Objective: Our aim was to develop the minimally invasive coronary artery bypass grafting (CABG) technique, which is equally effective and safe compared with conventional coronary grafting technique, is reproducible, and can be applied in the vast majority of patients with isolated coronary artery disease. Methods: From July 2017 to November 2018 a total of 170 nonselected consecutive patients underwent minimally invasive on-pump multivessel CABG through the left anterior minithoracotomy in the fourth intercostal space using a Chitwood clamp and blood cardioplegia. We named this technique total coronary revascularization via left anterior thoracotomy. The mean number of grafts was 3.1 ± 0.7. Left internal mammary artery was used in 159 (93.5%) patients, right internal mammary artery in 4 (2.4%) patients, radial artery in 25 (14.7%) patients, and veins in 148 (87%) patients. Results: We had no mortality, no postoperative myocardial infarcts, and no conversion to sternotomy. There were 2 postoperative strokes without residual neurological deficit and 2 revisions for postoperative bleeding. The total operation time was 258.8 ± 43.9 minutes, cardiopulmonary bypass time 135.8 ± 26.6 minutes, and aortic cross-clamp time 71.2 ± 19.4 minutes. The mean intensive care stay was 2.1 ± 0.56 days and mean total hospital stay 6.3 ± 1.3 days. Conclusions: Complete coronary revascularization could be routinely performed using the above-mentioned technique. No patient selection, based on number of grafts, quality and location of coronary vessels, left ventricle function, age, gender, or body mass index, is required.

OBJECTIVES: This article reports the safety and efficacy of a morphology-based algorithm for the surgical management of pulmonary atresia and ventricular septal defect with major aortopulmonary collateral arteries. METHODS: A total of 83 patients were operated from 2007 to 2014 using 3 surgical approaches: one-stage total repair, one-stage unifocalization with central shunt and delayed total repair and multistage unifocalization with subsequent total repair. Patients were divided into 2 groups depending on the surgical strategy used to choose the surgical approach. In Group I (2007–09), the surgeon-preferred procedure (71%—one-stage total repair) was used. In Group II (2010–14), a surgical algorithm based on pulmonary arterial tree morphology was applied. RESULTS: Median follow-up was 5.04 years and 98% complete. The overall survival rate was 92.59%. Cumulative operative mortality decreased from 10.7% in Group I to 0% in Group II (P = 0.036). Successful complete repair was performed in 23 (82%) of 28 patients in Group I (median follow-up, 7.99 years) and in 33 (60%) of 55 patients in Group II (median follow-up, 3.85 years). The difference in total survival was not significant between Groups I and II but was markedly influenced by the presence of the 22q11 deletion. The survival of 23 patients with confirmed 22q11 deletion was 73.91%; the survival of 28 patients with confirmed absence of the 22q11 deletion was 100%; and the survival of 32 patients not tested for the 22q11 deletion was 100% (P = 0.0001). CONCLUSIONS: Total survival was significantly lower in patients with the 22q11 deletion. Surgical management based on preoperative pulmonary arterial anatomical features improves early surgical results.

OBJECTIVES: Our goal was to describe the technique for and evaluate the results of the isolated coronary artery bypass grafting or combined grafting procedures with mitral valve repair/replacement and/or left ventricle aneurysm repair performed through a single left anterior minithoracotomy. METHODS: Perioperative data of all patients who required isolated or combined coronary grafting from July 2017 to December 2021 were observed. The focus was on 560 patients who underwent isolated or combined multivessel coronary bypass using the “Total Coronary Revascularization via left Anterior Thoracotomy” technique. The main perioperative outcomes were analysed. RESULTS: A left anterior minithoracotomy was used in 521 (97.7%) out of 533 patients who required isolated multivessel surgical coronary revascularization and in 39 (32.5%) out of 120 patients who required combined procedures. In 39 patients, multivessel grafting was combined with 25 mitral valve and 22 left ventricular procedures. Mitral valve repair was performed through the aneurysm (n = 8) or through the interatrial septum (n = 17). Perioperative outcomes in isolated and combined groups were next: aortic cross-clamp time—71.9 (SD: 19.9) and 120 (SD: 25.8) min; cardiopulmonary bypass time—145.7 (SD: 33.5) and 216 (SD: 45.8) min; total operating time—269 (SD: 51.8) and 324 (SD: 52.1) min; intensive care unit stay—2 (2–2) and 2 (2–2) days; total hospital stay—6 (5–7) and 6 (5–7) days; and total 30-day mortality was 0.54 and 0%, respectively. CONCLUSIONS: A left anterior minithoracotomy can be effectively used as a first-choice approach to perform isolated multivessel coronary grafting and can be combined with mitral valve and/or left ventricular repair. Experience with isolated coronary grafting through an anterior minithoracotomy is required to achieve the satisfactory results in combined procedures.

OBJECTIVES: We have developed a novel technique for accessing the aortic valve (AoV) through the left anterior minithoracotomy (LAmT). This approach has been used in patients requiring both AoV surgery and coronary artery bypass grafting (CABG). METHODS: From April 2023 to July 2023, we performed 6 concomitant AoV procedures and CABG through the LAmT. The mean age was 71.5 [standard deviation (SD): 5.8; 64; 82] years, and the mean left ventricular ejection fraction was 53% (SD: 12.1; 30; 60). Surgical technique includes LAmT in the fourth intercostal space, peripheral cardiopulmonary bypass, aortic cross-clamping using transthoracic clamp, cold blood cardioplegia, conventional oblique aortotomy and special surgical exposure manoeuvres, aimed to position the ascending aorta and AoV close to the surgical incision. RESULTS: AoV was effectively visualized and the procedure was performed as planned in all 6 patients. No conversion to sternotomy was required. AoV replacement with biological prosthesis was performed in 6 (100%) patients. Conventional surgical instruments were used in all cases. The long-shafted instruments were not required. Knot-pusher was used in 4 (67%)cases. Concomitant complete revascularization was achieved in all cases. The mean number of distal anastomosis was 2.0 (SD: 0.6; 1; 3). Total operation time was 371 (SD: 43; 300; 420) min, cardiopulmonary bypass time was 253 (SD: 36; 193; 284) min and cross-clamp time was - 162 (SD: 29; 128; 214) min. intensive care unit stay was—1.5 (SD: 0.55; 1; 2) days, total hospital stay was—7.3 (SD: 1; 6; 9) days. There were no revisions for bleeding, no strokes or other major complications, and no hospital or 30-days mortality. CONCLUSIONS: The simultaneous performance of AoV replacement and multivessel CABG through a single left anterior thoracotomy is technically feasible and can be carried out by experienced surgeons. However, a larger number of cases are required to fully comprehend the potential limitations of this procedure.

Minimally invasive coronary artery bypass grafting is as effective, reproducible, and safe as conventional coronary grafting technique and can be applied in the vast majority of patients with isolated coronary artery disease. In this video tutorial we present our technique for minimally invasive multivessel coronary artery bypass grafting, with total (complete) coronary revascularization via a left anterior thoracotomy.