Minimally Invasive Coronary Artery Bypass Grafting: Dual-Center Experience in 450 Consecutive Patients

Minimally invasive coronary artery bypass grafting: a systematic review

To minimize surgical morbidity in coronary artery bypass grafting, minimally invasive cardiac surgery has gained popularity. Minimally invasive coronary artery bypass grafting offers unique advantages compared to conventional off-pump coronary artery bypass or minimally invasive direct coronary artery bypass in that it enables the surgeon to harvest and graft bilateral internal thoracic arteries via a small thoracotomy while being conducted completely off-pump. This review focuses on current evidence behind off-pump coronary artery bypass, multi-arterial revascularization, patient populations that would most benefit from bilateral internal thoracic artery minimally invasive coronary artery bypass grafting, the surgical technique, and early outcomes. By overcoming the perceived inability to utilize bilateral internal thoracic arteries in minimally invasive coronary artery bypass grafting, the new technique further expands the armamentarium of surgeons and cardiologists. Hybrid coronary revascularization with bilateral internal thoracic artery minimally invasive coronary artery bypass grafting further augments the appeal of the next generation of minimally invasive cardiac surgery.

Predictors and Outcomes of Sternotomy Conversion and Cardiopulmonary Bypass Assistance in Minimally Invasive Coronary Artery Bypass Grafting

OBJECTIVE

This work's objective was to identify the determinants of conversion of minimally invasive coronary artery bypass grafting to sternotomy, with and without cardiopulmonary bypass assistance, and to compare clinical outcomes in patients who needed conversion.

METHODS

This is a prospectively collected data on patients who underwent minimally invasive coronary bypass done by a single surgeon from February 2005 to September 2014. Statistical analyses were expressed as mean values ± standard deviation or proportions.

RESULTS

The total number of patients was 266, with an average age of 62 years. The median number of grafted territories was 2, higher in those with pump assistance (median, 3 grafts; P ≤ 0.01). Predictors for use of cardiopulmonary bypass included diabetes, 3-vessel disease, left circumflex involvement, and small target vessels (P < 0.05). The rate for sternotomy conversion was 3.8%. Risk factors for conversion to sternotomy included smoking, preoperative bradycardia (<50 beats per minute), low intraoperative ejection fraction, inability to tolerate one-lung ventilation, inadequate surgical exposure, and hemodynamic instability. Postoperative complications included superficial thoracotomy infection (3%), sternotomy infection (10%), new atrial fibrillation (3%), and need for blood transfusion (14%). Twelve patients (5%) developed left-sided pleural effusion that required drainage. There were no perioperative deaths, major adverse cardiac event, or stroke.

CONCLUSIONS

Minimally invasive coronary bypass grafting with conversion to sternotomy and use of cardiopulmonary bypass is safe. Conversions may be alleviated by an effort to optimize modifiable risk factors and the adequacy of surgical exposure. These data may help develop objective selection criteria to identify patients who are excellent candidates for the procedure.

A lethal tension pneumothorax during minimally invasive coronary artery bypass surgery: Can transesophageal echocardiography pick it?

Minimally invasive cardiac surgery is establishing itself as the standard of care across the world. MICS CABG is currently performed in only a few centers. Hemodynamics disturbances are peculiar during MICS CABG due to space constraints. We report a 70-year-old man who underwent MICS CABG who developed tension pneumothorax during revascularization that was diagnosed in a novel way.

Effects of conventional CPB and mini-CPB on neutrophils CD162, CD166 and CD195 expression

OBJECTIVE

Cardiac surgery is known to trigger a systemic inflammatory response. While the use of conventional cardiopulmonary bypass (CPB) results in profound inflammation, modified mini-CPB is considered less harmful. We evaluated the impact of cardiac surgery on the expression of CD162, CD166, CD195 molecules and their association with the type of CPB used.

METHODS AND RESULTS

Twenty-four patients were enrolled in our study. Twelve of them were operated using conventional CPB while the other twelve patients underwent surgery with mini-CPB. Blood samples were analysed by flow cytometry. We observed a significant increase in median fluorescence intensity of CD162 and CD195 that peaked instantly after surgery and normalized to the baseline value on the 1^st day post surgery, whereas CD166 was initially down-regulated and its median fluorescence intensity (MFI) value increased to the baseline in the next few days.

CONCLUSION

We observed immediate changes in the expression of CD162, CD166, and CD195 molecules on the neutrophils after surgery in both study groups of patients. The intensity of the observed changes was significantly greater in the group of patients who underwent conventional CPB compared to patients who underwent mini-CPB cardiac surgery.

Off-pump minimally invasive direct coronary artery bypass in patients with cosmetic prosthesis for pectus excavatum

Pectus excavatum can be associated with coronary artery diseases that can become difficult to manage in urgent situations. We describe the use of an off-pump minimally invasive direct coronary artery bypass (MIDCAB) through the fourth intercostal space incision in a patient with pectus excavatum and acute coronary syndrome who previously underwent a cosmetic prosthesis implantation. The patient refused any surgical procedure that could compromise the integrity of his cosmetic prosthesis and a left mini-thoracotomy was a good option to avoid the removal of the prosthesis. The preservation of the integrity of the thoracic cage enhanced chest wall stability and pulmonary function and permitted avoidance of inadvertent cardiac structure iatrogenic injuries. MIDCAB was optimal for the exposure of the left internal thoracic artery and the left anterior descending artery. The deformity of the chest should not be considered as an absolute contraindication to off-pump MIDCAB when other surgical options are not viable, even in emergency situations.

