{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,3]],"date-time":"2026-06-03T17:17:34Z","timestamp":1780507054273,"version":"3.54.1"},"reference-count":34,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2026,1,4]],"date-time":"2026-01-04T00:00:00Z","timestamp":1767484800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCDD"],"abstract":"<jats:p>Total Coronary Revascularization via left Anterior Thoracotomy (TCRAT) represents a modern evolution of sternum-sparing, on-pump multivessel coronary artery bypass grafting. In this review, we will summarize the historical development, detail the surgical principles, and provide a comprehensive overview of the clinical outcomes of TCRAT. The technique combines cardiopulmonary bypass using peripheral arterial as well as venous cannulation and cardioplegic cardiac arrest using transthoracic aortic cross-clamping with surgical access through a left anterior minithoracotomy. By applying special slinging and rotational maneuvers, both a stable exposition of all coronary territories\u2014in particular those of the right and the circumflex coronary artery\u2014and a quiet, bloodless operating field enable complete anatomical revascularization and complex coronary surgery procedures, including all variations in multiarterial grafting in unselected patients. Data from all published clinical series were integrated, and a weighted analysis of a total of 2282 patients was performed. TCRAT proved to be very effective with regard to complete anatomical revascularization and modern grafting strategies, and it showed excellent perioperative safety in an all-comers population. Both the 30-day mortality and perioperative stroke incidence were distinctly below 1.0%. Data from mid-term follow-up, although rare so far, are promising and compare well to those of the important RCTs. The TCRAT approach eliminates sternal complications completely and accelerates recovery. As an on-pump arrested-heart surgery, TCRAT inherently permits the combination of minimally invasive multivessel CABG with a variety of other cardiac operations, mainly the combination with valve procedures. The integration of robotic and endoscopic assistance represents the next evolutionary step. With its reproducibility and broad applicability, TCRAT holds strong potential to become a standard routine technique in the field of minimally invasive cardiac surgery.<\/jats:p>","DOI":"10.3390\/jcdd13010028","type":"journal-article","created":{"date-parts":[[2026,1,5]],"date-time":"2026-01-05T10:53:50Z","timestamp":1767610430000},"page":"28","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["The TCRAT Technique (Total Coronary Revascularization via Left Anterior Thoracotomy): Renaissance in Minimally Invasive On-Pump Multivessel Coronary Artery Bypass Grafting?"],"prefix":"10.3390","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-5887-9949","authenticated-orcid":false,"given":"Volodymyr","family":"Demianenko","sequence":"first","affiliation":[{"name":"Department of Cardiothoracic Surgery, Heart-Thorax Center, Klinikum Fulda, University Medicine Marburg, Campus Fulda, Pacelliallee 4, 36043 Fulda, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hilmar","family":"D\u00f6rge","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Heart-Thorax Center, Klinikum Fulda, University Medicine Marburg, Campus Fulda, Pacelliallee 4, 36043 Fulda, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-8485-0024","authenticated-orcid":false,"given":"Christian","family":"Sellin","sequence":"additional","affiliation":[{"name":"Department of Cardiothoracic Surgery, Heart-Thorax Center, Klinikum Fulda, University Medicine Marburg, Campus Fulda, Pacelliallee 4, 36043 Fulda, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,1,4]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"567","DOI":"10.1016\/S0022-5223(96)70308-2","article-title":"Port-Access Coronary Artery Bypass Grafting: A Proposed Surgical Method","volume":"111","author":"Stevens","year":"1996","journal-title":"J. Thorac. Cardiovasc. Surg."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"67","DOI":"10.1056\/NEJM199701023360113","article-title":"Minimally Invasive Coronary-Artery Bypass Surgery","volume":"336","author":"Reichenspurner","year":"1997","journal-title":"N. Engl. J. Med."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"51","DOI":"10.1016\/S0003-4975(98)01265-X","article-title":"First Report of the Port Access International Registry","volume":"67","author":"Galloway","year":"1999","journal-title":"Ann. Thorac. Surg."