Minimally invasive aortocoronary bypass grafting via left minithoracotomy: technique, results and evolution of the method

Aim: total arterial coronary bypass performed via minimally invasive access through an anterolateral mini-thoracotomy has significant advantages due to complete myocardial arterial revascularization. At the same time, it should be noted that this technique is technically challenging and requires overcoming a significant learning curve. This study presents a comprehensive analysis of the dynamics of development and improvement of the development and refinement of a surgical program over an 8-year period.

Materials and methods: a prospective data collection was performed for all patients who underwent this procedure at our institution between January 2015 and December 2023. During this period, the program underwent several modifications, including: optimization of surgical access using various available instruments and operative time management; standardization of the technique for all off-pump coronary artery bypass procedures; and implementation of a mentoring system for the surgical team. Changes in the quality control system involved a transition from routine postoperative coronary angiography to imaging only when clinically indicated.The effectiveness of these measures was evaluated according to the following parameters: Primary endpoint: in-hospital mortality. Secondary endpoints: procedure duration and incidence of perioperative myocardial infarction. The analysis was performed by comparing two time periods: Group 1 (n=137): patients operated on during the first 4 years of the study; Group 2 (n=142): patients operated on during the second 4 years.

Results: a total of 279 consecutive patients underwent elective total arterial minimally invasive coronary artery bypass grafting at our institution during the study period. The mean age was 66 years (±7), 86% (n=241) were male, and 33.1% (n=77) had diabetes mellitus. Three-vessel desease was present in 53% of patients (n=123), and left main coronary artery desease in 43% (n=101).The overall 30-day mortality was 0.4% (n=1). Compared to the initial 4-year period, the latter patient group showed threefold reduction in the incidence of perioperative myocardial infarction (4.3% vs. 1.4%, p=0.1) and a statistically significant reduction in the time of surgery (275±59.5 minutes vs. 246±72.6 minutes, p < 0.001).

Conclusion: total arterial minimally invasive coronary artery bypass grafting is a feasible surgical approach that can yield excellent results even during the initial learning phase. An evolving educational program can facilitate a smooth transition from off-pump coronary artery bypass grafting to minimally invasive coronary artery bypass grafting in selected patients at highly specialized cardiac surgery centers.

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