Coronary Bypass Surgery Explained: Traditional vs Keyhole (MIDCAB & TCRAT Options)
Introduction
Coronary artery bypass grafting (CABG), commonly known as heart bypass surgery, is a life-saving procedure for restoring blood flow to heart muscle when coronary arteries are severely narrowed or blocked. Traditionally, CABG is performed as an open-heart operation via a full sternotomy (cutting through the breastbone). However, advances in surgical techniques now allow certain bypass operations to be done with “keyhole” minimally invasive approaches. These include MIDCAB (Minimally Invasive Direct Coronary Artery Bypass) for single-vessel bypass and TCRAT (Total Coronary Revascularisation via Anterior Thoracotomy) for multi-vessel bypass.
Understanding Coronary Artery Bypass Surgery (CABG)
In coronary artery disease, plaques build up inside the coronary arteries and restrict blood flow to the heart muscle, causing chest pain (angina) or even heart attacks. CABG is a surgical treatment that creates a new route for blood to reach the heart tissue beyond these blockages. In a bypass operation, the surgeon takes a healthy blood vessel (a graft from the patient’s leg, arm, or chest) and attaches it to the clogged coronary artery at a point beyond the blockage, effectively “bypassing” the narrowed segment. This allows blood to flow around the obstruction and nourish the heart muscle. CABG can significantly improve symptoms and has been shown to prolong life in certain patient groups, especially those with multiple severe blockages.
Traditional CABG (Open-Heart Bypass via Sternotomy): In the conventional approach, the surgeon makes a long incision down the centre of the chest and splits the breastbone (sternum) to open the ribcage and access the heart. The patient is usually placed on a heart-lung bypass machine, which takes over circulation while the surgeon stops the heart to sew the grafts in place. Traditional CABG is a well-established, effective technique that allows the surgeon full access to all coronary arteries. This makes it feasible to bypass multiple arteries and handle complex disease in one operation. However, open-heart surgery via sternotomy is a major operation: it entails a large wound through bone, leading to more postoperative pain, a longer recovery period, and a scar running down the chest. Patients typically stay in hospital about a week and face a recovery time of around 8–12 weeks for the breastbone to heal completely. There is also a higher risk of certain complications compared to smaller-incision methods, such as deep sternal wound infections (a serious infection of the breastbone incision) and longer-term discomfort or risk of bone healing issues. On the other hand, virtually every cardiac surgery center offers traditional CABG, and most heart surgeons worldwide are very experienced with this technique, which contributes to its excellent success rates and reliability over decades of use.
Minimally Invasive “Keyhole” Bypass (MIDCAB & TCRAT): Minimally invasive coronary bypass procedures were developed to avoid the trauma of splitting the breastbone. In a MIDCAB approach, the surgeon operates through a small incision between the ribs (usually on the left side of the chest) rather than a full sternotomy. The heart is accessed through this keyhole incision – often about 6–10 cm long – using special instruments and sometimes small scopes or cameras to assist visualization. The MIDCAB technique is most commonly used to bypass the left anterior descending (LAD) artery on the front of the heart, using the left internal mammary artery (LIMA) graft from inside the chest. In many cases, MIDCAB is performed on a beating heart, without the heart-lung machine, by using stabilisation devices on the small area of the heart being grafted. Avoiding the heart-lung machine (called “off-pump” surgery) can reduce certain risks and may lead to a faster recovery in suitable patients. MIDCAB is considered an excellent alternative to stenting for a single-vessel LAD disease, offering the long-term benefits of a surgical bypass with a less invasive procedure than full open-heart surgery.
For patients with disease in multiple coronary arteries, a more advanced minimally invasive strategy can be used: Total Coronary Revascularisation via Anterior Thoracotomy (TCRAT). This mouthful of a term essentially means performing a complete multi-vessel bypass operation through an anterior thoracotomy (a small incision on the chest wall) instead of a sternotomy. In a TCRAT procedure, highly skilled surgeons graft additional arteries through the same small chest incision, sometimes using a combination of internal mammary arteries and other grafts to bypass all the necessary vessels. Only a handful of surgical teams worldwide are capable of performing triple or quadruple bypasses through a keyhole incision, due to the technical complexity. Mr. Inderpaul Birdi, for example, is one such specialist who has pioneered this technique – in 2022, he performed the UK’s first quadruple heart bypass via keyhole surgery on a 65-year-old patient (the first time four bypass grafts were completed through a minimal incision in the UK). This landmark case demonstrated that even complex multi-vessel disease can potentially be treated with a minimally invasive approach by an expert team, with excellent results.
