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Short-term clinical outcomes and long-term survival of minimally invasive direct coronary artery bypass grafting
Abstract
Background:
Minimally invasive direct coronary artery bypass (MIDCAB) grafting is regarded as an alternative to conventional coronary artery bypass grafting (CABG) through full sternotomy, particularly for patients with isolated proximal left anterior descending (LAD) artery stenosis deemed unsuitable for percutaneous coronary intervention. However, the technically demanding nature of the procedure and lack of long-term published outcomes have precluded its universal adoption. We report the comparative short-term outcomes and long-term survival of MIDCAB and conventional CABG through full sternotomy for grafting of isolated LAD.
Methods:
From February 1996 to October 2017, a total of 668 patients underwent MIDCAB (n=508) and full sternotomy (n=160) CABG for isolated proximal LAD stenosis. Their data were prospectively entered into the institutional cardiac surgery database (Patients Analysis & Tracking System; Dendrite Clinical Systems, Ltd, Oxford, England, United Kingdom) and analyzed retrospectively. Information on patient deaths was obtained from the institutional database and the National General Register Office for all patients.
Results:
The two groups were comparable with respect to preoperative demographics and risk profile. MIDCAB was associated with longer operative time (177±32 versus 141±12 min; P=0.003). The two groups did not significantly differ with regard to other complications including operative mortality. At a mean follow-up of 12.95±0.47 years, survival was also similar.
Conclusions:
This large single centre study with longest follow-up validates the status of MIDCAB as an effective strategy for grafting of LAD. However, it fails to show superiority of the minimally invasive approach compared to conventional CABG through full sternotomy.
... The MIDCAB approach may offer promising benefits for patients requiring surgical myocardial revascularization. However, its technically demanding nature and the lack of long-term outcomes remain major burdens for its further adoption [5]. The purpose of this retrospective study is to review and present the results of our single-center experience with MIDCAB for surgical myocardial revascularization. ...
... In recent years, MIDCAB surgery presented promising results as an effective and safe minimally invasive approach for coronary revascularization [4,6,7]. The less invasive nature of this approach provides advantages for various patient groups, including those with comorbidities that make a standard sternotomy impractical [5,7]. The present singlecenter, retrospective study reports our results on long-term survival and postoperative results of consecutive patients who underwent MIDCAB revascularization in our institution between July 1999 and April 2022. ...
... In recent years, MIDCAB surgery presented promising results as an effective and safe minimally invasive approach for coronary revascularization [4,6,7]. The less invasive nature of this approach provides advantages for various patient groups, including those with comorbidities that make a standard sternotomy impractical [5,7]. The present single-center, retrospective study reports our results on long-term survival and postoperative results of consecutive patients who underwent MIDCAB revascularization in our institution between July 1999 and April 2022. ...
Background: Coronary artery disease is a major cause of death globally. Minimally invasive direct coronary artery bypass (MIDCAB), using a small left anterior thoracotomy, aims to provide a less invasive alternative to traditional procedures, potentially improving patient outcomes with reduced recovery times. Methods: This retrospective, non-randomized study analyzed 310 patients who underwent MIDCAB between July 1999 and April 2022. Data were collected on demographics, clinical characteristics, operative and postoperative outcomes, and follow-up mortality and morbidity. Statistical analysis was conducted using IBM SPSS, with survival curves generated via the Kaplan–Meier method. Results: The cohort had a mean age of 63.3 ± 10.9 years, with 30.6% females. The majority of surgeries were elective (76.1%), with an average operating time of 129.7 ± 35.3 min. The median rate of intraoperative blood transfusions was 0.0 (CI 0.0–2.0) Units. The mean in-hospital stay was 8.7 ± 5.5 days, and the median ICU stay was just one day. Early postoperative complications were minimal, with a 0.64% in-hospital mortality rate. The 6-month and 1-year mortalities were 0.97%, with a 10-year survival rate of 94.3%. There were two cases of perioperative myocardial infarction and no instances of stroke or new onset dialysis. Conclusions: The MIDCAB approach demonstrates significant benefits in terms of patient recovery and long-term outcomes, offering a viable and effective alternative for patients suitable for less invasive procedures. Our results suggest that MIDCAB is a safe option with favorable survival rates, justifying its consideration in high-volume centers focused on minimally invasive techniques.
... To ensure optimal outcomes, the anesthesiology team also played a vital role in managing intrathoracic and intracardiac pressure [13]. In various studies, MICS demonstrated comparable results to coronary artery bypass surgery (CABG) through MS, particularly regarding long-term patency rates and other well-known complications [2,[14][15][16][17][18]. MICS has been associated with many advantageous outcomes, including decreased postoperative pain, enhanced cosmetic results, reduced surgical site infection rates, minimized surgical trauma, fewer blood transfusion requirements, and faster recovery and hospital discharge times [2,[14][15][16][17][18]. ...
... To ensure optimal outcomes, the anesthesiology team also played a vital role in managing intrathoracic and intracardiac pressure [13]. In various studies, MICS demonstrated comparable results to coronary artery bypass surgery (CABG) through MS, particularly regarding long-term patency rates and other well-known complications [2,[14][15][16][17][18]. MICS has been associated with many advantageous outcomes, including decreased postoperative pain, enhanced cosmetic results, reduced surgical site infection rates, minimized surgical trauma, fewer blood transfusion requirements, and faster recovery and hospital discharge times [2,[14][15][16][17][18]. Numerous studies have indicated that surgical coronary revascularization is superior to percutaneous coronary intervention (PCI) in both the short-term and long-term [19][20][21][22]. ...
... In terms of morbidity and perioperative complication, it must be taken into consideration that the avoidance of MS and CPB suggests absence or reduced incidence of postoperative stroke and low mortality, reduced rates of postoperative AF, fast-trackable patients, a decreased need for red blood cell transfusions, fewer infections, and shorter ICU and hospital stays after CABG [2,14,25,29,31,47]. Despite the technical complexity of MICS and the reduced exposure of the whole heart, our study demonstrated low in-hospital rates of postoperative MI (1.6%) and reoperations due to bleeding (1.6%). ...
Objectives: Minimally invasive coronary surgery (MICS) via lateral thoracotomy is a less invasive alternative to the traditional median full sternotomy approach for coronary surgery. This study investigates its effectiveness for short- and long-term revascularization in cases of single and multi-vessel diseases. Methods: A thorough examination was performed on the databases of two cardiac surgery programs, focusing on patients who underwent minimally invasive coronary bypass grafting procedures between 2010 and 2023. The study involved patients who underwent either minimally invasive direct coronary artery bypass grafting (MIDCAB) for the revascularization of left anterior descending (LAD) artery stenosis or minimally invasive multi-vessel coronary artery bypass grafting (MICSCABG). Our assessment criteria included in-hospital mortality, long-term mortality, and freedom from reoperations due to failed aortocoronary bypass grafts post-surgery. Additionally, we evaluated significant in-hospital complications as secondary endpoints. Results: A total of 315 consecutive patients were identified between 2010 and 2023 (MIDCAB 271 vs. MICSCABG 44). Conversion to median sternotomy (MS) occurred in eight patients (2.5%). The 30-day all-cause mortality was 1.3% (n = 4). Postoperative AF was the most common complication postoperatively (n = 26, 8.5%). Five patients were reoperated for bleeding (1.6%), and myocardial infarction (MI) happened in four patients (1.3%). The mean follow-up time was six years (±4 years). All-cause mortality was 10.3% (n = 30), with only five (1.7%) patients having a confirmed cardiac cause. The reoperation rate due to graft failure or the progression of aortocoronary disease was 1.4% (n = 4). Conclusions: Despite the complexity of the MICS approach, the results of our study support the safety and effectiveness of this procedure with low rates of mortality, morbidity, and conversion for both single and multi-vessel bypass surgeries. These results underscore further the necessity to implement such programs to benefit patients.
... Minimally invasive CABG is safe and effective in the treatment of proximal LAD stenosis (36)(37)(38)(39)(40)(41)(42)(43). Early postoperative mortality (in-hospital/30-day) is low, with most recent studies reporting rates of ≤1% (39)(40)(41)(43)(44)(45)(46)(47)(48). ...
... Overall, minimally invasive CABG has shown promising short-term results with several series reporting reduced surgical morbidity and patient recovery times as well as higher quality of life scores compared to conventional sternotomy CABG (40,43,46,(51)(52)(53)(54)(55). Reported rates of perioperative complications following minimally invasive CABG are comparable or lower than conventional sternotomy CABG (38,43,48), and risk of conversion to sternotomy is ≤2% (38,41,44,47) Advantages Minimally invasive CABG with the LIMA to LAD offers the durable graft patency of the LIMA over PCI while avoiding sternotomy and cardiopulmonary bypass (56). Use of a sternal-sparing approach eliminates the risk of sternal wound infections and improves cosmesis, which may be of particular importance in women given the increased risk of deep sternal wound infections in this population (8,17). ...
... Overall, minimally invasive CABG has shown promising short-term results with several series reporting reduced surgical morbidity and patient recovery times as well as higher quality of life scores compared to conventional sternotomy CABG (40,43,46,(51)(52)(53)(54)(55). Reported rates of perioperative complications following minimally invasive CABG are comparable or lower than conventional sternotomy CABG (38,43,48), and risk of conversion to sternotomy is ≤2% (38,41,44,47) Advantages Minimally invasive CABG with the LIMA to LAD offers the durable graft patency of the LIMA over PCI while avoiding sternotomy and cardiopulmonary bypass (56). Use of a sternal-sparing approach eliminates the risk of sternal wound infections and improves cosmesis, which may be of particular importance in women given the increased risk of deep sternal wound infections in this population (8,17). ...
Minimally invasive coronary artery bypass grafting (CABG) has emerged as a viable alternative to conventional sternotomy CABG in select patients requiring coronary revascularization. Specific techniques vary, but minimally invasive CABG (i.e., MIDCAB) usually involves revascularization of the left anterior descending (LAD) artery with the left internal mammary artery (LIMA). Minimally invasive CABG can be performed without cardiopulmonary bypass through a small anterior thoracotomy incision with robotic assistance. Use of minimally invasive CABG may offer specific benefits for women requiring revascularization, particularly given that female gender is an independent risk factor for inferior outcomes following CABG. Here we describe how to perform robot-assisted minimally invasive CABG, with a focus on technical modifications aimed at improving outcomes in women.
... La cirugía coronaria mediante derivación aortocoronaria mínimamente invasiva (MIDCAB) combina los beneficios de la derivación coronaria de AMII a la DA con una menor invasividad del procedimiento, lo que se traduce en una menor morbimortalidad, estancia hospitalaria y coste [3][4][5][6][7][8][9] . Además, en pacientes seleccionados con enfermedad coronaria multivaso se puede realizar un procedimiento híbrido en el que se combina el MIDCAB para la DA con la revascularización percutánea del resto de las lesiones 1 . ...
... La mediana del EuroSCORE II fue de 2,1 (IQR 1, [4][5][6][7]8). En todos los pacientes se realizó un puente de AMII a la DA. En dos pacientes con estenosis aórtica severa preoperatoria se realizó simultáneamente un implante de TAVI transapical, por tratarse de pacientes con riesgo quirúrgico elevado y patología vascular periférica. ...
... La cirugía coronaria mínimamente invasiva es una opción terapéutica en pacientes seleccionados que añade al beneficio a largo plazo del puente de AMII a la DA una menor morbilidad al evitar la esternotomía media y la circulación extracorpórea (accidente cerebrovascular, fracaso renal agudo, infección de herida quirúrgica), una menor estancia hospitalaria y menores costes [6][7][8][9] . Esto se traduce en un menor tiempo de recuperación postoperatorio y una incorporación más temprana a las actividades de la vida diaria, con una mejor calidad de vida durante el seguimiento 12 . ...
