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OBJECTIVE: Advances in minimally invasive techniques in cardiac surgery promise to greatly improve clinical outcomes. Although the literature is rife with reports of robotic and mini-valve surgery, experiences with minimally invasive coronary artery bypass grafting (MICS-CABG) via a left mini-thoracotomy have only recently been reported. To date there are no reports of simultaneous sternal-sparing, bilateral thoracotomies combining revascularization with valve repair or other cardiac procedures.
METHODS: We report 5 consecutive cases in which bilateral 5-cm mini-thoracotomies were used concurrently to perform a MICS-CABG and either mitral valve repair (MVR) or radiofrequency ablation (RFA) with left atrial appendage amputation from January 2011 through September 2012. All portions of the MICS-CABG operations were done via a left mini-thoracotomy. MVRs were done via a right mini-thoracotomy with femoral cutdown for cardiopulmonary bypass and RFAs were done via bilateral incisions.
RESULTS: Three patients underwent MICS-CABG+MVR, and 2 underwent MICS-CABG+RFA. All 5 patients were men. Of the 3 patients who underwent CABG+MVR, 1 had a single-vessel bypass, and 2 had double-vessel. Both patients who underwent CABG+RFA had double-vessel bypass. Cardiopulmonary bypass was used only in the MVR cases, and all patients received mechanical ventilation for less than 24 hours after surgery. There were no mortalities or significant complications. One patient required a transfusion after 2-vessel MICS-CABG+MVR and one patient was readmitted within 30 days after 2-vessel MICS-CABG+RFA for a pericardial effusion requiring pericardiocentesis.

Patient number	Age, years	BMI, kg/m2	Postoperative LOS, days	Operative time, minutes	Procedure	Vessels bypassed
1	75	24.0	5.0	247.0	MICS-CABG + MVR	LAD
2	80	27.8	5.0	329.0	MICS-CABG + MVR	LAD, PDA
3	66	34.7	9.0	430.0	MICS-CABG + RFA	LAD, OM
4	83	23.5	4.0	345.0	MICS-CABG + MVR	LAD, Ramus
5	66	26.7	5.0	308.0	MICS-CABG + RFA	LAD, OM
Mean ± SD	74.1 ± 7.6	27.3 ± 4.5	5.6 ± 1.9	331.8 ± 66.3	--	--

BMI=body mass index; LOS, length of stay; LAD=left anterior descending; OM=obtuse marginal; PDA=posterior descending artery.
CONCLUSIONS: A simultaneous bilateral mini-thoracotomy appears to be well-tolerated in select patients and may be the logical next step in sternal-sparing minimally invasive open heart surgery.