Comparison of clinical effects of coronary artery bypass grafting between left anterior small thoracotomy approach and lower-end sternal splitting approach

Abstract

Objective

To compare the clinical effects of coronary artery bypass grafting (CABG) between the left anterior small thoracotomy (LAST) and lower-end sternal splitting (LESS) approaches for coronary artery disease.

Methods

In total, 110 patients who underwent LAST from October 2015 to December 2020 in Tianjin Chest Hospital were selected as the observation group. Patients who underwent the LESS approach during the same period were analyzed. The propensity score was calculated by a logistic regression model, and nearest-neighbor matching was used for 1:1 matching.

Results

The length of hospital stay and ventilator support time were significantly shorter in the LAST than LESS group. The target vessels in the obtuse marginal branch and posterior left ventricular artery branch grafts were significantly more numerous in the LAST than LESS group, but those in the right coronary artery graft were significantly less numerous in the LAST group.

Conclusions

CABG using either the LAST or LESS approach is safe and effective, especially in low-risk patients. The LAST approach can achieve complete revascularization for multivessel lesions and has the advantages of less trauma and an aesthetic outcome. However, it requires a certain learning curve to master the surgical techniques and has specific surgical indications.

Keywords

Coronary artery disease minimally invasive coronary artery bypass grafting surgery left anterior small thoracotomy lower-end sternal splitting revascularization multivessel lesion

Introduction

Coronary artery disease is a major threat to human health. The first reports on successful aortocoronary bypass operations for the treatment of coronary artery disease were published in the early 1960s.¹ Since that time, coronary artery bypass grafting (CABG) has become one of the most frequently performed operations worldwide and has been continuously refined and developed.² Traditional CABG surgery is performed through a midsternal incision assisted by cardiopulmonary bypass, which is traumatic and requires a long postoperative recovery time.³ In 1996, Calafiore et al.⁴ first described anastomosis between the left internal mammary artery (LIMA) and the left anterior descending coronary artery (LAD) via left anterior small thoracotomy (LAST) on the beating heart. Niinami et al.⁵ subsequently introduced off-pump CABG by the lower-end sternal splitting (LESS) approach. Since then, minimally invasive CABG has been gaining wide acceptance in clinical practice. With the development of minimally invasive techniques in cardiac surgery in recent years, off-pump CABG, the LAST approach, the LESS approach, and other forms of minimally invasive CABG have evolved to minimize the surgical trauma associated with CABG. Minimally invasive CABG has the advantages of minimal surgical trauma and a short postoperative hospital stay.⁶ However, no studies to date have compared the surgical outcomes between different minimally invasive procedures. This study was performed to retrospectively compare and analyze the clinical data of 110 patients who underwent CABG by the LAST approach at Tianjin Chest Hospital and 110 patients who underwent CABG by the LESS approach after matching. The objective was to explore the safety and clinical efficacy of these two surgical modalities in the treatment of coronary heart disease.

Methods

General data

In this retrospective study, 110 patients who underwent CABG by the LAST approach from October 2015 to December 2020 at Tianjin Chest Hospital were selected as the observation group (LAST group). The identification of all patients’ details has been de-identified. The study flow chart is shown in Figure 1.

Figure 1.

Flow chart.

The inclusion criteria were a diagnosis of coronary artery disease by coronary angiography, >75% stenosis of the coronary artery lumen, inability to undergo interventional treatment, and failure of drug treatment. The exclusion criteria were more extensive: unstable hemodynamics potentially requiring surgery under cardiopulmonary bypass (CPB); emergency CABG; severe emphysema or chronic obstructive pulmonary disease with hypoxemia (PaO₂ <60 mmHg or PaCO₂ >40 mmHg without oxygen inhalation, 1 mmHg = 0.133 kPa); old myocardial infarction with little or no viable myocardium as indicated by isotope imaging, cardiac magnetic resonance imaging, or echocardiography; left ventricular enlargement with cardiac dysfunction (left ventricular ejection fraction (LVEF) of <40%, left ventricular end-diastolic diameter (LVEDD) of >70 mm, left ventricular aneurysm, or septal perforation); severe left pleural adhesion caused by chest radiotherapy; a history of surgery for thoracic deformity such as pectus excavatum or severe scoliosis; moderate obesity (body mass index (BMI) of >35 kg/m²); a history of cardiac surgery by median sternotomy; simultaneous valvular surgery or other intracardiac surgery; severe calcification of the ascending aorta on preoperative chest computed tomography (CT); and severe coronary calcification or myocardial bridging on preoperative coronary angiography.