Resumen
Introducción y objetivos
La revascularización coronaria de la arteria descendente anterior (DA) mediante derivación aortocoronaria mínimamente invasiva (MIDCAB) mantiene los beneficios del uso de la arteria mamaria interna izquierda y evita las complicaciones asociadas a la esternotomía media y a la circulación extracorpórea. El objetivo es presentar nuestra experiencia inicial en el MIDCAB.
Material y método
Se incluyeron todos los pacientes intervenidos mediante MIDCAB de marzo 2019 a junio del 2020. En todos los pacientes se realizó un puente coronario de arteria mamaria interna izquierda a la descendente anterior mediante minitoracotomía anterolateral izquierda sin circulación extracorpórea.
Resultados
Se intervinieron 22 pacientes. La mediana de edad era de 70 años (IQR 63-77) y el 90,9% (n = 20) eran varones. En dos pacientes con estenosis aórtica severa se realizó simultáneamente implante de una prótesis aórtica transcatéter por vía transapical y en ocho (36,4%) pacientes se realizó un procedimiento híbrido con revascularización percutánea al resto de lesiones. No hubo mortalidad hospitalaria, infarto agudo de miocardio, accidente cerebrovascular, ni fracaso renal agudo postoperatorio. La mediana de estancia hospitalaria fue de cuatro días (IQR 3-5).
Conclusiones
El MIDCAB es una técnica segura y eficaz para la revascularización coronaria en el territorio de la descendente anterior que combina las ventajas de un abordaje mínimamente invasivo sin circulación extracorpórea y el uso de la arteria mamaria interna izquierda para la realización de un puente coronario.
... Similar results regarding the mortality rate were published before: Raja and colleagues reported a 30-day mortality rate of 2% among 668 patients undergoing the MIDCAB procedure [12], while Holzhey noted a mortality of 0.8% in 1768 patients [13]. Calafiore et al. observed a 30-day mortality of 0.6% in 155 patients who underwent a MIDCAB procedure [14]. ...
... The rethoracotomy (for bleeding) rate in our study is 4.4%, that is comparable to published data which ranges between 1 and 4% [15,16]. Wound healing disturbances were observed in only 2.2% of our cohort, which is comparable to other studies, including 3.4% reported by Reuthebuch and colleagues in patients undergoing MIDCAB procedures [16] and 2.4% reported by Raja [12]. ...
Objectives: Minimally invasive direct coronary artery bypass (MIDCAB) is an alternative for revascularisation of the isolated left anterior descending (LAD) artery or as a multi-vessel (MV) procedure for the diagonal branch (RD) or the left circumflex coronary artery (LCX) region. Methods: From 2021 to 2022, 91 patients underwent MIDCAB or multi-vessel MIDCAB procedures in our heart center. The left internal mammary artery (LIMA) was anastomosed to the left anterior descending artery via the left minithoracotomy approach in all patients. Results: Of the patients, a total of 86.8% were male. Eighty percent of the patients had two- or three-vessel coronary artery disease. The mean age was 65.1 ± 10.1 years. The mean operation time was 2.6 ± 0.8 h. The 30-day mortality was 0. The mean required packed red blood cells (pRBC) was 0.4 ± 1.2 unit. The mean intensive care unit stay (ICU) was 1.5 ± 1.6 days. The mean follow-up time was 1.5 ± 0.5 years. One patient received percutaneous coronary intervention due to de novo stenosis of the RCA. Late mortality was 2.2%. The Kaplan–Meier survival rate was 98.8% at 1 and 2 years. Conclusions: The postoperative complication rate of our MIDCAB cohort is low, and the short-term survival is favorable. Our postoperative and short-term clinical results demonstrate that this procedure is safe and feasible.
... Similar results regarding the mortality rate were published before: Raja and colleagues reported a 30-day mortality rate of 2% among 668 patients undergoing the MIDCAB procedure [12], while Holzhey noted a mortality of 0.8% in 1768 patients [13]. Calafiore et al. observed a 30-day mortality of 0.6% in 155 patients who underwent MIDCAB procedure [14]. ...
... The rethoracotomy (for bleeding) rate in our study is 4%, that is comparable to published data which ranges between 1 and 4% [15,16]. Wound healing disturbances were observed in only 2% of our cohort, that is comparable to other studies as 3.4% reported by Reuthebuch and colleagues in patients undergoing MIDCAB procedures [16], respectively 2,4 % reported by Raja [12]. ...
Objectives: Minimally invasive direct coronary artery bypass (MIDCAB) is an alternative for revascularisation of isolated left anterior descending (LAD) or as multi-vessel (MV) procedure for diagonal branch (RD) or circumflex artery (RCX) region. Methods: From 2021 to 2022 91 patients underwent MIDCAB procedure in our heartcenter. 80% were male. Eighty percent of the patients had two or three vessel coronary artery disease. Mean age was 65±10 years. The left internal mammary artery (LIMA) was anastomosed to the left anterior descending via left minithoracotomy approach in all patients. Fourteen patients received multi-vessel MIDCAB (15%) with two or three anastomoses a saphenous vein graft (as T-graft to LIMA) was anastomosed to RD or RCX. Results: Mean operation time was 2.6±0.8 hours. The 30-day mortality was 0. Mean required packed red blood cells (pRBC) was 0.4±1.2 unit. The intensive care unit stay (ICU) was 1.5±1.6 days mean. We observed two patients (2%) with wound infections postoperatively. Four patients underwent rethoracotomy because of bleeding. Mean follow-up time was 1.5±0.5 years. Seventy-eight patients (86%) were in New York Heart Association (NYHA) class 1, 11 patients (12%) were in NYHA class 2. One patient received percutaneous coronary intervention due to de novo stenosis of the RCA. Late mortality was 2%. The Kaplan-Meier survival rate was 98.8% at 1 and 2 years. Conclusion: MIDCAB is technically demanding. Our postoperative and short-term clinical results demonstrate that this procedure is safe and feasible. Optimal patient selection and an experienced surgical team are mandatory.
... Long-term survival rates, tracked over a mean follow-up time of 12.95 ± 0.45 years were comparable between the two groups. The authors observed 153 deaths with 113 (22.24%) in MIDCAB group and 40 (25%) in the full sternotomy group with p = 0.64 (21). ...
... Nevertheless, Ng and colleagues reported a significant higher rate of wound complications after MIDCAB surgery as compared to the sternotomy approach (25). Similarly, Detter et al. and Raja et al. observed a higher incidence of postoperative wound infections in the MIDCAB group (21,22), a finding that we could not observe. However, the potential for wound infections after MIDCAB should be taken into consideration. ...
Objectives
Minimally-invasive direct coronary artery bypass (MIDCAB) is a less-invasive alternative to full sternotomy off-pump coronary artery bypass (FS-OPCAB) revascularization of the left anterior descending artery (LAD). Some studies suggested that MIDCAB is associated with a greater risk of graft occlusion and repeat revascularization than FS-OPCAB LIMA-to-LAD grafting. Data comparing MIDCAB to FS-OPCAB with regard to long-term follow-up is scarce. We compared short- and long-term results of MIDCAB vs. FS-OPCAB revascularization over a maximum follow-up period of 10 years.
Patients and methods
From December 2009 to June 2020, 388 elective patients were included in our retrospective study. 229 underwent MIDCAB, and 159 underwent FS-OPCAB LIMA-to-LAD grafting. Inverse probability of treatment weighting (IPTW) was used to adjust for selection bias and to estimate treatment effects on short- and long-term outcomes. IPTW-adjusted Kaplan–Meier estimates by study group were calculated for all-cause mortality, stroke, the risk of repeat revascularization and myocardial infarction up to a maximum follow-up of 10 years.
Results
MIDCAB patients had less rethoracotomies (n = 13/3.6% vs. n = 30/8.0%, p = 0.012), fewer transfusions (0.93 units ± 1.83 vs. 1.61 units ± 2.52, p < 0.001), shorter mechanical ventilation time (7.6 ± 4.7 h vs. 12.1 ± 26.4 h, p = 0.005), and needed less hemofiltration (n = 0/0% vs. n = 8/2.4%, p = 0.004). Thirty-day mortality did not differ significantly between the two groups (n = 0/0% vs. n = 3/0.8%, p = 0.25). Long-term outcomes did not differ significantly between study groups. In the FS-OPCAB group, the probability of survival at 1, 5, and 10 years was 98.4%, 87.8%, and 71.7%, respectively. In the MIDCAB group, the corresponding values were 98.4%, 87.7%, and 68.7%, respectively (RR1.24, CI0.87–1.86, p = 0.7). In the FS group, the freedom from stroke at 1, 5, and 10 years was 97.0%, 93.0%, and 93.0%, respectively. In the MIDCAB group, the corresponding values were 98.5%, 96.9%, and 94.3%, respectively (RR0.52, CI0.25–1.09, p = 0.06). Freedom from repeat revascularization at 1, 5, and 10 years in the FS-OPCAB group was 92.2%, 84.7%, and 79.5%, respectively. In the MIDCAB group, the corresponding values were 94.8%, 90.2%, and 81.7%, respectively (RR0.73, CI0.47–1.16, p = 0.22).
Conclusion
MIDCAB is a safe and efficacious technique and offers comparable long-term results regarding mortality, stroke, repeat revascularization, and freedom from myocardial infarction when compared to FS-OPCAB.
... mortality of 0.4% (0-4.9%), conversion to sternotomy 1.8% (0-6.2%) and reoperation for bleeding 1.1% (0-8%) [20,21]. The 10-year long-term survival of multivessel MIDCAB patients of 74.5% is also superior to the rates in the literature for conventional CABG, with Chikwe et al. [22] reporting a 10-year survival in over 40 000 patients of 66.6% in off-pump CABG and 70.4% in on-pump CABG. ...
... Previous meta-analyses comparing MIDCAB to both on-pump CABG and off-pump CABG have demonstrated similar outcomes [16,26]. A review with the longest follow-up of 12.95 ± 0.47 years revealed there was no difference between MIDCAB and traditional CABG in terms of complications or survival, reaffirming its safety but failing to demonstrate superiority over the conventional approach [21]. The benefits of MIDCAB in a selective high-risk surgical population has been studied by Jacob et al., demonstrating that incomplete revascularization via MIDCAB is a safe procedure compared with conventional CABG with a lower incidence of hospital mortality, neurological events, and perioperative myocardial infarction with comparable midterm results at 4 years [27]. ...
Objectives:
Previous studies have demonstrated the safety and excellent short-term and mid-term survival after minimally invasive direct coronary artery bypass (MIDCAB) (1, 2). We reviewed the long-term outcomes up to twenty years, including overall survival and freedom from reintervention.
Methods:
Consecutive patients who underwent MIDCAB between February 1997 and August 2020 were identified. Demographic details, operative information and long-term outcomes were obtained. The Australian National Death Index database was accessed to obtain long-term mortality data.
Results:
A total of 271 patients underwent a MIDCAB procedure during the study period. There were no intraoperative deaths and only one 30-day mortality (0.4%). The mean length of follow-up was 9.82 ± 8.08 years. Overall survival at 5, 10, 15 and 20-year survival was 91.9%, 84.7%, 71.3% and 56.5% respectively. Patients with single-vessel disease (LAD only) had significantly better survival compared to patients with multivessel disease (p = 0.0035). During long-term follow-up, there were no patients who required repeat revascularisation of the LAD territory. Sixty-nine patients died with the cause of death in 15 patients (21.7%) being attributable to ischaemic heart disease. An analysis comparing the isolated LAD disease MIDCAB cohort survival with the expected survival among an age/gender/year matched sample of the Australian reference population, using the standardised mortality ratio (SMR), demonstrated that the rate of survival returned to that of the reference population (SMR= 0.94).
