Policy Statement: Minimally Invasive Coronary Artery Bypass Surgery

Abstract

Policy statement: minimally invasive coronary artery bypass surgeryMinimally invasive coronary artery bypass procedures with or without cardiopulmonary bypass (CPB) are approaches for surgical coronary revascularization designed to reduce operative trauma, speed patient recovery, allow faster return to normal activity, and obtain cost containment as compared with conventional coronary artery bypass grafting (CABG).Minimally invasive direct coronary bypass (frequently referred to as MIDCAB) is an approach which does not use cardiopulmonary bypass or cardioplegia. Most commonly, a small left anterior thoracotomy is made and the left internal mammary artery is harvested and anastomosed to the left anterior descending coronary artery on the beating heart. Although single vessel bypass has been done in more than 90% of the cases, multiple grafting can be accomplished in some circumstances. The use of complete sternotomy with multivessel bypass on the beating heart without CPB is also an option, and some have referred to this as “minimally invasive” because CPB is not used. Another main approach to minimal access CABG is to employ CPB. In the first instance, the operation (frequently referred to as PA-CAB) is performed through a limited thoracic incision, but also using port access technology cardiopulmonary bypass is established through peripheral cannulation. Cardioplegia, is administered after an aortic occlusion with balloon clamp, and Port Access techniques are used for insertion of thoracoscopic and special instruments. Finally, minimally invasive CABG can also be performed with CPB through the same incisions, but without aortic occlusion using ventricular fibrillation and immobilization of the coronary arteries.The premise for adopting these less invasive approaches to coronary grafting is that patient morbidity can be reduced without reducing the safety or efficacy of the coronary bypass surgery. At this early stage in the minimally invasive CABG experience, considerable data are being generated. Clearly, minimally invasive coronary bypass surgery is misused if it is performed for cosmesis, as a result of peer pressure for marketing purposes, or without proper training and supervision. The Society of Thoracic Surgeons/American Association for Thoracic Surgery (STS/AATS) New Technology Committee specifically condemns minimally invasive CABG performance only for marketing purposes. The results obtained by using conventional open techniques must be matched by minimally invasive coronary artery bypass techniques.Minimally invasive coronary bypass is essentially a reconfiguration of a number of established and accepted cardiac surgical techniques using new incisional and anatomic approaches, rather than a new procedure to establish myocardial revascularization. Minimally invasive techniques continue to evolve, and may now include a variety of stabilization and/or visual enhancement systems. Minimally invasive coronary bypass must undergo rigorous evaluation in comparison to the established results of conventional surgery. Patients must be fully informed of the differences between conventional grafting and the minimal access grafting. Surgeon and center experience must be discussed. Graft patency data should be collected to help identify differences that may ultimately become significant and to establish the role of these techniques in the surgical treatment of coronary artery disease.The different approaches required for minimally invasive CABG and the problematic issues of performing precise anastomoses either on the beating heart or through small incisions on the arrested heart on CPB makes the issue of surgical education particularly important. As the various approaches to minimally invasive coronary artery bypass evolve, a profusion of new techniques and equipment has appeared. A surgeon wishing to adopt these new techniques or technologies should attend one or more CME- approved courses which conform to the STS/AATS New Technology Committee educational guidelines. These courses should include didactic sessions, and may include video sessions, ideally interspersed with a laboratory experience to master specific techniques. Observation of minimally invasive surgery at experienced centers is now possible and is strongly encouraged.Minimally invasive coronary bypass grafting will continue to evolve over the next several years and new or hybrid procedures and new technologies will likely emerge. As this occurs, it is incumbent on practitioners to appropriately educate themselves as well as to document and disseminate new information. The Joint Committee strongly recommends that performance of these procedures be currently restricted to established cardiac surgical programs staffed by board certified cardiothoracic surgeons who are skilled in the performance of conventional open heart surgical procedures. It is also strongly recommended that these procedures be monitored closely for morbidity and mortality by established hospital quality assurance committees. Such monitoring should include documentation of complications and long-term outcome, especially as these factors relate to conventional coronary bypass surgery. The STS/AATS New Technology Committee is available to consult with organizations such as the National Institutes of Health, Food and Drug Administration, HCFA, JCAHO and American Board of Thoracic Surgery on question; relating to the performance and evaluation of the operation, as well as the