Conventional Coronary Artery Bypass Grafting Research Articles

On-pump beating heart versus conventional on-pump coronary artery bypass grafting on clinical outcomes: a meta-analysis.

BackgroundA hybrid surgery method, on-pump beating heart coronary artery bypass graft (ON-BH CABG), is supposed to be a promising technology for coronary artery revascularization. Here, we conducted a comprehensive meta-analysis of the data derived from published studies on ON-BH CABG and conventional on-pump coronary artery bypass graft (C-CABG) to compare their short-term and long-term clinical outcomes.MethodsWe searched major electronic databases and 24 studies incorporating 6,862 patients (1,847 ON-BH CABG and 5,015 C-CABG) were included eventually, and 9 studies of them were focusing on high-risk patients.ResultsCompared with ON-BH CABG, C-CABG was associated with a higher risk in early mortality [odds ratio (OR), 1.45; 95% confidence interval (CI), 1.09 to 1.93; P=0.01], myocardial infarction (MI) (OR, 2.60; 95% CI, 1.41 to 4.78; P<0.01), low output syndrome (LOS) (OR, 2.56; 95% CI, 1.55 to 4.23; P<0.01), renal failure (OR, 1.84; 95% CI, 1.38 to 2.44; P<0.01). In contrast, there was no significant difference in long-term survival [hazard ratio (HR), 1.08; 95% CI, 0.81 to 1.43; P=0.60]. In systematic analysis of the studies in high-risk patients, ON-BH CABG showed a lower risk in terms of early mortality, intra-aortic balloon pump (IABP) usage, renal failure, hemodialysis, MI and pulmonary complication. No significant difference was observed in the long-term survival between ON-BH CABG and C-CABG.ConclusionsWith experienced and adept surgical team and mature ON-BH technology, ON-BH CABG may reduce the risk of postoperative death and complications in some patients. It might be an attractive alternative for high-risk patient populations.

Minimally Invasive Coronary Revascularisation Surgery: A Focused Review of the Available Literature.

Minimally invasive coronary revascularisation was originally developed in the mid 1990s as minimally invasive direct coronary artery bypass (MIDCAB) grafting is a less invasive approach compared to conventional coronary artery bypass grafting (CABG) to address targets in the left anterior descending coronary artery (LAD). Since then, MIDCAB has evolved with the adoption of a robotic platform and the possibility to perform multivessel bypass procedures. Minimally invasive coronary revascularisation surgery also allows for a combination between the benefits of CABG and percutaneous coronary interventions for non-LAD lesions – a hybrid approach. Hybrid coronary revascularisation results in fewer blood transfusions, shorter hospital stay, decreased ventilation times and patients return to work sooner when compared to conventional CABG. This article reviews the available literature, describes standard approaches and considers topics, such as limited access procedures, indications and patient selection, diagnostics and imaging, techniques, anastomotic devices, hybrid coronary revascularisation and outcome analysis.

In patients with multi-vessel coronary artery diseases, does hybrid revascularization provide similar outcomes to conventional coronary artery bypass grafting?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: In [patients with multivessel coronary artery diseases (CAD)] is [hybrid revascularization (HCR)] equal to [coronary artery bypass grafting (CABG)] in regard to [mortality, myocardial infarction, stroke and target vessel revascularization (TVR)]? Three-hundred and fifty-five papers were found using the reported search, of which 8 represented the best evidence to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The studies included 4 observational studies, 3 randomized controlled trials (RCTs) and 1 meta-analysis. The meta-analysis consisted of predominantly observational data with 1 randomized controlled trial and suggested non-significant differences in all major clinical outcomes. The observational studies generally cited benefit towards hybrid revascularization on the basis of equivalent major clinical outcomes rates compared to coronary artery bypass grafting, yet favourable in-hospital outcomes. One randomized controlled trial provided robust evidence of equivalent 5-year outcomes; however, the others were insufficiently powered for an effective comparison. There is a paucity of robustly designed studies to answer our clinical question effectively, given hybrid procedures are not routine in clinical practice. On the basis of mostly observational and small randomized cohorts with relatively short follow-up intervals, we conclude that current evidence suggests similar mid-term rates of major clinical outcomes after hybrid revascularization and coronary artery bypass grafting. However, without longer-term follow-up, the comparison of the two techniques, particularly relating to repeat revascularization, is still very much uncertain.