Conclusions:
MIDCAB is a safe and effective revascularisation strategy which can be successfully performed in a carefully selected patient population with low morbidity, and excellent long-term results. The survival of MIDCAB patients returns to that of their age/gender/year matched counterparts within the normal population, hence should be offered as an alternative to coronary stenting when counselling patients with ischaemic heart disease.
... and 4 (2.5%), and 30-day mortality was 10 (2.0%) and 4 (2.5%) for MIDCAB and OPCAB groups respectively. Conversion to sternotomy in the case of MIDCAB was 3 (0.6%), one was because of intra myocardial LAD, another with not enough length of LIMA, and the third one with LIMA damage [17]. A study from the third hospital of Peking university by Zhang et al. showed total surgery time of 152.0 ± 43.5 and 263.2 ± 52.4 min, postoperative ventilation time of 9.27 ± 5.14 and 24.92 ± 37.87 h, length of ICU stay 24.27 ± 17.25 and 59.13 ± 60.39 h, postoperative MI 2/300 (0.67%) and 2/355 (0.56%), re-exploration for bleeding 2/300 (0.67%), and 3/355 (0.85%), and 1 month mortality 1/300 (0.33%) and 3/355 (0.85%) for MIDCAB and OPCAB groups respectively [18]. ...
... Raja et al. also reported that operative time for MIDCAB was significantly longer than OPCAB, but they also believe that this time improves with experience. They compared their recent surgery time of MIDCAB with 10 years previous MIDCAB time which decreased significantly, 231 ± 14 min before 2007, and 132 ± 42 min in 2017 (p = 0.0001) [17]. A study by Une et al. also reported that their performance reached an acceptable level at the 66th case for single vessel MIDCAB [28]. ...
Background:
Internal thoracic arteries (ITAs) are considered to be the standard conduits used for coronary revascularization. Recently minimally invasive procedures are performed to harvest ITAs. The aim of this retrospective cohort study is to observe the effect and safety of less invasive LIMA harvesting approaches in the learning curve compared to conventional harvesting.
Methods:
We retrospectively analyzed the data of 138 patients divided into three different groups based on the LIMA harvesting techniques: conventional sternotomy LIMA harvesting, CSLH (n: 64), minimally invasive direct LIMA harvesting, MIDLH (n: 42), and robotic-assisted LIMA harvesting, RALH (n: 32). The same 138 patients were also divided into sternotomy (n: 64), and non-sternotomy (n: 74) groups keeping both MIDLH and RALH in the non-sternotomy category. Parameters associated with LIMA's quality and some other perioperative parameters such as harvesting time, LIMA damage, perioperative myocardial infarction, ventilation time, 24 h drainage, ICU stay, hospital mortality, computed tomographic angiography (CTA) LIMA patency on discharge, and after one year were recorded.
Results:
The mean LIMA harvesting time was 36.9 ± 14.3, 74.4 ± 24.2, and 164.7 ± 51.9 min for CSLH, MIDLH, and RALH groups respectively (p < 0.001). One patient 1/32 (3.1%) in the RALH group had LIMA damage while the other two groups had none. One-month LIMA CTA patency was 56/57 (98.2%), 34/36 (94.4%), and 27/27 (100%) (p = 0.339), while 1 year CTA patency was 47/51 (92.1%), 30/33 (90.9%), and 24/25 (96%) for CSLH, MIDLH, and RALH groups respectively (p = 0.754). In the case of sternotomy vs non-sternotomy, the LIMA harvesting time was 36.9 ± 14.3 and 113.6 ± 59.3 min (p < 0.001). CTA patency on discharge was 56/57 (98.2%) and 61/63 (96.8%) (p = 0.619), while 1 year CTA patency was 47/51 (92.1%) and 54/58 (93.1%) (p = 0.850) for sternotomy vs non-sternotomy groups.
Conclusion:
Minimally invasive left internal mammary artery harvesting techniques during the learning curve are safe and have no negative impact on the quality of LIMA. Perioperative outcomes are comparable to conventional procedures except for prolonged harvesting time. RALH is the least invasive and most time-consuming procedure during the learning curve. These procedures are safe and can be performed for selected patients even during the learning curve.
... MIDCAB has been shown to be safe and has a similar efficacy profile to conventional on-pump CABG and OPCAB, as demonstrated by several smaller studies [ 28,29 ]. A large series, of 1,060 patients undergoing MIDCAB from 1997 to 2016, reported perioperative mortality in 0.8% and stroke in 0.3% [ 30 ]. Survival and freedom from major adverse events were 87.1% and 87.0%, respectively, after 5 years and 79.8% and 70.5%, respectively, after 15 years. ...
... Additional advantages of MIDCAB may include reduced need for blood transfusion, early extubation, shorter hospital stay, and improved quality of life [ 28 ]. After median sternotomy, bone reunion usually takes 4-6 weeks during which the patient should adhere to restriction in physical activity. ...
Recent years have seen an important shift in the target population for myocardial revascularization. Patients are increasingly presenting with more complex coronary artery disease (CAD), but also with multiple comorbidities and frailty. At the same time, minimally invasive strategies such as Minimally Invasive Direct Coronary Artery Bypass Grafting (MIDCAB) and Percutaneous Coronary Interventions (PCI) have been developed, which might be more appealing for this group of patients. As a result, the landscape of options for myocardial revascularization is evolving while adequate use of all resources is required to ensure optimal patient care. Heart Teams are confronted with the challenge of incorporating the new minimally invasive strategies into the decision process, yet current guidelines do not fully address this challenge. In this review, the current evidence regarding outcomes, indications, benefits, and risks of off-pump coronary artery bypass grafting (OPCAB), MIDCAB, PCI, and hybrid coronary revascularization (HCR) are discussed. Based on this evidence and on experiences from Heart Team discussions, a new decision tree is proposed that incorporates recent advances in minimally invasive revascularization strategies, thereby optimizing adequate delivery of care for each individual patient's needs. Introducing all important considerations in a logical way, this tool facilitates the decision-making process and might ensure appropriate use of resources and optimal care for individual patients.
... Coronary artery bypass grafting (CABG) is the gold standard for the treatment of coronary artery disease (CAD) in multivessel disease and high anatomic complexity [1]. For the overwhelming majority of coronary artery surgery worldwide, full median sternotomy (FS) is used [2]. As a highly invasive therapeutic procedure, it is associated with complications such as restricted physical activity, wound-related issues, persistent thoracic pain, and poor quality of life. ...
Objective: Renal dysfunction and acute renal failure after coronary artery bypass grafting (CABG) are among the main causes of increased mortality and morbidity. A sternum-sparing concept of minimally invasive total coronary revascularization via anterior minithoracotomy (TCRAT) was introduced with promising early and midterm outcomes in multivessel coronary artery disease. There are limited data regarding renal complications in patients undergoing the TCRAT technique. The present study analyzed renal outcomes in TCRAT compared to CABG via full median sternotomy (FS). Methods: We analyzed the records of 227 consecutive TCRAT patients (from September 2021 to June 2023) and 228 consecutive FS patients (from January 2017 to December 2018) who underwent nonemergent CABG. Following propensity score matching, preoperative baseline characteristics—including age, sex, diabetes mellitus, arterial hypertension, left ventricular ejection fraction, EuroSCORE II, preoperative serum creatinine, estimated glomerular filtration rate (eGFR), serum urea, and pre-existing chronic renal insufficiency—were comparable between the TCRAT (n = 170) and the FS group (n = 170). The examined postoperative renal parameters and complications were serum creatinine, eGFR, and serum urea on the first postoperative day. Moreover, serum creatinine, eGFR and serum urea at the time of discharge, postoperative ARF, and hemodialysis were investigated. Additionally, the duration of operation, CPB time, aortic cross-clamp time, ICU and hospital stay, ECMO support, rethoracotomy and in-hospital mortality were analyzed. The parameters were compared between groups using a Student’s t-test or Mann–Whitney U test. Results: The duration of operation (332 ± 66 vs. 257 ± 61 min; p < 0.05), CPB time (161 ± 40 vs. 116 ± 38 min; p < 0.05), and aortic cross-clamp time (100 ± 31 vs. 76 ± 26; p < 0.05) were longer in the TCRAT group. ICU (1.8 ± 2.2 vs. 2.9 ± 3.6 days; p < 0.05) and hospital (10.4 ± 7.6 vs. 12.4 ± 7.5 days; p < 0.05) stays were shorter in the TCRAT group. There were no differences between groups with regard to the renal parameters examined. Conclusions: Despite a prolonged duration of operation, CPB time, and aortic cross-clamp time when using the TCRAT technique, no increase in renal complications were found. In addition, ICU and hospital stays in the TCRAT group were shorter compared to CABG via full median sternotomy.
... Data presented in our systematic review suggest that the immediate decisions for surgical intervention in CABG should be patient-centered and driven more by clinical indications to achieve optimal outcomes [26]. While the MICABG has demonstrated potential in this field, particularly for simpler cases and associated evaluations, traditional open CABG remains the gold standard for providing durable grafts that realistically promise excellent long-term symptom relief despite its more invasive nature. ...
Coronary artery bypass grafting (CABG) is an essential operation for patients who have severe coronary artery disease (CAD). Both open and minimally invasive CABG methods are used to treat CAD. This in-depth review looks at the latest research on the effectiveness of open versus minimally invasive CABG. The goal is to develop evidence-based guidelines that will improve surgical outcomes. This systematic review used databases such as PubMed, MEDLINE, and Web of Science for a full electronic search. We adhered to the PRISMA guidelines and registered the results in the PROSPERO. The search method used MeSH phrases and many different study types to find papers. After removing duplicate publications and conducting a screening process, we collaboratively evaluated the full texts to determine their inclusion. We then extracted data, including diagnosis, the total number of patients in the study, clinical recommendations from the studies, surgical complications, angina recurrence, hospital stay duration, and mortality rates. Many studies that investigate open and minimally invasive CABG methods have shown that the type of surgery can have a large effect on how well the patient recovers and how well the surgery works overall. While there are limited data on the possible advantages of minimally invasive CABG, a conclusive comparison with open CABG is still dubious. Additional clinical trials are required to examine a wider spectrum of patient results.
... Minimally invasive direct coronary artery bypass grafting (MIDCAB) is the most common type of minimally invasive CABG. It has been safely and effectively performed for over 20 years (2)(3)(4)(5)(6). MIDCAB was originally developed as an alternative to conventional CABG for patients with isolated proximal left anterior descending (LAD) artery stenosis who were not suitable candidates for percutaneous coronary intervention (PCI). ...
Introduction
The safety and efficacy of minimally invasive direct coronary artery bypass (MIDCAB) surgery has been confirmed in numerous reports. However, minimally invasive multi-vessel off-pump coronary artery bypass grafting (MICS CABG) has lower uptake and has not yet gained widespread adoption. The study aimed to investigate the non-inferiority of MICS CABG to MIDCAB in long-term follow-up for several clinical outcomes, including angina pectoris, major adverse cardiac and cerebrovascular events (MACCE) and overall survival.
Methods
This is an observational, retrospective, single center study of 1,149 patients who underwent either MIDCAB (n = 626) or MICS CABG (n = 523) at our institution between 2007 and 2018. The left internal thoracic artery and portions of the radial artery and saphenous vein were used for the patients’ single-, double-, or triple-vessel revascularization procedures. We used gradient boosted propensity-score estimation to account for possible interactions between variables. After propensity-score adjustment, the two groups were similar in terms of preoperative demographics and risk profile. Long-term follow-up (mean 5.87, median 5.6 years) was available for 1,089 patients (94.8%).