Reprint of: Pendant allyl crosslinking as a tunable shape memory actuator for vascular applications

Thermo-responsive shape memory polymers (SMPs) can be programmed to fit into small-bore incisions and recover their functional shape upon deployment in the body. This property is of significant interest for developing the next generation of minimally-invasive medical devices. To be used in such applications, SMPs should exhibit adequate mechanical strengths that minimize adverse compliance mismatch-induced host responses (e.g. thrombosis, hyperplasia), be biodegradable, and demonstrate switch-like shape recovery near body temperature with favorable biocompatibility. Combinatorial approaches are essential in optimizing SMP material properties for a particular application. In this study, a new class of thermo-responsive SMPs with pendant, photocrosslinkable allyl groups, x%poly(ε-caprolactone)-co-y%(α-allyl carboxylate ε-caprolactone) (x%PCL-y%ACPCL), are created in a robust, facile manner with readily tunable material properties. Thermomechanical and shape memory properties can be drastically altered through subtle changes in allyl composition. Molecular weight and gel content can also be altered in this combinatorial format to fine-tune material properties. Materials exhibit highly elastic, switch-like shape recovery near 37 °C. Endothelial compatibility is comparable to tissue culture polystyrene (TCPS) and 100%PCL in vitro and vascular compatibility is demonstrated in vivo in a murine model of hindlimb ischemia, indicating promising suitability for vascular applications.

STATEMENT OF SIGNIFICANCE

With the ongoing thrust to make surgeries minimally-invasive, it is prudent to develop new biomaterials that are highly compatible and effective in this workflow. Thermo-responsive shape memory polymers (SMPs) have great potential for minimally-invasive applications because SMP medical devices (e.g. stents, grafts) can fit into small-bore minimally-invasive surgical devices and recover their functional shape when deployed in the body. To realize their potential, it is imperative to devise combinatorial approaches that enable optimization of mechanical, SM, and cellular responses for a particular application. In this study, a new class of thermo-responsive SMPs is created in a robust, facile manner with readily tunable material properties. Materials exhibit excellent, switch-like shape recovery near body temperature and promising biocompatibility for minimally-invasive vascular applications.

Thoracoscopic surgery via a single-incision subxiphoid approach is associated with less postoperative pain than single-incision transthoracic or three-incision transthoracic approaches for spontaneous pneumothorax

BACKGROUND

Comparison of the degree of postoperative pain associated with different thoracoscopic surgical techniques for spontaneous pneumothorax has never reported. In this study we compared perioperative outcomes and degrees of postoperative pain associated with single-incision subxiphoid thoracoscopic surgery, single-incision transthoracic thoracoscopic surgery and three-incision transthoracic thoracoscopic surgery for spontaneous pneumothorax.

METHODS

During the period August 2013 to September 2015, fifty-seven consecutive patients with spontaneous pneumothorax were treated via single-incision subxiphoid thoracoscopic surgery, single-incision transthoracic thoracoscopic surgery or three-incision transthoracic thoracoscopic surgery. Demographic data, operative time, operative blood loss, length of hospital stay, duration of chest tube drainage, postoperative complications, and numeric pain rating scale scores were collected from the medical records for analysis.

RESULTS

Among the 57 patients, 14 received single-incision subxiphoid thoracoscopic surgery, 26 underwent single-incision transthoracic surgery and 17 received three-incision thoracoscopic surgery. In all patients, surgeries were completed without the need for conversion to open surgery. Patients who underwent the single-incision subxiphoid procedure had significantly lower 1-, 8-, 24- and 32-hour postoperative pain scale scores than patients who underwent the other two procedures. The average and maximum pain scale scores during the first 24 hours were lowest in the single-incision subxiphoid group (P<0.0001).

CONCLUSIONS

Single-incision subxiphoid thoracoscopic surgery is associated with significantly lower postoperative pain intensity than transthoracic approaches and therefore may provide an alternative surgical technique for patients with spontaneous pneumothorax.

Minimally invasive direct coronary artery bypass grafting with an improved rib spreader and a new-shaped cardiac stabilizer: results of 200 consecutive cases in a single institution

Background

Performing minimally invasive direct coronary artery bypass (MIDCAB) grafting via small chest incisions on a beating heart is challenging. We report our experiences of MIDCAB with the utilization of both an improved rib spreader to harvest the left internal mammary artery (LIMA) and a new-shaped cardiac stabilizer to facilitate LIMA-left anterior descending (LAD) coronary anastomosis.

Methods

Between May 2012 and June 2104, a total of 200 patients who were consecutively operated on in this period were enrolled in this study. Data reported included demographic information, preoperative clinical and cardiac status, LIMA harvest time, postoperative in-hospital outcomes, and 30-day mortality.

Results

The average LIMA harvest time was 43 min. The mean age was 62.59 ± 10.19 years, and 45 of the 200 were females. The 30-day mortality was 0.5 % (one patient) due to perioperative myocardial infarction. Duration of mechanical ventilation and length of stay in intensive care unit was 9.27 ± 7.65 and 24.27 ± 17.85 h, respectively. The unit of packed RBC transfusion was 0.79 ± 1.58. Postoperative atrial fibrillation was observed in 14 (7 %) patients. There was no postoperative stroke, renal failure, or incision complication.

Conclusion

Performing MIDCAB with the improved retractor and stabilizer utilized in this study showed favorable outcomes in terms of harvesting the LIMA, postoperative morbidities, and 30-day mortality.

Long-term Outcome after Percutaneous Coronary Intervention Compared with Minimally Invasive Coronary Artery Bypass Surgery in the Elderly

Background:

Elderly patients with unstable coronary artery disease (CAD) have better outcomes with coronary revascularization than conservative treatment. With the improvement in percutaneous coronary intervention (PCI) techniques using drug eluting-stents, this became an attractive option in elderly. Minimally invasive coronary artery bypass grafting (MICS-CABG) is a safe and effective alternative to conventional CABG. We aimed to explore the long-term outcomes after PCI vs MICS-CABG in ≥75 year-old patients with severe CAD.

Methods:

A total of 1454 elderly patients (≥75 year-old patients) underwent coronary artery revascularization between January 2005 and December 2009. Patients were selected in the study if they have one of the Class-I indications for CABG. Groups were divided according to the type of procedure, PCI or MICS-CABG, and 5 year follow-up.