The data of all 206 patients who underwent CABG by the LESS approach during the same period were collected, and propensity score matching was applied. Sex, age, BMI, LVEF, degree of coronary vascular disease according to the LVEDD, smoking, diabetes, hypertension, chronic obstructive pulmonary disease, history of stroke, and history of myocardial infarction were matched 1:1 with patients who underwent CABG by the LAST approach using nearest-neighbor matching. After matching, 110 patients who underwent CABG by the LESS approach were selected as the control group.

Surgical methods

LAST group

All patients in the LAST group underwent chest CT, pulmonary function testing, great saphenous vein ultrasound, internal mammary artery ultrasound, upper limb artery ultrasound, and neck artery ultrasound before the operation. After combined inhalation and intravenous anesthesia, right single-lung ventilation was performed using a double-lumen endotracheal tube or a bronchial blocker. The patients were placed in the supine position with the left chest elevated at 20 to 30 degrees. Paravertebral nerve block anesthesia was performed before the operation to relieve postoperative pain. A left anterior external incision was made in the fourth or fifth intercostal space at the midclavicular line underneath the nipple, and the length of the incision was approximately 7 to 9 cm. The incision was exposed with minimally invasive retractors, and LIMA harvesting extended from the first to fifth intercostal space (Figure 2). If necessary, the great saphenous vein was obtained by endoscopy. Minimally invasive lateral wall forceps combined with special exposure methods were used to complete the proximal graft anastomosis (Figures 3 and 4). Handsewn proximal anastomoses of the ascending aorta were performed after completion of the distal anastomosis of the LIMA to the LAD. We applied a minimally invasive distractor, pericardial traction wire suspension, apical aspirator, and suction cup stabilizer to fully expose the target vessel position. After dissection of the coronary artery, a coronary artery shunt was inserted and the distal anastomosis of the bridge vessel was completed under routine off-pump CABG (Figure 5).

Figure 2.

LAST incision. LAST, left anterior small thoracotomy.

Figure 3.

Proximal graft anastomosis.

Figure 4.

Distal end of the graft.

Figure 5.

LAST surgical panorama. LAST, left anterior small thoracotomy.

LESS group

After administration of combined intravenous and inhalation anesthesia, the patients in the LESS group were conventionally intubated in the supine position. A median sternal incision was made approximately 2 cm below the manubrium of the sternum, extending to the base of the xiphoid process. The length of the incision was approximately 10 to 14 cm. The xiphoid process was then removed. A bottom-up saw was used to open the sternum to the second intercostal space. The left hemi-sternum was transected to the right along the lower border of the second rib on the left, making the sternal incision in an inverted “L” shape. The LIMA was obtained by routine methods. When anastomosing the proximal end of the graft, a lateral wall clamp was placed in the opposite direction, and part of the wall of the ascending aorta was clamped. The remaining procedures were the same as those for conventional midsternal CABG. A comparison of the postoperative wounds between the two procedures is shown in Figures 6 and 7.

Figure 6.

LAST incision length. LAST, left anterior small thoracotomy.

Figure 7.

LESS incision. LESS, lower-end sternal splitting.

Observation indicators

The observation indicators in this study were the hospital stay, postoperative hospital stay, intensive care unit stay, ventilator support time, postoperative LVEF, postoperative LVEDD, average number of anastomoses, secondary intubation, secondary thoracotomy, postoperative wound infection, sternal complications, postoperative atrial fibrillation, postoperative pulmonary infection, target vessel location, and major adverse cardiac and cerebrovascular events (MACCE).

Postoperative re-examination and follow-up

Myocardial enzymes, electrocardiography, echocardiography, and coronary CT angiography (CTA) were routinely reviewed after the operation. After discharge, the patient’s MACCE status was recorded by telephone or outpatient review. One year after surgery, coronary CTA was performed to evaluate the patency of the bridge vessels.