Benefits of Keyhole Heart Surgery (MIDCAB/TCRAT)
Minimally invasive or “keyhole” heart bypass surgery offers several patient-centred benefits compared to the traditional open-heart method:
Faster, Easier Recovery: One of the biggest advantages is a quicker return to normal life. Without a broken breastbone, the body heals faster. Many MIDCAB patients are up on their feet within a day or two and can resume light daily activities within a couple of weeks. In fact, keyhole patients often return to their normal routine in about 3–4 weeks, versus roughly 3 months for a typical sternotomy recovery. This dramatically shorter rehabilitation time means less disruption to work and family life. Clinical studies have confirmed that patients undergoing minimally invasive bypass tend to have shorter hospital stays and faster recovery than those who have open-heart surgery [1].
Less Pain and Scarring: The incision for MIDCAB or TCRAT is much smaller than the long chest scar from a full sternotomy. There is no bone cut, which means patients generally experience less postoperative pain and require less pain medication. The smaller scar (often hidden on the side of the chest) is cosmetically more discreet, which can be important for patient confidence. More importantly, less trauma to the chest translates to an easier time with breathing and coughing exercises after surgery, aiding recovery.
Lower Risk of Major Infection: By avoiding the split sternum and large wound, keyhole surgery reduces the risk of deep wound infection in the chest bone. Sternal wound infections, though not common, can be serious when they occur in open-heart cases (especially in patients with diabetes or obesity). Keyhole incisions still carry some risk of infection, but these tend to be more superficial and are usually easier to treat if they occur. Overall, the risk of any major infection or complication is lower with minimally invasive CABG in appropriately selected patients [1][2].
Less Blood Loss and Transfusion: Smaller incisions and avoiding the heart-lung machine in off-pump cases often result in less blood loss during surgery. Patients who have keyhole bypass are less likely to need a blood transfusion compared to traditional CABG patients [1]. This is beneficial because transfusions can occasionally cause complications or immune reactions. Less blood loss is a sign of less trauma during surgery and contributes to the faster recovery profile of minimally invasive techniques.
Reduced Hospital Stay: With quicker recovery and fewer complications, keyhole bypass patients can go home sooner. The hospital stay after a minimally invasive CABG is typically only 2–5 days, versus about a week or more for open-heart surgery. Being able to recover in the comfort of your home sooner not only improves patient satisfaction, but also reduces the risk of hospital-related issues and can lower overall healthcare costs.
Psychological Benefits: Many patients feel less anxious going into surgery knowing that a keyhole procedure will be performed instead of a full open-heart operation. The idea of avoiding “cracking the chest” can alleviate a lot of fear. Postoperatively, patients often report feeling encouraged by the smaller incision and quicker regain of mobility. Avoiding a prominent chest scar can also have positive emotional benefits for some individuals.
It’s important to note that the primary goal – effective revascularisation of the heart – is still achieved with keyhole surgery. In experienced hands, minimally invasive bypass can provide long-term outcomes comparable to traditional CABG. For example, the patency (long-term openness) of grafts placed via MIDCAB has been shown to be equivalent to those placed via open surgery – one large study found over 95% graft patency at 5 years with minimally invasive techniques, which is on par with traditional bypass results [2]. In terms of relieving symptoms and improving survival in the long run, keyhole bypass offers the same clinical benefits as open CABG for the appropriate candidates [3]. In some series, the success rates (freedom from angina and need for re-intervention) are as high as or even higher than those of conventional surgery, particularly when done by specialised surgeons [3].