Results:

Among 175 elderly patients, 109 underwent PCI and 66 had MICS-CABG. There was no significant difference observed in both groups with long-term all-cause mortality (31 PCI vs 21% MICS-CABG, p=0.151) and the overall 5 year survival was similar on Kaplan-Meier curve (Log rank p=0.318). The average length of stay in hospital was significantly shorter in the PCI than in the MICS-CABG group (4.3 vs 7.8 days, p<0.001). Only 4.7% of the PCI group were discharged to rehabilitation facility compared with 43.9% of the MICS-CABG group (p<0.001). The rate of repeat revascularization was significantly higher in the PCI group than in the MICS-CABG group (15 vs 3%, p=0.014).

Conclusion:

Among elderly patients, long-term all-cause mortality is similar after PCI and MICS-CABG. However, there is a significantly higher rate of repeat revascularization after PCI.

Minimally Invasive Coronary Artery Bypass Grating Using Bilateral In Situ Internal Thoracic Arteries

When performing minimally invasive coronary artery bypass grafting (MICS CABG), it is difficult to access the right internal thoracic artery (ITA) under direct vision. We successfully performed off-pump MICS CABG using the bilateral in situ ITAs through a 8-cm left thoracotomy under direct vision for a 76-year-old man. His postoperative course was uneventful and all the grafts were patent. This novel, minimally invasive approach safely preserves the sternum and delivers the benefits of bilateral in situ ITA grafting, providing an alternative to conventional CABG and off-pump CABG.

Additional right-sided upper "Half-Mini-Thoracotomy" for aortocoronary bypass grafting during minimally invasive multivessel revascularization

BACKGROUND

Although minimally invasive coronary artery bypass grafting (MICS-CABG) has been shown to result in excellent clinical outcomes overall adoption rates still remain low. Traditional strategies for minimally invasive multivessel revascularization - usually performed through single-thoracotomy - have to deal with restricted grafting possibilities and possible increased susceptibility of arterial grafts to competitive flow, restraining their applicability to very specific indications or hybrid approaches and on top, are prone to conversion to full-sternotomy in case of left internal thoracic artery (LITA) insufficiency.

METHODS

Here, we present a novel alternative to the traditional MICS-CABG approaches by adding a right-sided upper "half-mini-thoracotomy", which allows for aortocoronary bypass grafting in standard "off-pump" manner and adoption of similar revascularization principles as with conventional CABG during minimally invasive multivessel revascularization, though reducing restrictions inherent to current MICS-CABG strategies.

RESULTS

So far, feasibility and safety of this new approach has been successfully shown in 7 consecutive patients requiring surgical revascularization with no procedure-specific complications and graft configuration as well as intraoperative flow assessment comparable to those of similar patients operated via standard full-sternotomy off-pump coronary artery bypass (OPCAB) surgery.

CONCLUSIONS

Further evaluation warranted, this technique might have the potential to develop into an additional approach for minimally invasive multivessel revascularization, especially in cases where competitive flow to arterial grafts is feared, while also serving as a bailout-strategy for traditional approaches in case of LITA insufficiency.

Pendant allyl crosslinking as a tunable shape memory actuator for vascular applications

Thermo-responsive shape memory polymers (SMPs) can be programmed to fit into small-bore incisions and recover their functional shape upon deployment in the body. This property is of significant interest for developing the next generation of minimally-invasive medical devices. To be used in such applications, SMPs should exhibit adequate mechanical strengths that minimize adverse compliance mismatch-induced host responses (e.g. thrombosis, hyperplasia), be biodegradable, and demonstrate switch-like shape recovery near body temperature with favorable biocompatibility. Combinatorial approaches are essential in optimizing SMP material properties for a particular application. In this study, a new class of thermo-responsive SMPs with pendant, photocrosslinkable allyl groups, x%poly(ε-caprolactone)-co-y%(α-allyl carboxylate ε-caprolactone) (x%PCL-y%ACPCL), are created in a robust, facile manner with readily tunable material properties. Thermomechanical and shape memory properties can be drastically altered through subtle changes in allyl composition. Molecular weight and gel content can also be altered in this combinatorial format to fine-tune material properties. Materials exhibit highly elastic, switch-like shape recovery near 37°C. Endothelial compatibility is comparable to tissue culture polystyrene (TCPS) and 100%PCL in vitro and vascular compatibility is demonstrated in vivo in a murine model of hindlimb ischemia, indicating promising suitability for vascular applications.

STATEMENT OF SIGNIFICANCE

With the ongoing thrust to make surgeries minimally-invasive, it is prudent to develop new biomaterials that are highly compatible and effective in this workflow. Thermo-responsive shape memory polymers (SMPs) have great potential for minimally-invasive applications because SMP medical devices (e.g. stents, grafts) can fit into small-bore minimally-invasive surgical devices and recover their functional shape when deployed in the body. To realize their potential, it is imperative to devise combinatorial approaches that enable optimization of mechanical, SM, and cellular responses for a particular application. In this study, a new class of thermo-responsive SMPs is created in a robust, facile manner with readily tunable material properties. Materials exhibit excellent, switch-like shape recovery near body temperature and promising biocompatibility for minimally-invasive vascular applications.

Early and Midterm Results of No-Touch Aorta Multivessel Small Thoracotomy Coronary Artery Bypass Grafting: A Propensity Score-Matched Study

Objective

To carry out the comparative analysis of early and midterm results of no-touch aorta multivessel small thoracotomy coronary artery bypass grafting (MVST CABG), conventional off-pump (OPCABG) and on-pump CABG (ONCABG).

Methods

From 2007 to 2014, 537 consecutive patients underwent CABG by the same surgeon. Propensity score computer matching was performed, and a total of 453 patients were successfully matched in 3 groups of 151 patients.

