Enhanced Recovery and Reduced Complications with Minimally Invasive Coronary Artery Bypass Grafting Compared to Open Sternotomy.

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. 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. 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.

Minimally invasive coronary artery bypass grafting (MICS CABG) offers a new paradigm in coronary revascularization. This study aims to compare the outcomes of MICS CABG with those of conventional median sternotomy CABG (MS CABG) within a growing minimally invasive cardiac surgical program in Singapore. Propensity matching produced 111 patient pairs who underwent MICS CABG or MS CABG between January 2009 and February 2020 at the National University Heart Centre, Singapore. Minimally invasive direct coronary artery bypass surgery patients were matched to single- or double-graft MS CABG patients (Group 1). Multivessel MICS CABG patients were matched to MS CABG patients with equal number of grafts (Group 2). Overall, MICS CABG patients experienced shorter postoperative length of stay (P<0.071). In Group 2, procedural duration (P<0.001) was longer among MICS CABG patients, but it did not translate to adverse postoperative events. Postoperative outcomes, including 30-day mortality, reopening for bleeding, new onset atrial fibrillation as well as neurological, pulmonary, renal, and infectious complications were comparable between MICS and MS CABG groups. MICS CABG is a safe and effective approach for surgical revascularization of coronary artery disease and trends toward a reduction in hospital stay.

Backgroundconventional coronary artery bypass grafting (CCABG) tends to cause severe complications in patients with comorbid Coronary Artery Diseases (CAD) and diabetes. On the other hand, the Minimally Invasive Cardiac Surgery Coronary Artery Bypass Grafting (MICS CABG) via transthoracic incision is associated with rapid recovery and reduced complications. Adding to the limited literature, this study compares CCABG and MICS CABG in terms of efficacy and safety.MethodsHerein, 104 CCABG and MICS CABG cases (52 cases each) were included. The patients were recruited from the Minimally Invasive Cardiac Surgery Center, Anzhen Hospital, between January 2017 and December 2021 and were selected based on the Propensity Score Matching (PSM) model. The key outcomes included All-cause Death, Myocardial Infarction (MI), Cerebrovascular Events, revascularization, Adverse Wound Healing Events and one-year patency of the graft by coronary CTA.ResultsCompared to CCABG, MICS CABG had longer surgical durations [4.25 (1.50) h vs.4.00 (1.13) h, P = 0.028], but showed a reduced intraoperative blood loss [600.00 (400.00) mL vs.700.00 (300.00) mL, P = 0.032] and a lower secondary incision debridement and suturing rate (5.8% vs.19.2%, P = 0.038). In follow up, no statistically significant differences were found between the two groups in the cumulative Major Adverse Cardiovascular and Cerebrovascular Events (MACCEs) incidence (7.7% vs. 5.9%), all-cause mortality (0 vs. 0), MI incidence (1.9% vs. 2.0%), cerebral apoplexy incidence (5.8% vs. 3.9%), and repeated revascularization incidence (0 vs. 0) (P > 0.05). Additionally, coronary CTA results revealed that the two groups’ one-year graft patency (94.2% vs. 90.2%, P = 0.761) showed no statistically significant difference.ConclusionIn patients with comorbid CAD and diabetes, MICS CABG and CCABG had comparable revascularization performances. Moreover, MICS CABG can effectively reduce, if not prevent, poor clinical outcomes/complications, including incision healing, sternal infection and prolonged length of stay in diabetes patients.

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. 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. 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). 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.

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. 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. 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). 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.

We examined the effects of learning curve on clinical outcomes and operative time in minimally invasive coronary artery bypass grafting (MICS CABG). 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. 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, R = 0.18, P < 0.001, and 241 ± 80 minutes, R = 0.38, P < 0.001, respectively) but not in CPB-assisted MVST (258 ± 44 minutes, R = 0.004, P = 0.7). No complications occurred as a result of CPB assistance. 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.

The minimally invasive coronary artery bypass grafting (MICS CABG) operation performed via a small thoracotomy has not previously been examined in a direct comparison to sternotomy off-pump coronary artery bypass grafting (OPCAB). We matched, according to age, gender, left ventricular function, and median number of distal anastomoses, 150 patients who underwent MICS CABG via small left thoracotomy, and 150 patients who received sternotomy OPCAB. All operations were performed by the same surgeon. There was no perioperative mortality (0/300). In the MICS CABG group, pump assistance was used in 28/150 (19%) patients, and conversion to sternotomy occurred in 10/150 (6.7%) patients. In the OPCAB group, conversion to on-pump occurred in 3/150 (2.0%) patients. There were four (2.7%) reoperations for bleeding and one (0.7%) for anastomotic revision in each group. The median hospital length of stay was 5 days for MICS CABG (average 5.4), and 6 days for OPCAB (average 7.2) (P=0.02). New-onset atrial fibrillation occurred in 35 (23%) MICS CABG patients and in 42 (28%) OPCAB patients (P=0.3). No wound infection occurred with MICS CABG versus six (4.0%) with OPCAB (P=0.03). A self-limiting left pleural effusion developed in 22 (15%) MICS CABG patients and in six (4.0%) OPCAB patients (P=0.002). The median time to return to full physical activity was 12 days in MICS CABG patients versus >5 weeks in OPCAB patients (P<0.001). MICS CABG is a valuable alternative for patients in need of multivessel CABG. The operation appears at least as safe as OPCAB, and associated with shorter hospital length of stay, less wound infections, and faster postoperative recovery than OPCAB.

