An open randomized controlled trial of median sternotomy versus anterolateral left thoracotomy on morbidity and health care resource use in patients having off-pump coronary artery bypass surgery: the Sternotomy Versus Thoracotomy (STET) trial.

OBJECTIVE Our objective was to compare off-pump coronary artery bypass surgery carried out via a left anterolateral thoracotomy (ThoraCAB) or via a conventional median sternotomy (OPCAB). BACKGROUND Recent advances in minimally invasive cardiac surgery have extended the technique to allow complete surgical revascularization on the beating heart via thoracotomy. METHODS Patients undergoing nonemergency primary surgery were enrolled between February 2007 and September 2009 at 2 centers. The primary outcome was the time from surgery to fitness for hospital discharge as defined by objective criteria. RESULTS A total of 93 patients were randomized to off-pump coronary artery bypass surgery via a median sternotomy (OPCAB) and 91 to off-pump coronary artery bypass surgery via a left anterolateral thoracotomy (ThoraCAB). The surgery was longer for patients in the ThoraCAB group (median, 4.1 vs 3.3 hours) and there were fewer with more than 3 grafts (2% vs 17%). The median time from surgery to fitness for discharge was 6 days (interquartile range, 4-7) in the ThoraCAB group versus 5 days (interquartile range, 4-7) in the OPCAB group (P = .53). The intubation time was shorter, by on average 65 minutes, in the ThoraCAB group (P = .017), although the time in intensive care was similar (P = .91). Pain scores were similar (P = .97), but more analgesia was required in the ThoraCAB group (median duration, 38.8 vs 35.5 hours, P < .001; tramadol use, 66% vs 49%, P = .024). ThoraCAB was associated with significantly worse lung function at discharge (average difference, -0.25 L, P = .01) but quality of life scores at 3 and 12 months were similar (P = .52). The average total cost was 10% higher with ThoraCAB (P = .007). CONCLUSIONS ThoraCAB resulted in no overall clinical benefit relative to OPCAB.

[1]  P. Goldschmidt-Clermont,et al.  Combination of minimally invasive coronary bypass and percutaneous transluminal coronary angioplasty in the treatment of double-vessel coronary disease: Two-year follow-up of a new hybrid procedure compared with "on-pump" double bypass grafting. , 2001, American heart journal.

[2]  Volkmar Falk,et al.  Comparison of stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery. , 2002, The New England journal of medicine.

[3]  M. di Mauro,et al.  Impact of aortic manipulation on incidence of cerebrovascular accidents after surgical myocardial revascularization. , 2002, The Annals of thoracic surgery.

[4]  S. Aranki,et al.  Reduction in incidence of deep sternal wound infections: random or real? , 2010, The Journal of thoracic and cardiovascular surgery.

[5]  M. Sculpher,et al.  Economic evaluation of coronary artery bypass grafting surgery with and without cardiopulmonary bypass: cost-effectiveness and quality-adjusted life years in a randomized controlled trial. , 2008, Artificial organs.

[6]  M. Underwood,et al.  Inflammatory response after coronary revascularization with or without cardiopulmonary bypass. , 2000, The Annals of thoracic surgery.

[7]  W. Weintraub,et al.  Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial. , 2004 .

[8]  P. den Heijer,et al.  Minimally invasive coronary artery bypass grafting versus coronary angioplasty for isolated type C stenosis of the left anterior descending artery. , 1997, The Journal of thoracic and cardiovascular surgery.

[9]  Johannes Bonatti,et al.  Integrated Coronary Revascularization: Percutaneous Coronary Intervention Plus Robotic Totally Endoscopic Coronary Artery Bypass , 2006, Circulation.

[10]  A. Barsotti,et al.  Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. , 1996, The Annals of thoracic surgery.

[11]  Peter Wilde,et al.  Integrated left small thoracotomy and angioplasty for multivessel coronary artery revascularisation , 1996, The Lancet.

[12]  G. Angelini,et al.  Hybrid coronary revascularization in the era of drug-eluting stents. , 2004, The Annals of thoracic surgery.

[13]  D J Rowlands,et al.  A multi-centre randomised controlled trial of minimally invasive direct coronary bypass grafting versus percutaneous transluminal coronary angioplasty with stenting for proximal stenosis of the left anterior descending coronary artery. , 2004, Health technology assessment.

[14]  S. Schroter,et al.  Coronary revascularisation outcome questionnaire (CROQ): development and validation of a new, patient based measure of outcome in coronary bypass surgery and angioplasty , 2004, Heart.

[15]  M. Amrani,et al.  Effect of off-pump coronary artery bypass surgery on clinical, angiographic, neurocognitive, and quality of life outcomes: randomised controlled trial , 2006, BMJ : British Medical Journal.

[16]  D. Bainbridge,et al.  Does Off-pump Coronary Artery Bypass Reduce Mortality, Morbidity, and Resource Utilization When Compared with Conventional Coronary Artery Bypass? A Meta-analysis of Randomized Trials , 2005, Anesthesiology.

[17]  H. Akaike,et al.  Information Theory and an Extension of the Maximum Likelihood Principle , 1973 .

[18]  Raimondo Ascione,et al.  Early and midterm outcome after off-pump and on-pump surgery in Beating Heart Against Cardioplegic Arrest Studies (BHACAS 1 and 2): a pooled analysis of two randomised controlled trials , 2002, The Lancet.

[19]  T. Treasure,et al.  A SCORING METHOD (ASEPSIS) FOR POSTOPERATIVE WOUND INFECTIONS FOR USE IN CLINICAL TRIALS OF ANTIBIOTIC PROPHYLAXIS , 1986, The Lancet.

[20]  M. Guida,et al.  Multivessel revascularization on the beating heart by anterolateral left thoracotomy. , 2006, The Annals of thoracic surgery.

[21]  Unexpected stent thrombus after minimally invasive direct coronary artery bypass in hybrid re-vascularisation. , 2009, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[22]  S. K. Mishra,et al.  Multivessel Total Arterial Revascularization via Left Thoracotomy , 2004, Asian cardiovascular & thoracic annals.

[23]  Sudhir P Srivastava,et al.  Off-pump complete revascularization through a left lateral thoracotomy (ThoraCAB): the first 200 cases. , 2003, The Annals of thoracic surgery.