Results
A total of 626, 454 and 69 patients underwent single, double and triple coronary revascularization, respectively. The long-term outcomes of freedom from angina pectoris, acute myocardial infarction, and revascularization rate were similar between the two groups. During follow-up, there were 123 deaths in the MIDCAB group and 96 in the MICS CABG group. The 1-, 3-, 5-, and 10-year survival rates were 97%, 92%, 85%, and 69% for the MIDCAB group and 97%, 93%, 89%, and 74% for the MICS CABG group, respectively. The hazard ratio of overall survival for patients with two or more bypass grafts compared to those with one bypass graft was 1.190 (p-value = 0.234, 95% CI: 0.893–1.586). This indicates that there was no significant difference in survival between the two groups. Furthermore, if we consider a hazard ratio of 1.2 to be clinically non-relevant, surgery with two or more grafts was significantly non-inferior to surgery with just one graft (p-value = 0.0057).
Conclusion
In experienced hands, MICS CABG is a safe and effective procedure. Survival and durability are comparable with MIDCAB.
... If minimally invasive direct coronary artery bypass graft (MIDCAB) performed with an off-pump technique via small left anterior mini-thoracotomy is established to be safe and effective with excellent short-and long-term results [7][8][9], the use of robotic assistance during LITA harvest may further benefit the surgeon, improving their comfort and the quality of the surgical procedure. ...
In recent years, there has been a growing interest in robotic-assisted coronary artery revascularization in Europe. Two different types of surgery can be performed using a robotic platform: RA-MIDCAB, in which the mammary artery is harvested endoscopically with robotic assistance and off-pump bypass graft is achieved under direct vision through mini thoracotomy, and TE-CAB, completely robotically performed. We started the robotic cardiac surgery program for mitral valve disease in our hospital, Humanitas Gavazzeni (Bergamo, Italy), in 2019; and in 2021, we addressed our experience with RA-MIDCAB. After a learning curve period, we have developed our technique to optimize the benefits offered by the robotic platform, tailoring strategy to individual patients, based on preoperative radiological images.
... Over the past 10 years, minimally invasive direct coronary artery bypass (MIDCAB) surgery has been gaining popularity with smaller skin incisions and surgical trauma than conventional sternotomy coronary artery bypass grafting (CABG) [1]. The MIDCAB provides an effective alternative to coronary artery disease (CAD) patients requiring single or multi-vessel CABG through left anterior thoracotomy between the ribs [2]. It does not increase the risk of perioperative adverse cardiovascular and cerebrovascular events or 30-day mortality with reduced postoperative pain, faster recovery, and improved quality of life [3,4]. ...
Background
Minimally invasive direct coronary artery bypass (MIDCAB) surgery offers an effective option for coronary artery disease (CAD) patients with the avoidance of median sternotomy and fast postoperative recovery. However, MIDCAB is still associated with significant postoperative pain which may lead to delayed recovery. The erector spinae plane block (ESPB) is a superficial fascial plane block. There have not been randomized controlled trials evaluating the effects of ESPB on analgesia and patient recovery following MIDCAB surgery. We therefore designed a double-blind prospective randomized placebo-controlled trial, aiming to prove the hypothesis that ESPB reduces postoperative pain scores in patients undergoing MIDCAB surgery.
Methods
The study protocol has been reviewed and approved by the Ethical Review Committee of Peking University People’s Hospital. Sixty adult patients of either sex scheduled for MIDCAB surgery under general anesthesia (GA) will be included. Patients will be randomly allocated to receive either a preoperative single-shot ESPB with 30 mL of ropivacaine 0.5% (ESPB group) or normal saline 0.9% (control group). The primary outcomes are the difference between the two groups in numeric rating scale (NRS) scores at rest at different time points (6, 12, 18, 24, 48 h) after surgery. The secondary outcomes include NRS scores on deep inspiration within 48 h, postoperative hydromorphone consumption, and quality of patient recovery at 24 h and 48 h, using the Quality of Recovery-15 (QoR-15) scale. The other outcomes include intraoperative fentanyl requirements, the need for additional postoperative rescue analgesics, time to tracheal extubation and chest tube removal after surgery, incidence of postoperative nausea and vomiting (PONV) and postoperative cognitive dysfunction (POCD), intensive care unit (ICU) length of stay (LOS), hospital discharge time, and 30-day mortality. Adverse events will be also evaluated.
Discussion
This is a novel randomized controlled study evaluating a preoperative ultrasound-guided single-shot unilateral ESPB on analgesia and quality of patient recovery in MIDCAB surgery. The results of this study will characterize the degree of acute postoperative pain and clinical outcomes following MIDCAB. Our study may help optimizing analgesia regimen selection and improving patient comfort in this specific population.
Trial registration
The study was prospectively registered with the Chinese Clinical Trial Registry (trial identifier: ChiCTR2100052810). Date of registration: November 5, 2021.
... In 2015, Raja et al. [45], on behalf of the Harefield Cardiac Outcomes Research Group, compared propensity score-matched patients undergoing MIDCABG versus full sternotomy revascularisation for isolated LAD disease, with 143 matched sets. In 2018, they compared the short-and long-term outcomes of MIDCABG versus full sternotomy offpump LIMA to LAD anastomosis for isolated proximal LAD stenosis [46]. They looked at 668 patients, with 508 patients in the MIDCABG group and 160 patients in the full sternotomy off-pump group. ...
Minimal-access cardiac surgery appears to be the future. It is increasingly desired by cardiologists and demanded by patients who perceive superiority. Minimal-access coronary artery revascularisation has been increasingly adopted throughout the world. Here, we review the history of minimal-access coronary revascularization and see that it is almost as old as the history of cardiac surgery. Modern minimal-access coronary revascularization takes a variety of forms—namely minimal-access direct coronary artery bypass grafting (MIDCAB), hybrid coronary revascularisation (HCR), and totally endoscopic coronary artery bypass grafting (TECAB). It is noteworthy that there is significant variation in the nomenclature and approaches for minimal-access coronary surgery, and this truly presents a challenge for comparing the different methods. However, these approaches are increasing in frequency, and proponents demonstrate clear advantages for their patients. The challenge that remains, as for all areas of surgery, is demonstrating the superiority of these techniques over tried and tested open techniques, which is very difficult. There is a paucity of randomised controlled trials to help answer this question, and the future of minimal-access coronary revascularisation, to some extent, is dependent on such trials. Thankfully, some are underway, and the results are eagerly anticipated.
... With an increasing demand for minimally invasive surgery and the continuous improvement of minimally invasive surgical techniques, the minimally invasive CABG has become an important subject of research in the surgical treatment of coronary heart disease [9][10][11][12]. As the mainstream minimally invasive CABG method, MICS CABG involves a small incision of 6-8 cm at the fourth or fifth intercostal space on the left side, which avoids splitting the sternum, retains the integrity of the thorax, significantly shortens the postoperative recovery time and is easily accepted by patients because of the concealed and small incision [13][14][15][16]. ...
Objectives:
To discuss the perioperative effects of obesity on minimally invasive coronary artery bypass grafting (CABG) and its surgical techniques.
Methods:
A total of 582 patients with multivessel lesion who underwent off-pump CABG by our medical group of Beijing Anzhen Hospital between January 2017 and January 2021 were divided into the minimally invasive cardiac surgery (MICS) group and the conventional group (median sternotomy) according to the surgical method used. The body mass index of the patients was calculated, based on which both groups were divided into obese (≥28 kg/m2) and non-obese subgroups (<28 kg/m2). Firstly, the perioperative data of the obese subgroups of both MICS and conventional groups were compared. Secondly, the obese and non-obese subgroups were compared in MICS group.
Results:
Despite a higher proportion of diabetes in the MICS group, there was no significant difference in preoperative baseline nor in the incidence of major complications within 30 days after surgery between obese subgroups of the MICS and conventional groups. The MICS group had a significantly lower rate of poor wound healing, along with a higher predischarge Barthel Index. Also, preoperative baseline between the obese and non-obese subgroups of the MICS group exhibited no statistically differences. The obese subgroup had longer postoperative ventilator assistance, while other intraoperative data and postoperative observation indexes exhibited no significant differences.
Conclusions:
MICS CABG method is safe and feasible for obese patients with multivessel lesion. Minimally invasive surgery is beneficial to wound healing in obese patients. However, it requires a thorough preoperative evaluation and adequate surgical experience and skills.
... In 2015, Raja et al [38], on behalf of the Harefield Cardiac Outcomes Research Group, compared propensity score matched patients undergoing MIDCABG versus full sternotomy revascularisation for isolated LAD disease, with 143 matched sets. In 2018, they compared the short-and long-term outcomes of MIDCABG versus full sternotomy off-pump LIMA to LAD anastomosis for isolated proximal LAD stenosis [39]. They looked at 668 patients, with 508 patients in the MIDCABG group and 160 patients in the full sternotomy off-pump group. ...
Minimal access cardiac surgery appears to be the future. It is increasingly desired by cardiologists and demanded by patients who perceive superiority. Minimal access coronary artery revascularisation has been increasingly adopted throughout the world. Here we review the history of minimal access coronary revascularization and see that it is almost as old as the history of cardiac surgery. Modern minimal access coronary revascularization takes a variety of forms – namely minimal access direct coronary artery bypass grafting (MIDCAB), hybrid coronary revascularisation (HCR) and totally Endoscopic Coronary Artery Bypass Grafting (TECAB). It is noteworthy that there is significant variation in nomenclature and approaches for minimal access coronary surgery and this truly presents a challenge to comparing the different methods. However, these approaches are increasing in frequency and proponents demonstrate clear advantages for their patients. The challenge that remains, as for all areas of surgery, is demonstrating superiority of these techniques over tried and tested open techniques which is very difficult. There is a paucity of randomized controlled trials to help answer this question, and the future of minimal access coronary revascularisation to some extent is dependent on such trials. Thankfully some are underway and the results eagerly anticipated.
... Raja et al reported a 30day mortality of 2%. 18 Holzhey et al reported an early postoperative mortality of 0.8% and Calafiore et al reported 0.6%, and Seo et al reported a 30-day mortality rate of 1.5%. 4,16,19 It is still controversial whether OPCAB procedures in general reduce the risk for postoperative strokes compared with on-pump techniques. ...
Background To evaluate the midterm follow-up and 5-year survival outcome of the minimally invasive direct coronary artery bypass (MIDCAB) procedure compared with the survival of the general Swiss population.
Methods Retrospective study on preoperative data, intraoperative data, and postoperative outcome of patients who underwent MIDCAB surgery between June 2010 and February 2019. To assess validity of this surgical therapy, outcomes were compared with survival data of a gender- and age-matched cohort of the general Swiss population taken from the database of the Swiss Federal Statistical Office.
Results A total of 88 patients were included. Median (interquartile range [IQR[) age was 66 (56–75) years, and 27% (n = 24) were female. The median (IQR) length of the in-hospital stay was 7 (6–8) days. No postoperative stroke occurred. The 30-day mortality was 1.1% (n = 1). Reintervention for failed left internal mammary artery was needed in 1.1% (n = 1). The median (IQR) ejection fraction was 58% (47–60) preoperatively and remained stable during follow-up. The median (IQR) follow-up period was 3 (1.1–5.2) years. Five years postoperatively, 83% (confidence interval, 69–91) of the patients were alive, showing an overlap with the range of survival of the matched subcohort of the general Swiss population (range, 84–100%).
Conclusion Though suffering from coronary heart disease, patients after MIDCAB show almost equal survival rates as an equivalent subcohort corresponding to the general Swiss population matched on age and gender. Thus, our data show this treatment to be safe and beneficial.
... 7,12 Our all-cause mortality rate of 2.5% at follow-up supports these prior findings. [13][14][15][16][17] We found a cardiac mortality rate of 1.6%, which is higher than what was found by others (0% to 1%) in cohort studies and randomized controlled trials. 7 However, of the 7 cases we classified as cardiac deaths, the cause of death was unknown for 4 patients. ...
Objective
Robot-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) surgery and hybrid coronary revascularization (HCR) are minimally invasive alternative strategies to conventional coronary artery bypass surgery in patients with isolated left anterior descending (LAD) stenosis or multivessel coronary disease. We analyzed a large, multicenter data-set based on the Netherlands Heart Registration including all patients undergoing RA-MIDCAB.
