Minimally Invasive Multivessel Coronary Surgery Avoiding Sternotomy: Early Results of Total Coronary Revascularization via Left Anterior Thoracotomy (TCRAT)

Background: Avoidance of sternotomy while preserving the key principle of complete revascularization remains challenging in the vast majority of multivessel coronary disease patients. Recently, Babliak et al proposed a novel minithoracotomy approach as a standard technique for unselected patients and named it “total coronary revascularization via left anterior thoracotomy” (TCRAT). We present our early experience with this technique.

Method: From 11/2019 to 9/2021, CABG via left anterior minithoracotomy on cardiopulmonary bypass (peripheral cannulation) and cardioplegic cardiac arrest (transthoracic aortic cross-clamping) was successfully performed in 102 patients (92 males; 67 ± 10 [42–87] years). Another three patients were converted to sternotomy intraoperatively. Slings placed around ascending aorta, left pulmonary veins and inferior vena cava for exposure of lateral and inferior ventricular wall enabled reproducible standard anastomotic techniques. All patients had multivessel coronary disease with indication to surgical revascularization (three-vessel: n = 72; two-vessel: n = 30; left main stenosis: n = 44). We included patients at old age (> 80 years: 14.7%), with severe left ventricular dysfunction (EF < 30%: 6.9%), massive obesity (BMI > 35: 11.6%), chronic lung disease (11.8%), and at increased risk (EuroSCORE II > 4: 15.7%).

Results: Left internal thoracic artery (n = 101), radial artery (n = 83), and saphenous vein (n = 39) grafts were used for total (61.8%) or multiple (19.6%) arterial grafting in most cases. A total of 323 distal anastomoses (3.2 ± 0.7 [2–5] per patient) were performed to revascularize the territories of left anterior descending (100%), circumflex (91.2%), and right (67.7%) coronary artery. Complete revascularization was achieved in 95.1%. Hospital mortality was 2.9%, stroke rate was 0.9%, myocardial infarction rate was 2.9%, and repeat revascularization rate was 1.9%. ICU-stay was ≤1 day in 67.7% of patients, and 65.7% of patients left the hospital within 8 days after the operation.

Conclusion: This novel surgical technique allows complete coronary revascularization in the broad majority of multivessel disease patients without sternotomy, and it can be introduced into clinical routine safely. Long-term results remain to be investigated. Respecting sternal integrity might enhance both patients and cardiologists acceptance to coronary surgery significantly.

Publication History

Article published online:
03 February 2022