Minimally Invasive vs Open Coronary Surgery: A Multi-Institutional Analysis of Cost and Outcomes

Comparison of clinical effects of coronary artery bypass grafting between left anterior small thoracotomy approach and lower-end sternal splitting approach

OBJECTIVE

To compare the clinical effects of coronary artery bypass grafting (CABG) between the left anterior small thoracotomy (LAST) and lower-end sternal splitting (LESS) approaches for coronary artery disease.

METHODS

In total, 110 patients who underwent LAST from October 2015 to December 2020 in Tianjin Chest Hospital were selected as the observation group. Patients who underwent the LESS approach during the same period were analyzed. The propensity score was calculated by a logistic regression model, and nearest-neighbor matching was used for 1:1 matching.

RESULTS

The length of hospital stay and ventilator support time were significantly shorter in the LAST than LESS group. The target vessels in the obtuse marginal branch and posterior left ventricular artery branch grafts were significantly more numerous in the LAST than LESS group, but those in the right coronary artery graft were significantly less numerous in the LAST group.

CONCLUSIONS

CABG using either the LAST or LESS approach is safe and effective, especially in low-risk patients. The LAST approach can achieve complete revascularization for multivessel lesions and has the advantages of less trauma and an aesthetic outcome. However, it requires a certain learning curve to master the surgical techniques and has specific surgical indications.

2024 Heart Disease and Stroke Statistics: A Report of US and Global Data From the American Heart Association

BACKGROUND

The American Heart Association (AHA), in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, nutrition, sleep, and obesity) and health factors (cholesterol, blood pressure, glucose control, and metabolic syndrome) that contribute to cardiovascular health. The AHA Heart Disease and Stroke Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, brain health, complications of pregnancy, kidney disease, congenital heart disease, rhythm disorders, sudden cardiac arrest, subclinical atherosclerosis, coronary heart disease, cardiomyopathy, heart failure, valvular disease, venous thromboembolism, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The AHA, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States and globally to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2024 AHA Statistical Update is the product of a full year's worth of effort in 2023 by dedicated volunteer clinicians and scientists, committed government professionals, and AHA staff members. The AHA strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional global data, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Evaluation of the effect of simultaneous hybrid coronary revascularization on postoperative bleeding and renal function: A comparison study with minimally invasive direct off-pump coronary artery bypass grafting in patients with multivessel coronary artery disease

OBJECTIVES

The present study sought to compare postoperative bleeding and renal function in patients with multivessel coronary artery disease undergoing simultaneous hybrid coronary revascularization (HCR) and minimally invasive direct off-pump coronary artery bypass grafting (MIDCABG).

METHODS

The study retrospectively collected the data of 594 consecutive patients who underwent simultaneous HCR and 351 patients who underwent MIDCABG with planned staged HCR (MIDCABG first, then elective percutaneous coronary intervention) in Fuwai Hospital from June 2007 to December 2020. A total of 317 pairs of patients who were matched in a 1:1 ratio with propensity score matching were enrolled in this study. Bleeding and changes in renal function were compared between the 2 groups.

RESULTS

Compared with patients who underwent MIDCABG, patients who underwent simultaneous HCR had significantly greater chest tube drainage on the day of the operation (492.7 ± 282.4 mL vs 441.0 ± 261.9 mL; P = .023), but no significant difference was detected in the total amount during the postoperative period (788.8 ± 458.9 mL vs 753.3 ± 409.8 mL; P = .74). The differences in re-exploration for bleeding (0.3% vs 1.6%; P = .13), blood transfusion (18.9% vs 16.4%; P = .13), acute kidney injury (23.3% vs 18.6%; P = .53), and in-hospital major adverse cardiovascular and cerebrovascular events (including all-cause death, myocardial infarction, stroke, and repeated revascularization) (2.5% vs 1.9%; P = .67) between the 2 groups did not reach statistical significance.

CONCLUSIONS

Compared with MIDCABG, simultaneous HCR (MIDCABG first, instant percutaneous coronary intervention) did not increase postoperative bleeding or the incidence of acute kidney injury.

Comparing perioperative outcomes following off-pump multi-vessel minimally invasive via a single left intercostal space incision with median sternotomy coronary artery bypass grafting: A single-center retrospective cohort study

BACKGROUND

The perioperative outcomes following off-pump multi-vessel minimally invasive surgery (MICS) coronary artery bypass grafting (CABG) via a single left intercostal space incision has not been well evaluated.

METHOD

From July 2019 to January 2022, a total of 444 patients with multi-vessel coronary artery disease (CAD) were enrolled and divided into MICS (n = 179) and sternotomy CABG (n = 265). Perioperative outcomes were compared between these two groups, including intraoperative blood loss, postoperative first 24 h drainage, ventilation duration, length of stay (LOS) in ICU and total LOS in hospital. Intraoperative blood flow of graft vessels were measured by transit-time flow measurement after vascular anastomosis and mean flow (MF) and pulsatile index (PI) were compared.