Statistical analysis

SPSS 26.0 statistical software (IBM Corp., Armonk, NY, USA) was used for data analysis. The propensity score was calculated by a logistic regression model, and nearest-neighbor matching was used to conduct 1:1 matching between the LAST group and LESS group. Measurement data are expressed as mean ± standard deviation. The two-sample t-test was used for continuous variables that conformed to a normal distribution, the rank sum test was used for continuous variables that did not conform to a normal distribution, and the two-sample nonparametric test was used for discontinuous variables. Count data are presented as number (percentage), and the χ² test was used for comparison between groups. Fisher’s exact probability method was used for comparison when the minimum theoretical frequency was <1. A P value of <0.05 was considered statistically significant.

Results

Comparison of baseline data between the two groups

In total, 110 patients were enrolled in the observation group (LAST group), including 93 (84.5%) men. Their mean age was 60.6 ± 8.3 years, and their mean BMI was 24.5 ± 3.0 kg/m². There were 206 cases of lower sternal incision bypass. Before matching, the proportion of men in the LAST group was lower than that in the LESS group (75.7% vs. 86.7%, respectively; P = 0.037), and the proportion of patients with hypertension in the LAST group was higher than that in the LESS group (60.9% vs. 43.6%, respectively; P = 0.020). After propensity score matching, 110 patients were selected as the control group (LESS group), and after matching, there was no significant difference in the baseline data between the two groups (Table 1).

Table 1.

Comparison of baseline data between the two groups after matching.

	LAST (n = 110)	LESS (n = 110)	t/χ²	P
Male sex	93 (84.5)	80 (72.7)	4.573	0.032
Age, years	60.6 ± 8.3	61.0 ± 9.6	−0.384	0.702
BMI, kg/m²	25.4 ± 3.0	25.7 ± 3.2	−0.813	0.417
Smoking	49 (44.5)	59 (53.6)	1.819	0.177
Hypertension	60 (54.5)	70 (63.6)	1.880	0.170
Diabetes	28 (25.5)	21 (19.1)	1.287	0.257
Stroke history	9 (8.2)	15 (13.6)	1.684	0.194
COPD	1 (0.9)	3 (2.7)	0.255	0.614
History of MI	23 (20.9)	26 (23.6)	0.236	0.627
LVEF	61.4 ± 5.3	60.8 ± 6.5	0.683	0.495
LVEDD, mm	50.0 ± 3.5	50.8 ± 3.8	−1.634	0.104
Number of diseased vessels	2.20 ± 1.01	1.97 ± 0.90	1.757	0.080
LAD lesion	109 (99.1)	108 (98.2)	0.000	>0.99

Data are presented as n (%) or mean ± standard deviation.

LAST, left anterior small thoracotomy; LESS, lower-end sternal splitting; BMI, body mass index; COPD, chronic obstructive pulmonary disease; MI, myocardial infarction; LVEF, left ventricular ejection fraction; LVEDD, left ventricular ejection fraction; LAD, left anterior descending artery.

Perioperative data

Two in-hospital deaths occurred during hospitalization in the LAST group, and one in-hospital death occurred during hospitalization in the LESS group. There were two cases of perioperative myocardial infarction in each group during hospitalization, two cases of cerebrovascular accidents in each group after the operation, and no revascularization in either group. There was no significant difference in the proportion of perioperative MACCE between the two groups.

The proportion of Y-grafts in the LAST group was higher than that in the LESS group (χ² = 13.149, P = 0.001). The length of the hospital stay in the LAST group was significantly shorter than that in the LESS group (χ² = 2.255, P = 0.025). The ventilator support time in the LAST group was significantly shorter than that in the LESS group (χ² = 2.875, P = 0.004). The visual analogue scale scores were lower in the LAST group than those in the LESS group (χ² = −6.949, P <0.01). The volume of postoperative chest drainage and blood transfusion in the LAST group were lower than those in the LESS group (χ² = −9.528, P <0.01). There were no significant differences between the two groups in the postoperative hospital stay, intensive care unit duration, postoperative LVEF, postoperative left ventricular end-diastolic volume, mean number of grafts, secondary intubation, secondary thoracotomy, postoperative wound infection, sternal complications, postoperative atrial fibrillation, and postoperative pulmonary infection (Table 2).

Table 2.

Comparison of perioperative data between the two groups after matching.