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"S103","DOI":"10.1016\/S1010-7940(99)00199-2","article-title":"The Clinical and Financial Impact of Port-Access Coronary Revascularization","volume":"16","author":"Watson","year":"1999","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_5","first-page":"S76","article-title":"Economic Evaluation of Different Minimally Invasive Procedures for the Treatment of Coronary Artery Disease","volume":"16","author":"Reichenspurner","year":"1999","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"S43","DOI":"10.1093\/ejcts\/16.Supplement_2.S43","article-title":"Patient Selection for Port-Access Multivessel Revascularization","volume":"16","author":"Matheis","year":"1999","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1537","DOI":"10.1016\/S0003-4975(02)03947-4","article-title":"How Safe Is the Port Access Technique in Minimally Invasive Coronary Artery Bypass Grafting?","volume":"74","author":"Dogan","year":"2002","journal-title":"Ann. Thorac. Surg."},{"key":"ref_8","first-page":"S39","article-title":"Comparison of Postoperative Pain, Stress Response, and Quality of Life in Port-Access vs. Standard Sternotomy Coronary Bypass Patients","volume":"16","author":"Grossi","year":"1999","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1018","DOI":"10.1016\/S0003-4975(98)00710-3","article-title":"Minimally Invasive Surgical Treatment of Coronary Artery Multivessel Disease","volume":"66","author":"Gulielmos","year":"1998","journal-title":"Ann. Thorac. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1502","DOI":"10.1016\/S0003-4975(99)01032-2","article-title":"The Dresden Approach for Complete Multivessel Revascularization","volume":"68","author":"Gulielmos","year":"1999","journal-title":"Ann. Thorac. Surg."},{"key":"ref_11","first-page":"S34","article-title":"Influence of Median Sternotomy on the Psychosomatic Outcome in Coronary Artery Single-Vessel Bypass Grafting","volume":"16","author":"Gulielmos","year":"1999","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_12","first-page":"109","article-title":"Multiple Coronary Artery Bypass via Mini Left Thoracotomy with Conventional Aortic Occlusion","volume":"4","author":"Zapolanski","year":"2001","journal-title":"Heart Surg. Forum"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"330","DOI":"10.1177\/1556984519849126","article-title":"Complete Coronary Revascularization via Left Anterior Thoracotomy","volume":"14","author":"Babliak","year":"2019","journal-title":"Innovations"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1299","DOI":"10.1007\/s00380-022-02034-x","article-title":"Novel Concept of Routine Total Arterial Coronary Bypass Grafting Through a Left Anterior Approach Avoiding Sternotomy","volume":"37","author":"Sellin","year":"2022","journal-title":"Heart Vessel."},{"key":"ref_15","doi-asserted-by":"crossref","unstructured":"Demianenko, V., Schl\u00f6micher, M., Grossmann, M., Belmenai, A., D\u00f6rge, H., and Sellin, C. (2025). Early Outcomes in Severely Obese Patients Undergoing Sternum-Sparing Minimally Invasive Multivessel Artery Bypass Grafting (TCRAT). J. Clin. Med., 14.","DOI":"10.3390\/jcm14082545"},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e20230299","DOI":"10.21470\/1678-9741-2023-0299","article-title":"Left Anterior Mini-Thoracotomy vs. Conventional Sternotomy in On-Pump Multivessel Coronary Revascularization","volume":"40","author":"Sicim","year":"2025","journal-title":"Braz. J. Cardiovasc. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Demirsoy, E., Mavioglu, I., Dogan, E., Gulmez, H., Dindar, I., and Erol, M.K. (2023). The Feasibility and Early Results of Multivessel Minimally Invasive Coronary Artery Bypass Grafting for All Comers. J. Clin. Med., 12.","DOI":"10.3390\/jcm12175663"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"e70071","DOI":"10.1002\/rcs.70071","article-title":"Robotic Assisted Minimally Invasive Coronary Revascularisation: Midterm Results","volume":"21","author":"Arslanhan","year":"2025","journal-title":"Int. J. Med. Robot. Comput. Assist. Surg."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"402","DOI":"10.5606\/tgkdc.dergisi.2024.26471","article-title":"Total Coronary Revascularization via Left Anterior Thoracotomy: Comparison of Early- and Mid-Term Results with Conventional Surgery","volume":"32","author":"Akyol","year":"2024","journal-title":"Turk Gogus Kalp Damar Cerrahisi Derg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"2","DOI":"10.21037\/jovs-22-2","article-title":"Multivessel Minimally Invasive On-Pump Direct Coronary Artery Revascularization","volume":"9","author":"Babliak","year":"2023","journal-title":"J. Vis. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"707","DOI":"10.1097\/JS9.0000000000000259","article-title":"Clinical Outcomes and Quality of Life after Contemporary Isolated Coronary Bypass Grafting: A Prospective Cohort Study","volume":"109","author":"Sandner","year":"2023","journal-title":"Int. J. Surg."