training of the surgeons that perform minimally invasive cardiac surgery. Policy statement: minimally invasive coronary artery bypass surgeryMinimally invasive coronary artery bypass procedures with or without cardiopulmonary bypass (CPB) are approaches for surgical coronary revascularization designed to reduce operative trauma, speed patient recovery, allow faster return to normal activity, and obtain cost containment as compared with conventional coronary artery bypass grafting (CABG).Minimally invasive direct coronary bypass (frequently referred to as MIDCAB) is an approach which does not use cardiopulmonary bypass or cardioplegia. Most commonly, a small left anterior thoracotomy is made and the left internal mammary artery is harvested and anastomosed to the left anterior descending coronary artery on the beating heart. Although single vessel bypass has been done in more than 90% of the cases, multiple grafting can be accomplished in some circumstances. The use of complete sternotomy with multivessel bypass on the beating heart without CPB is also an option, and some have referred to this as “minimally invasive” because CPB is not used. Another main approach to minimal access CABG is to employ CPB. In the first instance, the operation (frequently referred to as PA-CAB) is performed through a limited thoracic incision, but also using port access technology cardiopulmonary bypass is established through peripheral cannulation. Cardioplegia, is administered after an aortic occlusion with balloon clamp, and Port Access techniques are used for insertion of thoracoscopic and special instruments. Finally, minimally invasive CABG can also be performed with CPB through the same incisions, but without aortic occlusion using ventricular fibrillation and immobilization of the coronary arteries.The premise for adopting these less invasive approaches to coronary grafting is that patient morbidity can be reduced without reducing the safety or efficacy of the coronary bypass surgery. At this early stage in the minimally invasive CABG experience, considerable data are being generated. Clearly, minimally invasive coronary bypass surgery is misused if it is performed for cosmesis, as a result of peer pressure for marketing purposes, or without proper training and supervision. The Society of Thoracic Surgeons/American Association for Thoracic Surgery (STS/AATS) New Technology Committee specifically condemns minimally invasive CABG performance only for marketing purposes. The results obtained by using conventional open techniques must be matched by minimally invasive coronary artery bypass techniques.Minimally invasive coronary bypass is essentially a reconfiguration of a number of established and accepted cardiac surgical techniques using new incisional and anatomic approaches, rather than a new procedure to establish myocardial revascularization. Minimally invasive techniques continue to evolve, and may now include a variety of stabilization and/or visual enhancement systems. Minimally invasive coronary bypass must undergo rigorous evaluation in comparison to the established results of conventional surgery. Patients must be fully informed of the differences between conventional grafting and the minimal access grafting. Surgeon and center experience must be discussed. Graft patency data should be collected to help identify differences that may ultimately become significant and to establish the role of these techniques in the surgical treatment of coronary artery disease.The different approaches required for minimally invasive CABG and the problematic issues of performing precise anastomoses either on the beating heart or through small incisions on the arrested heart on CPB makes the issue of surgical education particularly important. As the various approaches to minimally invasive coronary artery bypass evolve, a profusion of new techniques and equipment has appeared. A surgeon wishing to adopt these new techniques or technologies should attend one or more CME- approved courses which conform to the STS/AATS New Technology Committee educational guidelines. These courses should include didactic sessions, and may include video sessions, ideally interspersed with a laboratory experience to master specific techniques. Observation of minimally invasive surgery at experienced centers is now possible and is strongly encouraged.Minimally invasive coronary bypass grafting will continue to evolve over the next several years and new or hybrid procedures and new technologies will likely emerge. As this occurs, it is incumbent on practitioners to appropriately educate themselves as well as to document and disseminate new information. The Joint Committee strongly recommends that performance of these procedures be currently restricted to established cardiac surgical programs staffed by board certified cardiothoracic surgeons who are skilled in the performance of conventional open heart surgical procedures. It is also strongly recommended that these procedures be monitored closely for morbidity and mortality by established hospital quality assurance committees. Such monitoring should include documentation of complications and long-term outcome, especially as these factors relate to conventional coronary bypass surgery. The STS/AATS New Technology Committee is available to consult with organizations such as the National Institutes of Health, Food and Drug Administration, HCFA, JCAHO and American Board of Thoracic Surgery on question; relating to the performance and evaluation of the operation, as well as the training