65 Članek prispel / Received 10. 12. 2020 Članek sprejet / Accepted 20. 8. 2021 Abstract Purpose: oronary artery bypass graft (CABG) using median sterno- tomy remains the standard care for patients with multi-vessel coronary artery disease (CAD). However, me- dian sternotomy considerably affects morbidity and mortality after cardiac surgery. For this reason, less invasive access routes, including mini–tho- racotomy or mini–sternotomy, have been developed to avoid full median sternotomy. Case report: A 42–year–old male patient with a single–vessel CAD was admitted to the Department of Cardi- ac Surgery, University Medical Cen- tre Maribor for surgical treatment. Endoscopic mammary artery harve- sting and direct left internal mamma- ry artery to left anterior descending artery anastomosis via left mini–tho- racotomy were performed. The early postoperative course was uneventful and the patient was discharged on the Izvleček Namen: Mediana sternotomija je dejavnik, ki močno vpliva na obolev- nost in umrljivost po operacijah na odprtem srcu. Glavne prednosti mini- malno invazivnega pristopa so kraj- ša hospitalizacija, manj transfuzij, manj postoperativne bolečine in bolj- ši kozmetični izgled. Kiurška tehnika je tehnično zahtevna, zato je primer- na za omejeno populacijo bolnikov. Prikaz primera: 42–letni bolnik s stenozo proksimalne LAD je bil sprejet na Oddelek za kardiokirur- gijo UKC Maribor za kirurško zdra- vljenje. Levo notranjo prsno arterijo (LIMA) smo odvzeli endoskopsko, anastomozo LIMA–LAD smo na- pravili skozi levo mini–torakotomijo. Postoperativni potek je potekal brez posebnosti, bolnik je bil odpuščen peti postoperativni dan. Zaklju~ek: Prispevek predstavlja pristop k minimalno invazivni ki- rurški revaskularizaciji miokarda z Ključne besede: srčna kirurgija, zunajtelesni obtok, srčni obvodi, minimalno invazivna kirurgija Key words: cardiac surgery, cardiopulmonary bypass, coronary artery bypass, minimally invasive surgery Prva uspešna endoskopska kirurška revaskularizacija miokarda pri ishemični bolezni srca v Sloveniji The first successful endoscopic atraumatic coronary artery bypass graft for coronary artery disease in Slovenia Avtor / Author Anže Djordjević1,2, Boris Robič1,2, Peter Jurič1, Rene Petrovič1,2, Jernej Železnik1, Miha Antonič1,2 Ustanova / Institute 1Univerzitetni klinični center Maribor, Klinika za kirurgijo, Oddelek za kardiokirurgijo, Maribor, Slovenija; 2Univerza v Mariboru, Medicinska fakulteta, Katedra za kirurgijo, Maribor, Slovenija; 1University Medical Centre Maribor, Clinic for Surgery, Department of Cardiac Surgery, Maribor, Slovenia; 2University of Maribor, Faculty of Medicine, Department of Surgery, Maribor, Slovenia; Poročilo o primeru / Case report: ACTA MEDICO-BIOTECHNICA 2021; 14 (1): 11–19 66 Poročilo o primeru / Case report: ACTA MEDICO-BIOTECHNICA 2021; 14 (1): 11–19 INTRODUCTION Coronary artery bypass graft (CABG) remains the standard of care for patients with multi–ves- sel coronary artery disease (CAD) (1). It is tradi- tionally performed via median sternotomy, which is considered a potential cause of morbidity  due to increased risk of deep sternal wound infection, mediastinitis, and delayed  return to daily activi- ties (2–3). To avoid these potential complications, less invasive access routes, including mini–thora- cotomy or mini–sternotomy, have been developed. New access routes have been associated with ex- cellent surgical outcomes, such as reduced patient recovery time (4), lower transfusion rates, fewer wound infections, shorter hospitalization time, and low hospital mortality rates (5). Apart from a minimally invasive direct coronary artery bypass and total endoscopic coronary artery bypass, en- doscopic coronary artery bypass (Endo–CABG) is applicable to single– and multi–vessel coronary artery disease (CAD) regardless of the vessel in- volved (6). In this report we present the first case of a successful Endo–CABG in Slovenia. CASE PRESENTATION A 42–year–old male patient with single–vessel disease (proximal stenosis of the left anterior de- scending artery (LAD)) was referred to the Depart- ment of Cardiac Surgery for a single CABG. After careful evaluation, a