MICS CABG In-service Presentation - Medtronic of MICS CABG Procedure/ Instrumentation Recommended • Thoracotomy/Incisions • IMA Harvest – Rultract ® is required with ThoraTrak

MICS CABG In-service Presentation

This presentation is based on a compilation of the

surgical techniques and protocols of:

Dr. Joseph McGinn - Staten Island, New York

Dr. Marc Ruel - Ottawa, Canada

Dr. Steven Hoff - Nashville, TN

Trademarks may be registered and are the property of their respective owners.

• What is a MICS CABG Procedure?

– Off-Pump CABG in which the anastomoses are performed

under direct vision through a lateral thoracotomy

– LIMA harvested– under direct vision, robotically or with

video assistance

– Additionally, in order to achieve complete revascularization,

a pump-assisted beating heart approach or hybrid approach

can be employed

MICS CABG: Overview


• Complete revascularization can be achieved

• 5 – 7 cm posterior-lateral thoracotomy providing improved patient

and referring physician satisfaction1

• Shortened intubation time1

• Reduced hospital length of stay1

• Quicker return to normal activities and less restrictions post

surgery2

1 Poston RS, Tran R, Collins M, Reynolds M, Connerney I, Reicher B, Zimrin D, Griffith BP, Bartlett ST. Comparison of economic and patient outcomes with minimally invasive versus traditional off-pump coronary

artery bypass grafting techniques. Ann Surg 2008;248:638-646.

2 Lapierre H, Chan V, Sohmer B, Mesana TG, Ruel M. Minimally invasive coronary artery bypass grafting via small thoracotomy versus off-pump: A case-matched study. Eur J Cardiothorac Surg. 2011;40:804-810.

Potential Benefits of MICS CABG

MICS CABG vs. MIDCAB



• Coronary Anatomy

– Left main coronary artery disease (CAD) with normal right

coronary artery (RCA)

– Triple vessel disease with medium to large posterior

descending artery (PDA)

– Complex proximal left sided lesions with or without large branch

involvement

– Previous unsuccessful stenting

Patient Selection/Inclusion Criteria


• Co-Morbidities:

Includes patients who are at a high risk for problems with

median sternotomy

– Long-term steroid use

– Severe chronic obstructive pulmonary disease (COPD)

– Advanced age

– Need for other major operative procedures

– Severe deconditioning

– Patients with arthritic or orthopedic problems

– Patients who want the procedure and seek out less invasive

surgical options

Patient Selection/Inclusion Criteria


• Contraindications

– Emergency cases

– Patients with hemodynamic instability

• Potential Contraindications

– Previous CABG surgery

– Morbid obesity

– Patients with posterolateral branch disease

– EF < 20%

– Patients with peripheral vascular disease (PVD)

– Patients with dilated cardiomyopathy

Contraindications


Anesthesia

• Double lumen or bronchial blocker for single lung ventilation

• Defibrillator pads placed over right lateral chest wall and left scapula

• Positive ionotropic agents

• Continuous monitoring of hemodynamics

• Fluid for volume control and blood pressure support

• Maintain body temperature


Patient Positioning

• Lumbar region at break of bed

• Patient pulled towards left side

of bed

• Vertical roll between spine and

left scapula

• Left arm slightly flexed and

tucked

Photo courtesy of Dr. Ramchandani, Houston, TX

MICS CABG Set-up

Rultract ® Rultract® with

optional

Swivel (Preferred)

Surgeon

Position

1st

Assistant Pump 4th ICS

ThoraTrak®

MICS

Retractor

System

Mounting Rail

Mounting Rail

Sub-xyphoid incision

(Starfish® NS and

Octopus Nuvo placement) 6th ICS

Octopus® Nuvo

Rultract® is a registered trademark of Rultract, Inc.



MICS CABG Incisions

4th or 5th ICS –

1/3 Medial, 2/3

Lateral to

Nipple

5-7 cm

6th ICS at Mid

Axillary Line

1-2 cm

Sub-

Xyphoid

1-2 cm

Window Incision


Octopus®

Nuvo Starfish® NS

MICS CABG - The Tools and Technology

ThoraTrak®

MICS Retractor

System


ThoraTrak® MICS Retractor Positioning

Position Rultract®

post at patient's

neck

Swivel towards

feet to provide

access to

mammary

Swivel towards

head to access

aorta


Positioning and Stabilization

6th ICS

Sub-xyphoid

Octopus® Nuvo

Tissue Stabilizer

Starfish® NS Heart Positioner


Pump-Assisted Beating Heart

Bio-Medicus® Arterial cannula

Bio-Medicus® Venous cannula

Reduced Prime Pump Set-Up

Pump flow rate 2-3 Liters

Order of MICS CABG Procedure/

Instrumentation Recommended

• Thoracotomy/Incisions

• IMA Harvest – Rultract® is required with ThoraTrak® #1 or #2 blades to provide access

– Small and medium endoscopic clip appliers

– Bovie with extended blade

– Minimally invasive Debakey Forceps

– Soft-tissue retractor

• Proximal Attachment – Rultract is required with ThoraTrak #1 or #2 blades

– Vaginal packing (if utilizing a technique to go behind the aorta)

– C-Clamp

– Partial occlusion clamp

– Knot pusher

• Distal Attachment – ThoraTrak MICS Retractor System, Octopus® Nuvo Tissue Stabilizer,

and Starfish® NS Heart Positioner are needed to complete distal attachments

– LIMA-LAD is the last anastomosis performed

• Pain Management – Recommend pain pump



MICS CABG Product Overview

• ThoraTrak® MICS Retractor System

• Octopus® Nuvo Tissue Stabilizer

• Starfish® NS Heart Positioner


• Modular retractor system with

interchangeable blades to

accommodate various

procedures and patient

anatomies

• Reusable, stainless steel

retractor designed specifically

for minimally invasive procedures

• Low-profile design

ThoraTrak® MICS Retractor System


Octopus® Nuvo Tissue Stabilizer

• Incorporation of the Octopus® Evolution headlink for minimally invasive

– Malleable pods

– Increased headlink flexibility

and range of motion

– Flexible suction tubing

• Three pod design

– Smaller headlink for MICS CABG procedure

• Quick connect, detachable headlink

• New whale tail

• Improved flex arm


• Enables multi-vessel therapy

through a thoracotomy

• Presents coronary artery for direct vision

anastomosis

• Remote shaft insertion eliminates clutter at

the incision site

• Dependable positioning technology that you

are already using in your OPCAB patients

• No additional suction tube

Starfish® NS Heart Positioner


• Starfish® NS Heart Positioner through a sub-xyphoid incision

• Octopus® Nuvo Tissue Stabilizer through the 6th ICS

• Positioning and stabilization of several vessels directly under the

mini-thoracotomy is possible

• Active pain management with pain pump

MICS CABG Technology Overview


UC 200903819 EN


UC201105477a EN

Documents

MICS CABG In-service Presentation - Medtronic of MICS CABG Procedure/ Instrumentation Recommended • Thoracotomy/Incisions • IMA Harvest – Rultract ® is required with ThoraTrak