The clinical effects of coronary artery bypass grafting via the left anterior small thoracotomy approach versus the lower-end sternal splitting approach: A propensity score matching study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

LI Jinghui , ZHANG Zhejun , YANG Yin , BAI Yunpeng , ZHANG Kai , YANG Dongyan , LI Junshan , WEI Dong ,  WANG Lianqun

Department of Cardiovascular Surgery, Tianjin Chest Hospital, Tianjin, 300071, P. R. China;

Corresponding?author：

WANG Lianqun, Email: 08yuwulei08@sina.com

Keywords：

Coronary artery disease; minimally invasive; surgery; left anterior small thoracotomy; lower-end sternal splitting

DOI：

10.7507/1007-4848.202105035

Video：

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Objective To compare the clinical effects of coronary artery bypass grafting (CABG) via the left anterior small thoracotomy (LAST) versus lower-end sternal splitting (LESS) approach in the treatment of coronary heart disease. Methods The patients who underwent LAST CABG in Tianjin Chest Hospital from October 2015 to December 2020 were allocated to an observation group (LAST group), and the patients who underwent LESS CABG at the same period were allocated to a LESS group. Propensity score matching method was applied with a ratio of 1∶1. The baseline data, perioperative data and grafts data were compared between the two groups after matching. Results Before matching, there were 110 patients in the LAST group, and 206 patients in the LESS group. After matching, there were 110 patients in each group. In the LAST group, there were 83 males and 27 females with an average age of 60.6±8.3 years. In the LESS group, there were 80 males and 30 females with an average age of 61.0±9.6 years. There was no statistical difference in baseline data between the two groups after matching (P>0.05). The hospital stay time (t=2.255, P=0.025) and ventilator using time (t=?2.229, P=0.027) in the LAST group were significantly shorter than those in the LESS group. There were no statistical differences between the two groups in the postoperative hospital stay time, ICU stay time, postoperative left ventricular ejection fraction, postoperative left ventricular end-diastolic diameter, average number of grafts, secondary intubation, secondary thoracotomy, postoperative wound infection, sternal complications, postoperative atrial fibrillation, postoperative pulmonary infection or main adverse cardiovascular and cerebrovascular events (P>0.05). There was no statistical difference in the distribution of target vessels in the anterior descending branch, diagonal branch or posterior descending branch between the two groups (P>0.05). The grafts of the LAST group were significantly more than those of the LESS group in the area of obtuse marginal branch and posterior ventricular branch, and the grafts of the LESS group were significantly more than those of the LAST group in the area of right coronary artery (P<0.05). Postoperative computerized tomography angiography indicated that 1 patient in the LAST group had obtuse marginal branch vein bridge vessel occlusion, and the bridge vessels in the other patients were unobstructed. Conclusion Minimally invasive CABG via both LAST and LESS approaches is safe and effective. LAST approach can achieve complete revascularization for multi-vessel lesions, and it is safe and reliable, with the advantages of less trauma and aesthetic appearance. However, it requires a certain learning curve of surgical techniques and certain surgical indications.

Citation： LI Jinghui, ZHANG Zhejun, YANG Yin, BAI Yunpeng, ZHANG Kai, YANG Dongyan, LI Junshan, WEI Dong, WANG Lianqun. The clinical effects of coronary artery bypass grafting via the left anterior small thoracotomy approach versus the lower-end sternal splitting approach: A propensity score matching study. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2023, 30(7): 1002-1007. doi: 10.7507/1007-4848.202105035 Copy

1.	Dai H, Much AA, Maor E, et al. Global, regional, and national burden of ischemic heart disease and its attributable risk factors, 1990-2017: Results from the global Burden of Disease Study 2017. Eur Heart J Qual Care Clin Outcomes, 2020: qcaa076.
2.	萬峰, 陳彧, 王懷軍, 等. 四種不同類型的微創小切口冠狀動脈搭橋術. 北京醫學, 2003, 25(1): 42-44.
3.	Niinami H, Takeuchi Y, Ichikawa S, et al. Partial median sternotomy as a minimal access for off-pump coronary artery bypass grafting: Feasibility of the lower-end sternal splitting approach. Ann Thorac Surg, 2001, 72(3): S1041-S1045.
4.	王圣, 程兆云, 趙子牛, 等. 胸骨下段小切口行非體外循環冠狀動脈旁路移植術的臨床體會. 中國循環雜志, 2016, 31(z1): 80-81.
5.	馬維國, 孫寒松, 胡盛壽, 等. 胸骨下段正中小切口直視冠狀動脈旁路移植術. 中國胸心血管外科臨床雜志, 2005, 12(4): 240-242.
6.	孫廣龍, 曹向戎, 黃國暉, 等. 胸骨下段小切口非體外循環冠狀動脈旁路移植術臨床分析. 中國胸心血管外科臨床雜志, 2018, 25(9): 821-824.
7.	Nesbitt JJ, Mori G, Mason-Apps C, et al. Comparison of early and late quality of life between left anterior thoracotomy and median sternotomy off-pump coronary artery bypass surgery. Perfusion, 2017, 32(1): 50-56.
8.	Teman NR, Hawkins RB, Charles EJ, et al. Minimally invasive vs. open coronary surgery: A multi-institutional analysis of cost and outcomes. Ann Thorac Surg, 2021, 111(5): 1478-1484.
9.	Repossini A, Di Bacco L, Nicoli F, et al. Minimally invasive coronary artery bypass: Twenty-year experience. J Thorac Cardiovasc Surg, 2019, 158(1): 127-138.
10.	Tekin A?, Arslan ü. Perioperative outcomes in minimally invasive direct coronary artery bypass versus off-pump coronary artery bypass with sternotomy. Wideochir Inne Tech Maloinwazyjne, 2017, 12(3): 285-290.
11.	Seo DH, Kim JS, Park KH, et al. Mid-term results of minimally invasive direct coronary artery bypass grafting. Korean J Thorac Cardiovasc Surg, 2018, 51(1): 8-14.
12.	Van Praet KM, Kofler M, Shafti TZN, et al. Minimally invasive coronary revascularisation surgery: A focused review of the available literature. Interv Cardiol, 2021, 16: e08.
13.	張犁雪, 楊威, 陳彧, 等. 微創小切口雙側乳內冠狀動脈旁路移植術早期臨床結果傾向評分匹配分析. 中華胸心血管外科雜志, 2020, 36(8): 493-497.
14.	Xu ZF, Ling YP, Cui ZQ, et al. Feasibility and safety of minimally invasive cardiac coronary artery bypass grafting surgery for patients with multivessel coronary artery disease: Early outcome and short-mid-term follow up results. Beijing Da Xue Xue Bao Yi Xue Ban, 2020, 52(5): 863-869.
15.	宮一宸, 凌云鵬, 張魯鋒, 等. 左胸小切口多支冠狀動脈旁路移植術244例臨床分析. 中華外科雜志, 2020, 58(5): 363-368.
16.	劉碩, 尤斌, 陳長城, 等. 經左胸前外側小切口冠狀動脈手術161例總結. 中國醫藥, 2018, 13(8): 1148-1151.

