Minimally invasive direct coronary artery bypass grafting: midterm results and quality of life

Mid-Term Results of Minimally Invasive Direct Coronary Artery Bypass Grafting

Background

Minimally invasive direct coronary artery bypass grafting (MIDCAB) has the advantage of allowing arterial grafting on the left anterior descending artery without a sternotomy incision. We present our single-center clinical experience of 66 consecutive patients.

Methods

All patients underwent MIDCAB through a left anterior small thoracotomy between August 2007 and July 2015. Preoperative, intraoperative, postoperative and follow-up data—including major adverse cardiovascular and cerebrovascular events (MACCE), graft patency, and the need for re-intervention—were collected.

Results

The mean age of the patients was 69.4±11.1 years and 73% were male. There was no conversion to an on-pump procedure or a sternotomy incision. The 30-day mortality rate was 1.5%. There were no cases of stroke, although 2 patients had to be re-explored for bleeding, and 81.8% were extubated in the operating room or on the day of surgery. The median stay in the intensive care unit and in the hospital were 1.5 and 9.6 days, respectively. The median follow-up period was 11 months, with a 5-year overall survival rate of 85.3%±0.09% and a 5-year MACCE-free survival rate of 72.8%±0.1%. Of the 66 patients, 32 patients with 36 grafts underwent a postoperative graft patency study with computed tomography angiography or coronary angiography, and 88.9% of the grafts were patent at 9.7±10.8 months postoperatively.

Conclusion

MIDCAB is a safe procedure with low postoperative morbidity and mortality and favorable mid-term MACCE-free survival.

Comparison of early and late quality of life between left anterior thoracotomy and median sternotomy off-pump coronary artery bypass surgery

OBJECTIVE

Minimally invasive coronary artery bypass surgery performed through a left thoracotomy has potential benefits over conventional sternotomy, including reduced surgical trauma, faster recovery and potential improvement in quality of life. This study is a prospective assessment of quality of life in patients undergoing off-pump coronary bypass by median sternotomy and left anterior thoracotomy.

METHODS

Quality of life was assessed by the EuroQoL questionnaire, with additional questions on dyspnoea, angina, wound pain and scar aesthetics. Outcomes were compared across the data sets at pre-operation, three weeks and three months post-operation.

RESULTS

Sixty-six (17 minimally invasive and 49 off-pump) patients (mean age 65±12, 7 females and 59 males) were included. Significant differences in mean EuroQol outcomes were observed for activities, F(1,64) = 5.86, (p<0.05), pain scores, F(1,64) = 4.658 (p=0.035) and scar aesthetics, F(1,64) = 16.83 (p<0.05). There was an additional significant interaction, F(1.898, 121.49) = 3.282, (p<0.05), between time and group for activity levels; exploring this further indicated no significant difference at baseline, but significantly greater improvement observed in the minimally invasive group over time. At 3 weeks, 50% of minimally invasive patients compared to 82% of sternotomy patients (p<0.001) required oral analgesia. At 3 months, 8% of minimally invasive patients and 21% of sternotomy patients (p<0.001) required oral analgesia.

CONCLUSIONS

Off-pump coronary artery bypass performed with a minimally invasive approach through a left thoracotomy appears to result in earlier improvement in quality of life outcomes compared to conventional sternotomy. These results are important when counselling patients regarding the benefits and difference between a left anterior thoractomy MIDCABG and conventional OPCAB and can be used as pilot data for a larger trial examining differences in the MIDCABG and conventional full sternotomy OPCAB procedures.

Multivessel Total Arterial Revascularization via Left Thoracotomy

Off-pump coronary artery bypass grafting is now becoming the preferred method of coronary revascularization. The trend is towards complete revascularization, preferably arterial. We are describing here a method of multivessel, total arterial, complete revascularization via an anterolateral thoracotomy approach in 27 patients. There was an average of 3.2 grafts/patient. Angiograms were performed in 9 patients (33.33 %). There were no operative mortalities. None of the patients required conversion to cardiopulmonary bypass or midsternotomy.

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.

Robotically assisted atraumatic coronary artery bypass: a feasible option for off-pump coronary surgery

This retrospective study of the largest single center experience (100 patients) with off-pump robotically assisted coronary procedures in the United Kingdom (April 2002-June 2008) aimed to rationalize patient selection, describe the technique, and determine the learning curve, technical feasibility and operative outcome of robotically assisted Atraumatic Coronary Artery Bypass (ACAB). Selected patients underwent either a robotic Totally Endoscopic Coronary Artery Bypass (12) or robotically assisted ACAB (88) using a standard Da Vinci robot with three arms. A fifth of all cases had percutaneous interventions as part of a hybrid strategy. The majority of patients were overweight men. After one hundred robotic coronary procedures, this operation is now performed as part of a routine theatre list. The mean operative and total procedure times for robotically assisted atraumatic procedures were 157 and 238 min, respectively. These measurements were significantly less in the atraumatic than the totally endoscopic group with a 34.3 and 20.6% reduction, respectively (P < 0.001; equal variance not assumed). The procedural learning curve was short and independent from internal thoracic artery harvesting. We have proven conclusively that robotically assisted ACAB is feasible, more so than the totally endoscopic procedure in this particular setting. Even in the absence of an ideal stabilizer device, this procedure causes minimal disruption to the daily operating room schedule. We have also proven that body mass index is a weak predictor of the ease of robotic internal thoracic artery harvesting and should not affect patient selection.

Coronary artery bypass grafting without full sternotomy

Coronary artery bypass grafting is performed without full sternotomy in selected patients because it is less invasive. Left internal thoracic artery-left anterior descending artery bypass (LITA-LAD bypass) via a small left anterior thoracotomy is a well established procedure, which achieves good graft patency with low mortality and morbidity rates. Multiple revascularization is possible with a limited lateral thoracotomy or L-figure approach. Axillary-coronary bypass and right gastroepiploic artery-right coronary artery bypass (RGEA-RCA bypass) are alternative methods, especially for redo surgery, in selected patients.

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.

Assessment of Health-Related Quality of Life after Coronary Revascularization

The use of patient-oriented outcomes, in particular health-related quality if life (HRQOL), to evaluate coronary revascularization is continuously increasing. Current data underline that patients undergoing conventional CABG show a tremendous improvement of HRQOL status as early as 3 months postoperatively. There seems to be no clear benefit concerning HRQOL for off-pump coronary surgery versus conventional CABG. The benefits of minimal invasive CABG via mini-thoracotomy are compromised by increased incidence of pain during the immediate postoperative period. Totally endoscopic approaches seem to be more effective with regard to pain reduction and resume of every day activities. Compared to catheter-based interventions there is evidence that conventional CABG offers significant advantages over PCI. The influence of drug-eluting stents and newer surgical techniques on HRQOL remains to be determined. Inclusion of HRQOL data in CABG and PCI databases can play a central role in order to identify patient groups who benefit the most from each revascularization strategy.

Pulmonary function tests in preoperative pulmonary evaluation

Pulmonary function testing (PFT) is used extensively by pulmonary specialists to address two common clinical questions: (1) What is the risk of a postoperative pulmonary complication in an individual with lung disease? and (2) Will the patient be able to tolerate lung resection surgery? Today, there are numerous tests available to measure pulmonary function; making judicious use of these tests essential. In this article, the authors describe significant postoperative pulmonary complications, and discuss the surgical and patient factors contributing to the risk of these complications. They provide an evidence-based approach using pulmonary function data to determine an individual patient's risk for pulmonary complications associated with three types of surgical procedures-upper abdominal, cardiac, and lung resection-and discuss recommendations for risk education.