Methods
We included 440 consecutive patients who underwent RA-MIDCAB with the left internal thoracic artery to LAD between January 2016 and December 2020. A proportion of patients underwent percutaneous coronary intervention (PCI) of non-LAD vessels (i.e., HCR). The primary outcome was all-cause mortality at median follow-up of 1 year, which was subdivided into cardiac and noncardiac. Secondary outcomes included target vessel revascularization (TVR) at median follow-up as well as 30-day mortality, perioperative myocardial infarction, reoperation for bleeding or anastomosis-related problems, and in-hospital ischemic cerebrovascular accident (iCVA).
Results
Among all patients, 91 (21%) underwent HCR. At median (IQR) follow-up of 19 (8 to 28) months, 11 patients (2.5%) had died. In 7 patients, the cause of death was defined as cardiac. TVR occurred in 25 patients (5.7%), of whom 4 underwent CABG and 21 underwent PCI. At 30-day follow-up, 6 patients (1.4%) had a perioperative myocardial infarction, of whom 1 died. One patient (0.2%) developed an iCVA, and 18 patients (4.1%) underwent reoperation for bleeding or anastomosis-related problems.
Conclusions
The clinical outcomes of patients undergoing RA-MIDCAB or HCR in the Netherlands are good and promising when compared with the currently available literature.
... Prognostic tools and minimization of the POCD risk imply screening of risk factors for cerebral ischemia, such as asymptomatic carotid stenosis [5], and modification of surgical approach [6], if suitable. There are contradictory data on the impact of different perfusion strategies, i.e. on-pump CABG versus off-pump CABG, on POCD. ...
Background — Postoperative cognitive dysfunction (POCD) is an important complication of coronary artery bypass grafting (CABG). Large amount of data points to the problem of POCD in patients with high surgical risk of CABG. Low-risk patients are not safe from these complications either. Assessment of the severity, duration of POCD, degree of recovery and risk factors in off- and on-pump patients with stable coronary artery disease is crucial in minimization of the POCD risk in patients with low surgical risk. Objective — to analyze incidence, severity, reversibility and risk factors of POCD in patients undergoing elective low-risk CABG. Methods and Results — The retrospective cohort study included 79 patients who underwent on-pump (N=44) or off-pump (N=35) elective CABG with low surgical risk (mean EuroSCORE II death risk 1.08±0.71%), with observation period of 6 months. Pre-CABG markers of cognitive impairment were found in 50% of patients, with 44% of patients demonstrating POCD. Patients who underwent off-pump CABG demonstrated more pronounced decline in MoCA score compared to on-pump (-3.9±2.0 vs. -2.2±2.0 at 8 days point, p=0.018), with regress to pre-CABG results after 3 weeks. Baseline MoCA score <25 was found to be a predictor for more pronounced cognitive decline at 8 days point. MMSE demonstrated less predictive value compared to MoCA. Conclusion — POCD risk differs in off-pump and on-pump CABG cohorts, with significantly higher prevalence in the former group, whether assessed using MMSE or MoCA tests. Differences are observed within 3 weeks post-CABG. Pre-CABG MoCA score <25 is associated with more pronounced POCD in low-risk elective CABG cohort.
... The LIMA was also harvested through the same incision. Surgeons perform sternotomy and harvest LIMA even for single vessels disease (LIMA to LAD) [11,12]. In this technique, after chest opening through sternotomy, the ITAs retractor is used to elevate the target side, and to have good exposure of the ITA. ...
Internal thoracic arteries (ITAs) are the gold standard conduits for coronary revascularization because of their long-term patency and anti-atherosclerotic properties. Harvesting and preparation of ITAs for revascularization is a technically demanding procedure with multiple challenges. Over the last few decades, various methods and techniques for ITAs harvesting have been introduced by different surgeons and applied in clinical practice with different results. Harvesting of ITAs in pedicled or skeletonized fashion, with electrocautery or harmonic scalpel, with open or intact pleura, with clipping the end or keeping it perfused; papaverine delivery with intraluminal injection, perivascular injection, injecting into endothoracic fascia, and papaverine topical spray are the different techniques introduced by the number of researchers. At the same time, access to the ITAs for harvesting has also been studied. Access and harvesting through median sternotomy, mini anterolateral thoracotomy, thoracoscopic, and robotic-assisted harvesting of ITAs are the different techniques used in clinical practice. However, the single standard method for harvesting and preparation of ITAs has yet to be determined. In this review article, we aimed to discuss and analyze all these techniques of harvesting and preparing ITAs with the help of literature to find the best way for ITAs harvesting and preparation for myocardial revascularization.
... Previous reports have demonstrated that RA-MIDCAB is a safe and efficacious alternative to traditional CABG, providing favorable short-term outcomes and longterm graft patency (16,17). Additional advantages of the technique include reduced need for blood transfusion, shorter hospital stay, and improved quality of life (18). However, despite having been around for more than two decades, the technique only represents 1% of all CABG surgeries performed each year (15). ...
Background:
Learning curves are inevitably encountered when first implementing an innovative and complex surgical technique. Nevertheless, a cluster of failures or complications should be detected early, but not deter learning, to ensure safe implementation. Here, we aimed to examine the presence and impact of learning curves on outcome after robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB).
Methods:
A retrospective analysis of the first 300 RA-MIDCAB surgeries between July 2015 and December 2020 was performed. Learning curves were obtained via logarithmic regression for surgical time. Cumulative sum (CUSUM) analysis was performed for (I) major complications including MI, stroke, repeat revascularization, and mortality, and (II) other complications, including prolonged ventilation, pneumonia, pleura puncture, lung herniation, pericarditis, pleuritis, arrhythmia, wound complications, and delirium. Expected and unacceptable rates were set at 12% and 20%, respectively, for major complications, and at 40% and 60% for other complications, based on historical data in conventional coronary artery bypass grafting (CABG).
Results:
Demographic characteristics did not differ between terciles, except for more smokers in the first tercile, and less hypercholesterolemia and more complex procedures in the third tercile. The mean surgical time for all operations was 258±81 minutes, ranging from 127 to 821 minutes. A learning curve was only observed in the first tercile. Subgroup analysis revealed that this learning curve was only observed for procedures consisting of single internal mammary artery (SIMA) with 1 or 2 distal anastomoses but not with bilateral internal mammary arteries (BIMA) or more than 2 distal anastomoses. CUSUM analysis showed that the cumulative rate of major and other complications never crossed the lines for unacceptable rates. Rather, the lower 95% confidence boundary was crossed after 50 cases, indicating improvement in safety.
Conclusions:
These results suggest that integration of RA-MIDCAB in the surgical landscape can be safely achieved and complication rates can quickly be reduced below those expected in traditional CABG. Collective experience plays a key role in overcoming the learning curve when more complex procedures and cases are introduced.
... This study has the largest MIDCAB experience in the literature with a 20-year follow-up. [2][3][4][5][6] The survival results are similar not only to those reported in other MIDCAB studies, 5,6 but also to those reported for conventional coronary artery bypass via sternotomy and cardiopulmonary bypass. 7 Also encouraging was the lower revascularization rate for MIDCAB compared with PCI for proximal LAD disease (5.5% vs 20%-34%). ...
Background Combined mitral valve and coronary artery surgery is usually accomplished via a median sternotomy and is associated with increased mortality and morbidity.
Case Description We report on a 67-year-old patient with mitral valve regurgitation and concomitant coronary artery disease (CAD). The mitral valve was repaired using the loops and ring technique, and the left anterior descending artery was revascularized using the left internal mammary artery through a bilateral minithoracotomy approach. The postoperative course was uneventful.
Conclusion Patients with mitral valve pathologies and concomitant CAD can be successfully operated via a bilateral minithoracotomy approach.
Coronary artery disease (CAD) is a leading cause of mortality worldwide. Severe symptomatic CAD is treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Alternative CABG (ACABG) approaches including thoracotomy, off-pump, total endoscopic, and robotic-assisted CABG are increasing in prevalence to address the increased early risk of CABG. This systematic review and meta-analysis aims to review the contemporary literature comparing outcomes after ACABG and PCI. Pubmed, Medline, and Embase were systematically searched by 2 authors for articles comparing the outcomes after ACABG and PCI. A total of 1154 articles were screened, and 11 were included in this review. The RevMan 5.4 software was used to perform a meta-analysis of the pooled data. Individual studies found rates of long-term survival, major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), and repeat revascularization either favored ACABG or did not differ significantly. Pooled estimates of the compiled data identified rates of MACCE, MI, and repeat revascularization favored ACABG. The results of this review demonstrated the favorable rates of long-term mortality, MACCE, MI, and repeat revascularization for ACABG in addition to similar short-term mortality and stroke when compared with PCI. Advancement of both CABG and PCI continues to improve patient outcomes. With the increasing prevalence of ACABG, similar studies will need to be undertaken with further direct comparisons between ACABG and PCI. Finally, hybrid revascularization should continue to be explored for its combined benefits of long-term outcomes, short-term safety, and ability to achieve complete revascularization.
Minimally invasive cardiac surgery has emerged as a safe and feasible alternative to the traditional surgical technique, embraced by an always-growing number of cardiac surgeons. In this context, myocardial revascularization can be performed without cardio-pulmonary bypass (CPB) and through a left mini-thoracotomy, sufficient for left internal mammary artery (LIMA) harvesting and its anastomosis on the left anterior descending (LAD) coronary artery on a beating heart.The minimally invasive direct coronary artery bypass (MIDCAB) for LIMA on LAD graft is the technique of surgical myocardial revascularization of LAD performed through approaches other than the full sternotomy. This technique has shown excellent results in terms of postoperative and long-term outcomes, especially when offered to patients with a high surgical risk and a contraindication for a percutaneous coronary intervention (PCI).Moreover, a combination of a mini-invasive surgical and percutaneous strategy for left main stenoses in the setting of a hybrid coronary revascularization (HCR) may offer the best of both procedures.In this chapter a series of aspects of the mini-invasive surgical approach for left main coronary artery disease will be discussed: the indications and counterindications, the step-by-step surgical technique, the short- and long-term clinical outcomes, and the postoperative quality of life.
Background
Robotic assistance (RA) in the harvesting of internal thoracic artery during minimally invasive direct coronary artery bypass grafting (MIDCAB) provides several potential benefits for surgeon and patient in comparison with conventional MIDCAB. The two technical options have not been thoroughly compared in the literature yet. We aimed to perform this in our cohort with the use of propensity-score matching (PSM).
Methods
This was a retrospective comparison of all consecutive patients undergoing conventional MIDCAB (2005–2021) and RA-MIDCAB (2018–2021) at our institution with the use of PSM with 27 preoperative covariates.
Results
Throughout the study period 603 patients underwent conventional and 132 patients underwent RA-MIDCAB. One hundred and thirty matched pairs were selected for further comparison. PSM successfully eliminated all preoperative differences. Patients after RA-MIDCAB had lower 24 h blood loss post-operatively (300 vs. 450 ml, p = 0.002). They had shorter artificial ventilation time (6 vs. 7 h, p = 0.018) and hospital stay (6 vs. 8 days, p < 0.001). There was no difference in the risk of perioperative complications, short-term and mid-term mortality between the groups.
Conclusions
RA-MIDCAB is an attractive alternative to conventional MIDCAB. It is associated with lower post-operative blood loss and potentially faster rehabilitation after surgery. The mortality and the risk of perioperative complications are comparable among the groups.
