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Minimally Invasive, Total Arterial Multi-Vessel Revascularization via an Antero-Lateral Access. Experience Related Time Improvement
Marc Albert, Ragi Nagib, Adrian Ursulescu, Ulrich F.W. Franke.
Robert-Bosch-Hospital, Stuttgart, Germany.

OBJECTIVE: Off-pump total-arterial multi-vessel myocardial revascularization allows improved results regarding mortality and neurological outcome. Similar to other cardiac procedures, a minimally invasive approach has been developed within the last years using an antero-lateral access. The post-operative outcome of these patients, reported in few publications, is beneficial, but the procedure is more challenging and takes a longer skin-to-skin-time. This study demonstrates the decrease of skin-to-skin time of 3 surgeons performing this technique.
METHODS: Since August 2008 more than 450 patients received a minimally invasive, total arterial multi-vessel revascularization via an antero-lateral thoracotomy in our department. 444 of the procedures were performed by 3 surgeons. In all patients, the left internal mammary artery (LIMA) was used. Additionally, the left radial artery was harvested endoscopically afterward for use as T-graft originated into the LIMA. We grouped each 10 procedures of every surgeon and compared the skin-to-skin time in relation to the number of performed anastomoses (see the tab. 1). As the graft harvesting time did not differ during the study period, the decrease of time per anastomosis represents the improved experience.
RESULTS: The mean number of anastomoses was 2.1 0.4. Four patients (0,9%) died in the perioperative course. There was no post-operative stroke, 3 patients (0.7%) have had a myocardial infarction. The length of hospital stay was 8.4 4.8 days. The skin-to-skin time of all 3 surgeons decreased significantly over time.
CONCLUSIONS: The minimally invasive total arterial multi-vessel revascularization via an antero-lateral mini-thoracotomy is a feasible and safe procedure. The learning curve for this challenging technique is significant. Surgeons need about 50 cases in order to establish this technique as a routine alternative to the conventional median sternotomy.

Tab.1: skin-to-skin time per anastomosis [min/anastomosis]
skin-to-skin time [min]1st decade2nd decade5th decade10th decade14th decadep-value
Surgeon A167.347.684.682.381.076.576.10.032
Surgeon B176.439.188.587.285.479.776.30.041
Surgeon C188.529.294.794.20.916

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Endorsed by:
The Society of Thoracic Surgeons

Co-sponsored by:
Association of Physician Assistants in Cardiovascular Surgery (APACVS) The International Society for Minimally Invasive Cardiothoracic Surgery Japanese Association for Coronary Artery Surgery
Brazilian Society of Cardiovascular Surgery Fu-Wai Hospital of Beijing Indian Association of Cardiovascular-Thoracic Surgeons
Society for Cardiothoracic Surgery in Great Britain & Ireland