Median sternotomy using cardiopulmonary bypass is the standard approach to coronary artery bypass grafting (CABG) surgery. Alternatives to conventional CABG, broadly termed “minimally invasive CABG,” have been developed in order to reduce the amount of invasiveness traditionally required for this procedure. For CABG, the degree of invasiveness can be reduced in two primary ways. First, the degree of physical access can be minimized by using smaller incisions that require less sternal separation or none at all. Second, the degree of physiological manipulation may be reduced by performing CABG without using cardiopulmonary bypass and ischemic, cardioplegic arrest, termed “off-pump” CABG, which is the focus of Chapter C.3 "Coronary Artery Bypass without CPB." This chapter focuses solely on CABG techniques and outcomes related to the first definition of invasiveness, termed minimal access coronary surgery, the most common version of which is minimally invasive direct coronary artery bypass (MIDCAB).
It is well established that the left internal mammary artery (LIMA) is the preferred conduit for all coronary surgery, as use of this vessel has been associated with both improved short- and long-term graft patency and survival benefits when placed to the left anterior descending (LAD) coronary artery.[1] A minimally invasive incision limits facile access to and visualization of the heart to primarily the anterior surface, where the LAD courses. Therefore, during MIDCAB, a minimally invasive approach via a limited left anterior thoracotomy incision is used to achieve surgical revascularization of the left anterior descending artery (LAD) via anastomosis of the LIMA. Fortunately, the LAD supplies the largest territory of any coronary artery, so MIDCAB ensures that the LAD territory is revascularized with the optimal conduit. MIDCAB for multivessel bypass grafting has also been described, but is performed in a very limited number of centers worldwide.[2]
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