	LAST (n = 110)	LESS (n = 110)	t/χ²	P	OR	95% CI
Radial artery grafts	25 (22.7)	19 (17.3)	1.023	0.312	0.710	[0.365, 1.381]
Y-grafts	38 (34.5)	15 (13.6)	13.149	<0.01	0.299	[0.153, 0.586]
Sequential grafts	30 (27.3)	20 (18.2)	2.588	0.108	0.593	[0.312, 1.125]
Hospital stay, days	14.4 ± 6.6	13.2 ± 4.0	1.608	0.110
Postoperative hospital stay, days	8.6 ± 6.3	10.5 ± 3.4	−2.780	0.006
ICU stay, hours	66.2 ± 42.7	57.4 ± 19.5	1.963	0.051
Ventilator support time, hours	17.6 ± 15.5	21.3 ± 8.5	−2.229	0.027
Postoperative LVEF	58.4 ± 5.0	57.6 ± 3.1	1.455	0.147
Postoperative LVEDD, mm	48.2 ± 3.7	48.3 ± 2.9	−0.121	0.903
Average number of anastomoses	1.6 ± 0.7	1.5 ± 0.5	1.578	0.116
Secondary intubation	7 (6.4)	3 (2.7)	1.676	0.195	0.413	[0.104, 1.639]
Secondary thoracotomy	6 (5.5)	2 (1.8)	1.167	0.280	0.321	[0.063, 1.627]
Postoperative wound infection	5 (4.5)	1 (0.9)	1.542	0.214	0.193	[0.022, 1.677]
Sternal complications	0 (0.0)	2 (1.8)	0.505	0.477
Postoperative atrial fibrillation	14 (12.7)	17 (15.5)	0.338	0.561	1.253	[0.585, 2.687]
Postoperative pulmonary infection	14 (12.7)	18 (16.4)	0.585	0.444	1.342	[0.631, 2.854]
MACCE	7 (6.4)	6 (5.5)	0.082	0.775	0.849	[0.279, 2.612]
In-hospital death	1 (0.9)	1 (0.9)	0.000	>0.99	1.000	[0.062, 16.192]
Perioperative myocardial infarction	5 (4.5)	5 (4.5)	0.000	>0.99	1.000	[0.281, 3.556]
Postoperative stroke	2 (1.8)	0 (0.0)	0.505	0.477
VAS score	2.7 ± 0.7	3.4 ± 0.7	−6.949	<0.01
Chest drainage volume, mL	181.2 ± 90.6	315.8 ± 117.3	−9.528	<0.01
Postoperative blood transfusion, U	0.9 ± 0.7	1.2 ± 1.0	−2.566	0.011
Revascularization	0 (0.0)	0 (0.0)	–	–
Emergent CPB conversion	0 (0.0)	0 (0.0)
Conversion to thoracotomy	0 (0.0)	0 (0.0)

Data are presented as n (%) or mean ± standard deviation.

LAST, left anterior small thoracotomy; LESS, lower-end sternal splitting; OR, odds ratio; CI, confidence interval; ICU, intensive care unit; LVEF, left ventricular ejection fraction; LVEDD, left ventricular end-diastolic diameter; MACCE, major adverse cardiac and cerebrovascular event; VAS, visual analogue scale; CPB, cardiopulmonary resuscitation.

Target vessel distribution

There was no significant difference in the distribution of target vessels in the LAD, diagonal branch, and posterior descending artery branch between the two groups. The target vessels in the obtuse marginal branch and posterior left ventricular artery branch were significantly more numerous in the LAST group than in the LESS group, and the target vessels in the right coronary artery were significantly more numerous in the LESS group than in the LAST group (Table 3).

Table 3.

Comparison of target vessel distribution between the two groups after matching.

	LAST (n = 110)	LESS (n = 110)	χ²	P	OR	95% CI
LAD	109 (99.1)	107 (97.3)	0.255	0.614	3.056	[0.034, 3.195]
DIAG	16 (14.5)	16 (14.5)	0.000	>0.99	1.000	[0.473, 2.116]
OM	31 (28.2)	0 (0.0)	36.085	<0.01
PDA	13 (11.8)	12 (10.9)	0.045	0.832	0.914	[0.397, 2.102]
PLA	9 (8.2)	0 (0.0)	7.414	0.006
RCA	0 (0.0)	7 (6.4)	5.312	0.021

Data are presented as n (%).

LAST, left anterior small thoracotomy; LESS, lower-end sternal splitting; OR, odds ratio; CI, confidence interval; LAD, left anterior descending artery; DIAG, diagonal branch; OM, obtuse marginal branch; PDA, posterior descending artery; PLA, posterior left ventricular artery; RCA, right coronary artery.

