Surgical Myocardial Revascularization Without Cardiopulmonary Bypass

Abstract

Vasilii Kolesov, who performed the first sutured coronary bypass in a human patient on February 25, 1964, was not convinced, even 10 years later, that the negative inflammatory aspects of the extracorporeal circulation balanced the positive facilitating aspects. A coronary bypass was, at that moment in time, a venous graft between the aorta and a very visible proximal coronary segment on the right coronary or the left anterior descending artery, performed on a non-supported beating heart. Coronary surgeons have explored, since then, different target vessels, different grafts, and different anastomotic techniques to improve the late benefit of the procedure. Full arterial sequential revascularization, intramural vessels, as well as septal artery revascularization have been part of the mandatory armamentarium of a coronary surgeon for years. The fact that the heart was on full extracorporeal circulation, preferably immobilized with cardioplegia, facilitated and leveraged the explosion of coronary surgical revascularization, but not necessarily the implementation of these more complex anastomotic techniques and methods.

The original Kolesov method of coronary surgery has been insufficiently documented and forgotten, but a revival of coronary revascularization without the use of extracorporeal circulation was driven by Federico Benetti in the 1990s. This revival, although visionary, was confronted with considerable criticism for different reasons. It was insufficiently documented, the patient was insufficiently monitored, and some mandatory supportive surgical tools as shunts, stabilizers, and positioners were not yet available. In addition, it demanded an openness for change and appropriate learning processes; even the traditional parachuted anastomotic technique became difficult, if not impossible, in this very reduced airspace.

Since the original reporting by Benetti, the matured off-pump approach has been well documented and has become the first surgical experience in newer generations of coronary surgeons for two decades. There is some variability, but some components are mandatory if one wants to combine a hemodynamic physiological performance and the most complex anastomotic targets and methods.

In this chapter, we address more in detail the conditions, criteria, and processes leading to an optimal exposure of all sides of the heart without the use of the extracorporeal circulation.