minimally invasive Endo– CABG was performed. The procedure was carried out under general anaesthesia with the patient in a supine position. Left internal mammary ar- tery (LIMA) was harvested ipsilaterally via three 5–mm endoscopic ports in the second, third, and fourth left intercostal spaces, approximately 2 cm above and below the anterior axillary line in a tri- angular configuration. The pericardium was freed from fatty tissue and opened anteriorly to the left phrenic nerve (Figure 1). After systemic heparin- ization, a cardiopulmonary bypass (CPB) was ini- tiated via peripheral cannulation of the common femoral artery and vein through a 2–cm oblique skin incision below the inguinal ligament. A 5–cm skin incision was performed through the left third intercostal space and a soft tissue retractor was placed to provide a sufficient view of the heart. The LIMA–LAD anastomosis was performed on an empty beating heart in a standard fashion us- ing a 7/0 polypropylene suture (Figure 2). After completing the anastomosis, the graft flow was checked with a TransitTime Flow Measurement probe (Medistim ASA, Oslo, Norway). The patient was then weaned from the CPB and heparin was reversed with protamine sulphate. The pericar- dium was closed with three interrupted sutures, leaving enough space for the LIMA entrance. Tho- racic and inguinal surgical wounds were closed in layers in a standard manner (Figure 3). The surgi- cal procedure and the early postoperative course were uneventful and the patient was discharged on the fifth postoperative day. Three months after the procedure the patient is doing well with no episodes of chest pain. endoskopskim odvzemom notranje prsne arterije in našitjem anastomo- ze LIMA–LAD skozi levo mini tora- kotomijo z uporabo mehkotkivnega razpirala. fifth postoperative day. Conclusion: This report presents the first case of a minimally invasive CABG procedure using endoscopic mammary artery harvesting in Slovenia. Naslov za dopisovanje / Correspondence Boris Robič, dr. med., Univerzitetni klinični center Maribor, Oddelek za kardiokirurgijo, Ljubljanska 5, 2000 Maribor, Slovenija Telefon: +386 2 321 1787 E–pošta: boris.robic@gmail.com 67 Poročilo o primeru / Case report: ACTA MEDICO-BIOTECHNICA 2021; 14 (1): 11–19 DISCUSSION The key to a successful Endo–CABG lies in careful patient evaluation and selection performed by the cardiac team (cardiologists, anaesthesiologists, and cardiac surgeons). Ideally, the patient has a proximal LAD lesion, left ventricular ejection fraction of >50%, no acute coronary syndrome signs, and no thoracic deformities (7). Indications for Endo–CABG are broad. However, since the learning curve is very steep, starting with a single–vessel LAD lesion is reasonable. Long–term LIMA–LAD patency has a survival benefit. Vassiliades et al. published the largest single– or bi–vessel Endo–CABG series with long–term outcomes. A total of 607 patients underwent Endo–CABG with 721 constructed anastomoses. The 30–day mortality and five–year survival rates were 1% and 92%, respectively. After a mean follow–up of 18 months, LIMA– LAD patency was 98.5% (8). In terms of morbidity, postoperative atrial fibrillation (AF) remains the most common rhythm disturbance after an on–pump CABG. With Endo–CABG surgery performed on an empty beating heart without cardiac arrest, the incidence of AF and other extracorporeal circulation–associated comorbidities is likely to decrease (9). CONCLUSIONS Endoscopic atraumatic coronary artery bypass is a viable option for treatment in patients with single– vessel LAD disease. Apart from the benefits of this sternum–sparing technique (fewer infections, shorter mechanical ventilation time, and better cosmetic outcome), it also has a steep learning curve. Therefore, careful patient selection must be a priority for the heart team. The present manuscript describes the first case of a patient with single–vessel LAD disease successfully treated with Endo–CABG. In the future, off– pump and hybrid approaches in combination with percutaneous techniques will also be a reasonable option for patients with multivessel disease. Figure 1. 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