The approach to left main coronary artery disease (CAD) in diabetic patients has been extensively debated. Diabetic patients have an elevated risk of left main disease in addition to multivessel disease. Previous trials have shown increased revascularization rates in percutaneous coronary intervention compared with coronary artery bypass grafting (CABG) but overall comparable outcomes, although many of these studies were not using the latest stent technology or CABG with arterial revascularization. Our aim is to review the most recent trials that have recently published long-term follow-up, as well as other literature pertaining to left main disease in diabetic patients. Furthermore, we will be discussing some future treatment strategies that could likely create a paradigm shift in how left main CAD is managed.
Continuous progress in percutaneous coronary intervention (PCI) has inspired surgeons to reduce the invasiveness of surgical revascularization techniques, resulting in the development of minimally invasive cardiac surgery (MICS) procedures, which have widely expanded the use of these techniques over the last couple of decades (1; 2; 3; 4). The main goals of MICS are to avert any form of sternotomy, reduce postoperative blood product transfusion, shorten ventilation times, reduce intensive care and hospital stays, diminish postoperative pain, and accelerate return to normal activities (5). In the field of coronary artery bypass graft (CABG) surgery, minimally invasive direct coronary artery bypass (MIDCAB) grafting involving the use of the left internal thoracic artery (LITA) to graft the left anterior descending (LAD) artery through a left anterior small thoracotomy has become an attractive alternative approach to sternotomy for surgical revascularization for proximal LAD disease. MIDCAB is currently the most widely performed MICS procedure to graft the LAD artery and is being routinely performed with excellent outcomes in centers of expertise in such operations during the last 25 years (2; 6; 7). Moreover, this has prompted the emergence of more sophisticated technologies such as totally endoscopic and robotic MIDCAB procedures to further reduce the invasiveness, increase safety in LITA take down and enhance the possibility to harvest the right internal thoracic artery (RITA) as well. The following expert opinion offers an overview of the techniques, results and benefits and drawbacks of robotic and non-robotic approaches to MIDCAB procedures.
Objective
Minimally invasive direct coronary artery bypass (MIDCAB) surgery involving left anterior descending coronary artery (LAD) grafting with the left internal thoracic artery through a left anterior small thoracotomy is being routinely performed in some specified centers for patients with isolated complex LAD disease, but very few reports regarding long-term outcomes exist in literature. Our study aimed at assessing and analyzing the early and long-term outcomes of a large cohort of patients undergoing MIDCAB procedures and identifying the effects of changing trends in patient characteristics on early mortality.
Methods
A total of 2667 patients, who underwent MIDCAB procedures between 1996 and 2018, were divided into 3 groups based on the year of surgery: Group A- 1996-2003 (n=1333); Group B- 2004-2010 (n=627) and Group C- 2011-2018 (n=707). Group-wise characteristics and early postoperative outcomes were compared. Long-term survival for all patients was analyzed and predictors for late mortality were identified using Cox proportional hazards methods.
Results
The mean age was 64.5± 10.9 years and 691 (25.9%) patients were female. Group C patients (log EuroSCORE I=4.9±6.9) were older with more cardiac risk factors and comorbidities than groups A (log EuroSCORE I=3.1±4.5) and B (log EuroSCORE I=3.5±4.7). Overall and group-wise in-hospital mortality was 0.9%, 1.0%, 0.6% and 1.0% (P=0.7), respectively. Overall 10-, 15- and 20-year survival estimates for all patients were 77.7±0.9%, 66.1±1.2% and 55.6±1.6%, respectively.
Conclusion
MIDCAB can be safely performed with very good early and long-term outcomes. In-hospital mortality remained constant over the 22-year period of the study despite worsening demographic profile of patients.
Background
This study was designed to compare short‐term and long‐term clinical outcomes of minimally invasive direct coronary artery bypass (MIDCAB) and off‐pump coronary artery bypass grafting (OPCAB) via median sternotomy in patients with single‐vessel left anterior descending (LAD) artery disease.
Methods
In this retrospective study, 194‐patients met the inclusion criteria and were divided into the MIDCAB group (n = 111) and OPCAB via median sternotomy group (n = 83). Short‐term outcomes included: in‐hospital mortality, perioperative myocardial infarction (MI), perioperative cerebrovascular adverse events (CAEs), chest drainage, reoperation for bleeding, duration of surgery, ventilation time, deep wound infection, packed red blood cell (pRBC) transfusion and duration of hospital stay. The long‐term outcomes included: all‐cause mortality, the incidence of MI and stroke, target vessel revascularization (TVR) and composite of mortality/MI/stroke. Propensity score matching (PSM) was used to match patients between the groups.
Results
Before as well as after the PSM, no significant differences were observed between both groups in terms of in‐hospital mortality, incidence of perioperative MI, incidence of CAEs, reoperation for bleeding, pRBC transfusions, deep wound infection and ventilation time. However, MIDCAB group had lower chest tube drainage and shorter hospital stay. On the other hand, OPCAB group had shorter time of surgery before as well as after PS matching. At 7‐years, before and after PSM, freedom from all‐cause mortality, MI, stroke, TVR as well as composite of mortality/MI/stroke were comparable between both groups.
Conclusions
Short‐term as well as long‐term outcomes of MIDCAB in terms of mortality, MI, stroke, and target vessel revascularization are satisfactory and as safe and effective as OPCAB via sternotomy.
Although it is not a new technique, minimally invasive direct coronary artery bypass (MIDCAB) is employed only by a few surgeons in the UK. We compared our experience with MIDCAB with that of single vessel off-pump coronary artery bypass (OPCAB) graft surgery through a standard median sternotomy.
Patients who underwent either MIDCAB or OPCAB between April 2008 and July 2011 were reviewed. Exclusion criteria included patients with an ejection fraction of <0.5 or previous cardiac surgery. Data were obtained retrospectively from our prospective database, medical records and through general practitioners.
Overall, 74 patients were analysed in the MIDCAB group and 78 in the OPCAB group. Their demographics and EuroSCORE (European System for Cardiac Operative Risk Evaluation) values were comparable (p>0.05). There was no statistically significant difference in the two groups in terms of mortality, recurrent myocardial infarction, postoperative stroke, wound infection, atrial fibrillation or need for reintervention. The MIDCAB group had six conversions to a sternotomy. Eight patients in each group required blood transfusion, with the average transfusion being 1.8 units in the MIDCAB group and 3.2 units in the OPCAB group. The mean duration of ventilation and intensive care unit stay was 5.0 hours and 38.4 hours in the MIDCAB group and 5.4 and 47.8 hours in the OPCAB group. The mean hospital stay was significantly reduced in the MIDCAB population (6.1 vs 8.5 days, p<0.05).
MIDCAB can be performed safely in appropriately selected patients with outcomes comparable with OPCAB. The potential benefits include shorter hospital stay, reduced need for blood transfusion and faster recovery.
To assess whether the use of the full logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) is superior to the standard additive EuroSCORE in predicting mortality in high-risk cardiac surgical patients.
Both the simple additive EuroSCORE and the full logistic EuroSCORE were applied to 14,799 cardiac surgical patients from across Europe, of whom there were 4293 high-risk patients (additive EuroSCORE of 6 or more). The systems were compared for absolute prediction and discrimination (area under the receiver operating characteristic (ROC) curve).
Actual mortality was 4.72%. The logistic model was closer to this than the additive model (4.84% (4.72-4.94) versus 4.21 (4.21-4.26)). Most of this difference was due to high-risk patients where actual mortality was 11.18% and predicted was 7.83% (additive) and 11.23% (logistic). Discrimination was similar in both systems as measured by the area under the ROC curve (additive 0.783, logistic 0.785).
The additive EuroSCORE model remains a simple "gold standard" for risk assessment in European cardiac surgery, usable at the bedside without complex calculations or information technology. The logistic model is a better risk predictor especially in high-risk patients and may be of interest to institutions engaged in the study and development of risk stratification.
Off-pump cardiac surgery is becoming an established method of surgical revascularization. However, performing anastomoses on a beating heart can be challenging, especially through small incisions. We compared our midterm results in patients with 1 vessel disease using full sternotomy (OPCAB) or a left anterior minithoracotomy (MIDCAB).
At our institution between December 1996 and December 1998, 102 patients (OPCAB, n = 45, MIDCAB, n = 57); age, 61 +/- 11 years; 69% men with 1-vessel disease of the left anterior descending coronary artery (LAD) underwent off-pump myocardial revascularization through the left internal thoracic artery (LITA). In the OPCAB group 17 (37.8%) of the patients received an additional vein graft to a diagonal branch. OPCAB was generally preferred in obese or high-risk patients or patients with a long LITA-LAD distance (>7 cm) on an electron beam computed tomography of the chest.
Operative mortality was 0. Time of surgery (169 +/- 48 versus 197 +/- 45 minutes) and coronary artery occlusion time (19 +/- 7 versus 23 +/- 6 minutes) were significantly lower (P = .004 and P = .009) in the OPCAB group. MIDCAB surgery was related to a higher incidence of occluded (4 versus 0; P = .039) or stenosed (7 versus 2; P = .06) anastomoses and necessity for immediate reintervention (9 versus 0; P = .023). During a mean follow-up period of 5.2 years, MIDCAB patients (6 MIDCAB patients versus 1 OPCAB patient) tended to need more coronary interventions and develop more recurrent angina (23 MIDCAB versus 12 OPCAB patients). Two OPCAB patients died during the follow-up period.
Our initial experience in beating heart surgery demonstrated that MIDCAB is technically more challenging than OPCAB. MIDCAB procedures should therefore be performed by experienced surgeons on selected patients. Midterm results after OPCAB procedures tend to a lower rate of adverse cardiac events.
Coronary artery bypass grafting has been performed predominantly with the use of cardiopulmonary bypass and cardioplegic arrest, which allows optimization of the surgical field and consistent placement of grafts. However, the use of cardiopulmonary bypass is also associated with numerous complications. A surgical technique avoiding cardiopulmonary bypass should, in theory, reduce the incidence of such complications and lead to improved patient outcomes. This assumption has rekindled interest in performing off-pump coronary artery bypass surgery, which is currently the focus of scientific scrutiny. The existing world medical literature contains a staggering amount of research related to this technique. Although the available evidence from a large number of randomized clinical trials, nonrandomized clinical trials, propensity-matched analyses, and experimental data suggests that outcomes are better after off-pump than after on-pump coronary artery bypass surgery, skepticism still exists about the safety and efficacy of the off-pump technique. In the present era of evidence-based medicine, results from randomized clinical trials are given the highest recognition. This review attempts to evaluate the best currently available evidence from clinical trials about the safety and efficacy of off-pump coronary artery bypass surgery.
Minimally invasive direct coronary artery bypass (MIDCAB) has been proposed as an attractive alternative to full sternotomy (FS) revascularization in isolated left anterior descending (LAD) artery disease not suitable for percutaneous coronary intervention. However, surgeons are still reluctant to perform MIDCAB owing to concerns about early and late outcomes. We aimed to compare short- and long-term outcomes after MIDCAB versus FS revascularization.
Prospectively collected data from institutional database were reviewed. Data for late mortality were obtained from the General Register Office. MIDCAB was performed in 318 patients, whereas 159 had FS, according to the surgeon's preference, among 477 patients with isolated LAD disease. Inverse propensity score weighting was used to estimate treatment effects on short- and long-term outcomes.
In the propensity score-adjusted analysis, FS revascularization versus MIDCAB was associated increased rate of surgical site infection [4 (2.8%) versus 1 (0.7%); P = 0.04]. The 2 groups did not significantly differ with regard to other complications including operative mortality. Mean length of hospital stay was similar for the 2 groups. After a mean follow-up time of 6.2 years (interquartile range, 3.5-9.7 years), compared to MIDCAB, FS was not associated with an improved late survival (β coef, -1.42; standard error, 1.65; P = 0.39) or risk reduction for repeat revascularization (β coef, 1.22; standard error, 1.41; P = 0.15).
MIDCAB was associated with a trend toward better short-term outcomes and excellent long-term results comparable to FS revascularization. According to these findings, surgeons should not be reluctant to perform MIDCAB in isolated LAD disease.