Graft patency

Postoperative CTA examination was performed in all patients at the 1-year follow-up. The obtuse branch vein graft was occluded in one patient in the LAST group; however, the remaining bridging vessels were unobstructed in both groups. In the LESS group, one patient with angina pectoris was examined by coronary angiography, and the bridging vessels were patent. Symptoms were relieved after drug treatment.

Discussion

Coronary artery disease is still a major threat to the health of Chinese people. Between 1990 and 2017, approximately 38.2% of the increase in ischemic heart disease-related deaths worldwide occurred in China, with China having the largest increase in the number of deaths over the study period compared with other countries.⁷ Since the development of CABG in the 1960 s, this technique remains the first-choice treatment for complex coronary artery disease after decades of development.¹ Traditional bypass surgery by median thoracotomy is highly traumatic, and postoperative complications such as pain, poor sternal healing, mediastinal infection, and pulmonary infection often occur.⁸ As technology has continued to develop, minimally invasive direct CABG has rapidly advanced, including LESS CABG, video-assisted CABG, LAST CABG, robot-assisted CABG, and hybrid surgery.⁹

Niinami et al.⁵ introduced off-pump CABG by the LESS approach. LESS CABG has the following advantages. First, it is safe and minimally traumatic. Because the sternum is not completely broken, the stability of the thorax is maintained and the incidence of sternal dehiscence after surgery is reduced. Second, unlike LAST CABG, there is no need to open the pleural cavity, and lung collapse does not occur. Thus, lung function is protected in patients with poor lung function. Third, if necessary, the incision can be extended upward and the sternum can be completely split without an additional incision. Fourth, the internal mammary artery in the LESS approach is harvested from the same perspective as conventional CABG. This differs from LAST CABG, which requires a different surgical field of view and a relatively long learning curve. Finally, LESS CABG is characterized by a low incision position, short incision length, and highly aesthetic appearance. However, a disadvantage is the difficulty of exposing the left ventricular lateral wall through the LESS approach.⁴ Although some surgeons have improved the operation, such as by performing left transection of the second or third intercostal sternum, it is still difficult to expose the left ventricular lateral wall. This study showed that the target vessels in the obtuse marginal branch and posterior left ventricular artery branch were significantly more numerous in the LAST group than in the LESS group, confirming the findings reported in the literature.

Calafiore et al.⁴ first described LIMA-to-LAD anastomosis via the LAST approach on the beating heart in 1996. Since then, minimally invasive CABG has been gaining wide acceptance in clinical practice. LAST CABG has the following advantages: less trauma, less bleeding, faster recovery, an aesthetic incision, no damage to sternal integrity, less mediastinal infection, less cardiopulmonary bypass injury, and high patient acceptance. Thus, it has been rapidly developed and popularized in recent years.^10,11 Repossini et al.¹² reported 1060 patients who underwent internal mammary artery and anterior descending artery bypass grafting through the LAST approach, with a perioperative mortality rate of 0.8% and a 10-year survival rate of 84.3%. LAST CABG has demonstrated good clinical efficacy for single anterior descending artery disease, and it is the routine procedure for patients with isolated proximal LAD stenosis.^13,14 However, LAST CABG still has some contraindications, such as emergency operation, pectus excavatum, severe scoliosis, left pleural adhesion, a target vessel diameter of <1.5 mm, diffuse disease, severe calcification, and intramural position of the LAD.¹⁵

Internal mammary artery and anterior descending artery bypass grafting through the LAST approach has high patency, and the procedure can be performed at many cardiac centers. However, LAST CABG is still quite difficult in patients with multivessel coronary artery disease. Off-pump minimally invasive CABG using total arterial revascularization with the bilateral internal thoracic arteries is reportedly a feasible and safe operation associated with excellent short-term outcomes and early graft patency.¹⁶ However, because of the limitation of the internal mammary artery length and number, it is still quite difficult to achieve complete minimally invasive revascularization for patients with multivessel disease. The limited accessibility of the aorta during LAST CABG makes it difficult to perform proximal anastomoses for additional grafts. Minimally invasive cardiac surgery CABG (MICS CABG) was first introduced in 2005 by McGinn et al.¹⁷ for multivessel coronary disease as a modified version of minimally invasive direct vision coronary artery bypass (MIDCAB) from 1990. Research has proven that in selected patients, MICS CABG can be safely initiated as a minimally invasive, multivessel alternative to open surgical coronary revascularization with excellent midterm results.^18,19 In the present study, complete revascularization of multivessel lesions by LAST CABG was achieved by proximal ascending aorta anastomosis and Y-type anastomosis or sequential graft anastomosis in patients who were strictly screened before surgery.