Cardioprotection with Adenosine during Coronary Revascularization

Background: Postoperative cardiac dysfunction is a common cause of mortality and morbidity associated with CABG Surgery. Adenosine enhances tolerance of the myocardium to ischemic arrest. Therefore, the study on adenosine pre-treatment as an adjunct to cardioplegia in patients undergoing CABG will definitely help to provide better myocardial protection for better postoperative outcome.&#x0D; Methods: Quasi experimental study was done in the Department of Cardiac Surgery, NICVD during July 2012 to June 2014 with patients who underwent conventional CABG surgery. Patients were divided in two groups. Group A: Patients received at regular institutional high-potassium ([K+] = 20 mol/ l) cold (12 °C) blood cardioplegia. and Group B: Patients received 250 μg /kg bolus dose of adenosine pre-treatment, which was immediately followed by high-potassium cold (12 °C) blood cardioplegia after clamp-on. Patients were followed up to evaluate the degree of myocardial damage by measuring perioperative Troponin I, amount of inotropic support, time of assisted ventilation, arrhythmia and mortality.&#x0D; Results: Most of the patients in each group belongs to 51-60 years of age range. There was no difference regarding operative parameters in two groups. Time to arrest was significantly shorter in group B compared to group A, indicating that adenosine has the potential to enhance the efficacy of cardioplegic arrest. Plasma level markers of myocardial damage: cardiac Troponin I (cTnI) obtained from serial venous blood samples post-operatively were significantly lower in group B than group A (p&lt;0.05). There was significantly decreased requirement of inotrope in group B during first 24 hrs (p &lt;0.05).&#x0D; Conclusion: Decreased level of cardiac enzymes and lower inotropic requirement suggests that an optimal myocardial protection with less cellular damage is obtained with adenosine pre-treatment as adjunct to cold blood cardioplegia.&#x0D; Cardiovasc. j. 2021; 13(2): 128-134

LEVOSEMINDAN VERSUS INTRA-AORTIC BALLOON PUMP IN LOW EJECTION FRACTION CABG PATIENTS

Background: Preoperative left ventricular dysfunction is an independent risk factor for perioperative mortality and morbidity and is also associated with postoperative low cardiac output syndrome. IABP improved outcomes in high-risk cardiac patients. However, installation of the balloon has many disadvantages. Recently, a new drug named Levosimendan is commonly used as an inotropic support. it does not increase oxygen demand of myocardium.Aim of the work: The purpose of our study was to compare the efficiency of levosimendan versus intra-aortic balloon pump in patients with poor left ventricular function undergoing coronary artery bypass grafting (CABG) with ejection fraction less than 35%.Patients and Methods: sixty patients were randomized into 2 groups, according to the treatment they received - either levosimendan (Group A) or intra-aortic balloon counter pulsation (Group B). and compared with respect to The use of inotropic drugs, weaning from CPB, Hemodynamics, transfusion requirements, ICU stay, hospital stay and in-hospital mortality.Results: There were no differences in preoperative characteristics including patients’ age, sex, BMI, and comorbidities. The Levosemindan group had reduced transfusion requirements and shorter ICU stay as compared to IABP group.Conclusion: levosimendan infusion after induction of anesthesia is a good choice with an acceptable option in comparison to IABP. The use of levosimendan in high-risk cardiac patients is comparable to IABP in improving hemodynamics during and after conventional on-pump CABG and results in a shorter ICU stay.

Prediction value of EuroSCORE II in total arterial revascularization and its usage in the evaluation of postoperative complications: Single-center experience

Total arterial revascularization is the most durable and technically the most demanding type of coronary artery bypass grafting procedure. It has proven long-term supremacy in comparison to conventional coronary artery bypass grafting. In our study, we investigated the reliability of EuroSCORE II as a predictor of intrahospital death. We showed its impact on adverse perioperative events. In this nonrandomized prospective study, we analyzed 116 consecutive patients who underwent the total arterial revascularization procedure at our Institute from January 2011 until the present. For myocardial revascularization, the most suitable combinations with left internal mammary artery, right internal mammary artery, and radial artery grafts were used. Main fact in this research was intrahospital mortality value in comparison with the value predicted. There were 104 (89.7%) males and 12 (10.3%) females. Mean preoperative EuroSCORE II prediction value was 1.98% and postoperative we obtained 1.72%. Postoperative redo for bleeding was 6%. Positive correlation was proven between the EuoroSCORE II value and intensive care unit stay (0.452; p < 0.001). Among patients who received two internal mammary arteries, the highest EuroSCORE II was among those with presternal wound infection (p = 0.005). Patients with bilateral internal mammary arteries and diabetes showed that they have the highest values of EuroSCORE II and, at the same time, that they are extremely prone to wound problems. We achieved a lower intrahospital mortality level than it was predicted with preoperative EuroSCORE II value. This tool is a reliable method for preoperative death risk calculation in this group of patients.

Advances in revascularization of the left coronary artery.

Ischaemic heart disease is the most common cardiovascular disease worldwide, and it contributes to a significant source of morbidity and mortality internationally. It can be asymptomatic for many years and present suddenly with acute coronary syndrome or can be progressive with angina and eventual acute myocardial infarction. Diseases of the left coronary system can be drastic and fatal if not managed correctly. With ongoing increase in the practice of percutaneous intervention; patient demographics for conventional coronary artery bypass grafting surgery have more risk factors than before. Conventional bypass surgery has also evolved to include minimally invasive and hybrid techniques. Although some evidence supports each approach, controversies remain.

