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OBJECTIVE: The morbidity of the conventional Coronary artery bypass grafting (CABG) has been the major drawback in competing with other revascularization techniques. Over the last decade, attempts at robotic and endoscopic sternal sparing approaches have met with limited success due to prohibitive cost and lack of reproducibility. We propose the middle path of a direct sternal sparing approach through a small (3.5 inches) left thoracotomy for multi-vessel revascularization and present our experience of fifty patients.

METHODS: Exclusion criteria were left ventricular ejection fraction less than 30%, distal LAD disease and chronic obstructive pulmonary disease. Chest is entered through fourth intercostal space using a 3.5 inch incision. LIMA is dissected under direct vision using specially designed retractors. For CPB assisted patients, femoral artery and vein are cannulated. Single proximal anastomosis is next constructed under direct vision on the aorta or left axillary artery. Distal anastomosis were then constructed. Piggy back proximal anastomosis was constructed for the third graft.

RESULTS: Fifty patients underwent CABG through a small left thoracotomy between June 2010 and August 2011. Seven had single, fifteen had double and twenty-eight had triple vessel disease. Femoral cardio-pulmonary bypass was used in twenty three patients and rest had off pump surgery. The men age was 64±6 years. Fifty eight percent were diabetic. The mean number of grafts were 2.4±0.7. The average blood transfusion requirement was 1.1±0.8 units. The mean intensive unit stay was 2.1±1.3 days. The mean hospital stay was 4.5±2.3 days. There were no deaths or wound infection.

CONCLUSIONS: Minimally invasive, sternal sparing direct surgical revascularization combines the benefit of a direct vision good anastomosis with the morbidity of percutaneous intervention. It is safe, reproducible and cost-effective due to shortened intensive care and hospital stay.