Difficulties in beating-heart totally endoscopic coronary artery bypass grafting: how to handle the problem endoscopically.

We describe 2 cases of successful conversion from beating-heart (BH) to arrested-heart (AH) totally endoscopic coronary artery bypass surgery (TECAB). The preoperative computed tomographic (CT) scan of the first patient showed significant artherosclerosis of the femoral vessels in both groins. Therefore we tried to avoid inguinal cannulation by performing an off-pump BH-TECAB. But the target vessel was strongly fissured, and bleedings from the surrounding tissue made anastomotic suturing impossible. Therefore we cannulated the groin cautiously and endoclamped the aorta. The preoperative CT scan of the second patient showed a soft plaque in the ascending aorta. Therefore we tried to perform an on-pump BH-TECAB to avoid clamping of the aorta. Even though we snared the target vessel, significant backbbleeding occurred. Therefore we performed endoclamping of the aorta distal to the aortic plaque. In both cases the following AH-TECAB procedure was performed successfully without any problems.