RESULTS

There were no significant differences in preoperative profiles between these two groups except younger and lower proportion of female in MICS. No significant difference in the number of graft vessels was observed between MICS (3.18 ± 0.74) and sternotomy CABG (3.28 ± 0.86). Compared to sternotomy CABG, patients with MICS showed longer operation duration [(4.33 ± 0.86) h versus (5.10 ± 1.09) h], fewer intraoperative blood loss [700 (600, 900) mL versus 500 (200, 700) mL], fewer postoperative first 24 h drainage [400 (250, 500) mL versus 300 (200, 400) mL], shorter postoperative ventilation duration [16.5 (12.5, 19.0) h versus 15.0 (12.0, 17.0) h], LOS in ICU [20.0 (16.0, 23.0) h versus 18.0 (15.0, 20.0) h] and total LOS in hospital [(14.5 ± 3.9) d versus (12.6 ± 2.7) d] (all p < .001). MI and PI of graft vessels were similar and no significant differences in major perioperative complications and mortality were observed between MICS and sternotomy CABG (all p > .05).

CONCLUSION

Off-pump multi-vessel MICS may be an alternative treatment for patients with multi-vessel CAD with better perioperative outcomes than sternotomy CABG.

Heart Disease and Stroke Statistics-2023 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Epidemiology and Prevention Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update with review of published literature through the year before writing. The 2023 Statistical Update is the product of a full year's worth of effort in 2022 by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. The American Heart Association strives to further understand and help heal health problems inflicted by structural racism, a public health crisis that can significantly damage physical and mental health and perpetuate disparities in access to health care, education, income, housing, and several other factors vital to healthy lives. This year's edition includes additional COVID-19 (coronavirus disease 2019) publications, as well as data on the monitoring and benefits of cardiovascular health in the population, with an enhanced focus on health equity across several key domains.

RESULTS

Each of the chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policymakers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

Prognostic significance of postoperative loss of skeletal muscle mass in patients underwent coronary artery bypass grafting

Background

Increasing life expectancy of coronary artery bypass grafting (CABG) remains to be the major concern of cardiac surgeons. However, few studies have investigated the effect of postoperative skeletal muscle index (SMI) loss on prognosis. This study aims to evaluate the prognostic role of postoperative SMI loss ≥ 5% after CABG, in order to develop a novel nomogram to predict overall survival (OS).

Methods

Patients underwent CABG via midline sternotomy from December 2015 to March 2021 were recruited in this study. Preoperative and postoperative 3 months chest computed tomography (CT) images were compared to assess changes in SMI at T12 level. Based on this, patients were classified into the presence or absence of SMI loss ≥ 5%. The association between postoperative SMI loss ≥ 5% and OS was then analyzed by the Kaplan-Meier curves and Cox model. A novel nomogram incorporating independent clinical prognostic variables was also developed.

Results

The study enrolled 506 patients receiving CABG, of whom 98 patients experienced T12 SMI loss ≥ 5% and had a significantly worse OS (P < 0.0001). Multivariate regression analysis showed that T12 SMI per cent change (%T12 SMI-change) was an independent prognostic factor for OS (HR = 0.809, 95% CI = 0.749–0.874). The nomogram incorporating %T12 SMI-change with other variables was accurate for predicting OS. Besides, we also found that postoperative oral nutritional supplement (ONS) can rescue T12 SMI loss.

Conclusion

Postoperative SMI loss can predict survival outcome after CABG. The nomogram incorporating changes in SMI provides a superior performance than existing systems.

Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump

OBJECTIVE

To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay.

DESIGN

A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence.

METHODS

Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions.

CONCLUSIONS

Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.

Less invasive multivessel coronary artery bypass grafting: now is the time

PURPOSE OF REVIEW

Less invasive multivessel coronary artery bypass grafting techniques have seen a progressive evolution over the last two decades. In their current state, they are easily reproduced and applicable to most patients requiring multivessel revascularization. The purpose of this review is to highlight their importance among a spectrum of evolving therapies and the accruing evidence in their favour.

RECENT FINDINGS

The first large dual center experience with minimally invasive coronary artery bypass grafting (MICS CABG) demonstrated the feasibility of performing multivessel surgical revascularization without the need for sternotomy or cardiopulmonary bypass. Subsequent angiographic studies to assess graft patency showed excellent early results. Studies comparing MICS CABG to conventional CABG demonstrate faster recovery while reducing hospitalization and cost.

SUMMARY

Multivessel less invasive coronary artery bypass grafting is basically limited to two procedures, MICS CABG and robotically assisted totally endoscopic CABG (TECAB). MICS CABG has evolved as a procedure that preserves the safety and efficacy of conventional CABG while avoiding the associated morbidity. It is reproducible, versatile and holds promise as the procedure of choice for multivessel coronary revascularization in the future. TECAB is likely the pinnacle of minimally invasive coronary surgery, the growth of which is hindered by widespread acceptance and industry involvement.