Results

Significant differences were found in the intraoperative blood loss: 220 (180; 300) mL in MVST CABG versus 400 (300; 550) mL in OPCABG vs 350 (250; 435) mL in ONCABG group; first 24-hour postoperative blood loss: 170 (100; 280), 320 (200; 470), and 380 (200; 500)mL, respectively; operation time: 352.4 ± 74.4,289.3 ± 55.0, and 280.4 ± 56.4 minutes, respectively; median time to return to full physical activity: 14, 56, and 56 days, respectively (P < 0.05); rate of deep wound infection: 0.0%, 2.0%, and 2.0%, respectively; and postoperative length of stay (surgical department): 4.5, 7.0, and 7.5 days, respectively (P < 0.1). No significant differences were observed in rates of severe in-hospital events (P > 0.05), cumulative midterm survival, and freedom from major adverse cardiac and cerebrovascular events (P > 0.05).

Conclusions

The MVST CABG seems as safe as OPCABG and ONCABG and is associated with less wound infections, perioperative blood loss, shorter hospital length of stay and time to return to full physical activity. Multivessel small thoracotomy CABG can be applied to most patients with coronary heart disease saving the effectiveness during midterm follow-up. The MVST CABG can be introduced avoiding a prolonged learning curve.

Strategies for the coronary surgeon to remain "competitive and co-operative" in the PCI era

BACKGROUND

The advent of percutaneous intervention has made surgical treatment of coronary artery disease less favored by patients though the evidence that supports CABG in certain patient subsets is strong.

METHODS

Literature review was done using Pubmed, Scopus, Google and Google Scholar with MeSH terms-coronary artery bypass grafting, internal mammary artery, drug eluting stent, stroke, myocardial revascularization.

RESULTS

The adoption of evolving techniques like anaortic off pump grafting, bilateral internal mammary artery use, hybrid and minimally invasive coronary revascularization techniques, intra-operative graft assessment, and heart team approach can lead to better outcomes following surgery as is evidenced by recent literature.

CONCLUSIONS

Though the adoptability of the newer strategies may vary between centers a close coalition between coronary surgeons and cardiologists would ensure that the management of coronary artery disease is based on evidence for the benefit of the patient.

Off-Pump Minimally Invasive Coronary Artery Bypass Grafting with a Heart Positioner Direct Retraction for a Better Exposure

Objective

Lateral and inferior territories are difficult to expose during off-pump minimally invasive coronary artery bypass grafting (MICS CABG). The use of cardiopulmonary bypass is required at times. We initiated a direct retraction method by using a cardiac positioner for a better exposure, in order to complete off-pump, multivessel MICS CABG safely.

Methods

We recently initiated multivessel MICS CABG, performed via a 6- to 9-cm left thoracotomy. For distal anastomoses, the lateral pericardial edge was pulled to the chest wall to optimize exposure of the lateral and inferior area. Next, a single- or multisuction cardiac positioner was put on the sides of the target vessel through the small thoracotomy and pulled directly toward the incision. Finally, a distal anastomosis was made with an epicardial stabilizer via the thoracotomy, as in standard off-pump CABG.

Results

There was no mortality or conversion to sternotomy. A total of 10 cases were targeted for off-pump multivessel MICS CABG with this approach. Nine were completed, while 1 still required pump assist. The average number of distal anastomoses was 2.8 ± 0.8. Two were successful off-pump quadruple bypass grafting with sequential anastomoses. All patients were discharged and remain well to this day.

Conclusions

Most multivessel MICS CABG was feasible without pump assist even at the initiation period. This approach is easy and helpful in providing good exposure of target vessels without requirement of additional incisions.

Minimally invasive coronary bypass in a patient with metal allergy

Patients with metal allergy represent a challenge for current surgical techniques, particularly minimally invasive ones, in which metal implants are routinely used to facilitate procedures. We report on a 60-year-old woman with metal allergy who presented with non-ST elevation myocardial infarction, and in whom we performed minimally invasive coronary artery bypass via small thoracotomy. In conclusion, we show that minimally invasive coronary surgery might feasibly be done without the aid of metal implants or surgical clips for hemostasis.

Minimally Invasive Coronary Artery Bypass Grafting is Associated with Improved Clinical Outcomes

Objective

Minimally invasive coronary artery bypass grafting (MICS CABG) via left minithoracotomy is an alternative to off-pump coronary artery bypass (OPCAB) via sternotomy. Our objective was to evaluate the clinical outcomes after MICS CABG versus OPCAB.

Methods

The medical records of patients who underwent MICS CABG from December 2009 to December 2011 and OPCAB from January 2005 to April 2011 were reviewed. Patients who underwent OPCAB were matched 2:1 to patients who underwent MICS CABG by age, sex, preoperative ejection fraction, creatinine concentration, as well as history of diabetes and myocardial infarction.

Results

A total of 130 MICS CABG patients were matched with 260 OPCAB patients. Mean bypasses in the MICS CABG and OPCAB groups were 2.1 and 3.2, respectively ( P = 0.001). Extubation in the operating room (OR) occurred in 70.0% and 12.7% of patients in the MICS CABG and OPCAB groups, respectively ( P = 0.001). Mean postoperative length of stay was 4 days for the MICS CABG patients versus 5 days for the OPCAB patients ( P = 0.002) and 3.8 days versus 4.6 days for the MICS CABG patients extubated in the OR compared with those who remained intubated ( P = 0.007). There were no 30-day mortalities in the MICS CABG group and 1 in the OPCAB group (P= 0.999). Thirty-day readmissions were similar, with 5.4% and 7.4% in the MICS CABG and OPCAB groups, respectively ( P = 0.527).

Conclusions

Minimally invasive coronary artery bypass grafting is safe, and early clinical outcomes are comparable, if not superior in some respects, to OPCAB. Extubation in the OR is feasible, well tolerated, and associated with earlier discharge. Shorter hospital stays may decrease resource use and promote earlier return to activities; however, further research is needed.

