Miami Minimally Invasive Valves
Joseph Lamelas, MD
Dedicated to the Advancement of Minimally Invasive Cardiac Surgery

Coronary Bypass

During a minimally invasive AVR case, a single SVG to the RCA can be performed.  The PDA is more difficult to bypass, and unless the anatomy is very favorable, it will not be accessible.  Before considering a bypass to the RCA,  I prefer to stent the RCA, unless it is totally occluded.


1.  It is best to perform the distal vein anastomosis before the AVR.

2.  The best retraction method is placing multiple silk sutures on either side of the RCA as well as one retracting the artery cephalad. I have used different suction devices but the space is very limited. Occasionally a sponge stick can help.

3.  The anastomosis needs to start at the toe of the vein.  If one begins at the heel, which is the usual way, the toe will be very difficult to see.

I have enclosed representative pictures.   Don’t let the pictures fool you.    It does take a little practice!







I have enclosed a link to the Annals of Cardiothoracic Surgery.
I have submitted 4 publications to this journal that I would like for all of you to review.
Two are relevant to Minimally Invasive AVR/MVR, one on Minimally Invasive AVR, and one on Building a Minimally Invasive Valve Program, of which I was a co-author with Dr. Tom Nguyen.
In addition, I think that all of the contributions to this journal are significant and will help advance the subspecialty of minimally invasive valve surgery.
I urge all to subscribe.
There are previous editions of this journal which are excellent and I believe serve as a reference for all Cardiothoracic Surgeons.

I know that we are all busy in our daily work and family lives , but please take the time to answer a few questions.
Everyone who has subscribed to the blog has an interest in minimally invasive surgery.
To those that don’t accept it, it is disruptive. To those that embrace it, realize that the future is minimally invasive surgery.

1. How can we disseminate the word to the public?
2. How can we better train surgeons?
3. Why is adoption slow?
4. How can we facilitate the operation? (Different techniques or instruments)
5.  Should these techniques be offered to all surgeons? (Recently graduated or experienced surgeons)

Our patients have benefited and there is a real benefit. Don’t let the skeptics and antagonists cloud our vision of the future. Remember, nothing comes easily, but those who change the current philosophies in cardiac surgery are those who contribute to its advancement.

Please respond directly through the blog or my personal email (

I value EVERYONE’S response. They will be kept anonymous unless you chose otherwise.

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.