Minimally invasive coronary artery bypass grafting on a beating heart

Background. We reviewed our experience with left internal mammary artery (LIMA)-to-left anterior descending artery (LAD) anastomosis on a beating heart through a left anterior small thoracotomy. Methods. This procedure was performed in 343 of 358 scheduled patients; in 15 (4.2%) the LAD was not suitable or was too small. The chest was opened in the fourth (127, 37.0%) or fifth (197, 57.4%) intercostal space, or both (19, 5.6%); the length of the harvested LIMA was 4–15 cm. The LAD was occluded by means of two 4-0 Prolene (Ethicon, Somerville, NJ) sutures, both snared on a small piece of silicone tubing. The anastomosis was performed with two 8-0 Prolene sutures. In the early postoperative period all patients underwent angiography or a doppler flow assessment of the LIMA or both. Results. In 310 patients the LIMA was connected directly to the LAD; to elongate the LIMA, in 30 patients an inferior epigastric artery and in 3 patients a saphenous vein was used. In 2 patients the diagonal branch was also grafted using an inferior epigastric artery from the LIMA. Three patients (0.9%) died during the first 30 days after the operation, and 4 other patients (1.2%) died after the first month. Twenty-five patients (7.3%) were reoperated on because of anastomotic or conduit failure, 18 (5.2%) early and 7 (2.1%) late; one additional patient had a late percutaneous transluminal coronary angioplasty for anastomotic stenosis. At a mean of 9.5 ± 5.7 months of follow-up, 336 patients (98.0%) were alive, asymptomatic with or without medical treatment, and without cardiac events. Comment. Left internal mammary artery-to-LAD anastomosis performed on a beating heart through a left anterior small thoracotomy is a procedure that can be performed with low risk and acceptable midterm results in selected patients.