Clinical outcomes of hybrid coronary revascularization versus coronary artery bypass surgery in patients with diabetes mellitus

BACKGROUND

Hybrid coronary revascularization (HCR) involves minimally invasive left internal mammary artery to left anterior descending coronary artery grafting combined with percutaneous coronary intervention (PCI) of non-left anterior descending vessels. The safety and efficacy of HCR among diabetic patients are unknown.

METHODS

Patients with diabetes were included who underwent HCR at a US academic center between October 2003 and September 2013. These patients were matched 1:5 to similar patients treated with coronary artery bypass grafting (CABG) using a propensity score (PS)-matching algorithm. Conditional logistic regression and Cox regression stratified on matched pairs were performed to evaluate the association between HCR and inhospital complications, a composite measure of 30-day mortality, myocardial infarction and stroke, and up to 3-year all-cause mortality.

RESULTS

Of 618 patients (HCR = 103; CABG = 515) in the PS-matched cohort, the 30-day composite of death, MI, or stroke after HCR and CABG was 4.9% and 3.9% (odds ratio: 1.25; 95% CI [0.47-3.33]; P = .66). Compared with CABG, HCR also had similar need for reoperation (7.6% versus 6.3%; P = .60) and renal failure (4.2% versus 4.9%; P = .76) but required less blood products (31.4% versus. 65.8%; P < .0001), lower chest tube drainage (655 mL [412-916] versus 898 mL [664-1240]; P < .0001), and shorter length of stay (<5 days: 48.3% versus 25.3%; P < .0001). Over a 3-year follow-up period, mortality was similar after HCR and CABG (12.3% versus 14.9%, hazard ratio: 0.94, 95% CI [0.47-1.88]; P = .86).

CONCLUSION

Among diabetic patients, the use of HCR appears to be safe and has similar longitudinal outcomes but is associated with less blood product usage and faster recovery than conventional CABG surgery.

Robotically assisted coronary artery bypass grafting: a systematic review and meta-analysis

BACKGROUND

It remains uncertain as to whether robotically assisted coronary bypass surgery (RACBS) is superior to non-robotic procedures.

METHODS

Literature searches were conducted using MEDLINE, EMBASE and LILACS. Two review authors independently screened citations, assessed trial quality and performed data extraction.

RESULTS

Three trials met the inclusion criteria. None was randomized. Compared with non-robotic approaches, RACBS was associated with longer surgical times, shorter intensive care unit and hospital stays, higher extubation rates and lower odds for atrial fibrillation as well as myocardial infarction. There were no differences for the odds of stroke and mortality between the interventions.

CONCLUSIONS

Although robotic-assisted coronary bypass appears to be promising, the study designs were not adequate and may have a high risk of selection bias. There is a need for randomized trials to corroborate the findings and to determine the long-term benefits of RACBS compared with traditional surgical approaches.

Comparison of hybrid coronary revascularization versus coronary artery bypass grafting in patients≥65 years with multivessel coronary artery disease

Hybrid coronary revascularization (HCR) combines minimally invasive left internal mammary artery-to-left anterior descending coronary artery grafting with percutaneous coronary intervention of non-left anterior descending coronary arteries. The safety and efficacy of HCR in patients≥65 years of age is unknown. In this study, patients aged≥65 years were included who underwent HCR at an academic center from October 2003 to September 2013. These patients were matched 1:4 to similar patients treated with coronary artery bypass grafting (CABG) using a propensity-score matching algorithm. Conditional logistic regression and Cox regression stratified on matched pairs were performed to evaluate the association between HCR and CABG, and 30-day major adverse cardiovascular and cerebrovascular events (a composite of mortality, myocardial infarction, and stroke), periprocedural complications, and 3-year all-cause mortality. Of 715 patients (143 of whom underwent HCR and 572 CABG) in the propensity score-matched cohort, rates of 30-day major adverse cardiovascular and cerebrovascular events were comparable after HCR and CABG (5.6% vs 3.8%, odds ratio 1.46, 95% confidence interval 0.65 to 3.27, p=0.36). Compared with CABG, HCR resulted in fewer procedural complications (9.1% vs 18.2%, p=0.018), fewer blood transfusions (28.0% vs 53.3%, p<0.0001), less chest tube drainage (838±484 vs 1,100±579 cm3, p<0.001), and shorter lengths of stay (<5 days: 45.5% vs 27.4%, p=0.001). Over a 3-year follow-up period, mortality rates were similar after HCR and CABG (13.2% vs 16.6%, hazard ratio 0.81, 95% confidence interval 0.46 to 1.43, p=0.47). Subgroup analyses in high-risk patients (Charlson index≥6, age≥75 years) rendered similar results. In conclusion, although the present data are limited, we found that in older patients, the use of HCR is safe, has fewer procedural complications, entails less blood product use, and results in faster recovery with similar longitudinal outcomes relative to conventional CABG.

Long-term mortality in minimally invasive compared with sternotomy coronary artery bypass surgery in the geriatric population (75 years and older patients)

OBJECTIVES

Ischaemic heart disease is the leading cause of death in the elderly population. Coronary artery bypass graft (CABG) surgery via sternotomy remains the standard of care for patients with multivessel coronary artery disease (CAD). Minimally invasive cardiac surgery (MICS)-CABG via left thoracotomy has been used as an alternative to sternotomy. The aim of our study was to assess the overall survival after MICS-CABG and sternotomy-CABG in elderly patients with CAD.

METHODS

This observational study included patients who underwent coronary bypass from 2005 to 2008. Patients 75 years and older (n = 159) were included in the final analysis. Each arm was further divided into the MICS-CABG group or sternotomy-CABG group. Primary outcome and overall survival were obtained from our records and the social security death index.

