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Published on: March 26, 2018
Early Results of Total Coronary Revascularization via Left Anterior Thoracotomy
Christian Sellin1, Silke Asch1, Ahmed Belmenai1
1Klinik für Herz- und Thoraxchirurgie, Klinikum Fulda gAG, Fulda, Germany.
Insights
Total coronary revascularization via a small left anterior thoracotomy (TCRAT) safely achieves complete revascularization in most multivessel disease patients. This sternotomy-sparing technique shows promising in-hospital outcomes for complex cardiac surgery.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Cardiac Surgery
- Interventional Cardiology
Background:
- Sternotomy is the traditional approach for coronary artery bypass grafting (CABG), but it carries risks.
- Achieving complete revascularization in multivessel coronary disease without sternotomy presents significant challenges.
- Minimally invasive techniques aim to reduce surgical trauma and improve patient outcomes.
Purpose of the Study:
- To report the technical aspects and in-hospital outcomes of total coronary revascularization via a small left anterior thoracotomy (TCRAT).
- To evaluate the feasibility of TCRAT in a nonselected group of patients with multivessel coronary disease.
- To assess the safety and efficacy of a sternotomy-sparing approach for complex CABG.
Main Methods:
- Coronary artery bypass grafting using TCRAT was performed on 102 patients between November 2019 and September 2021.
- The procedure involved cardiopulmonary bypass and cardioplegic cardiac arrest, with specialized cannulation and sling placement for optimal exposure.
- Patients included those with multivessel disease, advanced age, severe left ventricular dysfunction, obesity, and high surgical risk (EuroSCORE II > 4).
Main Results:
- Complete revascularization was achieved in 95.1% of patients.
- A total of 323 distal anastomoses were performed, utilizing left internal thoracic artery, radial artery, and saphenous vein grafts.
- In-hospital outcomes included a 2.9% mortality rate, 1.0% stroke rate, 2.9% myocardial infarction rate, and 2.0% repeat revascularization rate.
Conclusions:
- TCRAT is a novel surgical technique enabling complete coronary revascularization in the majority of multivessel disease patients without sternotomy.
- The TCRAT procedure can be safely integrated into routine clinical practice.
- Further investigation into the long-term results of TCRAT is warranted.
Background:
Avoidance of sternotomy while preserving complete revascularization remains challenging in multivessel coronary disease. Technical issues and in-hospital outcomes of total coronary revascularization via a small left anterior thoracotomy (TCRAT) in nonselected patients with multivessel disease are reported.
Methods:
From November 2019 to September 2021, coronary artery bypass grafting via left anterior minithoracotomy on cardiopulmonary bypass and cardioplegic cardiac arrest was performed in 102 patients (92 males; 67 ± 10 [42-87] years). Slings were placed around ascending aorta, left pulmonary veins, and inferior vena cava for exposure of lateral and inferior ventricular wall. All patients had multivessel coronary disease (three-vessel disease: n = 72; two-vessel disease: n = 30; left main stenosis: n = 44). We included patients at old age (> 80 years, 14.7%), with severe left ventricular dysfunction (ejection fraction < 30%, 6.9%), massive obesity (body mass index > 35, 11.6%), and at increased risk (EuroSCORE II > 4, 15.7%).
Results:
Left internal thoracic artery (n = 101), radial artery (n = 83), and saphenous vein (n = 39) grafts were used for total (61.8%) or multiple (19.6%) arterial grafting. A total of 323 distal anastomoses (3.2 ± 0.7 [2-5] per patient) were performed to revascularize left anterior descending (100%), circumflex (91.2%), and right coronary artery (67.7%). Complete revascularization was achieved in 95.1%. In-hospital mortality was 2.9%, stroke rate was 1.0%, myocardial infarction rate was 2.9%, and repeat revascularization rate was 2.0%.
Conclusion:
This novel surgical technique allows complete coronary revascularization in the broad majority of multivessel disease patients without sternotomy. TCRAT can be introduced into clinical routine safely. Long-term results remain to be investigated.