Considerations and Limitations of Minimally Invasive Bypass
Despite all the advantages, keyhole heart surgery is not suitable for everyone. There are important considerations and potential limitations to be aware of:
Patient Selection is Key: Whether a bypass can be done minimally invasively depends on factors like the complexity of coronary disease, the patient’s body shape, and overall health. Patients with a low body mass index (thin build) and disease limited to the front of the heart (e.g. a blockage in the LAD) are often ideal candidates for MIDCAB.
At The Keyhole Heart Clinic, Mr Inder Birdi has also perfected a treatment called TCRAT, or Total Coronary Revasacularisation via Anterior Thoracotomy. This is a method of grafting not only the LAD artery, but also the circumflex artery on the side of the heart and even the right coronary artery on the undersurface of the heart. He is one of only a handful of surgeons in the world who has performed this procedure, and the first in the UK to perform this procedure successfully in 2022. Each case must be evaluated individually. A thorough consultation with a cardiac surgeon, including review of angiograms and scans, is necessary to determine if minimally invasive bypass is an option.
Not Widely Available: Minimally invasive CABG like TCRAT requires special expertise and equipment, and relatively few surgeons currently perform these operations routinely. The technique has a learning curve; surgeons must undergo additional training to master operating in a confined space. As a result, most heart centers do not offer multi-vessel keyhole bypass surgery. Patients seeking these advanced procedures often have to travel to specialised centers or surgeons (such as The Keyhole Heart Clinic led by Mr. Birdi in the UK, or similar programs in other countries)
Potential for Conversion to Open Surgery: While uncommon, there is a small risk that a minimally invasive attempt may need to be converted to a full sternotomy in the event of unexpected difficulties. For example, if there is cardiac instability or if the target artery is too difficult to access safely through the small incision the surgeon will convert to the breastbone in theatre. This is often undertaken in a very safe and controlled theatre environment. Expert surgeons report low conversion rates (on the order of a few percent), but patients should be aware that the surgical team is always prepared to switch to an open procedure if it’s necessary to ensure safety. This is actually a positive safeguard, it means the priority is always the patient’s well-being, even if it means abandoning the keyhole approach mid-operation.
Longer Operative Time: Keyhole bypass surgeries can take longer to perform than standard CABG because working through a small opening is more technically demanding. For instance, a single-vessel MIDCAB might take slightly more time in the operating room than the same bypass done open, and a TCRAT (multi-vessel) can be significantly lengthy as each graft is done in a confined space. Longer cardiopulmonary bypass time (if the heart-lung machine is used) or simply longer anesthesia time can have some impact on recovery for certain patients. However, despite a longer surgery, the overall hospital recovery time is still shorter for minimally invasive cases.
Surgeon Skill and Volume: The success of minimally invasive bypass is highly dependent on the skill and experience of the surgical team. Patients should seek out a surgeon who has extensive experience in keyhole heart surgery. Studies underscore that outcomes for novel techniques improve dramatically with higher surgeon volume and institutional expertise. Choosing an experienced team minimises risks and maximises the chances of a successful minimally invasive operation. If your local surgeon or hospital does not routinely perform MIDCAB/TCRAT, they might recommend the traditional approach simply because that is what they do best. This is one reason why second opinions can be valuable (more on that below).
Not for Every Condition: There are scenarios where a sternotomy is still the better (or only) choice. For example, if the patient needs additional procedures like valve surgery or an aneurysm repair at the same time as the bypass, an open-chest operation might be necessary to address everything safely in one go. Similarly, if the coronary anatomy is very complex (e.g., multiple small branches needing grafts, or emergencies like a tear in the aorta), the surgeon may advise that the conventional approach is the gold standard. Traditional CABG remains the gold standard in many complex multi-vessel cases because it offers the surgeon maximal visibility and access [3]. Minimally invasive methods are an alternative, not a wholesale replacement for open-heart surgery, they are most beneficial in specific scenarios but not meant to handle every situation.
In summary, keyhole heart surgery must be tailored to the patient’s individual situation. When done on the right patient, by the right team, it can offer a superb outcome with fewer downsides. But it requires careful patient selection and a high level of surgical expertise to ensure it’s as safe and effective as the traditional approach. A candid discussion with a cardiac surgeon experienced in both techniques is essential to determine the best course of action.
