Miami Minimally Invasive Valves
Joseph Lamelas, MD
Dedicated to the Advancement of Minimally Invasive Cardiac Surgery
October 29, 2013
Can the LAD be bypassed via a Right Mini-thoracotomy?

While performing a minimally invasive AVR, I recently encountered a case  in which I, nor the Cardiologist appreciated the LM stenosis and the significant calcification surrounding the Left Main.  While giving a dose of antegrade cardioplegia, I noticed that the left main was unusually small.  After review of the cath films again, I noticed that the catheter did not completely engage the LM.  It constantly popped out. I knew at this point that the LAD needed to by bypassed. My choices were to perform a sternotomy or attempt to bypass the LAD from the right mini-thoracotomy incision. He was an elderly patient so I decided to harvest a segment of vein and bypass the LAD. Enclosed are pictures.

This was the mid LAD and I utilized a sponge stick to expose the LAD.  I am not sure if it will be reproducible in all cases but it is a start!!!! I am sure I could not do a LIMA from this approach unless I harvested it from a left sided exposure (I know that there is someone that I trained that did do this).  It does add another incision and layer of complexity so I wonder if it is worth the extra effort?  I would appreciate anyone’s input.


2 thoughts on “Can the LAD be bypassed via a Right Mini-thoracotomy?”

  1. James Jowers CSA-FA says:

    What about a RIMA to the LAD ? Always felt RIMA would be a better conduit than a vein. Also no leg incision. Just a thought.

    1. I think it can be done although it would have to be a planned ahead of time. My only 2 concerns would be obtaining adequate length and performing the distal anastomosis. With a vein, you can position it in any way that provides the best visualization. In this case, I decided to bypass the LAD after seeing a very narrowed ostium of the LM.

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