In multivessel LAST CABG, the proximal anastomoses are technically difficult because of the small surgical space and the long distance of the ascending aorta from the incision. After reviewing the literature and current surgical practice, we can summarize the following points of proximal anastomoses. First, the fat outside the pericardium and thymus should be removed to avoid interference with the surgical field. Second, the ascending aorta is mobilized outward and upward using several 2-0 silk stitches on the pericardium near the ascending aorta. Third, gauze is placed on the lower right side of the ascending aorta to reduce the distance between the aorta and the incision. Fourth, the systolic blood pressure is controlled at 80 to 90 mmHg with medication and volume management. Fifth, the pulmonary artery or right ventricular outflow tract is displaced leftward and posteriorly using a stabilizer. Sixth, maintaining relatively low right ventricular filling pressure and gradually increasing the right lung positive end-expiratory pressure makes the ascending aorta more approachable.²⁰ Finally, after dissection between the aorta and the pulmonary artery, a side-biting clamp is placed on the ascending aorta. Proximal anastomosis can be performed after completion of the distal anastomosis of the LIMA to the LAD. After proximal anastomoses are performed, the free flow of the vein/radial grafts should be checked to confirm adequate blood flow.²⁰

Among studies that reported the clinical outcomes of LAST CABG, the perioperative mortality rate ranged from 0.0% to 1.3%, the perioperative stroke rate ranged from 0.0% to 0.4%, and the conversion rate ranged from 0.0% to 6.7%.^17,19,21,22 Another report indicated that the rate of conversion to sternotomy was 3.8%, and the risk factors for conversion to sternotomy included smoking, preoperative bradycardia (<50 beats per minute), low intraoperative LVEF, inability to tolerate one-lung ventilation, inadequate surgical exposure, and hemodynamic instability.²³ The rate of emergent CPB conversion was 1%, and such conversion is known to be associated with increased perioperative mortality in off-pump CABG.²³ Factors influencing the elective use of CPB were diabetes, triple-vessel disease, left circumflex artery involvement, mild mitral regurgitation, small target vessels, and less use of coronary shunting.²³ In the present study, the cumulative incidence of MACCE in the LAST group was 6.4%, the hospital mortality rate was 0.9%, the sternotomy conversion rate was 0.0%, and the emergent CPB conversion rate was 0.0%. There was no significant difference in the rate of MACCE between the LAST group and LESS group, which confirms that both minimally invasive bypass grafting methods are safe and feasible. Our data showed that the length of hospital stay and the ventilator support time were significantly shorter in the LAST group than LESS group, which confirmed the advantages of LAST CABG (such as less trauma and faster recovery).

In contrast to open surgery, manipulation of the heart through thoracotomy is far more challenging. This places an anatomical limitation on the extent of target vessels that can be reached, especially on the lateral and posterior sides of the heart. The present study showed that the LAST incision has an advantage over the LESS incision in exposing the circumflex and posterior ventricular branches as well as in exposing the obtuse marginal and posterior left ventricular artery branches. In LAST group, it was difficult to expose the main right coronary artery, but the posterior descending artery could be fully exposed.

Conclusion

We believe that CABG by both the LAST and LESS approaches is a safe and effective minimally invasive bypass procedure, and this finding is consistent with the previous literature.^24,25 LAST CABG can achieve complete revascularization of multivessel disease. Although it is technically difficult; has high requirements for surgical instruments, surgeon experience, and patient screening; and requires a certain learning curve to be widely applied, it has been proven safe and reliable in experienced large heart centers. The operative time reached an acceptable level at the 66th case in off-pump single-vessel small thoracotomy, the 16th case in CPB-assisted multivessel small thoracotomy, and the 40th case in off-pump multivessel small thoracotomy.²⁶ Although LAST CABG is associated with a steep learning curve and longer operation time, its benefits secondary to the avoidance of sternotomy outweigh the drawbacks.²⁰ Furthermore, with the development of surgical devices, multivessel LAST CABG has become possible. LAST CABG will likely become widely adopted as an important option for treating multivessel coronary artery disease. The reporting of this study conforms to the STROBE guidelines.²⁷

Because this was a retrospective study with a small sample size, the treatment effect of the two minimally invasive CABG techniques needs to be further expanded and confirmed by randomized controlled studies. Notably, these techniques do not affect morbidity and mortality.

