# Distal LIMA\-to\-LAD Anastomosis in OPCAB — Expert Cardiac Surgical Demonstration How a surgeon sews a chest artery onto a blocked heart artery while the heart keeps beating, from exposing the target to checking blood flow\. By Dr Biju Sivam Pillai Topic: Human Body & Medicine [Open the interactive Jig](https://ask.jig.com/j/EpkWC0WMxXUd) ## Transcript ### 1. A bypass on a beating heart We are looking into an opened chest\. The breastbone has been split down the middle and held apart, and the heart keeps beating the whole time, with no heart\-lung machine\. A spare artery from inside the chest wall, the LIMA, will carry blood around a blockage in the heart's own artery, the LAD\. This is called off\-pump bypass, or OPCAB\. The heart beats about 60 to 80 times a minute throughout\. ### 2. 1\. Target identification The LAD runs down the front of the heart in a groove cushioned with yellow fat\. Upstream there is a narrowing, so the surgeon picks a healthy stretch beyond it\. A thin layer of fat is lifted away so the artery wall can be seen clearly\. A good target is usually at least 1\.5 mm wide, about the thickness of a pencil lead\. ### 3. 2\. Stabilization The Acrobat stabilizer clips onto the chest retractor\. Its bendy arm lowers a two\-pronged foot onto the heart, one prong on each side of the artery, never on it\. Gentle suction pods grip the muscle, so this small patch stays almost still while the rest of the heart keeps beating\. The arm is a chain of linked rings that locks stiff when the knob is turned\. ### 4. 3\. Coronary arteriotomy Soft loops around the artery above and below the target briefly limit bleeding\. A tiny coronary knife makes a small cut in the top wall only, and fine angled scissors lengthen it along the artery\. The opening is about 5 mm long\. Everything here is magnified about ten times\. The artery is only about 2 mm wide\. ### 5. 4\. Graft preparation The free end of the LIMA is cut at a slant, then split a little along its length\. This turns the round end into a wider, hood\-shaped mouth\. Its length is matched to the opening in the LAD, so the join will not be too tight\. The LIMA here is skeletonized: stripped of its surrounding tissue, with tiny clips on its side branches\. ### 6. 5\. Anastomotic suturing Now the graft is sewn to the artery with one continuous blue thread, 7\-0 Prolene, finer than a hair\. The curved needle is turned along its own curve, through the graft from outside in and through the artery from inside out, so the smooth inner linings meet\. Stitches start at the heel, go around the toe and come back\. Slow motion marks the heel and toe bites\. Each bite catches only the front wall, never the back wall of the artery\. ### 7. 6\. Completion The two thread ends are tied gently, so the join does not pucker or narrow\. The loops and the small clamp on the graft are released and blood flows through the new path\. The surgeon checks the join for leaks\. Blood from the LIMA now reaches the heart muscle beyond the blockage\. ### 8. 7\. Assessment The stabilizer lifts away and the whole heart beats freely again\. A small flow probe clipped around the graft uses ultrasound to measure how much blood passes through it\. A steady flow and a smooth wave mean the graft is open and working\. Typical good readings: flow above about 15 mL per minute and a pulsatility index below about 3\.