Reply to the Comment: Mitral valve procedures and multivessel CABG through a single left anterior minithoracotomy

10.1055/a-2809-8791

We thank the correspondents for their interest in our technical report describing concomitant mitral valve (MV) surgery and multivessel coronary artery bypass grafting (CABG) performed through a single left anterior minithoracotomy. We welcome critical discussion of emerging approaches; however, several statements in the letter conflate the intent of our report with claims we did not make and rely on categorical assumptions that are not supported by evidence.

Scope and claims. Our article was explicitly presented as an initial feasibility and early-safety experience in a highly selected cohort. We did not advocate indiscriminate adoption nor extrapolation to routine practice. On the contrary, we defined selection and exclusions and stated that, at this stage, the approach should be limited to centers with established expertise in sternum-sparing multivessel CABG and to MV pathologies suitable for reproducible repair strategies (e.g., annuloplasty) or replacement.

“Keyhole” versus a standardized platform. The letter's “keyhole” metaphor is misleading when applied to an on-pump, arrested-heart, fully decompressed strategy with exposure maneuvers. The coronary component in our combined procedure is performed within the same physiological and technical framework as Total Coronary Revascularization via left Anterior Thoracotomy (TCRAT).[1] [2] Importantly, TCRAT has evolved beyond isolated feasibility reports. In our recent review integrating all published TCRAT series, a weighted analysis of 2,282 patients demonstrates that the technique is being performed at scale and with a safety profile that is difficult to reconcile with claims of “inevitable compromise.”[3] Across reported all-comers cohorts, 30-day mortality and perioperative stroke were each distinctly below 1%, while complete anatomical revascularization and modern grafting strategies, including multiarterial concepts, were consistently achieved. Furthermore, volumes on the order of approximately 100 cases per center per year and reports describing TCRAT as a preferred standard approach for multivessel CABG strongly suggest that, in experienced programs, this is no longer an “experimental keyhole” operation but a standardized and reproducible revascularization platform.

Operative times and physiological burden. The correspondents interpret prolonged cardiopulmonary bypass (CPB) and cross-clamp times as evidence of unacceptable physiological burden attributable to access. This inference is not warranted. Complex combined procedures are inherently time-consuming regardless of incision, and operative duration alone is not a surrogate for safety in the absence of objective evidence of myocardial, neurologic, or end-organ injury. In published TCRAT experience, longer CPB and cross-clamp times have not translated into prolonged intensive care or hospital stays, and recovery metrics compare favorably with conventional sternotomy CABG—consistent with the broader concept that minimizing access trauma can offset procedural duration. In our combined series, myocardial protection was deliberately emphasized through repeated cold blood cardioplegia, including delivery via completed distal grafts, and early outcomes were free from stroke, reoperation for bleeding, or early mortality.

Coronary quality and the “inevitably compromises” claim. We strongly disagree with the statement that limited exposure “inevitably compromises target visualization, anastomotic precision, and bailout options.” The term “inevitably” implies universal truth, yet no evidence is presented. Moreover, it does not reflect the technical reality of an arrested-heart approach with defined slinging and rotational maneuvers. In the published TCRAT series,[3] the mean number of distal anastomoses typically ranges from around 2.5 to 3.4 (up to 5), with near-universal use of the internal thoracic artery and frequent use of additional arterial conduits—patterns that are incompatible with the notion of systematically compromised completeness or technical quality.

Durability and follow-up. We agree with the general principle that early outcomes are not a surrogate for long-term graft patency or valve durability. However, this statement does not invalidate a feasibility report; it simply defines the next evidentiary step. Notably, mid-term TCRAT outcomes, although still limited in the number of reporting cohorts, have been encouraging, with survival and event-free rates that compare well with contemporary benchmarks.[4] Our present report contributes to the correct point in the innovation pathway: It demonstrates that complete anatomical revascularization and MV intervention can be accomplished through a single left anterior minithoracotomy in selected patients without major early adverse events. Larger cohorts and systematic follow-up are required—and are precisely what we advocate.

Reference approach and the role of innovation. We fully acknowledge that median sternotomy remains an excellent and widely applicable standard approach for combined CABG and MV surgery. Yet “standard” does not mean “exclusive.” In contemporary practice, avoidance of sternotomy is not pursued for novelty, but to eliminate sternal complications, accelerate recovery, and expand tailored options for patients in whom sternotomy-related morbidity is clinically meaningful.

A categorical presumption that minimally invasive access must degrade quality risks, substituting conjecture for evidence, and may discourage responsible, stepwise innovation that addresses present-day patient and health system needs.

In summary, our report should be interpreted in the context in which it was written: An early experience and technical description performed in a program with established expertise in sternum-sparing multivessel CABG, proposing a controlled extension of a standardized revascularization platform to carefully selected combined MV–CABG cases. We support the development of prospective registries and long-term surveillance focusing on graft durability and valve outcomes. At the same time, we caution against claims of “inevitable compromise,” which are inconsistent with the growing body of clinical evidence demonstrating that TCRAT can be performed routinely, reproducibly, and safely in experienced centers.

Publication History

Received: 16 January 2026

Accepted: 09 February 2026

Article published online:
24 February 2026

• References

• 1 Babliak O, Demianenko V, Melnyk Y, Revenko K, Pidgayna L, Stohov O. Complete coronary revascularization via left anterior thoracotomy. Innovations (Phila) 2019; 14 (04) 330-341
• 2 Dörge H, Sellin C, Belmenai A, Asch S, Eggebrecht H, Schächinger V. Novel concept of routine total arterial coronary bypass grafting through a left anterior approach avoiding sternotomy. Heart Vessels 2022; 37 (08) 1299-1304
• 3 Demianenko V, Dörge H, Sellin C. The TCRAT Technique (Total Coronary Revascularization via Left Anterior Thoracotomy): Renaissance in minimally invasive on-pump multivessel coronary artery bypass grafting?. J Cardiovasc Dev Dis 2026; 13 (01) 28
• 4 Sellin C, Belmenai A, Niethammer M, Schächinger V, Dörge H. Sternum-sparing multivessel coronary surgery as a routine procedure: Midterm results of total coronary revascularization via left anterior thoracotomy. JTCVS Tech 2024; 26: 52-60