Comparison of standard coronary artery bypass grafting and minimary invasive direct coronary artery bypass grafting. Early and mid-term result

Short-term clinical outcomes and long-term survival of minimally invasive direct coronary artery bypass grafting

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.

Review of a 13-year single-center experience with minimally invasive direct coronary artery bypass as the primary surgical treatment of coronary artery disease

BACKGROUND AND AIM OF THE STUDY

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Seven-Year Follow-up After Minimally Invasive Direct Coronary Artery Bypass: Experience With More Than 1300 Patients

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Magnetic vascular coupling for distal anastomosis in coronary artery bypass grafting: a multicenter trial

OBJECTIVE

The hand-sewn anastomosis is the "gold standard" for performing coronary artery bypass grafts. However, performing a hand-sewn anastomosis is more demanding and time-consuming when used in less invasive approaches such as small access, totally endoscopic or beating heart surgery. In conjunction with attempts to reduce the surgical trauma of coronary artery bypass grafts by using these less invasive approaches, alternative methods for constructing distal anastomoses should be explored. These data report on predischarge angiographic findings and 30-day clinical follow up of patients who have received a new distal anastomotic device.

METHODS

In a multicenter trial, 32 patients (mean age: 65 +/- 9 years; 85% men) requiring multivessel coronary artery bypass surgery had 1 of the anastomoses performed using a novel anastomotic technology. The Magnetic Vascular Positioner System was used in 1 of the bypass grafts and the other bypasses were completed by conventional hand-sewn technique. The Magnetic Vascular Positioner System consists of 4 magnetic, gold-plated implants and 2 delivery devices that facilitate the creation of a functional end-to-side anastomosis. A predischarge angiogram was performed to evaluate graft patency.

RESULTS

There were no device-related major adverse events. The application of the Magnetic Vascular Positioner device was successful in 32 of 41 cases (78%). Nine patients were intended for treatment but did not receive the Magnetic Vascular Positioner System. In 5 of the cases the coronary artery was too small; 1 case had a posterior wall plaque in the target artery; and 3 patients had a nonhemostatic anastomosis after coupling of the port and were subsequently converted to hand-sewn anastomoses. The median total Magnetic Vascular Positioner anastomotic time was 137 seconds with a range from 65 to 370 seconds. Overall patency rate of the Magnetic Vascular Positioner anastomosis was 93.5% versus 91.7% (P = not significant) in hand-sewn grafts. One patient (3.1%) died due to low cardiac output but had patent grafts at autopsy. One myocardial infarction (3.1%) occurred the day after a percutaneous transluminal coronary angioplasty of a hand-sewn graft. One prolonged mechanical ventilation (3.1%) was required because of pneumonia and adult respiratory distress syndrome.

CONCLUSIONS

Magnetic vascular coupling in coronary surgery is safe and effective and has acceptable early patency rates. This new technique may facilitate beating heart and minimally invasive coronary artery bypass grafts.