Outcomes and Success Rates: Open vs Keyhole
Patients and their families often want to know: does choosing a minimally invasive operation compromise the success of the surgery in any way?
The encouraging answer from current data is that when performed on appropriate candidates, minimally invasive CABG has outcomes comparable to traditional CABG in terms of graft longevity and patient survival [3][4]. If the grafts are placed properly, they will do the job of supplying blood to the heart muscle regardless of whether the chest was opened widely or not. This is why clinical expertise is critical.
Multiple studies have examined outcomes of MIDCAB versus conventional CABG. For instance, a large study with over 500 MIDCAB patients compared to sternotomy CABG for single-vessel LAD disease found no difference in long-term survival between the two methods [3]. At an average of 13 years follow-up, patients’ survival and freedom from cardiac events were equivalent, confirming that the minimally invasive approach was just as durable as open surgery for that patient group. Other research focusing on multi-vessel minimally invasive techniques (including robotic-assisted bypass) has shown excellent graft patency rates (over 95% at 5 years) and low incidence of major cardiac events, indicating that keyhole surgery can maintain very high-quality results [2].
It’s also worth noting that bypass surgery in general has very high success rates. Whether done open or keyhole, CABG is one of the most frequently performed major surgeries worldwide and has a strong track record of relieving angina and improving life expectancy in suitable patients. The risk of something going wrong (like not being able to complete the bypasses, or serious complications) is low in the hands of an experienced team. Keyhole approaches, despite being newer, have matured to the point that their safety profile is on par with traditional surgery for selected patients [4]. In fact, some registries suggest certain complications are less common with minimally invasive surgery – for example, reduced risk of stroke or cognitive issues, possibly due to avoiding the heart-lung machine in off-pump cases [1]. The main takeaway is that outcome quality is not sacrificed by avoiding a big incision, as long as the operation is done by a skilled surgeon.
Of course, every patient is unique. Your own outcome will depend on factors like your age, other medical conditions, the state of your heart function, and how many arteries need bypassing. These factors influence risk regardless of surgical approach. This is why personalisation is key: the “best” approach is one that achieves a complete and safe revascularisation for you. Sometimes that will be minimally invasive, and other times a traditional operation is the wiser choice. What’s important is that you are aware you have options and can discuss them with your healthcare providers.
Seeking a Second Opinion and Expert Advice
If you have been told you need coronary bypass surgery, or if you are a relative researching on behalf of a patient – it’s natural to have questions about the procedure and whether less invasive alternatives exist. Many patients initially assume that an open-heart sternotomy is the only way to have bypass surgery, simply because that’s the most common method and what many doctors first mention. However, if the idea of a keyhole heart surgery appeals to you, it is entirely reasonable to seek a second opinion from a surgeon who specialises in minimally invasive cardiac surgery. Getting a second opinion does not offend competent doctors; in fact, any good clinician will understand and support your desire to gather all information before making a decision.
When seeking an expert opinion on keyhole bypass, look for a consultant cardiac surgeon who has specific experience in MIDCAB/TCRAT CABG. These specialists can review your angiograms and medical history to determine if you are a candidate for a minimally invasive approach. In some cases, patients who were told elsewhere that they “weren’t eligible” for keyhole surgery find that, in the hands of a more experienced keyhole surgeon, the operation is indeed feasible. This experience is all too frequent.
In this video, one patient in Mr. Birdi’s practice had been advised by his local London hospital that a triple bypass had to be done with open-heart surgery. The patient sought a second opinion at The Keyhole Heart Clinic, where after careful evaluation the team performed a successful quadruple bypass through a small lateral incision. The patient was walking the next day and went home after a few days, a far cry from the prolonged recovery he anticipated with a sternotomy. Such cases highlight that surgeon experience and perspective can make a difference in what options are available.