Supplemental Material

sj-pdf-1-imr-10.1177_03000605241247656 - Supplemental material for Comparison of clinical effects of coronary artery bypass grafting between left anterior small thoracotomy approach and lower-end sternal splitting approach

Supplemental material, sj-pdf-1-imr-10.1177_03000605241247656 for Comparison of clinical effects of coronary artery bypass grafting between left anterior small thoracotomy approach and lower-end sternal splitting approach by Li Jinghui, Yang Yin, Muhetaer Xiaokaitijiang, Tang Yipeng, Wang Lianqun, Bai Yunpeng, Zhang Zhejun, Jiang Nan, Wang Qiang, Chen Qingliang, Xu Dong, Yang Dongyan, Guo Zhigang and Zhao Feng in Journal of International Medical Research

Supplemental Material

sj-pdf-2-imr-10.1177_03000605241247656 - Supplemental material for Comparison of clinical effects of coronary artery bypass grafting between left anterior small thoracotomy approach and lower-end sternal splitting approach

Supplemental material, sj-pdf-2-imr-10.1177_03000605241247656 for Comparison of clinical effects of coronary artery bypass grafting between left anterior small thoracotomy approach and lower-end sternal splitting approach by Li Jinghui, Yang Yin, Muhetaer Xiaokaitijiang, Tang Yipeng, Wang Lianqun, Bai Yunpeng, Zhang Zhejun, Jiang Nan, Wang Qiang, Chen Qingliang, Xu Dong, Yang Dongyan, Guo Zhigang and Zhao Feng in Journal of International Medical Research

Footnotes

Conflicts of interest

The authors declare that there are no conflicts of interest.

Ethical statement

The authors are accountable for all aspects of the work, including ensuring that any questions related to the accuracy or integrity of any part of the work have been appropriately investigated and resolved. All the procedures performed in this study were conducted in accordance with the ethical standards of the institutional and/or national research committees and with the Helsinki Declaration (as revised in 2013). The study protocol was approved by the Ethics Review Committee of Tianjin Chest Hospital (2023YS-020-1). All patients provided verbal informed consent.

Funding

This work was funded by the Tianjin Key Medical Discipline (Specialty) Construction Project (TJYXZDXK-042A), the Tianjin Health Science and Technology Project (TJWJ2022QN070 and ZC20147), and the Tianjin Science and Technology Program (No. 22JCYBJC01440).

ORCID iD

Tang Yipeng

References

Melly

Torregrossa

Lee

, et al. Fifty years of coronary artery bypass grafting. J Thorac Dis 2018; 10: 1960–1967.

Gaudino

Bakaeen

Davierwala

, et al. New strategies for surgical myocardial revascularization. Circulation 2018; 138: 2160–2168.

Mack

Squiers

Lytle

, et al. Myocardial revascularization surgery: JACC historical breakthroughs in perspective. J Am Coll Cardiol 2021; 78: 365–383.

Calafiore

Giammarco

Teodori

, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg 1996; 61: 1658–1663. discussion 64-5.

Niinami

Takeuchi

Ichikawa

, et al. Partial median sternotomy as a minimal access for off-pump coronary artery bypass grafting: feasibility of the lower-end sternal splitting approach. Ann Thorac Surg 2001; 72: S1041–S1045.

Davierwala

Verevkin

Bergien

, et al. Twenty-year outcomes of minimally invasive direct coronary artery bypass surgery: the Leipzig experience. J Thorac Cardiovasc Surg 2023; 165: 115–127.e4.

Dai

Much

Maor

, et al. Global, regional, and national burden of ischaemic heart disease and its attributable risk factors, 1990-2017: results from the Global Burden of Disease Study 2017. Eur Heart J Qual Care Clin Outcomes 2022; 8: 50–60.