RESULTS

Among patients 75 years and older (159 patients), MICS-CABG had a significantly lower 5-year all-cause mortality than sternotomy-CABG (19.7 vs 47.7%, P < 0.001). Similarly, Kaplan-Meier curves showed significantly higher overall survival in the MICS-CABG group compared with sternotomy-CABG (log-rank P = 0.014). After adjusting for confounders, MICS-CABG demonstrated a lower mortality than sternotomy-CABG (HR 0.51, 95% confidence interval 0.26-0.97, P = 0.04). For patients less than 75 years old, MICS and sternotomy groups had similar survival according to both uni- and multivariate analyses.

CONCLUSIONS

The adjusted models demonstrated that MICS-CABG has a significantly better long-term survival than sternotomy-CABG despite slightly differing baseline characteristics. Further studies are needed to compare the short- and long-term outcomes of the two approaches among the elderly population.

Coronary artery bypass grafting: Part 2--optimizing outcomes and future prospects

Since first introduced in the mid-1960s, coronary artery bypass grafting (CABG) has become the standard of care for patients with coronary artery disease. Surprisingly, the fundamental surgical technique itself did not change much over time. Nevertheless, outcomes after CABG have dramatically improved over the first 50 years. Randomized trials comparing percutaneous coronary intervention (PCI) to CABG have shown converging outcomes for select patient populations, providing more evidence for wider use of PCI. It is increasingly important to focus on the optimization of the short- and long-term outcomes of CABG and to reduce the level of invasiveness of this procedure. This review provides an overview on how new techniques and widespread consideration of evolving strategies have the potential to optimize outcomes after CABG. Such developments include off-pump CABG, clampless/anaortic CABG, minimally invasive CABG with or without extending to hybrid procedures, arterial revascularization, endoscopic vein harvesting, intraprocedural epiaortic scanning, graft flow assessment, and improved secondary prevention measures. In addition, this review represents a framework for future studies by summarizing the areas that need more rigorous clinical (randomized) evaluation.

Early and mid-term results of minimally invasive coronary artery bypass grafting

INTRODUCTION

Minimally invasive coronary artery bypass grafting (MICABG) is a less invasive method of performing surgical revascularization. This technique coupled with use of off pump technique of surgical revascularization makes it truly less invasive. This method is highly effective even in high-risk patients. Results of this procedure are comparable to standard off pump technique and are better than percutaneous coronary intervention utilizing drug-eluting stent. We present an early and mid-term result of the use of this technique.

METHOD

We enrolled 33 patients for analysis operated between 2008 and 2012. Operation was performed utilizing off-pump technique of coronary artery bypass grafting through a minimal invasive incision. Left internal mammary artery graft was done for single vessel disease and radial artery was utilized for other grafts if required. Median follow up of 2.5 years (6 months-4 years) is available.

RESULTS

Median age was 58.5 years (41-77) and all were male. Single vessel disease was present in 7, double vessel in 14 and triple vessel disease in 12 patients. All the patients had normal left ventricular size and function. There was no operative and 30-day mortality. Conversion to median sternotomy to complete the operation was done in 6.6% (2 out of 33 patients). One patient had acute myocardial infarction and there were no deaths during follow up.

CONCLUSION

MICABG is a safe and effective method of revascularization in low risk candidates for coronary artery bypass grafting.

Transapical aortic valve implantation and minimally invasive off-pump bypass surgery

Transcatheter aortic valve implantation (TAVI) has gained increasing popularity for high-risk patients with symptomatic aortic valve stenosis. A concomitant coronary artery disease leads to a complicated management and an increased perioperative risk. This case report describes the successful total arterial coronary revascularization of the left anterior descending and the left marginal branch of the circumflex artery utilizing the left internal mammary artery (LIMA) and left radial artery in off-pump technique in combination with the transapical transcatheter aortic valve implantation via minimally invasive anterolateral access in the fifth intercostal space.

Minimally Invasive Coronary Bypass Using Internal Thoracic Arteries via a Left Minithoracotomy

Objective

Harvesting of the right internal thoracic artery (RITA) under direct vision, through a left minithoracotomy, without robotic or thoracoscopic assistance has never been done or described before. Bilateral internal thoracic arteries (BITAs) in coronary artery bypass grafting (CABG) have shown greater survival and freedom from reintervention. The aim was to develop a multivessel minimally invasive CABG technique in which the BITAs are harvested under direct vision and complete revascularization of the myocardium is done by the off-pump method, using only BITAs (left internal thoracic artery [LITA]–RITAY) through a 2-in left minithoracotomy, without robotic/thoracoscopic assistance—the “Nambiar Technique.”

Methods

From August 2011 to December 2012, a total of 150 patients underwent off-pump minimally invasive multivessel CABG using BITAs, through a 2-in left minithoracotomy incision. Both internal thoracic arteries were harvested directly under vision, and complete revascularization of the myocardium was done using the LITA-RITAY composite conduit, followed by flow study of the grafts. Coronary artery stabilization for anastomoses was done by using epicardial stabilizers introduced through the minithoracotomy.

Results

One hundred fifty patients had minimally invasive total arterial myocardial revascularization using BITAs (LITA-RITA Y composite conduit) via a left minithoracotomy. The mean number of grafts was 2.8. A total of 81.6% of the patients had three grafts. Ejection fraction was 34.5 ± 5.2. There was one mortality but no major morbidity. The RITA and LITA harvest times were 39.5 ± 11.2 and 35.2 ± 8.6 minutes, respectively. The total time in the operating room (including extubation) was 331.5 ± 42.5 minutes, and operating time was 240.8 ± 24.6 minutes. One hundred twenty-six patients (87.7%) were extubated on the table. The mean hospital stay was 3.1 days. One patient (0.6%) had an elective conversion to sternotomy because the flow in the LITA-RITA Y composite conduit was inadequate and had saphenous vein grafts. Coronary angiograms were done in 37 patients (25%); and computed tomographic angiograms, in 33 patients (22%), and the grafts were patent. Stress test was done in 80 patients (53%), which had normal findings.

