Anesthesia and Regional Anesthetic Techniques for Minimally Invasive Direct Coronary Artery Bypass Surgery

An innovative new approach to coronary revasculariza tion, 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 tech nique, including thoracoscopic video-assisted harvest ing of the internal mammary artery, often with har monic scalpel and potentially even robotic assistance, necessitate prolonged one-lung ventilation. In the ab sence 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 seg ments mandate a versatile analgesic technique. Re gional anesthesia as analgesic adjuvant allows lighter levels of general anesthesia during surgery with mini mal intraoperative hemodynamic changes and a smooth transition to postoperative analgesia. Although a num ber of regional techniques may be used to achieve this goal, thoracic epidural analgesia or continuous percuta neous paravertebral block seem to offer specific advan tages of cardiac sympathectomy.