OBJECTIVE: To minimize the risk of standard and reoperative coronaryartery bypass, we developed a minimally invasive approach. In this study wehave evaluated the effectiveness of this technique. METHOD: Between April1994 and September 1995, 12 men and 6 women, aged 55-84 years (mean, 69years) with chronic stable angina (4) and recent post- myocardialinfarction unstable angina (14), with left ventricular ejection fractionsranging 17-60% (mean 37%), underwent reoperative coronary artery bypassgrafting using 7-cm mini-left and right anterior thoracotomy and subxiphoidincisions. Coronary artery anastomoses were carried out on beating heartswith local coronary occlusion. Ischemic preconditioning, beta and calciumchannel blockers and the maintenance of mean arterial pressure at 75-80 mmHg, were used as adjuncts for myocardial protection. The internal mammaryartery was isolated under direct vision up to the second rib with excisionof the fourth costal cartilage. Coronary artery target sites were the leftanterior descending in 12, right coronary artery in 4, obtuse marginal in3, posterior descending in 1 and diagonal branch in 1 patient. Arterialgrafts (mammary, right gastroepiploic, radial), either as single orcomposite grafts, were used liberally. Preoperative risk factors includedcongestive heart failure (7), chronic renal insufficiency (5), secondreoperation (2), third reoperation (1), cerebrovascular disease (5), priorangioplasty (8) and preoperative intra-aortic balloon pumping in twopatients. RESULTS: There was no perioperative mortality with minimalmorbidity. Twelve patients underwent patency study of the grafts 48-72 hpostoperatively. Ten of the twelve grafts were patent; one internal mammaryartery graft to the left anterior descending coronary artery (<1.5 mm)early in our series was occluded and one additional left internal mammarygraft had a kink several centimeters away from the anastomosis, which wassuccessfully opened by angioplasty. At a mean follow-up interval of 8months all 16 surviving patients are in functional class I or II and all ofthem remain free of angina. CONCLUSION: In selected patients reoperativecoronary artery bypass grafting can be performed with this minimallyinvasive approach with a low perioperative morbidity and mortality rate andsatisfactory early graft patency rate with good symptomaticimprovement.