Minimally invasive coronary artery bypass grafting (MICS CABG) via a small left thoracotomy is a novel technique for coronary revascularization that is increasingly used around the world. However, multivessel MICS CABG is difficult, and concerns about repeat revascularization (RR) have been raised. This longitudinal study describes the rates of RR among patients who have undergone MICS CABG and identifies targets for improvement. A prospective observational study was performed on the 306 MICS CABG patients operated on by a single surgeon from 2005 to 2015. Minimally invasive coronary artery bypass grafting was performed through a small left thoracotomy, using the in situ left internal mammary artery, ± a radial artery, and 1 to 3 saphenous veins anastomosed proximally to the aorta. Patients were followed annually. We examined the difference between the first half and second half of the series to ascertain the effects of a learning curve. Eighty percent of the procedures were performed off-pump. The median number of grafts performed were 2, and the left anterior descending, diagonals, obtuse marginals, and posterior interventricular artery were the distal targets in 94%, 12%, 44%, and 26%, respectively. The graftability index (#grafts/#diseased vessels) was 0.93. Revascularization of targets smaller than 1.5 mm decreased from 69% to 50% (P = 0.002) between the series' first and second halves. Overall, RR was needed in 21 patients (6.9%) and was performed at a mean ± SD of 1.7 ± 1.6 years postoperatively. The culprit lesion was attributed to the index surgical procedure ("graft-associated") in 52%, to a stent stenosis or progression of native disease in 43%, and was unidentified in 5%. Patients with graft-associated RR had a lower graftability index at operation (0.73 vs 0.94) and more frequent involvement of the circumflex system (0.8 vs 0.3). The overall rate of RR at 3 years decreased from 11% in the first half to 2.6% in the second half (P = 0.001). The need for RR is part of the learning curve with MICS CABG, involves a graft in half of the cases, is more common in patients who had a lower graftability index at operation, and markedly improves with experience.

To explore the feasibility, safety and mid-term outcome of minimally invasive cardiac surgery coronary artery bypass grafting (MICS CABG) surgery. Data of patients who underwent MICS CABG between November 2015 and November 2017 in Peking University Third Hospital were retrospectively analyzed. Results were compared with the patients who underwent off-pump coronary aortic bypass grafting (OPCABG) surgery over the same period. The two groups were matched in propensity score matching method according to age, gender, left ventricular ejection fraction, body mass index, severity of coronary artery disease, smoking, diabetes mellitus, hypertension, hyperlipidemia, renal insufficiency, history of cerebrovascular accident, and history of chronic obstructive pulmonary disease (COPD). There were 85 patients in MICS CABG group, including 68 males (80.0%) and 17 females (20%), with an average age of (63.8±8.7) years; 451 patients were enrolled in OPCABG group, and 85 patients were matched by propensity score as control group (OPCABG group). There was no significant difference in general clinical characteristics (P>0.05). The average grafts of MICS CABG and OPCABG were 2.35±0.83 and 2.48±0.72 respectively (P=0.284). No conversion to thoracotomy in MICS CABG group or cardiopulmonary bypass in neither group occurred. There was no significant difference in the major adverse cardiovascular events (MACCEs, 1.17% vs. 3.52%), reoperation (2.34 vs. 3.52%), new-onset atrial fibrillation rate (4.70% vs. 3.52%) or new-onset renal insufficiency rate (1.17% vs. 0%) between MICS CABG group and OPCABG group (P>0.05). The operation time in MICS CABG group was longer than that in OPCABG group [(282.8±55.8) min vs. (246.8±56.9) min, P < 0.05], while the time of ventilator supporting(16.9 h vs. 29.6 h), hospitalization in ICU [(29.3±20.8) h vs. (51.5±48.3) h] and total hospitalization [(18.3±3.2) d vs. (25.7±4.2) d] in MICS CABG group were shorter than those in OPCABG group (P < 0.05). The total patency rate (A+B levels) of MICS CABG was 96.5% after surgery. There was no significant difference in MACCEs rate between the two groups [1.18%(1/85) vs. 3.61%(3/83), P>0.05] in 1-year follow up. The MICS CABG surgery is a safe and feasible procedure with good clinical results in early and mid-term follow-up.

