Anesthesia and regional anesthetic techniques for minimally invasive direct coronary artery bypass surgery

An innovative new approach to coronary revascularization, minimally invasive direct coronary artery bypass is performed via a small anterior minithoracotomy or ministernotomy on a beating heart without the aid of cardiopulmonary bypass. Components of this technique, including thoracoscopic video-assisted harvesting of the internal mammary artery, often with harmonic scalpel and potentially even robotic assistance, necessitate prolonged one- lung ventilation. In the absence of cardioplegia, myocardial protection during normothermic beating heart surgery poses a challenge. Patient selection is important to avoid intraoperative and postoperative complications. Prolonged single-lung ventilation, incomplete revascularization in hybrid procedures, and limited access for rapid intervention pose challenges with patient management. Conversion to sternotomy may be required in 5% to 7% of patients, and extension of portals over several dermatomal segments mandate a versatile analgesic technique. Regional anesthesia as analgesic adjuvant allows lighter levels of general anesthesia during surgery with minimal intraoperative hemodynamic changes and a smooth transition to postoperative analgesia. Although a number of regional techniques may be used to achieve this goal, thoracic epidural analgesia or continuous percutaneous paravertebral block seem to offer specific advantages of cardiac sympathectomy. (C) 2000 by W. B. Saunders Company.