Off-Pump Coronary Bypass through Very Limited Sternotomy

This study was designed to evaluate the feasibility of beating heart coronary bypass operations on the anterior vessels of the heart through very limited sternotomy (VLS).

Between February 1, 2000, and October 1, 2001, 76 patients with stenosis of the left anterior descending artery (LAD) and right coronary artery (RCA) underwent coronary bypass grafting through 6- to 7-cm T-shaped VLS. Mean age of the patients was 56 +/- 4.7 years. Fourteen patients were women. Nine (12%) of the patients had a left ventricular ejection fraction of less than 35%. Forty-three patients had single-vessel disease, and the others had 2-vessel disease. Patients who needed emergency operations were excluded from the study.

In 7 patients the operation was converted to full sternotomy with or without cardiopulmonary bypass. This outcome accounted for an over all failure rate of 9%. The internal mammary artery/arteries were the inflow vessels in all cases. Various types of composite grafts were created with the saphenous vein and radial artery. Thirty-five (46%) of the patients received a single graft to the LAD, 12 (16%) received 2 grafts to the LAD and RCA, 8 (11%) received 2 grafts to the LAD and a diagonal artery, and 21 (27%) received 3 grafts to the LAD, RCA, and a diagonal artery. Average graft number was 1.8 per patient. Mean operation time was 97 +/- 26 minutes (range, 41-177 minutes). Mean anastomosis time for each graft was 16.0 +/- 2.6 minutes in the first 26 patients and 9.0 +/- 1.7 minutes in the rest. Mean intubation time, intensive care unit, and in-hospital stays were 4.1 +/- 1.6 hours, 17.6 +/- 3.4 hours, and 4.1 +/- 0.8 days, respectively. One (1%) of the patients had perioperative myocardial infarction, and 1 (1%) had right lung laceration and prolonged air leakage. There were no cases of cerebrovascular accident, pulmonary insufficiency, deep wound infection, or renal failure. There was no hospital mortality. The mean followup period was 26. 8 +/- 3.5 months. Thirty-nine (51%) of the patients underwent coronary angiography 1 year after the operation. Fifty-eight grafts were examined. There were 6 occluded grafts, with an overall patency rate of 90%. Three patients died in the follow-up period, 1 (1%) of these patients died of a cardiac cause.

Coronary bypass grafting on the LAD, the RCA, and their tributaries can be safely performed through VLS. Early and midterm results are comparable with those of classic methods of myocardial revascularization. Conversion to full sternotomy is quite easy and safe, should the necessity arise.