We studied indications and problems involved in minimally invasive coronary artery bypass grafting (MIDCAB).
We compared patients profiles, graft patency, stenosis severity, morbidity, mortality, long-term survival and freedom from cardiac accidents in 174 patients undergoing elective standard coronary artery bypass grafting (CABG) and 128 undergoing between January 1996 and March 1999.
No statistically difference was seen in gender, diabetes mellitus, renal failure, cerebrovascular accident, multi-vessel disease ratios, or left main trunk stenosis between 2 groups. Internal thoracic artery graft patency was 97% (114/118) and the rate of anastomotic stenosis (> 50%) was 9% (10/118) compared to 96% (213/221) in the MIDCAB group. The 3-year survival rate was 91% in the MIDCAB group and 92% in the CABG group and freedom from cardiac accidents, most involving pericutaneus transluminal coronary angioplasty retreatment, was 66% in the MIDCAB group and 88% in the CABG group.
Although patency and stenosis incidence did not differ between 2 groups, freedom from cardiac accidents was lower in the MIDCAB group.
Background— Randomized trials comparing stenting with minimally invasive direct coronary artery bypass surgery in patients with isolated proximal left anterior descending lesions have shown a significantly higher reintervention rate for stenting and similar results for mortality and reinfarction at short-term follow-up. Long-term follow-up data are sparse.
Methods and Results— Patients with isolated proximal left anterior descending stenosis were randomized to either surgery (n=110) or bare-metal stenting (n=110). At 5 years, follow-up data were obtained with respect to the primary end point of death, reinfarction, or repeated target vessel revascularization. Clinical symptoms were assessed by the Canadian Cardiovascular Society (CCS) classification. Follow-up information was completed for 216 patients (98.2%), and mean follow-up was 5.6±1.2 years. With respect to mortality (surgery, 12%; stenting, 10%; P =0.54) and reinfarctions (surgery, 7%; stenting, 5%; P =0.46), there were no differences between treatment strategies. The need for repeated target vessel revascularization was significantly higher after stenting (32%) compared with surgery (10%; P <0.001). Clinical symptoms improved significantly in both treatment groups compared with baseline; however, there was a favorable trend for surgery (stenting: CCS, 2.6±0.9 to 0.5±0.8, P <0.001; surgery: CCS, 2.6±0.9 to 0.3±0.6, P <0.001; P =0.05, stenting versus surgery).
Conclusions— At the 5-year follow-up, minimally invasive bypass surgery and bare-metal stenting showed similar results for the end points of mortality and reinfarctions. However, the reintervention rate is higher after stenting, and the relief in clinical symptoms is slightly better after surgery.
Received July 25, 2005; revision received August 29, 2005; accepted October 3, 2005.
In this study, we review our experience with 1768 minimally invasive direct coronary artery bypass (MIDCAB) operations. The focus is on long-term outcome with more than 10 years of follow-up.
All patients undergoing standard MIDCAB between 1996 and 2009 were included. For all 1768 patients, pre-, intra-, and postoperative data could be completed. Long-term follow-up information about health status, major adverse cardiac and cerebrovascular events (MACCE), and freedom from angina was collected annually via questionnaire or personal contact. Five-year follow-up is available for 1313 patients, and 10-year-follow-up is available for 748 patients. A multivariate Cox regression analysis was performed to determine risk factors for long-term outcome.
Mean age was 63.4 ± 10.8 years, mean ejection fraction was 60.0% ± 14.2%, and perioperative mortality risk calculated by logistic EuroSCORE was 3.8 ± 6.2%. In 31 patients (1.75%) intraoperative conversion to sternotomy was necessary. Early postoperative mortality was 0.8% (15 patients); 0.4% (7 patients) had a perioperative stroke. Seven hundred twelve patients received routine postoperative angiogram, showing 95.5% early graft patency. Short-term target vessel reintervention was needed in 59 patients (3.3%) (11 percutaneous transluminal coronary angioplasty (PTCA)/stent, 48 re-operation). Kaplan-Meyer analysis revealed a 5-year survival rate of 88.3% (95% confidence interval [CI], 86.6% to 89.9%) and a 10-year-survival rate of 76.6% (95% CI, 73.5% to 78.7%). The freedom from MACCE and angina after 5 and 10 years was 85.3% (95% CI, 83.5% to 87.1%) and 70.9% (95% CI, 68.1% to 73.7%), respectively.
MIDCAB is a safe operation with low postoperative mortality and morbidity. With excellent short-term and long-term results, it is a very good alternative compared to both percutaneous coronary intervention (PCI) and conventional surgery.
Standard (conventional) coronary artery bypass grafting (CABG) is an invasive procedure which requires full median sternotomy and is performed with extracorporeal circulation (ECC), which can lead to serious complications.
To analyse the results of minimally invasive CABG (MIDCAB) in elderly patients.
Between 1999 and 2007, a total of 698 MIDCAB procedures were performed at our institution. We present the data on 235 elderly (≥ 70 years) patients (160 males, mean age 74.5 ± 3.2 years, range: 70-83 years) who were consecutively operated on in this period. Early mortality, post-operative complications, long-term survival, impact of multivessel disease (MVD) and hybrid coronary artery revascularisation on total mortality were analysed. Logistic EuroSCORE was 8.7%. The survival of 235 elderly patients was compared to the survival of the remaining 463 MIDCAB patients aged < 70 years (including risk factors for total mortality).
The 30-day mortality was 2.5% (six patients). During follow-up, two patients underwent coronary reoperation and percutaneous coronary intervention (PCI) was performed in 16 patients. Kaplan-Meier analysis revealed a 1.5-year survival of 89.8% (95% CI 85.9-93.7%) and five-year survival of 79.7% (95% CI 74.3-85%). Compared to single vessel disease (SVD) patients, the MVD patients had significantly higher total mortality (p = 0.0038). Our study revealed MVD (p = 0.0016) and male sex (p = 0.0091) as important independent factors of total mortality in this group of elderly patients. The difference in total mortality between non-hybrid vs hybrid MIDCABs was not significant (p = 0.63). The younger MIDCAB patients (< 70 years) have a tendency to better survival, but the difference did not achieve statistical significance (p = 0.088). They had the same independent factors of total mortality as in the elderly group: MVD (p = 0.0001) and male sex (p = 0.0059).
The MIDCAB is a reasonable option for elderly patients with SVD, and in selected patients with MVD. The decision to perform MIDCAB rather than PCI in these high risk patients should always be very carefully considered in conjunction with the interventional cardiologist.
Internal mammary artery (IMA) bypass grafting to the anterior descending coronary artery was performed in 2,100 patients between January 1978 and July 1986. The average number of additional saphenous vein grafts (SVGs) per patient was 1.8. During the same period, 1,753 patients underwent coronary artery bypass grafting using an SVG (average number of grafts per patient, 3.2). The average patient age was similar: 62.3 years for IMA grafts and 64.7 years for SVGs. Men constituted two thirds of each group. Left ventricular function was impaired (ejection fraction less than 45%) in 1,071 (51%) of IMA grafts and 847 (48.3%) of SVGs. Other aggregate risk factors, ie, elevated blood pressure, diabetes mellitus, previous myocardial infarction, and congestive heart failure, were similar in each group. Operative results and postoperative mortality of the IMA and SVG patients were comparable. However, the long-term probability of cumulative survival and occlusion-free survival were significantly greater and the probability of recurrent angina and reoperative coronary artery bypass grafting were significantly less in IMA graft patients (p less than 0.015). The relative risk of occlusion in an SVG was 4 to 5 times greater than that of the IMA graft. These data indicate that a patent IMA graft to the anterior descending coronary artery protects against recurrent angina and death from cardiac-related causes, and that the IMA should be the conduit of choice.
In 1975, 80 patients undergoing revascularization were prospectively randomized to receive either a greater saphenous vein (SV) graft (41 patients, Group 1) or a left internal mammary artery (LIMA) graft (39 patients, Group 2) to the left anterior descending coronary artery (LAD). All patients were completely revascularized. The average number of grafts per patient in both groups was 3.2. Patients were followed 10 years; follow-up was 97.5% complete. Group 1 and Group 2 were compared in regard to mortality, treadmill response, myocardial infarction, reoperation, percutaneous transluminal coronary angioplasty, and return to work. Mortality in Group 1 was 17.9% versus 7.7% in Group 2 (p less than 0.05). Treadmill studies were positive in 17 Group 1 patients and 7 Group 2 patients (p less than 0.05). Myocardial infarctions occurred in 8 patients in Group 1 versus 3 in Group 2. The number of reoperations was 2 in Group 1 versus 1 in Group 2. Percutaneous transluminal coronary angioplasty was performed in 3 patients in Group 1 and 2 in Group 2. Repeat studies revealed 76.3% patency of the SV graft to the LAD (Group 1) and 94.6% patency of the LIMA graft to the LAD (Group 2). Cardiac-related mortality in Group 1 was 12.8% at 10 years (5 patients) versus 7.7% in Group 2 (3 patients). Based on this study, the IMA is a superior conduit for bypass to the LAD.
We studied survival rates among 767 men with good left ventricular function who participated in the European Coronary Surgery Study, 10 to 12 years after they were randomly assigned to either early coronary bypass surgery or medical therapy. At the projected five-year follow-up interval, we observed a significantly higher survival rate (+/- 95 percent confidence interval) in the group that was assigned to surgical treatment than in the group assigned to medical treatment (92.4 +/- 2.7 vs. 83.1 +/- 3.9 percent; P = 0.0001). During the subsequent seven years, the percentage of patients who survived decreased more rapidly in the surgically treated than in the medically treated group (70.6 +/- 5.8 vs. 66.7 +/- 5.3 percent at 12 years). Thus, the improvement in the survival rate among patients with stable angina who were treated surgically appears to have been attenuated after five years. However, the gradually diminishing difference between the two survival curves still favored surgical treatment after 12 years (P = 0.04), despite the fact that 136 patients in the medically treated group had coronary bypass surgery and 23 in the "surgically treated" group did not. The benefit of surgical treatment tended to be greater, but not significantly so, as assessed by interaction analysis in the subgroups of patients who were older or who had signs of ischemia or previous infarction on the resting electrocardiogram, a markedly ischemic response to exercise testing, peripheral arterial disease, an absence of hypertension, and proximal obstruction in the left anterior descending artery. The reasons for the loss of a beneficial effect of surgery after five years are unknown and merit further study.
We compared patients who received an internal-mammary-artery graft to the anterior descending coronary artery alone or combined with one or more saphenous-vein grafts (n = 2306) with patients who had only saphenous-vein bypass grafts (n = 3625). The 10-year actuarial survival rate among the group receiving the internal-mammary-artery graft, as compared with the group who received the vein grafts (exclusive of hospital deaths), was 93.4 percent versus 88.0 percent (P = 0.05) for those with one-vessel disease; 90.0 percent versus 79.5 percent (P less than 0.0001) for those with two-vessel disease; and 82.6 percent versus 71.0 percent (P less than 0.0001) for those with three-vessel disease. After an adjustment for demographic and clinical differences by Cox multivariate analysis, we found that patients who had only vein grafts had a 1.61 times greater risk of death throughout the 10 years, as compared with those who received an internal-mammary-artery graft. In addition, patients who received only vein grafts had 1.41 times the risk of late myocardial infarction (P less than 0.0001), 1.25 times the risk of hospitalization for cardiac events (P less than 0.0001), 2.00 times the risk of cardiac reoperation (P less than 0.0001), and 1.27 times the risk of all late cardiac events (P less than 0.0001), as compared with patients who received internal-mammary-artery grafts. Internal-mammary-artery grafting for lesions of the anterior descending coronary artery is preferable whenever indicated and technically feasible.