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"Sellin, C., Sand, U., Demianenko, V., Schmitt, C., Sch\u00e4fer, B., Schier, R., and D\u00f6rge, H. (Thorac. Cardiovasc. Surg., 2024). Comparison of Pulmonary Outcome in Minimally Invasive (TCRAT) and Full Sternotomy CABG, Thorac. Cardiovasc. Surg., Online ahead of print.","DOI":"10.1055\/a-2378-8459"},{"key":"ref_23","doi-asserted-by":"crossref","unstructured":"Sellin, C., Laube, S., Demianenko, V., Balan, R., D\u00f6rge, H., and Benoehr, P. (2024). Renal Outcome in Patients Undergoing Minimally Invasive Total Coronary Revascularization via Anterior Minithoracotomy Compared to Full Median Sternotomy Coronary Artery Bypass Grafting. J. Clin. Med., 13.","DOI":"10.3390\/jcm13185418"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"52","DOI":"10.1016\/j.xjtc.2024.05.018","article-title":"Sternum-Sparing Multivessel Coronary Surgery as a Routine Procedure: Midterm Results of Total Coronary Revascularization via Left Anterior Thoracotomy","volume":"26","author":"Sellin","year":"2024","journal-title":"JTCVS Tech."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"2645","DOI":"10.1161\/CIRCULATIONAHA.109.899211","article-title":"Outcomes in Patients with De Novo Left Main Disease Treated with Either Percutaneous Coronary Intervention Using Paclitaxel-Eluting Stents or Coronary Artery Bypass Graft Treatment in the SYNTAX Trial","volume":"121","author":"Morice","year":"2010","journal-title":"Circulation"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1056\/NEJMoa2112299","article-title":"Fractional Flow Reserve-Guided PCI as Compared with Coronary Bypass Surgery","volume":"386","author":"Fearon","year":"2022","journal-title":"N. Engl. J. Med."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"233","DOI":"10.1093\/ejcts\/ezab080","article-title":"Short- and Long-Term Mortality after Deep Sternal Wound Infection Following Cardiac Surgery: Experiences from SWEDEHEART","volume":"60","author":"Kaspersen","year":"2021","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_28","doi-asserted-by":"crossref","unstructured":"Bl\u00fcher, M., Brandt, D., Lankiewicz, J., Mallow, P.J., and Saunders, R. (2020). Economic Analysis of the European Healthcare Burden of Sternal-Wound Infections Following Coronary Artery Bypass Graft. Front. Public Health, 8.","DOI":"10.3389\/fpubh.2020.557555"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"494","DOI":"10.1093\/ejcts\/ezy274","article-title":"Economic Burden of Surgical Site Infections in Patients Undergoing Cardiac Surgery","volume":"55","author":"Findeisen","year":"2019","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"ezad182","DOI":"10.1093\/ejcts\/ezad182","article-title":"Left Anterior Minithoracotomy as a First-Choice Approach for Isolated Coronary Artery Bypass Grafting and Selective Combined Procedures","volume":"64","author":"Babliak","year":"2023","journal-title":"Eur. J. Cardiothorac. Surg."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1298","DOI":"10.1007\/s00380-023-02281-6","article-title":"Novel Concept of Less Invasive Concomitant Surgical Aortic Valve Replacement and Coronary Artery Bypass Grafting Avoiding Full Median Sternotomy","volume":"38","author":"Sellin","year":"2023","journal-title":"Heart Vessel."},{"key":"ref_32","first-page":"ivad214","article-title":"New Approach for Combined Aortic Valve and Coronary Procedures Through the Left Anterior Minithoracotomy","volume":"38","author":"Babliak","year":"2024","journal-title":"Interdiscip. Cardiovasc. Thorac. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"419","DOI":"10.1177\/15569845251339187","article-title":"Minimally Invasive Combined Aortic Valve Replacement and Coronary Artery Bypass Grafting Through Left Anterior Minithoracotomy","volume":"20","author":"Demianenko","year":"2025","journal-title":"Innovations"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"57","DOI":"10.1016\/j.xjtc.2023.11.015","article-title":"New Approach to the Mitral Valve Through the Left Anterior Minithoracotomy for Combined Valve and Coronary Surgical Procedures","volume":"24","author":"Babliak","year":"2023","journal-title":"JTCVS Tech."}],"container-title":["Journal of Cardiovascular Development and Disease"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2308-3425\/13\/1\/28\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,5]],"date-time":"2026-01-05T11:20:38Z","timestamp":1767612038000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2308-3425\/13\/1\/28"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1,4]]},"references-count":34,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,1]]}},"alternative-id":["jcdd13010028"],"URL":"https:\/\/doi.org\/10.3390\/jcdd13010028","relation":{},"ISSN":["2308-3425"],"issn-type":[{"value":"2308-3425","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1,4]]}}}