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.

Tips:

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!

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.