Objective: Previous publications from our institutions have shown that minimally invasive coronary artery bypass grafting (MICS CABG) is safe, widely applicable, and associated with fewer infections, less transfusions, and better recovery than standard CABG. However, graft patency rates are unknown. The MICS CABG Patency Study prospectively evaluated angiographic bypass graft patency at 6 months after MICS CABG. Methods: In this dual-center study, 61 patients were prospectively enrolled and underwent MICS CABG through a 4-7cm left thoracotomy approach, where the left internal thoracic artery (LITA), the ascending aorta for proximal anastomoses, and all distal coronary targets were accessed without endoscopic or robotic assistance. The primary outcome was graft patency at 6 months, using 64-slice CT angiography. Secondary outcomes included conversions to sternotomy and major adverse cardiovascular events (MACE). ( Clinical Trial Registration Unique identifier: NCT01334866 ) Results: Mean age was 64.1±8.1 years, the mean ejection fraction was 48.8±10.4%, and there were 8 females in the study (13.1%). Surgeries were performed off-pump in 52 patients (85.2%). Complete revascularization was achieved in all patients, and the median number of grafts was 3. There was no perioperative mortality, no conversion to sternotomy, and 1 reopening for bleeding. Transfusion occurred in 15 patients (24.6%).The median length of hospital stay was 4 days, and patients were followed-up to 6 months, with no mortality or MACE. At 6 months, overall CT angiographic graft patency was 91.2% for all grafts, and 100% for LITA grafts. Conclusions: MICS CABG is safe, feasible, and associated with excellent rates of graft patency at 6 months post-surgery.

Minimally invasive coronary artery bypass grafting (MICS CABG) through a small left thoracotomy is a novel technique for surgical coronary revascularization, which is increasingly being adopted around the world. This study aimed to describe the characteristics and mid-term outcomes of a series of MICS CABG to identify areas for improvement. A prospective longitudinal study was performed on the 306 MICS CABG patients operated on by a single surgeon from 2005 to 2015. Minimally invasive coronary artery bypass grafting used a small left thoracotomy to enable coronary revascularization with a similar configuration to an open sternotomy technique, with left internal thoracic artery harvesting, and hand-sewn proximal radial/saphenous and distal anastomoses, under direct visualization. We compared patients who were operated on during the first and second halves of the series to ascertain the impact of a learning curve on outcomes. The mean ± SD age was 62 ± 9 years, 87% were male, and 23% had three-vessel disease. Off-pump coronary artery bypass was performed in 80%, and the median number of grafts was 2 (range 1-4). Sternotomy conversion occurred in 3.3%, reoperation for bleeding in 2%, and unplanned, emergency CPB conversion in 1%. Superficial thoracotomy infection, atrial fibrillation, and left-sided pleural effusion requiring drainage were encountered in 2%, 4%, and 4%, respectively. There were no perioperative stroke, myocardial infarction, or death. At a mean ± SD follow-up of 2.8 ± 2.5 years, 97.4% of patients were free from major adverse cardiac and cerebrovascular events. Between the first and latter half of the series, there was a decrease in the rate of conversion to sternotomy (5.2%-1.3%, P = 0.05) and in the mid-term need for repeat revascularization (11% vs 2.6%, P = 0.03). Overall repeat revascularization rate was 2.5% per year. The intensive care unit and hospital lengths of stay (1.6 ± 1.5 vs 1.4 ± 0.9, P = 0.2, and 6.1 ± 2.6 vs 5.6 ± 1.8, P = 0.4) were not statistically different. Minimally invasive coronary artery bypass grafting can be safely initiated as a minimally invasive, multivessel alternative to open surgical coronary revascularization, with excellent mid-term results. Learning phase effects were not observed with regard to overall procedural safety, but rather in terms of improved freedom from conversion to sternotomy and from repeat revascularization.

To evaluate long-term clinical efficacy of MICS CABG compared to surgery through sternotomy. The study included 158 patients who underwent minimally invasive CABG through left-sided mini-thoracotomy between 2017 and 2023. The primary endpoints were in-hospital mortality and 5-year survival, secondary endpoint - freedom from adverse cardiac events. The control group enrolled 150 patients who underwent median sternotomy. Mean follow-up period was 3.1±1.9 years. There were no differences in 5-year freedom from adverse cardiac events (84.7% versus 81.6%, p>0.05). Long-term survival (after 5 years) was 99% and 95%, respectively (p>0.05). In our study, the risk rate of wound complications after MICS CABG was 3 times lower compared to surgeries through sternotomy. Naturally, this reduces postoperative hospital-stay, promotes faster recovery and shortens the rehabilitation period. No significant differences in the quality of life after minimally invasive and traditional CABG indicates that MICS CABG does not reduce the effectiveness of myocardial revascularization. Thus, MICS CABG is not only characterized by low surgical risk, but also able to provide stable long-term results. MICS CABG is a safe and effective surgery. This surgery is not inferior to standard CABG through median sternotomy regarding long-term results, quality of life and life expectancy. However, this approach has advantages in patients with high risk of postoperative sternal wound complications. It also reduces the rehabilitation period and promotes early return to everyday life.

