A randomised controlled trial of median sternotomy vs. anterolateral left thoracotomy on morbidity and healthcare resource use in patients having off-pump coronary artery bypass surgery (SteT)

Previous randomised controlled trials have compared the effectiveness of coronary artery bypass surgery on the beating heart without the heart-lung machine (off-pump coronary artery bypass, OPCAB) with conventional bypass surgery, by arresting the heart and using the heart-lung machine to pump blood around the body.  These trials have concluded that OPCAB reduces post-operative morbidity and hospital costs without compromising mid-term clinical outcome.  Because patients who have OPCAB are less likely to experience complications or transfusion, they recover quicker and leave hospital sooner – a “win-win” situation for both patients and the NHS.  It has been suggested that recovery may be even faster if the operation is carried out through an incision in the left hand side of the chest (thoracotomy) instead of through a central, vertical incision through the sternum (sternotomy).  In a recent study of 200 patients who had a thoracotomy incision, less than 20% of patients required ventilation in intensive care, and most patients were discharged within 4 days, shorter than is usual with OPCAB through a sternotomy; for example, since the year 2000 in our institution, the majority of patients having OPCAB through a sternotomy were ventilated for several hours and less than 5% were discharged within 4 days.  However, this simple comparison of the outcome of thoracotomy and sternotomy incisions is likely to be biased since patients may have been selected for the thoracotomy study, and the two kinds of incision were used in operations carried out by different surgeons in different institutions.  Therefore, we carried out an unbiased, “head-to-head” comparison of thoracotomy and sternotomy incisions for off-pump coronary artery bypass, controlling for all factors other than the specific surgical methods.