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

Abstract

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.

Keywords: 1; 23; 23.1; 28; CABG; CI; CPB; FEV(1); FVC; IL; MICS; MIDCAB; OPCAB; RCT; SIRS; TR; ThoraCAB; cardiopulmonary bypass; confidence interval; coronary artery bypass graft; forced expiratory volume after 1 second; forced vital capacity; interleukin; minimally invasive cardiac surgery; minimally invasive direct coronary artery bypass; off-pump coronary artery bypass surgery via a left anterolateral thoracotomy; off-pump coronary artery bypass surgery via a median sternotomy; randomized controlled trial; systemic inflammatory response syndrome; time ratio.