Introduction

Off-pump coronary artery bypass (OPCAB) surgery via a median sternotomy is an established surgical technique for patients undergoing coronary revascularization. Recently the left anterolateral thoracotomy has been proposed as an alternative approach (1). Advantages of this technique have been reported including less surgical trauma, quicker recovery and improved cosmesis. This study compares the clinical outcomes of Anterolateral Thoracotomy Coronary Artery Bypass (ALTCAB) vs. Median Sternotomy Coronary Artery Bypass (MSCAB) on the beating heart in patients with multivessel disease.

Patients and Methods

The study includes 100 patients with multivessel coronary artery disease who underwent OPCAB between 2005 and 2006 in a multiethnic single cardiac surgical unit in Trinidad and Tobago. Two surgeons according to their preferred technique performed each 50 cases using the ALTCABs or MSCABs procedure. The two groups were matched for age, gender, and extent of coronary disease, diabetes, hypertension and ejection fraction. Clinical notes were reviewed retrospectively.

Surgical Technique

Results

Patient Demographics

The two groups showed similar demographics. Table1.

Figure 1

Table 1

There were no conversions to median sternotomy from the anterolateral thoracotomy group and no conversions to cardiopulmonary bypass in either group. There were no deaths or stroke. Patients undergoing sternotomy received more grafts than those undergoing left anterolateral thoracotomy (p<0.001). One patient in the sternotomy group required postoperative dialysis. The only difference in early hospital morbidity was the need for greater transfusion in the sternotomy than the thoracotomy group (p<0.031). Postoperative hemoglobin levels were also higher in the thoracotomy group at 24 hours post-operatively (p<0.001) (Table 2.)

Figure 2

Table 2. Results (values are expressed as mean  SD)

Discussion

Coronary artery bypass surgery on the beating heart allows multivessel revascularization while avoiding the deleterious effects of CPB. These include bleeding, fluid retention, arrhythmias and organ dysfunction (3). Several randomized studies have reported reduced morbidity with OPCAB compared to conventional CABG with CPB (2,4,5). MIDCAB has been used for limited single vessel grafting, redo surgery and valve surgery with good results, thereby avoiding the potential complications of sternotomy (6,7).

The ALTCAB technique offers the possibility of avoiding both CPB and sternotomy and their potential adverse effects while allowing complete multiple revascularizations (1).

No obvious differences where found in our study with the exception of transfusion.

Both surgeons in our series were very experienced and the one performing the ALTCAB has already published a personal series of 255 consecutive patients (1). The ALTCAB approach has a demanding learning curve, as it is a more difficult technique compared to the familiar median sternotomy.

The limitations of our study are the small numbers and its retrospective nature. A full randomized prospective controlled trial is at present recruiting at the Bristol Heart Institute.

Conclusion

The anterolateral thoracotomy is a safe surgical approach and a reliable alternative to median sternotomy in patients undergoing off-pump CABG.