of the surgeons that perform minimally invasive cardiac surgery. Minimally invasive coronary artery bypass procedures with or without cardiopulmonary bypass (CPB) are approaches for surgical coronary revascularization designed to reduce operative trauma, speed patient recovery, allow faster return to normal activity, and obtain cost containment as compared with conventional coronary artery bypass grafting (CABG). Minimally invasive direct coronary bypass (frequently referred to as MIDCAB) is an approach which does not use cardiopulmonary bypass or cardioplegia. Most commonly, a small left anterior thoracotomy is made and the left internal mammary artery is harvested and anastomosed to the left anterior descending coronary artery on the beating heart. Although single vessel bypass has been done in more than 90% of the cases, multiple grafting can be accomplished in some circumstances. The use of complete sternotomy with multivessel bypass on the beating heart without CPB is also an option, and some have referred to this as “minimally invasive” because CPB is not used. Another main approach to minimal access CABG is to employ CPB. In the first instance, the operation (frequently referred to as PA-CAB) is performed through a limited thoracic incision, but also using port access technology cardiopulmonary bypass is established through peripheral cannulation. Cardioplegia, is administered after an aortic occlusion with balloon clamp, and Port Access techniques are used for insertion of thoracoscopic and special instruments. Finally, minimally invasive CABG can also be performed with CPB through the same incisions, but without aortic occlusion using ventricular fibrillation and immobilization of the coronary arteries. The premise for adopting these less invasive approaches to coronary grafting is that patient morbidity can be reduced without reducing the safety or efficacy of the coronary bypass surgery. At this early stage in the minimally invasive CABG experience, considerable data are being generated. Clearly, minimally invasive coronary bypass surgery is misused if it is performed for cosmesis, as a result of peer pressure for marketing purposes, or without proper training and supervision. The Society of Thoracic Surgeons/American Association for Thoracic Surgery (STS/AATS) New Technology Committee specifically condemns minimally invasive CABG performance only for marketing purposes. The results obtained by using conventional open techniques must be matched by minimally invasive coronary artery bypass techniques. Minimally invasive coronary bypass is essentially a reconfiguration of a number of established and accepted cardiac surgical techniques using new incisional and anatomic approaches, rather than a new procedure to establish myocardial revascularization. Minimally invasive techniques continue to evolve, and may now include a variety of stabilization and/or visual enhancement systems. Minimally invasive coronary bypass must undergo rigorous evaluation in comparison to the established results of conventional surgery. Patients must be fully informed of the differences between conventional grafting and the minimal access grafting. Surgeon and center experience must be discussed. Graft patency data should be collected to help identify differences that may ultimately become significant and to establish the role of these techniques in the surgical treatment of coronary artery disease. The different approaches required for minimally invasive CABG and the problematic issues of performing precise anastomoses either on the beating heart or through small incisions on the arrested heart on CPB makes the issue of surgical education particularly important. As the various approaches to minimally invasive coronary artery bypass evolve, a profusion of new techniques and equipment has appeared. A surgeon wishing to adopt these new techniques or technologies should attend one or more CME- approved courses which conform to the STS/AATS New Technology Committee educational guidelines. These courses should include didactic sessions, and may include video sessions, ideally interspersed with a laboratory experience to master specific techniques. Observation of minimally invasive surgery at experienced centers is now possible and is strongly encouraged. Minimally invasive coronary bypass grafting will continue to evolve over the next several years and new or hybrid procedures and new technologies will likely emerge. As this occurs, it is incumbent on practitioners to appropriately educate themselves as well as to document and disseminate new information. The Joint Committee strongly recommends that performance of these procedures be currently restricted to established cardiac surgical programs staffed by board certified cardiothoracic surgeons who are skilled in the performance of conventional open heart surgical procedures. It is also strongly recommended that these procedures be monitored closely for morbidity and mortality by established hospital quality assurance committees. Such monitoring should include documentation of complications and long-term outcome, especially as these factors relate to conventional coronary bypass surgery. The STS/AATS New Technology Committee is available to consult with organizations such as the National Institutes of Health, Food and Drug Administration, HCFA, JCAHO and American Board of Thoracic Surgery on question; relating to the performance and evaluation of the operation, as well as the training of the surgeons that perform minimally invasive cardiac surgery.