Effectiveness of MIDCAB vs OPCAB in LAD revascularization procedures in octogenerians: Results from KROK Registry.

Minimally invasive coronary artery surgery: Robotic and nonrobotic minimally invasive direct coronary artery bypass techniques.

Off-pump coronary artery bypass surgery: To do or not to do? Current best available evidence

OPCAB surgery: time for a reappraisal?

Although it is not a new technique, minimally invasive direct coronary artery bypass (MIDCAB) is employed only by a few surgeons in the UK. We compared our experience with MIDCAB with that of single vessel off-pump coronary artery bypass (OPCAB) graft surgery through a standard median sternotomy. Patients who underwent either MIDCAB or OPCAB between April 2008 and July 2011 were reviewed. Exclusion criteria included patients with an ejection fraction of <0.5 or previous cardiac surgery. Data were obtained retrospectively from our prospective database, medical records and through general practitioners. Overall, 74 patients were analysed in the MIDCAB group and 78 in the OPCAB group. Their demographics and EuroSCORE (European System for Cardiac Operative Risk Evaluation) values were comparable (p>0.05). There was no statistically significant difference in the two groups in terms of mortality, recurrent myocardial infarction, postoperative stroke, wound infection, atrial fibrillation or need for reintervention. The MIDCAB group had six conversions to a sternotomy. Eight patients in each group required blood transfusion, with the average transfusion being 1.8 units in the MIDCAB group and 3.2 units in the OPCAB group. The mean duration of ventilation and intensive care unit stay was 5.0 hours and 38.4 hours in the MIDCAB group and 5.4 and 47.8 hours in the OPCAB group. The mean hospital stay was significantly reduced in the MIDCAB population (6.1 vs 8.5 days, p<0.05). MIDCAB can be performed safely in appropriately selected patients with outcomes comparable with OPCAB. The potential benefits include shorter hospital stay, reduced need for blood transfusion and faster recovery.

MIDCAB vs Conventional Surgery

MIDCAB versus off-pump CABG: Comparative study

Off-pump coronary artery bypass grafting: For the many or the few?

The purpose of the study was to evaluate the best surgical approach in off-pump single vessel revascularization of the left anterior descending coronary artery (LAD). In 256 patients a single left internal mammary artery (LIMA) to LAD bypass was performed with beating heart techniques through a left anterior minithoracotomy (minimally invasive direct coronary artery bypass (MIDCAB), n=129) or a full sternotomy (off-pump coronary artery bypass (OPCAB), n=127). In the OPCAB group, significantly more severe comorbidities (P=0.001) and redo-operations were noted (P<0.001). Conversion to sternotomy or CPB was necessary in five MIDCAB patients and one OPCAB patient. No cerebrovascular accident was seen in both groups. There was no hospital death in MIDCAB- and two deaths in OPCAB procedures (P=ns). There was a significant reduction in time of surgery (P=0.028) and coronary occlusion (P=0.009) in the OPCAB group. No differences in postoperative ventilation time, ICU stay and length of hospital stay were recorded between groups. Wound infections occurred in six MIDCAB patients (4.7%) and one OPCAB patient (0.8%). Early postoperative reoperation due to graft failure was necessary in three patients after MIDCAB and two patients after OPCAB (P=ns). Confirmed by angiography, the early graft patency rate was 96 and 98%, respectively (P=ns). Both beating heart techniques showed good results with low hospital mortality, low early complications and comparable angiographic results. Nevertheless, MIDCAB is a challenging technique as demonstrated by the longer times of surgery and coronary occlusion with a tendency towards a higher risk of conversion and wound infection. Thus, this technique should only be performed in selected patients with favourable coronary anatomy. Through a sternotomy approach, single vessel revascularization can be performed safely off-pump even in high-risk patients.

“To exist is to change, to change is to mature, to mature is to go on creating oneself endlessly.” Henri Bergson In a recent editorial, Bonchek and Ullyot1 raised concerns regarding minimally invasive coronary bypass surgery. Their purpose was to “stimulate discussion and debate,” and to that end, we wish to challenge several of their assertions. While we totally agree that unbridled enthusiasm with a blind eye toward critical analysis is dangerous, equally precarious is taking the stance that we have a perfect operation that cannot or should not be made better. We believe that we are at a strategic inflection point in cardiac surgery and are in danger of becoming obsolete. In the history of information systems, the typewriter made a valuable contribution; however, it subsequently was made obsolete by computers. Although there is no question that coronary artery bypass surgery has changed the management of coronary artery disease dramatically, we need to realize that we are in the field of coronary revascularization and not just coronary artery surgery. Incremental progress, carefully measured, documented, and reported, should be encouraged rather than always accepting the status quo. The authors begin by limiting the obvious successes of minimally invasive surgery to technically simple operations that require “a minimum of precision and almost no sewing.” Our colleagues in general surgery would most likely disagree that their successes in laparoscopic Nissen procedures and inguinal hernia repairs were not precise and did not requiring sewing. Although cardiac operations are technically more complex, this does not mean that we should ignore the principles, techniques, and enabling technology developed from technically simpler operations and extend them to more complex procedures. Is this not the nature of evolution? The authors relate their own experience of isolated internal mammary artery (IMA)–to–left anterior descending coronary artery (LAD) grafting …

