Left thoracotomy for coronary artery bypass grafting in patients with CAD

Aim: To assess the immediate and long-term results of patients undergoing off-pump coronary artery bypass grafting through left antero-lateral thoracotomy.

Methods: Medical records of 1,178 patients referred to elective cardiac surgery at the Federal Center for High Medical Technologies in the period from September 2012 to June 2023 were retrospectively reviewed. All patients underwent off-pump CABG through left antero-lateral thoracotomy. Men (n=946; 80.3%) prevailed in the study population. The mean age of patients was 64.3±15.4 years. A large proportion of patients suffered from class 2 (n=387; 32.8%) and class 3 (n=691; 58.6%) angina. A positive history of postinfarction cardiosclerosis was detected in 694 (66.2%) patients. Almost half of them were present with polyvascular diseases, including 182 (15,4%) patients with atherosclerotic lesions of the brachiocephalic arteries and 161 (13,6%) patients with peripheral artery disease and renal artery stenosis. 627 (53.2%) patients underwent hybrid procedures. Subclavian artery revascularization was performed in 13 (1.1%) patients. All the patients received a risk stratification based on the EuroSCORE II (2.2±1.1%). Early mortality, postoperative complications, and mid-term outcomes were assessed.

Results: All patients (1,178 patients) underwent off-pump CABG through left antero-lateral thoracotomy. Of them, 627 patients underwent CABG as a stage of hybrid procedure. Four (0.3%) patients required conversion to full sternotomy. The mean length of stay in the ICU was 1.1 days. The mean lengths of the in-hospital stay – 5.9 days. Thirteen (1.1%) patients had early postoperative bleeding that required re-exploration. Twentynine (2,5%) patients had atrial fibrillation treated with antiarrhythmic drugs. Superficial incisional infection occurred in 8 (0.7%) patients. In-hospital mortality was 0.7% (n=8). The mid-term follow-up period was up to 56±7 months. 161 patients (13.6%) were followed up. Elective percutaneous coronary intervention was performed in 15 (9.3%) patients. None of the patients underwent CABG. Three (1.8%) patients suffered from stroke, 6 (3.7%) – from myocardial infarction. Five (3.1%) patients died.

Conclusion: Off-pump coronary artery bypass grafting through left antero-lateral thoracotomy is associated with favorable immediate and long-term outcomes in patients with coronary artery disease undergoing isolated LAD revascularization or hybrid procedure for multivessel or polyvascular diseases.

1. Demographic Yearbook of Russia. Moscow; 2017. 263 p. (In Russ.)

2. Lemma M, Atanasiou T, Contino M. Minimally invasive cardiac surgery-coronary artery bypass graft. Multimed Man Cardiothorac Surg. 2013;2013:mmt007. doi:10.1093/mmcts/mmt007

3. Halkos ME, Vassiliades TA, Myung RJ, et al. Sternotomy versus nonsternotomy LIMA-LAD grafting for singlevessel disease. Ann Thorac Surg. 2012;94(5):1469-1477. doi:10.1016/j.athoracsur.2012.05.049

4. Kolesov VI. The first experience in the treatment of angina pectoris by applying corono-systemic vascular fistulas. Cardiology 1967; 4: 20-25 (In Russ.)

5. Etienne PY, D'hoore W, Papadatos S, et al. Fiveyear follow-up of drug-eluting stents implantation vs minimally invasive direct coronary artery bypass for left anterior descending artery disease: a propensity score analysis. Eur J Cardiothorac Surg. 2013;44(5):884890. doi:10.1093/ejcts/ezt137

6. Cisowski M, Morawski W, Drzewiecki J, Bochenek A. Integrated Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) grafting and angioplasty for coronary artery revascularization. Heart Surg Forum. 2002;5 Suppl 4:S282-S295.

7. Kolesov VI. Mammary artery-coronary artery anastomosis as method of treatment for angina pectoris. J Thorac Cardiovasc Sug 1967; 54: 535-544.

8. Jaffery Z, Kowalski M, Weaver WD, Khanal S. A meta-analysis of randomized control trials comparing minimally invasive direct coronary bypass grafting versus percutaneous coronary intervention for stenosis of the proximal left anterior descending artery. Eur J Cardiothorac Surg. 2007;31(4):691-697. doi:10.1016/j.ejcts.2007.01.018

9. Kofidis T, Emmert MY, Paeschke HG, Emmert LS, Zhang R, Haverich A. Long-term follow-up after minimal invasive direct coronary artery bypass grafting procedure: a multi-factorial retrospective analysis at 1000 patient-years. Interact Cardiovasc Thorac Surg. 2009;9(6):990-994. doi:10.1510/icvts.2009.213900

10. Thiele H, Oettel S, Jacobs S, et al. Comparison of bare-metal stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery: a 5-year follow-up. Circulation. 2005;112(22):3445-3450. doi:10.1161/CIRCULATIONAHA.105.578492

11. Belov YuV. Coronary bypass surgery through mini-thoracotomy on a beating heart without cardiopulmonary bypass. Cardiology 1998; 8:12-18. (In Russ.)

12. Lemma MG, Coscioni E, Tritto FP, et al. Onpump versus off-pump coronary artery bypass surgery in high-risk patients: operative results of a prospective randomized trial (on-off study). J Thorac Cardiovasc Surg. 2012;143(3):625-631. doi:10.1016/j.jtcvs.2011.11.011

13. Yokoyama T, Baumgartner FJ, Gheissari A, Capouya ER, Panagiotides GP, Declusin RJ. Off-pump versus onpump coronary bypass in high-risk subgroups. Ann Thorac Surg. 2000;70(5):1546-1550. doi:10.1016/s00034975(00)01922-6

14. Bokeria LA, Berishvili II, Sigaev IYu. Minimally invasive myocardial revascularization. M: Publishing house of the NCSSH them. A.N. Bakuleva RAMN 2001. 276 p. (In Russ.)