Background: Minimally Invasive coronary artery bypass grafting (MICS CABG) and Hybrid Revascularization (HR) are alternatives to sternotomy to reduce the procedure’s invasiveness. We aimed to assess the early and mid-term outcomes of MICS CABG. Methods: We retrospectively reviewed multivessel MICS CABG patients at Santa Maria Hospital, Bari, from 2017-2024. The primary outcome was 30-day and follow-up mortality. Results: Sixty-one patients underwent MICS CABG via left mini-thoracotomy, with mean 2.3±0.5 distal anastomoses using the left internal thoracic artery (LITA), right ITA (RITA), radial artery, or saphenous vein. Five MICS CABG patients (8.2%) had HR. More than half of MICS CABG cases were performed with planned peripheral cardiopulmonary bypass (CPB), without cross-clamping the Aorta. Of the total cohort, 26 patients (42.6%) received endoscopic MICS CABG, using 3D thoracoscopy for ITAs harvesting via bilateral ports in the 2nd, 3rd, and 4th IS, employing peripheral CPB and aortic clamping by Chitwood clamp at the second IS, with cardioplegia delivery via a 4 cm right anterior mini-thoracotomy. Distal anastomoses were performed via left anterior mini-thoracotomy, with subxiphoid manipulation of the emptied heart. Transit time flowmetry was used in all cases. No conversion to sternotomy was needed. No thirty-day mortality occurred, median ventilation was 4 [2-5] hours, and Intensive Care Unit-stay was 1 [1-2] days. All patients received graft evaluation via computerized tomography before hospital discharge. Mean follow-up was 2.9±1.9 years (max 5 years), with no deaths and 4 (1.9%) follow-up PCI. Conclusion: MICS CABG is safe and provides excellent early and mid-term outcomes.

We report our initial experience of an off-pump total arterial minimally invasive coronary arterial bypass grafting (MICS CABG) with the use of bilateral internal thoracic arteries (BITA) and the right gastroepiproic artery. A 47-year old male with renal dysfunction secondary to diabetes mellitus was admitted for heart failure due to severe triple-vessel disease. Off-pump MICS CABG with total arterial grafts was elected because the patient refused to undergo median sternotomy due to the strong desire to regain the baseline function promptly. Total arterial grafts were selected to maximize the potential long-term outcome. There were no postoperative complications except temporary dialysis. Postoperative coronary computed tomography revealed the patency of all grafts. Our experience suggests that BITA can be safely harvested under direct vision in MICS CABG. Total arterial graft revascularization with BITA via minimally invasive approach may offer the benefits of MICS CABG while providing the undetermined but potentially superior conduit longevity of arterial grafts.

The safety and feasibility of minimally invasive coronary artery bypass grafting (MICS CABG) were evaluated. From December 2012 to March 2019, 122 consecutive patients underwent MICS CABG via a left mini-thoracotomy under direct vision. The internal thoracic artery (ITA) was harvested from all, while bilateral ITAs (BITAs) were used in 36 patients, with the second ITA as an in situ (n = 18) or free (n = 18) graft. Proximal anastomosis of the free graft (ITA, radial artery, or saphenous vein segments) was performed directly onto the ascending aorta, or from the ITA as a Y- or I-composite graft. Patient ages ranged from 38 to 89years (mean 66.9 ± 9.6years) and 102 were males. MICS CABG was completed without conversion in 116 patients (95.1%), of whom 76 underwent multivessel bypass grafting, with 2 grafts used in 52 and 3 or more in 24 patients. A cardiopulmonary bypass was performed in 17 patients. Perioperative mortality occurred in 1 patient who died of advanced cancer. There were no cases of reoperation for bleeding, stroke, or chest wound infection. The perioperative transfusion rate was 11.2%. Early graft patency was noted in 97.1%. The rate of freedom from major adverse cardiac and cerebrovascular events (all-cause death, myocardial infarction, stroke, and repeated revascularization) was 89.7% at 5years. MICS CABG is feasible and showed good mid-term outcomes. BITAs can be harvested with this approach; thus, allowing for various graft designs. We recommend this as a useful option for coronary revascularization in selected cases.