In 1998, most cardiac surgical practices used cardiopulmonary bypass (CPB) and cardioplegic arrest as techniques to perform coronary artery bypass grafting (CABG) (1). More than 25% of patients undergoing CABG have ≥1 complications (e.g., atrial fibrillation, bleeding, myocardial infarction, sternal infection, stroke, or renal failure). Although some of the morbidity of CABG is directly related to patient comorbidity factors, some of these complications are due to the current technique of CABG. The goal of minimally invasive CABG is to avoid the morbid complications of standard CPB-supported CABG. The 2 most common techniques of minimally invasive CABG are minimally invasive direct coronary artery bypass (MIDCAB) and offpump coronary artery bypass (OPCAB). For example, the median sternotomy incision is avoided in techniques that gain access to the heart via a left anterior thoracotomy (MIDCAB, Port-Access). CPB is avoided in techniques that perform coronary bypasses on a beating heart (OPCAB). In MIDCAB, both the sternotomy and CPB are avoided. One of the very first attempts at using the left internal thoracic artery (LITA) to revascularize the left anterior descending coronary artery (LAD) was done in a minimally invasive fashion, avoiding CPB. Professor Vasili I. Kolessov, in his pioneering 1967 work in LITA-to-LAD anastomosis, reported on an experimental study of 14 dogs with autopsy confirmation of patency at an intermediate-term (19 months) follow-up (2). In addition, he reported on 6 human patients. The surgery was conducted through a left anterior thoracotomy in the fifth intercostal space with LITA harvesting. Ischemic preconditioning for 6 to 8 minutes was afforded by coronary occlusion of the LAD using a snare. Anastomosis on a beating heart was performed with an interrupted silk suture technique, with or without a Vineberglike intramyocardial tunnel technique. Among the human patients, Kolessov reported 4 excellent results, the return of angina in 1 patient after 1 year, and 1 perioperative death. In this paper, I will examine the controversies related to the use of different techniques, present some pertinent data about them, perform Bayesian analysis comparing minimally invasive CABG and CABG-CPB, and review some comparative trials with the goal of clarifying the best uses of each technique.

Emergence of a new direction in our specialty: catheter-assisted cardiac surgery

Benefits of OPCAB are not for everybody. Costs are.

534 Robotically assisted MIDCAB surgery may have similarly favourable outcomes in high risk and low risk patients

Off-pump coronary artery bypass sacrifices graft patency: Meta-analysis of randomized trials

Objective Off-pump coronary artery bypass (OPCAB),minimally invasive direct coronary artery bypass (MIDCAB) and robotic-assisted coronary artery bypass (RA-CAB) are all used to treat isolated left anterior descending artery (LAD) disease.The aim of this study is to compare the early outcomes after these three procedures.Methods From February 2009 to May 2012,102 consecutive patients underwent revascularization of LAD.31 patients were treated by OPCAB,45 by MIDCAB and 26 by RA-CAB.Patients received sternotomy in the OPCAB procedures.The MIDCAB procedures were performed through a 10-cm anterolateral muscle-sparing minithoracotomy.In the RA-CAB procedures,left internal mammary arteries (LIMA) were harvested with the aid of da Vinci surgical system and sewing of the anastomoses was performed under direct vision by a 3-cm anterolateral minithoracotomy.Results No significant difference was observed in graft flow,pulse index,renal failure,reoperation for hleeding,new onset of arterial fibrillation and deep wound infection between these three groups.There was also no significant difference in peri-operative mortality,major adverse cerebro-cardiovascular events (MACCE) between these three groups.Compared with OPCAB,MIDCAB and RA-CAB significantly reduced the need of blood transfusion (4.4％ vs.32.3％,P＜ 0.05; 7.7％ vs.32.3％,P＜0.05).The patients receiving RA-CAB had shorter length of postoperative stay than whom receiving OPCAB[(8.8 ± 3.2) days vs.(12.4 ± 7.7) days,P ＜ 0.05)].There is no significant difference between the outcomes of MIDCAB and RA-CAB.Conclusion These findings indicated that MIDCAB and RA-CABwere feasible,effective and safe options for revascularization of isolated LAD disease.MIDCAB and RA-CAB showed the advantage of less invasive and faster recovery,compared with OPCAB.Therefore,MIDCAB and RA-CAB should be the routine treatment for patients with isolated LAD disease.In some advanced centers,RA-CAB will be the preferred method.The mid-and long-term outcomes of these three methods should be further investigated. Key words: Coronary arteriosclerosis; Coronary artery bypass, off-pump; Surgical pocedures, minimally invasive; Robotics