Fearon

Zimmermann

De Bruyne

; FAME 3 Investigatorset al. Fractional flow reserve-guided PCI as compared with coronary bypass surgery. N Engl J Med 2022; 386: 128–137.

Gofus

Cerny

Shahin

, et al. Robot-assisted vs. conventional MIDCAB: a propensity-matched analysis. Front Cardiovasc Med 2022; 9: 943076.

10.

Nesbitt

Mori

Mason-Apps

, et al. Comparison of early and late quality of life between left anterior thoracotomy and median sternotomy off-pump coronary artery bypass surgery. Perfusion 2017; 32: 50–56.

11.

Teman

Hawkins

Charles

; Investigators for the Virginia Cardiac Services Quality Initiativeet al. Minimally invasive vs open coronary surgery: a multi-institutional analysis of cost and outcomes. Ann Thorac Surg 2021; 111: 1478–1484.

12.

Repossini

Di Bacco

Nicoli

, et al. Minimally invasive coronary artery bypass: twenty-year experience. J Thorac Cardiovasc Surg 2019; 158: 127–138 e1.

13.

Tekin

Aİ

Arslan

Ü.

Perioperative outcomes in minimally invasive direct coronary artery bypass versus off-pump coronary artery bypass with sternotomy. Wideochir Inne Tech Maloinwazyjne 2017; 12: 285–290.

14.

Seo

Kim

Park

, et al. Mid-term results of minimally invasive direct coronary artery bypass grafting. Korean J Thorac Cardiovasc Surg 2018; 51: 8–14.

15.

Van Praet

Kofler

Shafti

TZN

, et al. Minimally invasive coronary revascularisation surgery: a focused review of the available literature. Interv Cardiol 2021; 16: e08.

16.

Davierwala

Verevkin

Sgouropoulou

, et al. Minimally invasive coronary bypass surgery with bilateral internal thoracic arteries: early outcomes and angiographic patency. J Thorac Cardiovasc Surg 2021; 162: 1109–1119.e4.

17.

McGinn

Jr Usman

Lapierre

, et al. Minimally invasive coronary artery bypass grafting: dual-center experience in 450 consecutive patients. Circulation 2009; 120: S78–84.

18.

Ling

Cui

, et al. Feasibility and safety of minimally invasive cardiac coronary artery bypass grafting surgery for patients with multivessel coronary artery disease: early outcome and short-mid-term follow up results. Beijing Da Xue Xue Bao Yi Xue Ban 2020; 52: 863–869.

19.

Rodriguez

Lapierre

Sohmer

, et al. Mid-term follow-up of minimally invasive multivessel coronary artery bypass grafting: is the early learning phase detrimental? Innovations (Phila) 2017; 12: 116–120.

20.

Une

Sakaguchi

Initiation and modification of minimally invasive coronary artery bypass grafting. Gen Thorac Cardiovasc Surg 2019; 67: 349–354.

21.

Lapierre

Chan

Sohmer

, et al. Minimally invasive coronary artery bypass grafting via a small thoracotomy versus off-pump: a case-matched study. Eur J Cardiothorac Surg 2011; 40: 804–810.

22.

Ruel

Shariff

Lapierre

, et al. Results of the minimally invasive coronary artery bypass grafting angiographic patency Study. J Thorac Cardiovasc Surg 2014; 147: 203–208.

23.

Rodriguez

Lapierre

Sohmer

, et al. Predictors and outcomes of sternotomy conversion and cardiopulmonary bypass assistance in minimally invasive coronary artery bypass grafting. Innovations (Phila) 2016; 11: 315–320.

24.

Niinami

Ogasawara

Suda

, et al. Single-vessel revascularization with minimally invasive direct coronary artery bypass: minithoracotomy or ministernotomy? Chest 2005; 127: 47–52.

25.

Martinovic

Lindemann

Irqsusi

, et al. Minimally invasive direct coronary bypass surgery via distal mini-sternotomy: promising clinical results with an aortic, multivessel, all-arterial technique. Herz 2019; 44: 666–672.

26.

Une

Lapierre

Sohmer

, et al. Can minimally invasive coronary artery bypass grafting be initiated and practiced safely? A learning curve analysis. Innovations (Phila) 2013; 8: 403–409.

27.

Von Elm

Altman

Egger

, STROBE Initiativeet al. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Ann Intern Med 2007; 147: 573–577.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

1.34 MB

0.25 MB