During a second-opinion consultation, you can expect the surgeon to discuss all the pros and cons of each approach as they pertain to your situation. They should answer questions like: “How many of these keyhole procedures have you done?”, “What are the risks in my case?”, “What if you can’t complete it minimally invasively?”, and “What outcome can I expect?” Don’t hesitate to ask about the surgeon’s personal results and success rates with keyhole surgery. A true expert will be transparent about their track record and will only recommend the minimally invasive route if they genuinely believe it’s as safe and effective as the open approach for you. In some cases, they might concur with the first opinion that an open surgery is safer – and you should weigh that advice accordingly. The goal of seeking expert input is to ensure you have explored all avenues and feel confident in your treatment plan.
A Patient-Centred Choice
Whether you undergo a traditional open-heart bypass or a minimally invasive keyhole bypass, the ultimate goal is the same: to treat your heart condition effectively so you can enjoy a healthier, longer life. It’s normal to feel apprehensive about heart surgery, but being informed is the first step to feeling empowered. Take time to discuss all the options with your cardiologist and surgeon. If you’ve only heard about CABG as an open-heart operation, it may be enlightening to learn that less invasive alternatives exist – and for many patients, these can be total game-changers in terms of comfort and recovery. Conversely, if you are very keen on keyhole surgery, be open to the possibility that for some cases the traditional approach is still the safer route. A trustworthy surgical team will prioritise your safety and outcome above all, guiding you to the option that best fits your medical needs.
Conclusion and Next Steps
Facing the prospect of heart bypass surgery is undoubtedly daunting, but today’s patients are fortunate to have multiple pathways to recovery. Traditional CABG via sternotomy remains a dependable workhorse procedure with excellent outcomes, and for many it will be the recommended approach. Yet, minimally invasive techniques like MIDCAB and TCRAT are revolutionising the patient experience for those who are good candidates – offering the chance to have coronary artery bypass surgery without “open-heart” surgery in the classic sense. The key is to educate yourself and consult with experienced professionals so that you can make an informed choice about your care.
If you or your loved one are exploring the possibility of keyhole heart surgery, don’t hesitate to reach out for expert guidance or a second opinion. Equip yourself with knowledge: ask questions about the surgeon’s experience, success rates, and what recovery will look like in each scenario. When you have confidence in your surgical team and a clear understanding of your options, you will feel much more at ease moving forward.
To help you further in this journey, we’ve prepared a free downloadable PDF guide titled “How to Choose a Good Keyhole Heart Surgeon.” This guide offers practical tips and important questions to consider when evaluating a surgeon’s credentials and experience in minimally invasive heart surgery. It’s an educational resource designed to empower patients and families to make the best decision for their heart health. Click here to download “How to Choose a Good Keyhole Heart Surgeon.” Arm yourself with the right information, and take heart in knowing that cardiac surgery – whether open or keyhole – has a high success rate and can truly give you a new lease on life.
FREE DOWNLOAD
References:
- Balkhy HH, et al. Minimally Invasive Coronary Revascularisation Surgery: A Focused Review of the Available Literature. Journal of Clinical Medicine, 2021;10(16):3493. PMID: 34295373. (Discusses benefits of minimally invasive and hybrid coronary bypass, noting shorter hospital stay, less transfusion, and faster recovery compared to conventional CABG)
- Hwang B, et al. Systematic review and meta-analysis of two decades of outcomes for robotic coronary artery bypass grafting. Annals of Cardiothoracic Surgery, 2024;13(4):251–264. (Reports high 5-year graft patency ~96% and low complication rates for robot-assisted minimally invasive CABG, demonstrating excellent durability of keyhole bypass grafts)
- Raja SG, et al. Short-term clinical outcomes and long-term survival of minimally invasive direct coronary artery bypass grafting vs sternotomy CABG for isolated LAD disease. Annals of Cardiothoracic Surgery, 2018;7(5):604–612. (Large single-centre study showing MIDCAB had similar operative safety and 13-year survival as traditional open CABG for left anterior descending artery bypass)
- Aljohani S, et al. Comparing the effectiveness of open and minimally invasive approaches in coronary artery bypass grafting: A systematic review. Clinical Practice, 2024;14(5):1842-1868. (Highlights that patient selection is crucial; in suitable patients minimally invasive CABG yields fewer complications and faster recovery, while open surgery remains preferable for complex cases to ensure optimal long-term results)
