1995 - Dr. Clive Robinson from the University of Kentucky was the first to attempt minimally
invasive coronary bypass through a small incision betweeen the ribs ("thoracotomy") in animals.
Dr. Frederico Benetti from Buenos Aires, Argentina excited the surgical community by reporting
2 successful human MIDCAB cases ("Minimally Invasive Direct Coronary Artery Bypass"). He used
a small left thoracotomy assisted by a rigid fiberoptic telescope for harvesting of the left
internal mammary artery. Worldwide interest in developing a minimally invasive approach to
heart surgery exploded as a direct result of these independent reports by Robinson and Benetti.
May 13-15, 1996 - First Annual MIDCAB meeting, Minneapolis Heart Institute. Dr. James
Fonger from Johns Hopkins in Baltimore, MD reported using a subxiphoid approach to bypass an
artery on the bottom surface of the heart (the Right Coronary Artery or RCA). The sternum is
lifted and not divided. Dr. Mark Levinson, an attendee at this meeting, saw the potential for
other cardiac procedures using this sternal-sparing subxiphoid approach and designed a system to
perform this approach for an upcoming case of congenital heart disease.
Sept 1996 - Dr. Mark Levinson performs the first intracardiac surgery in the United States
through a subxiphoid approach when he repairs a congenital defect (patent foramen ovale) in
a young woman with the assistance of the heart-lung machine. Two more patients were
eventually done, all without complications. Dr. Levinson publishes his technique in the
inaugural issue The Heart Surgery Forum journal in May of 1998.
1997 - Akhter and colleagues report the use of the subxiphoid approach in patients needing a
single bypass to the underside of the heart (right coronary artery territory) after previous bypass
surgery ("redo").
1998 - Subxiphoid surgery for repair of congenital heart defects is also reported by Dr. Miguel
Barbero-Marcial from Sao Paulo, Brazil using a custom-made retraction system designed only for
infants and small children. No adult cases are done and no patients with coronary artery
disease were attempted.
1999, 2000 - Drs. Benetti, Dullum and coauthors report a xiphoid approach for single vessel
coronary bypass. Only 2 of these cases received double grafts. The authors state that the
back wall of the heart cannot be bypassed through this approach.
2005 - Dr. Mark Levinson successfully uses the subxiphoid approach in a patient who needed a
single vessel bypass but refused to have his sternum divided. Over the next year, his team
acquires specialized instruments to help expand this technique and permit access to more areas
of the heart through this small incision.
May 19, 2005 - Dr. Levinson performs the first successful "back wall" bypass (to the obtuse
marginal branch of the circumflex) using the subxphoid technique. The patient's surgery is
done without the heart lung machine or stoppage of the heart (i.e. "off-pump"). Dr. Levinson
publishes this breakthrough in The Heart Surgery Forum volume 8 issue 4, 2005.
July 25, 2005 - Dr. Levinson performs the first successful 3-vessel bypass using the
subxiphoid technique.
2005-2006 - Dr. Levinson and his team continue to develop new instruments and techniques to
reach all territories of the heart using "off-pump" subxiphoid techniques.
May 9, 2006 - Dr. Levinson performs the first successful sequential (LIMA-D1-LAD) and the
first successful T-graft using the subxiphoid approach (left internal mammary to left radial
artery).