Conclusions

The Nambiar Technique encompassed using a 2-in left minithoracotomy incision through which the BITAs were conveniently harvested in a skeletonized manner under direct vision without robotic or thoracoscopic assistance. Multivessel total arterial revascularization was then done using the LITA-RITA Y composite conduit by the off-pump methodology. The early outcomes have been excellent, and coronary angiograms showed widely patent grafts. This technique is reproducible and can be done on an empty beating heart to aid in training.

Can Minimally Invasive Coronary Artery Bypass Grafting be Initiated and Practiced Safely?

Objective

We examined the effects of learning curve on clinical outcomes and operative time in minimally invasive coronary artery bypass grafting (MICS CABG).

Methods

We studied 210 consecutive MICS CABG cases performed by the same surgeon, composed of 3 cardiopulmonary bypass (CPB)–assisted single-vessel small thoracotomy (SVST), 87 off-pump SVST, 51 CPB-assisted multivessel small thoracotomy (MVST), and 69 off-pump MVST. For each MICS CABG technique, the frequency of early clinical events (mortality, reopening, stroke, myocardial infarction, and revascularization) was compared between the first 25 cases and the remainder. Logarithmic curve regression analysis and a cumulative summation technique were performed to assess the correlation between operative time and the performed number of each technique.

Results

There was no mortality, and there were 10 conversions to standard sternotomy, all of which were intended as off-pump MVST ( P < 0.001, vs other procedures). Experience was otherwise not associated with perioperative outcome. However, experience numbers correlated with operative time in off-pump SVST and off-pump MVST (122 ± 30 minutes, R2 = 0.18, P < 0.001, and 241 ± 80 minutes, R2 = 0.38, P < 0.001, respectively) but not in CPB-assisted MVST (258 ± 44 minutes, R2 = 0.004, P = 0.7). No complications occurred as a result of CPB assistance.

Conclusions

Minimally invasive coronary artery bypass grafting can be safely initiated, with a very low perioperative risk. Pump assistance is a good strategy to alleviate some of the learning curve and avoid conversions to sternotomy when initiating a multivessel MICS CABG program. 2009:83–94.

Elevated preoperative neutrophil/lymphocyte ratio as a predictor of increased long-term survival in minimal invasive coronary artery bypass surgery compared to sternotomy

Background

Neutrophil lymphocyte ratio (NLR) is a predictor of major adverse cardiovascular outcomes. Our study explores the value of NLR in predicting long-term mortality after minimally invasive coronary artery bypass surgery (MICS) via lateral left-thoracotomy versus conventional sternotomy coronary artery bypass grafting (CABG) surgery.

Methods

A total of 1126 consecutive patients (729 sternotomy CABG and 397 MICS) from a single tertiary center between 2005 and 2008 were followed until 2011. We stratified the patients into equal tertiles according to preoperative NLR. The primary outcome, all-cause mortality, was compared among the NLR tertiles.

Results

Out of the 1126 patients included in the study, 1030 (91%) patients underwent off-pump CABG . The first (NLR <2.3) tertile had a significantly lower 5-year mortality (30/371 =8%) in comparison to the second (NLR =2.3-3.4) and third (NLR ≥3.5) tertiles (49/375 =13% and 75/380 =20%), respectively with p < 0.0001. After multivariate adjustment, NLR was a significant independent predictor of mortality (hazard ratio [HR] per each unit increase of NLR was 1.05, 95% confidence interval [CI] 1.01-1.10, p = 0.008). MICS and sternotomy CABG groups with NLR <3 had similar mortality (21/221 =9.5% and 40/403 =9.9%), p = 1. However among patients with NLR ≥3, MICS had a significantly lower mortality (23/176 = 13.1%) compared to the sternotomy CABG (70/326 =21.5%), p = 0.02. According to the multivariate analysis of patients with NLR ≥3, MICS had a significantly lower mortality compared to sternotomy CABG (HR = 0.44, 95% CI 0.24-0.78, p = 0.005).

Conclusion

Elevated preoperative NLR is an independent predictor of long-term mortality after CABG. Among the patients with NLR ≥ 3, MICS was associated with a significantly improved survival compared with sternotomy CABG.

Five hundred cases of robotic totally endoscopic coronary artery bypass grafting: predictors of success and safety

BACKGROUND

Robotic technology has enabled totally endoscopic coronary artery bypass (TECAB) grafting. Little information is available on factors associated with successful and safe performance of TECAB. We report a 10-year multicenter experience with 500 cases, elucidating on predictors of success and safety in TECAB procedures.

METHODS

Between 2001 and 2011, 500 patients (364 [73%] men; 136 [27%] women; median age [minimum-maximum] 60 years [31-90 years], median EuroSCORE 2 [0-13]), underwent TECAB. Single, double, triple, and quadruple TECAB was performed in 334, 150, 15, and 1 patient, respectively. Univariate analysis and binary regression models were used to identify predictors of success and safety. Success was defined as freedom from any adverse event and conversion procedure, safety was defined as freedom from major adverse cardiac and cerebral events, major vascular injury, and long-term ventilation.

RESULTS

Success and safety rates were 80% (400 cases) and 95% (474 cases), respectively. Intraoperative conversions to larger thoracic incisions were required in 49 (10%) patients. The median operative time was 305 minutes (112-1,050 minutes), and the mean lengths of stay in the intensive unit (ICU) and in hospital were 23 hours (11-1,048 hours) and 6 days (2-4 days), respectively. Independent predictors of success were single-vessel TECAB (p = 0.004), arrested-heart (AH)-TECAB (p = 0.027), non-learning curve case (p = 0.049), and transthoracic assistance (p = 0.035). The only independent predictor of safety was EuroSCORE (p = 0.002).

CONCLUSIONS

Single-vessel and multivessel TECAB procedures can be safely performed with good reproducible results. Predictors of success include procedure simplicity and non-learning curve cases, whereas predictors of safety are mainly associated with patient selection.