15. Gorki H, Patel NC, Balacumaraswami L, Jennings J, Goksedef D, Subramanian VA. Long-Term Survival After Minimal Invasive Direct Coronary Artery Bypass (MIDCAB) Surgery in Patients With Low Ejection Fraction. Innovations (Phila). 2010;5(6):400-406. doi:10.1177/155698451000500604

16. Holzhey DM, Jacobs S, Mochalski M, et al. Minimally invasive hybrid coronary artery revascularization. Ann Thorac Surg. 2008;86(6):1856-1860. doi:10.1016/j.athoracsur.2008.08.034

17. Holzhey DM, Jacobs S, Mochalski M, et al. Sevenyear follow-up after minimally invasive direct coronary artery bypass: experience with more than 1300 patients. Ann Thorac Surg. 2007;83(1):108-114. doi:10.1016/j.athoracsur.2006.08.029

18. Jegaden O, Wautot F, Sassard T, et al. Is there an optimal minimally invasive technique for left anterior descending coronary artery bypass?. J Cardiothorac Surg. 2011;6:37. doi:10.1186/1749-8090-6-37

19. Kettering K. Minimally invasive direct coronary artery bypass grafting: a meta-analysis. J Cardiovasc Surg (Torino). 2008;49(6):793-800. DOI:10.1016/s0195668x(03)95973-2.

20. Calafiore AM, Giammarco GD, Teodori G, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg. 1996;61(6):1658-1665. doi:10.1016/0003-4975(96)00187-7

21. Repossini A, Tespili M, Saino A, et al. Hybrid coronary revascularization in 100 patients with multivessel coronary disease. Ann Thorac Surg. 2014;98(2):574-581. doi:10.1016/j.athoracsur.2014.04.101

22. Wittwer T, Cremer J, Boonstra P, et al. Myocardial "hybrid" revascularisation with minimally invasive direct coronary artery bypass grafting combined with coronary angioplasty: preliminary results of a multicentre study. Heart. 2000;83(1):58-63. doi:10.1136/heart.83.1.58

23. Sorm Z, Harrer J, Voborník M, Cermáková E, Vojácek J. Early and long-term results of minimally invasive coronary artery bypass grafting in elderly patients. Kardiol Pol. 2011;69(3):213-218.

24. Coulson AS, Glasgow EF, Bonatti J. Minimally invasive subclavian/axillary artery to coronary artery bypass (SAXCAB): review and classification. Heart Surg Forum. 2001;4(1):13-25.

25. Shneider YuA, Tsoi VG, Pavlov AA, Shilenko PA, Fomenko MS. Subclavian-coronary autovenous bypass grafting. Thoracic and cardiovascular surgery. 2020; 6: 557-562. (In Russ.) DOI:10.24022/0236-2791-2020-62-6557-562

26. Knight WL, Baisden CE, Reiter CG. Minimally invasive axillary-coronary artery bypass. Ann Thorac Surg. 1997;63(6):1776-1777. doi:10.1016/s00034975(97)00311-1

27. Tarakji AM, Sinclair MC. Should axillary artery to coronary artery bypass be part of the cardiac surgeon's armamentarium?. Eur J Cardiothorac Surg. 2007;32(1):65-68. doi:10.1016/j.ejcts.2007.03.046

28. Neumann FJ, Sousa-Uva M, Ahlsson A, et al. 2018 ESC/EACTS Guidelines on myocardial revascularization [published correction appears in Eur Heart J. 2019 Oct 1;40(37):3096]. Eur Heart J. 2019;40(2):87-165. doi:10.1093/eurheartj/ehy394

29. Shroyer AL, Hattler B, Wagner TH, et al. Five-Year Outcomes after On-Pump and Off-Pump Coronary-Artery Bypass. N Engl J Med. 2017;377(7):623-632. doi:10.1056/NEJMoa1614341

30. Lamy A, Devereaux PJ, Prabhakaran D, et al. Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year. N Engl J Med. 2013;368(13):1179-1188. doi:10.1056/NEJMoa1301228

31. Ganyukov VI, Tarasov RS, Shilov AA, Kochergin NA, Barbarash LS. Hybrid minimally invasive myocardial revascularization in multivessel coronary disease. Current status of the issue. Complex Issues of Cardiovascular Diseases. 2016;2:46-50. (In Russ.) https://doi.org/10.17802/2306-1278-2016-2-46-50]

32. Shneider YuA, Tsoi VG, Pavlov AA, Antipov GN, Patlai II, Akobyan TL et al. Hybrid myocardial revascularization. Thoracic and cardiovascular surgery. 2019; 61(1): 38-44. (In Russ.) DOI: 10.24022/0236-2791-2019-61-1-38-44.]

33. Holzhey DM, Cornely JP, Rastan AJ, Davierwala P, Mohr FW. Review of a 13-year single-center experience with minimally invasive direct coronary artery bypass as the primary surgical treatment of coronary artery disease. Heart Surg Forum. 2012;15(2):E61-E68. doi:10.1532/HSF98.20111141

34. Repossini A, Di Bacco L, Nicoli F, et al. Minimally invasive coronary artery bypass: Twenty-year experience. J Thorac Cardiovasc Surg. 2019;158(1):127-138.e1. doi:10.1016/j.jtcvs.2018.11.149

35. Davierwala PM, Verevkin A, Bergien L, et al. Twenty-year outcomes of minimally invasive direct coronary artery bypass surgery: The Leipzig experience. J Thorac Cardiovasc Surg. 2023;165(1):115- 127.e4. doi:10.1016/j.jtcvs.2020.12.149