Background:

Sternotomy is still the standard approach in coronary artery bypass grafting (CABG) for multivessel disease, but it remains a very invasive procedure. The aim of our new surgical approach via left anterior mini-thoracotomy is the avoidance of sternotomy while maintaining the key principle of complete anatomical revascularization in the vast majority of multivessel disease patients. We present in-hospital results of our initial series.

Methods:

From 11/2019 to 11/2022, CABG via left anterior mini-thoracotomy on cardiopulmonary bypass (peripheral cannulation) and cardioplegic arrest (transthoracic aortic cross-clamping) was successfully performed in 240 non-emergency patients (218 male; 67.5±9.5 (42-88) years). Traction of tapes around ascending aorta, left pulmonary veins and inferior vena cava and rotating the arrested heart enabled addressing all coronary territories with reproducible standard anastomotic techniques. All patients had multivessel disease with indication to CABG (3-vessel: n=186; 2-vessel: n= 54; left main stenosis: n=80), and they represented an unselected all-comer population including patients at old age (>80 years: 12.5%), with severe left ventricular dysfunction (EF<30%: 6.3%), NSTEMI (37.1%), previous PCI (26.7%), massive obesity (BMI>35: 10%), COPD (19.5%), and at increased risk (EuroScore2>4: 20.8%). Mean EuroScore2 was 2.8±2.9.

Results:

Left internal thoracic artery (n=235), radial artery (n=189), and saphenous vein grafts (n=122) were used for total (46.3%) or multiple (29.6%) arterial grafting in most cases. A total of 743 distal anastomoses (3.1±0.8 (2-5) per patient) were performed for grafting of the left anterior descending (98.8%), circumflex (92.9%) and right (70.8%) coronary artery. Hospital mortality was 2.1% (O/E ratio: 0.75), stroke rate was 0.4%, myocardial infarction was 0.8%, and repeat revascularization rate was 1.6%. ICU stay was ≤1 day in 69.1% of all patients, and 51.7% left the hospital within 8 days after surgery.

Conclusion:

Minimally invasive multivessel coronary surgery via left anterior mini-thoracotomy allows complete anatomical revascularization in the broad majority of multivessel disease patients avoiding sternotomy. The rate of arterial bypass grafting was high and in-hospital results are promising. Long-term results remain to be investigated.