Minimally invasive cardiac surgery-coronary artery bypass graft

Coronary artery bypass graft (CABG) is among the most common operations performed in the world. Different surgical strategies can be used with different invasiveness. This paper describes a recent development of the technique that merges the advantages resulting from both the adoption of an 'off-pump no-touch aorta operation' and a 'complete arterial revascularization through a left minithoracotomy' in a single procedure. This operation is currently known with the acronym MICS (minimally invasive cardiac surgery)-CABG (minimally invasive cardiac surgery). It is an off-pump operation performed through a minithoracotomy in the fourth or fifth left intercostal space across the midclavicular line. The left internal thoracic artery (LITA) is harvested under direct vision using a special rib-retractor with multiple interchangeable thoracotomy blades, including blades to use with lift systems for proximal artery harvesting, while the right radial artery (RA) is harvested endoscopically. A Y-connection is made between the two arteries. The LITA is used to bypass the left anterior descending coronary artery, while the right RA is used on the obtuse marginal branches and/or the posterior descending coronary artery. A special coronary stabilizer and a heart positioner with a shaft for remote thoracic insertion are needed.

[Continuous paravertebral analgesia versus intravenous analgesia in minimally invasive cardiac surgery by mini-thoracotomy]

OBJECTIVES

Minimal access cardiac surgery via minithoracotomy aims faster recovery and shorter hospital length of stay. Pain control is essential in order to achieve this goal. A study was conducted to assess the quality of post-operative analgesia and complications related to the analgesia techniques after cardiac surgery by minithoracotomy.

MATERIAL AND METHODS

A descriptive, observational and retrospective study was conducted on the patients subjected to minimal access cardiac surgery in our centre between the years 2009 to 2011. The patients were divided into two groups according to the type of analgesia received: analgesia through a paravertebral catheter, with an infusion of local anaesthetics (PVB group), and intravenous analgesia with opioids (IOA group). The aim of the study was to compare the analgesic quality and the complications associated to the analgesic technique, extubation time, post-surgical complications, and length of hospital stay between both techniques.

RESULTS

A total of 37 patients underwent to a modified minimally invasive Heart-Port access cardiac surgery. Fifteen patients received analgesia through a paravertebral block and the other 22 IV analgesia with opioids. Data are shown as means and standard deviation (SD). Mean tracheal extubation time less than 4 hours was observed in 60% of the patients in the PVB group, compared to 22% in the IOA group (P<.05). Length of stay in ICU for the PVB group was 1.2 (0.7) days compared to 2.2 (0.7) days in the IOA group (P<.05). Mean hospital stay was 4.8 (1.2) days for the PVB group, and 5.6 (2.8) for the IOA group (P>.05. No complications associated to the continuous paravertebral block were observed.

DISCUSSION

PVB analgesia is an acceptable safe technique in cardiac surgery via thoracotomy which enables early extubation with optimal pain control when compared with IV analgesia with opioids.

Coronary artery bypass surgery

Coronary artery bypass surgery has taken many strides to become the effective intervention it is today. Although it has been the gold standard for cardiac revascularization for a number of years, the future of health care and technology will cause this standard to be morphed into a kinder, gentler approach that leads to even better quality outcomes and quality of life than is now expected. Research has been and will continue to be a focus in cardiovascular medicine and will only help further validate or dispute what is best for patients while challenging surgeons to become even more knowledgeable and skilled in the various treatment modalities. In addition, the emergence of super ORs will continue to blossom and create a highly technologically advanced environment that will limit the need for guesswork and gut feelings that many have practiced on for decades. The face of cardiac surgery will continue to change and we, as nurses, will be there to meet the challenge along the way.

Angiographic evaluation of flow distribution in sequential and composite arterial grafts for three vessel disease

OBJECTIVES

We sought to delineate the effects of the severity of target lesions and their combinations on the occurrence of competitive flow, especially in the composite Y-graft and to establish an optimal strategy for graft arrangement and patient selection.

METHODS

We reviewed early and late angiograms of 2514 bypass grafts in 601 patients, who underwent off-pump coronary revascularization to three-vessel vascular regions using the internal thoracic artery (ITA) and radial artery (RA) without aortic manipulation. As a standard technique, the left anterior descending artery (LAD) was bypassed with the in situ ITA, and the left circumflex and right coronary arteries (RCA) were bypassed with the composite RA. Bypass flow was graded as antegrade, competitive or no flow.

RESULTS

The early patency rate was 98.1% (2466/2514), while competitive flow was detected in 6.4% (162/2514). For the LAD, the individual and sequential in situ ITA provided lower incidence of competitive flow than the composite graft (0.3% (1/298) versus 7.6% (23/303), P < 0.0001). Regarding the RA to non-LAD bypass, 86.3% (113/131) of competitive flow occurred at the distal end of the I- or Y-graft, and the cumulative patency rate was significantly lower than that of sequential proximal anastomosis (80.1 versus 56.6% at 5 years, P < 0.0001). The number of sequential anastomoses did not affect the cumulative patency rate (P = 0.09). For the composite Y-graft to three-vessel regions, the rate of antegrade flow in patients with 76-100% stenosis in both the LAD and the RCA was 95.7% (178/186), which was significantly higher than that of 78.1% (100/128) in patients with 76-100% stenosis in the LAD and 51-75% stenosis in RCA (P < 0.0001).

CONCLUSIONS

Sequential and composite grafting was considered reliable, exclusively in appropriately selected situations. To secure entire patency of the Y-graft to three-vessel regions, balanced bypass flow toward LAD and RCA would be crucial.

Hybrid coronary revascularization: a review

The long-term benefits of a left internal mammary artery bypass graft compared to the left anterior descending artery have been well described. The use of drug-eluting stents has minimized the morbidity of revascularization. Hybrid coronary revascularization is the planned use of minimally invasive surgical techniques for left internal mammary artery-left anterior descending artery grafting and the use of percutaneous coronary intervention for nonleft anterior descending coronary artery target revascularization. The optimal timing and order of revascularization in hybrid coronary revascularization remains unclear.