1. Dai H, Much AA, Maor E, et al. Global, regional, and national burden of ischemic heart disease and its attributable risk factors, 1990-2017: Results from the global Burden of Disease Study 2017. Eur Heart J Qual Care Clin Outcomes, 2020: qcaa076.
2. 萬峰, 陳彧, 王懷軍, 等. 四種不同類型的微創小切口冠狀動脈搭橋術. 北京醫學, 2003, 25(1): 42-44.
3. Niinami H, Takeuchi Y, Ichikawa S, et al. Partial median sternotomy as a minimal access for off-pump coronary artery bypass grafting: Feasibility of the lower-end sternal splitting approach. Ann Thorac Surg, 2001, 72(3): S1041-S1045.
4. 王圣, 程兆云, 趙子牛, 等. 胸骨下段小切口行非體外循環冠狀動脈旁路移植術的臨床體會. 中國循環雜志, 2016, 31(z1): 80-81.
5. 馬維國, 孫寒松, 胡盛壽, 等. 胸骨下段正中小切口直視冠狀動脈旁路移植術. 中國胸心血管外科臨床雜志, 2005, 12(4): 240-242.
6. 孫廣龍, 曹向戎, 黃國暉, 等. 胸骨下段小切口非體外循環冠狀動脈旁路移植術臨床分析. 中國胸心血管外科臨床雜志, 2018, 25(9): 821-824.
7. Nesbitt JJ, Mori G, Mason-Apps C, et al. Comparison of early and late quality of life between left anterior thoracotomy and median sternotomy off-pump coronary artery bypass surgery. Perfusion, 2017, 32(1): 50-56.
8. Teman NR, Hawkins RB, Charles EJ, et al. Minimally invasive vs. open coronary surgery: A multi-institutional analysis of cost and outcomes. Ann Thorac Surg, 2021, 111(5): 1478-1484.
9. Repossini A, Di Bacco L, Nicoli F, et al. Minimally invasive coronary artery bypass: Twenty-year experience. J Thorac Cardiovasc Surg, 2019, 158(1): 127-138.
10. Tekin A?, Arslan ü. Perioperative outcomes in minimally invasive direct coronary artery bypass versus off-pump coronary artery bypass with sternotomy. Wideochir Inne Tech Maloinwazyjne, 2017, 12(3): 285-290.
11. Seo DH, Kim JS, Park KH, et al. Mid-term results of minimally invasive direct coronary artery bypass grafting. Korean J Thorac Cardiovasc Surg, 2018, 51(1): 8-14.
12. Van Praet KM, Kofler M, Shafti TZN, et al. Minimally invasive coronary revascularisation surgery: A focused review of the available literature. Interv Cardiol, 2021, 16: e08.
13. 張犁雪, 楊威, 陳彧, 等. 微創小切口雙側乳內冠狀動脈旁路移植術早期臨床結果傾向評分匹配分析. 中華胸心血管外科雜志, 2020, 36(8): 493-497.
14. Xu ZF, Ling YP, Cui ZQ, et al. Feasibility and safety of minimally invasive cardiac coronary artery bypass grafting surgery for patients with multivessel coronary artery disease: Early outcome and short-mid-term follow up results. Beijing Da Xue Xue Bao Yi Xue Ban, 2020, 52(5): 863-869.
15. 宮一宸, 凌云鵬, 張魯鋒, 等. 左胸小切口多支冠狀動脈旁路移植術244例臨床分析. 中華外科雜志, 2020, 58(5): 363-368.
16. 劉碩, 尤斌, 陳長城, 等. 經左胸前外側小切口冠狀動脈手術161例總結. 中國醫藥, 2018, 13(8): 1148-1151.

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The clinical effects of coronary artery bypass grafting via the left anterior small thoracotomy approach versus the lower-end sternal splitting approach: A propensity score matching study

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