Operating through a Keyhole on a Wide Battlefield

10.1055/a-2765-7072

I read with interest the recently published article describing mitral valve surgery combined with multivessel coronary artery bypass grafting (CABG) through a single left anterior minithoracotomy (total coronary revascularization via left anterior thoracotomy [TCRAT] approach).[1] While the authors should be commended for technical innovation, I believe that both the interpretation of the results and the broader implications of this technique warrant serious concern. The central limitation of the report is the conflation of technical feasibility with procedural safety and clinical acceptability. Performing an extremely complex combined operation in a very small, highly selected cohort does not justify extrapolation to routine practice. The reported cardiopulmonary bypass and aortic cross-clamp times are prolonged, underscoring the significant physiological burden imposed by restricted exposure and constrained operative angles—factors that are particularly relevant in combined valve and multivessel coronary surgery. More importantly, the article does not adequately address the quality or durability of coronary revascularization. Complete revascularization with meticulous distal coronary anastomoses remains the cornerstone of successful CABG and long-term freedom from ischemic events.[2] [3] [4] Limited exposure inherent to the TCRAT approach inevitably compromises target visualization, anastomotic precision, and bailout options. Early survival and short-term outcomes cannot be used as surrogates for graft durability or completeness of revascularization. Similarly, mitral valve surgery demands optimal exposure to ensure precision, reproducibility, and durability of repair or replacement. Any approach that restricts visualization or limits corrective options risks compromising the very principles that define high-quality valve surgery.

In contrast, conventional CABG through median sternotomy remains a well-established, reproducible, and extensively validated strategy. It provides unparalleled exposure of all coronary territories, facilitates optimal conduit selection, and allows meticulous, tension-free distal anastomoses. When combined with standard mitral valve surgery, median sternotomy offers a proven platform for achieving complete revascularization, durable valve correction, and maximal procedural safety. These advantages are consistently supported by randomized trials and large meta-analyses. Innovation in cardiac surgery should address a clear unmet clinical need or demonstrate superior—or at least non-inferior—long-term outcomes. In the absence of such evidence, the promotion of highly complex minimally invasive approaches for combined mitral valve and multivessel coronary disease risks prioritizes technical novelty over durability, reproducibility, and patient safety. We believe that the conclusions of the present article extend beyond what the presented data can support. Until compelling evidence demonstrates equivalent long-term safety and durability, conventional CABG via median sternotomy combined with standard mitral valve surgery should remain the reference approach for this challenging patient population.

Contributor's Statement

K.A. contributed to conceptualization, supervision, writing–original draft, writing–review and editing.

Publication History

Received: 16 January 2026

Accepted: 09 February 2026

Article published online:
24 February 2026

• References

• 1 Demianenko V, Dörge H, Schlömicher M, Grossmann M, Belmenai A, Sellin C. Mitral valve procedures and multivessel CABG through a single left anterior minithoracotomy. Thorac Cardiovasc Surg 2025; (E-pub ahead of print).
• 2 Al-Ebrahim KE. Conventional coronary bypass remains the gold standard reference technique. J Card Surg 2022; 37 (05) 1454
• 3 Hwang HY. Complete revascularization in coronary artery bypass grafting: Separating the wheat from the chaff. J Chest Surg 2026; 59 (01) 1-6
• 4 Al-Ebrahim EK, Madani TA, Al-Ebrahim KE. Future of cardiac surgery, introducing the interventional surgeon. J Card Surg 2022; 37 (01) 88-92