The results of the European Study apply to the patients who met the inclusion criteria of this study: men, aged under 65, with angina pectoris of more than three months' duration, 50% or greater intraluminal diameter narrowing in at least two major coronary arteries and good left ventricular function (ejection fraction greater than or equal to 50%). The results imply that prophylactic coronary bypass surgery should be considered only for those patients with angina who are at risk of premature death defined by the non-invasive prognostic predictors (ischemic abnormalities in the resting ECG, marked ST-depression during exercise, peripheral arterial disease, age) and the extent and size of coronary obstructions. The severity of angina is of limited relevance in this context. The patients in a low risk phase of the disease do not require surgery unless they have unacceptable symptoms in spite of adequate medical treatment. No evidence emerges to support the assumption that coronary bypass surgery protects against future myocardial infarction. Although surgery relieves angina pectoris and improves physical performance, it does not significantly delay retirement from work over a period of five years.
We explored the possibility of anastomosing the left anterior internal mammary artery (LIMA) to the left anterior descending artery in a beating heart via a left anterior small thoracotomy.
This procedure was performed in 155 of 162 scheduled patients; in 7 (4.3%) the left anterior descending artery was not suitable or was too small. The chest was opened in the fourth intercostal space (mean wound length, 10.5 cm) and the LIMA was harvested for about 4 cm. The left anterior descending artery was occluded by means of two 4/0 Prolene (Ethicon, Somerville, NJ) sutures, and the proximal suture was snared. The anastomosis was performed with two 8/0 Prolene sutures while the heart was beating. Early postoperatively all patients underwent repeat angiography or a Doppler flow assessment of the LIMA or both.
The LIMA was connected directly to the left anterior descending artery in 144 patients and with interposition of an inferior epigastric artery in 11. In 2 patients the diagonal branch was also grafted using an inferior epigastric artery from the LIMA. One patient (0.6%) died 38 days after the operation due to multiorgan failure. Nine patients (5.8%) had failure requiring a redo operation: 7 (4.5%) early and 2 (1.3%) late. One additional patient had a late percutaneous transluminal coronary angioplasty for anastomotic stenosis. At a mean 5.6 months of follow-up, 143 patients (92.2%) were alive, asymptomatic with or without medical treatment, and without cardiac events.
Left internal mammary artery-to-left anterior descending artery anastomosis performed on a beating heart via a left anterior small thoracotomy is a safe procedure. In selected patients the operation has good early and midterm results.
Because coronary heart disease is the leading cause of death in the industrialized world [(1)][1], many clinical investigations of purported cardiac risk factors and new treatments focus on death as a primary end point. It is intuitively appealing to attempt to better understand the association
The purpose of the study was to evaluate the best surgical approach in off-pump single vessel revascularization of the left anterior descending coronary artery (LAD).
In 256 patients a single left internal mammary artery (LIMA) to LAD bypass was performed with beating heart techniques through a left anterior minithoracotomy (minimally invasive direct coronary artery bypass (MIDCAB), n=129) or a full sternotomy (off-pump coronary artery bypass (OPCAB), n=127).
In the OPCAB group, significantly more severe comorbidities (P=0.001) and redo-operations were noted (P<0.001). Conversion to sternotomy or CPB was necessary in five MIDCAB patients and one OPCAB patient. No cerebrovascular accident was seen in both groups. There was no hospital death in MIDCAB- and two deaths in OPCAB procedures (P=ns). There was a significant reduction in time of surgery (P=0.028) and coronary occlusion (P=0.009) in the OPCAB group. No differences in postoperative ventilation time, ICU stay and length of hospital stay were recorded between groups. Wound infections occurred in six MIDCAB patients (4.7%) and one OPCAB patient (0.8%). Early postoperative reoperation due to graft failure was necessary in three patients after MIDCAB and two patients after OPCAB (P=ns). Confirmed by angiography, the early graft patency rate was 96 and 98%, respectively (P=ns).
Both beating heart techniques showed good results with low hospital mortality, low early complications and comparable angiographic results. Nevertheless, MIDCAB is a challenging technique as demonstrated by the longer times of surgery and coronary occlusion with a tendency towards a higher risk of conversion and wound infection. Thus, this technique should only be performed in selected patients with favourable coronary anatomy. Through a sternotomy approach, single vessel revascularization can be performed safely off-pump even in high-risk patients.
Although recent policy initiatives aimed at concentrating selected surgical procedures in high-volume hospitals may reduce mortality, their economic implications have not been considered fully. From the hospital perspective, the primary effect of these policies will be to redistribute surgical profits to bigger centers. From the payer perspective, prices paid for procedures will likely increase in some geographic areas. From the societal perspective, how these policies will affect the true cost of providing surgical care is uncertain, but use of discretionary procedures will likely increase. For these reasons, the primary argument for volume-based referral strategies should be improving quality, not reducing costs.
Recently minimally invasive direct coronary artery bypass grafting (MIDCAB) has become an interesting alternative to conventional coronary artery bypass grafting, especially in patients with a high-grade left anterior descending coronary artery (LAD) stenosis unsuitable for balloon angioplasty. Although MIDCAB offers several advantages such as the avoidance of sternotomy and cardiopulmonary bypass, concerns have been raised about the technical accuracy of the anastomoses that can be performed on a beating heart. Therefore, clinical and angiographic outcomes after MIDCAB are the subject of current controversy.
A literature search for all published outcome studies of MIDCAB grafting was performed for the period from January 1995 through April 2003. Sixteen articles were enrolled in this review. The data presented in the studies was analysed with regard to clinical outcome and angiographic results.
Early mortality ranged from 0% to 4.9% and late mortality (>30 days after MIDCAB) ranged from 0.3% to 12.6%. Infarct rates (non-fatal myocardial infarction) ranged between 0% and 3.1%. Intra- and postoperative complications (wound infections, reoperation for management of bleeding, arrhythmias, stroke, etc.) occurred in 1.6-40%. The conversion rate to sternotomy/cardiopulmonary bypass ranged between 0% and 6.2%. Reinterventions due to graft failure were necessary in up to 8.9% of patients (surgical revision or percutaneous transluminal coronary angioplasty, PTCA). Short-term and mid-term angiographic outcomes are given in Table I.
Clinical outcomes and immediate graft patency after MIDCAB are acceptable. However, long-term follow-up results and further randomized prospective clinical trials comparing this new technique with standard revascularization procedures are needed.
Minimally invasive direct coronary artery bypass (MIDCAB) for revascularization of the left anterior descending artery has become a routine operation. Here we present the experience after more than 1300 MIDCAB procedures with up to 7 years of follow-up.
All patients undergoing standard MIDCAB between 1996 and 2004 were included. Long-term follow-up information about health status, major cardiac and cerebral adverse events, and freedom of angina was collected annually by a questionnaire or personal contact. Preoperative, intraoperative, and postoperative data could be completed for all 1347 patients. Five-year follow-up was available for 450 patients and 7-year follow-up for 194 patients.
Mean age was 63.2 years (range, 25 to 92 years) and mean ejection fraction was 0.61 +/- 0.14. In 23 patients (1.7%), intraoperative conversion to sternotomy or CPB, or both, was necessary. Early postoperative mortality was 0.8% (n = 11), and 0.4% (n = 5) had a perioperative stroke. A routine postoperative angiogram in 709 patients showed 95.6% early graft patency. Short-term target vessel reintervention was needed 55 patients (4.1%): 10 had percutaneous transluminal coronary angioplasty/stent and 45 had reoperation. A repeat angiogram at the 6-month follow-up was available in 350 patients and demonstrated 94.3% graft patency. Kaplan-Meier analysis revealed a 5-year survival of 91.9% (95% confidence interval [CI], 90.1% to 93.8%) and a 7-year survival of 89.4% (95% CI, 86.7% to 92.1%). The freedom of major adverse events and angina was 89.5% (95% CI, 87.4% to 91.5%) after 5 years and 83.3% (95% CI, 79.0% to 87.5%) after 7 years.
MIDCAB can be safely performed with low postoperative mortality and morbidity. The excellent short-term and long-term survival as well as freedom from major adverse cardiac and cerebral events and angina compare favorably with stenting and conventional surgery.
Percutaneous intervention (PCI) and minimally invasive direct coronary bypass grafting (MIDCAB) are both well-accepted treatment options for isolated high-grade stenosis of proximal left anterior descending coronary artery. Small studies comparing the two modalities have yielded conflicting results. We performed a meta-analysis of randomized control trials to compare percutaneous intervention with minimally invasive coronary bypass grafting for isolated proximal left anterior descending artery stenosis. Five randomized trials with a total of 711 patients and average follow-up of 2.3 years were included in the analysis; 380 patients received stents and 331 underwent surgery. Only one trial used drug eluting stents. There were a small number of events overall in each trial. Difference between mortality was 12 events versus 15 between the PCI versus MIDCAB group. Similarly, the difference in myocardial infarction was 14 versus 10, and target vessel revascularization was 56 versus 19. The relative risk for stenting versus MIDCAB was 0.96 [(95% CI: 0.47, 1.99), p=0.92, I(2)=17.5%], for mortality and myocardial infarction, 0.77 [(95% CI: 0.30, 2.01), p=0.60, I(2)=10.4%] for mortality and 1.81 [(95% CI: 0.80, 4.06), p=0.15, I(2)=65.9%] for the composite end point of mortality, myocardial infarction and target vessel revascularization. Excluding the trial with drug eluting stents the relative risk for the composite outcome of mortality, myocardial infarction and target vessel revascularization was significantly higher for PCI [RR=2.27 (95% CI: 1.32, 3.90), p=0.003, I(2)=18.9%]. Overall mortality and myocardial infarction rates are similar for bare metal stents versus MIDCAB, but surgery was associated with significantly lower rates of repeat revascularization. The number of randomized patients and events were small. The effect of drug eluting stents might close the gap of repeat revascularization compared to MIDCAB for this disease.
Minimally invasive direct coronary artery bypass (MIDCAB) is a reliable method to revascularize the left anterior descending (LAD) coronary artery. However, a more consistent body of knowledge is needed to assess factors influencing long-term outcome. With this study, we retrospectively investigated the long-term determinants of survival and freedom from cardiac morbidity and revascularization in patients who underwent MIDCAB.
From 1997 to 2005, 109 patients underwent MIDCAB. Seventy-five (68.8%) presented isolated LAD disease and 34 (31.2%) multivessel disease. The first 57 patients (53.2%) in the series underwent early postoperative angiographic reinvestigation. All 109 patients were subsequently followed-up at our outpatient clinic. Follow-up (mean 50.7 months, range 3-93) was completed in 100% of cases.
No in-hospital deaths occurred; 2 patients (1.8%) experienced perioperative myocardial infarction. At early postoperative angiographic reinvestigation, the anastomotic perfect patency rate was 54/57 (94.7%); survival was 100% and 95.8% at 1 and 5 years, respectively. Overall freedom from repeated revascularization was 95.3% and 88.3% at 1 and 5 years respectively; freedom from LAD revascularization was 95.3% and 91.6% at 1 and 5 years, respectively; cardiac event-free survival was 95.3% and 80.8% at 1 and 5 years respectively. At multivariable analysis (Cox regression), women were found to have a higher risk of repeated LAD revascularization (hazard ratio [HR] 30.24; P<0.001); female sex and left ventricular dysfunction were the only predictors affecting long-term cardiac outcome (hazard ratio 29.35; P<0.001 and 5.1; P<0.001), respectively.
A key factor in the long-term success of MIDCAB seems to be appropriate patient selection. Special attention should be reserved for female patients, as they appear to have a worse cardiac outcome and a higher probability of repeated revascularization on LAD. MIDCAB may represent a viable option for treating multivessel disease when complete revascularization is unfeasible or a hybrid procedure is envisaged.
Cite this article as
- S G Raja
- S Garg
- M Rochon
- S Daley
Cite this article as: Raja SG, Garg S, Rochon M, Daley S,