Left anterior small thoracotomy procedure

Abstract

The left anterior descending (LAD) artery off-pump grafting with the left internal mammary artery (LIMA), via a left anterior small thoracotomy (LAST operation) introduced, for the first time, by Vasilii Kolesov in 1964, gained popularity in the second half of the 1990s. Patients with single LAD disease (not suitable for interventional treatment) or patients showing multivessel disease with the other coronaries occluded and refilled by collateral circulation, but not graftable because of technical issues, can be considered candidates for this type of operation. The incision is performed at the 4th intercostal space. Pectoralis and intercostal muscles are dissected and the pericardium is opened. The LIMA is harvested as a pedicle up to the clavicle to reach a more distal and/or more lateral anastomotical site. After the stabilizer has been positioned, the LAD is incised and an intracoronary shunt is inserted. The anastomosis is then performed on a beating heart. Finally, the anastomosis is checked by means of a transit-time flowmeter. The intercostal space is then closed in a standard fashion, leaving a drainage inside. In our experience, 853 patients underwent the LAST operation. Early mortality rate was 1.2% with a nine-year survival of 91.31.0.