly CTO of LAD. 1st case of redo CABG was carried out in 1999. Gradually field was expanded to DVD and since last 4 yrs. TVD cases are also incorporated. It also includes 10 cases of endarterectomy. One case with CMV and CABG. Patients’ age range between 32 – 92 yrs. LVEF = 25% (10 – 55%), 3 patients with EF of 10% were offered CABG with stem cells implantation. As much as 4 vessels were grafted. Patients overweight have no contra indication. Additional plural adhesion is also not a contra indication. Among TVD 20% had varying degree of left main disease (50 – 96%). 1 patient weighing 114 kg was also operated.

RESULT: - There was 1 mortality in a redo CABG group. The patient died on 6th POD due to VTVF. One case of TVD shows ST- elevation for 24 hrs, post operatively which subsided later on (peri operative MI). 1 patient required re-exploration due to bleeding from mammary bed. Average requirement of BT was 1.5 bottles per patient. Transfusion requirement usually depends upon pre operative HB level. Average hospital stay was 4 days (36 hrs to 6th POD). No major wound complication is seen. Average incision size is 3.5 inches (2.5- 4.2 in.). Conversion to mid sternotomy was required in 1 patient.

CONCLUSION: - Sternal sparing MIDCAB can be carried out in all but cardiogenic shock group of patients. We found it is particularly advantageous to old debilitating patient more so with farer sex group of patient. It can b learnt only by self indulgence. This method is not described anywhere in known literature. It is little time consuming and requires great deal of skill and patience on part of operator.

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