Multivessel Revascularization on the Beating Heart by Anterolateral Left Thoracotomy

Abstract

Off-pump coronary artery bypass is commonly performed through a full median sternotomy; however, the tendency to reduce surgical trauma has stimulated cardiac surgeons to use less invasive techniques for single-vessel disease. The use of thoracotomy for reoperative and valvular surgery has also been reported, but its application in primary revascularization is still uncommon. We report here a series of consecutive patients who underwent complete myocardial revascularization on the beating heart through anterolateral thoracotomy-coronary artery bypass (ALT-CAB). From November 2002 to July 2005, 255 patients (75.7% male, median age 57.9 +/- 10.1 years) underwent complete revascularization using the ALT-CAB approach. Eighty-two patients (32.2%) had low ejection fraction, 145 (56.9%) previous myocardial infarct, and 215 (84.3%) multivessel disease. The mean EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 3.8 and the Parsonnet score was 7.8. Complete revascularization was achieved in all patients (mean number of grafts 3.3 +/- 1.0). There were no conversions to cardiopulmonary bypass, and 3 patients died (1.2%). Two hundred thirty-seven patients (93.3%) were extubated in the operating room, and 164 patients (65.1%) were discharged home within 48 hours after surgery. Two patients (0.8%) experienced a stroke and 5 (2%) needed reexploration for bleeding. There was 1 perioperative myocardial infarction (0.4%), and 14 patients (5.5%) experienced postoperative atrial fibrillation. Five patients (2%) required treatment as an outpatient for superficial wound infection, 11 (4.4%) for left pleural effusion, and 11 (4.4%) for transient phrenic nerve palsy, which resolved spontaneously. Follow-up (median, 14.6 +/- 9.7 months) survival was 97.6%. One patient (0.4%), experienced a new myocardial infarction, 9 (3.6%) required new coronary angiography for recurrent of angina, and 3 of these (1.2%) underwent angioplasty. Complete revascularization on the beating heart through an anterolateral thoracotomy is safe and feasible in the majority of patients requiring coronary artery surgery.