Single-vessel revascularization with minimally invasive direct coronary artery bypass: minithoracotomy or ministernotomy?

Study Objectives: To compare the early outcome in patients who underwent off-pump single-vessel revascularization of the left anterior descending coronary artery (LAD) using two different approaches of minimally invasive direct coronary artery bypass grafting (MIDCAB): left anterior small thoracotomy (LAST) and lower ministernotomy.

Design: A retrospective analysis of the medical records on length of the skin incision, total operation time, duration of mechanical ventilation, blood transfusion rate, ICU stay, postoperative wound pain, and morbidities.

Patients: Thirty-two patients who underwent MIDCAB with the left internal thoracic artery to the LAD for single-vessel disease were studied. LAST was performed in 16 patients, and ministernotomy was performed in 16 patients. For the ministernotomy approach, the lower half of the sternum was split without transverse division, which we called the lower-end sternal splitting (LESS) approach. Postoperative pain was evaluated using a face-rating scale (scale, 1 to 6).

Results: There were no significant differences between the two groups in length of the skin incision, duration of mechanical ventilation, and ICU stay. Total operation time was shorter in the LESS group than in the LAST group (p < 0.05). No patients received a blood transfusion in either group. Atrial fibrillation developed in one patient in the LAST group and two patients in the LESS group. Early graft potency was 94% in the LAST group and 100% in the LESS group (p = 0.48). In the LAST group, subcutaneous emphysema developed in three patients and superficial wound dehiscence developed in two patients, but these complications were not observed in the LESS group (p < 0.05). Postoperative pain was significantly higher in the LAST group up to postoperative day 7 (p < 0.05).

Conclusions: Although LAST is the most commonly used approach for MIDCAB, wound complications and postoperative pain with this technique are not insignificant compared with the lower ministernotomy approach.