The use of “LAST” operation in high risk patient

Abstract

Surgical revascularization of the Left AnteriorDescending coronary artery (LAD) with the Left Internal Mammary Artery (LIMA) can be carried out through a left anterior small thoracotomy without cardiopulmonary bypass as a beating heart (LAST operation). This approach is quite appealing to the patients due to minimal invasiveness, short hospital stay and quick recovery.The LAST operation, introduced and popularised by Calafiore et al. [1] can be considered nowadays a good option for patients with an isolated proximal LAD lesion not favourable for PTCA (total obstruction or type C lesion) or in care of recurrent stenosis following PTCA. However there are few drawbacks related to the LAST operation. First of all harvesting of the LIMA is technically demanding when is performed through a small anterior thoracotomy and the arterial conduit can be occasionally traumatised and/or irreversibly damaged. Furthermore, due to a difficult exposure, the branches of the upper portion of the LIMA are usually not divided and this might produce a steal phenomenon with recurrent angina in spite of a patent LIMA graft [2].Finally, the LAST operation has to be occasionally converted into a midline sternotomy procedure because the LAD is not appropriately identified or exposed through a small thoracotomy as is running intramurally as is diffuses diseases and an endoarterectomy can be required.In this study we report our preliminary experience with the use of LAST operation in high risk patients. An incision of about 6 cm was made in the appropriate intercostal space and the LIMA (Left Internal Mammary Artery) was harvested using a special costal retractor. After heparin administration the LIMA is distally divided to check the adequacy of the blood flow. Following the insertion of a temporary intracoronary shunt, the LIMA was LAD anastomosis was carried out with a continuous 8-0 polypropylene suture. Matherial and Metods The patientsResults: No hospital or late mortality was observed. Uneventful conversion to midline sternotomy was necessary in one patient with low value of mammary flow. All patients were discharged within the first postoperative week.Conclusions: The use of the LAST operation enhances the role of minimally invasive surgery also in high risk patients who need coronary revascularization.