Lower Mini-Sternotomy: a New Approach for Minimally Coronary Artery Bypass Surgery: Chances and Limitations of a New Technology

Abstract

Background The rate of Coronary Artery Bypass Grafting (CABG) procedures decreased generally over the past years while the relative number of off-pump coronary artery bypass grafting (OPCAB) procedures remained stable. OPCAB can be performed in different ways also using a minimally invasive direct approach (MIDCAB). This technique consists usually of the approach through the Left Anterior Small Thoracotomy (LAST) and is in principle limited for single LAD revascularization only. Lower Mini-Sternotomy (LOMS) is an optimization of the minimal-invasive approach permitting the harvest of both internal thoracic arteries (ITA) as well as excellent exposure and immobilization of the left and right coronary arteries. Methods Between January 2016 and June 2017 LOMS was performed in 31 patients to achieve access to the left and right internal thoracic arteries and to reach the left anterior descending coronary artery, diagonal branches, and right coronary artery for off-pump, all-arterial, aortic no-touch revascularization. Postoperative pain intensity was assessed on a daily basis for 7 days and patients were followed prospectively after operation at our outpatient clinic on a monthly basis in order to assess the incidence of complications. Results The mean operative time was 163 ± 49 minutes (range 119 to 260 minutes). The mean length of the skin incision was 7.4 ± 1.3 cm (range 6 to 11 cm). Neither hemodynamic changes nor transient S-T segment changes on the ECG occurred during the operation. In most patients, recovery was rapid and uneventful. No hospital death or morbidity was observed. No blood transfusion was required perioperatively. There were no perioperative neurological cognitive dysfunction events. Maximal pain levels were registered on postoperative day 2 or 3, and pain had abated in most patients on day 5. At follow-up, all patients were in New York Heart Association class I. Conclusions Despite more demanding surgical technique than with full-sternotomy OPCAB, our experience demonstrates that the LOMS for MIDCAB is a technically feasible procedure for myocardial revascularization. Not only the LAD and its branches but also the RCA and can be used safely with very good procedural outcomes.