Off-pump coronary artery bypass grafting for patients with severely reduced ventricular function-A justified strategy?

Low ejection fraction (EF) has been identified as a main risk factor for perioperative complications and mortality after coronary artery bypass grafting (CABG). The purpose of this study was to compare the efficacy and early as well as midterm outcomes of off-pump CABG (OPCAB) and conventional CABG (ONCAB) surgery in patients with reduced EF. We performed a retrospective review of patient demographics, preoperative risk factors, operative and postoperative outcomes of patients with left ventricular EF (LV-EF) ≤35%, who underwent CABG at our institution between January 2015 and December 2017. Propensity score and multivariate logistic regression analysis were used to compare risk adjusted outcomes between groups. Overall, 111 consecutive CABG-patients with LV-EF ≤ 35% underwent either ONCAB (46 patients, 41.4%) or OPCAB surgery (65 patients, 58.6%). There was no difference in early mortality (5% vs. 7.5%, p = .64) between groups. After propensity score matching, OPCAB-patients required significantly less re-sternotomies for bleeding (20% vs. 2.5%,p = .03) and consequently received significantly less blood transfusions (57.5% vs. 32.5%, p = .03). Fewer OPCAB-patients experienced low cardiac output syndrome (22.5% vs. 42.5%, p = .06) and suffered from postoperative delirium (22.5% vs. 42.5%, p = .06). There were no differences in completeness of revascularization between groups (median 1 (1.0-1.33; 1.0-1.33) OPCAB versus median 1 (1-1.33; 0.67-2) ONCAB, p = .95). Survival after 6 months, one year and three years was similar for ONCAB- and OPCAB-patients (ONCAB 92.3%, 89.4%, and 89.4% vs. OPCAB 89.8%, 85.7%, and 82.1%; p = .403). More ONCAB-patients needed a coronary re-intervention during follow-up (8.6% vs. 2.3%, p = .402). OPCAB-surgery is a safe and effective option for patients with reduced EF. Furthermore, it does not come at the expense of less complete revascularization or increased coronary re-intervention during early follow-up.

The Performance of the Current Risk Prediction Scoring Systems in Patients Undergoing Anaortic Off-pump Coronary Artery Bypass Grafting.

BackgroundThis study aimed to evaluate the performance of the Society of Thoracic Surgeons (STS) risk model and European System for Cardiac Operative Risk Evaluation (EuroSCORE) II for patients undergoing anaortic off-pump coronary artery bypass grafting (OPCAB).MethodsFrom January 2010 to June 2017, 1,048 patients (isolated anaortic OPCAB: 1,043, on-pump conversion:5) undergoing isolated anaortic OPCAB were enrolled. The STS risk score and EuroSCORE II were calculated with dedicated online software. Calibration of the models were performed by the risk-adjusted event ratio that was defined as observed events divided by expected events (O/E ratio) and Hosmer-Lemeshow test. The discrimination powers were evaluated by the area under the receiver operating characteristic curve (AUC).ResultsOperative mortality occurred in 10 patients (0.95%). The predicted mortality rates by the EuroSCORE II and STS risk model were 2.58 ± 4.15% and 1.72 ± 2.92%, respectively. The O/E ratio of the EuroSCORE II was 0.370 with significant overprediction of operative mortality (confidence interval [CI], 0.157–0.652; P = 0.003). The STS score also overpredicted the operative mortality (O/E ratio, 0.556) with marginal significance (CI, 0.266–1.023; P = 0.052). Permanent stroke occurred in 6 patients (0.53%). The predicted permanent stroke occurrence rate was 1.73 ± 1.48%. The O/E ratio was 0.332 with significant overprediction of permanent stroke (CI, 0.121–0.722; P = 0.011). Regarding discrimination power for the STS risk model, the operative mortality was excellent (AUC, 0.876) and permanent stroke was acceptable (AUC, 0.740). The EuroSCORE II showed good discrimination power (AUC, 0.784). There was a significant difference in discrimination power for mortality between STS and EuroSCORE II risk models (P = 0.007).ConclusionPreexisting risk predicting scoring systems, STS risk model and EuroSCORE II, overpredict the risk of mortality and stroke rate for anaortic OPCAB. These findings suggest the possibility that anaortic OPCAB can lower the operative mortality and occurrence of postoperative stroke than conventional coronary artery bypass grafting.

The Anaortic Technique with Bilateral Internal Thoracic Artery Grafting - Filling the Gap in Coronary Artery Bypass Surgery.

Coronary artery bypass grafting (CABG) has consolidated its role as the most effective procedure for treating patients with advanced atherosclerotic coronary artery disease, reducing the long-term risk of myocardial infarction and death compared to other therapies and relieving angina. Despite the recognized benefits afforded by surgical myocardial revascularization, a subset of higher-risk patients bears a more elevated risk of perioperative stroke. Stroke remains the drawback of conventional CABG and has been strongly linked to aortic manipulation (cannulation, cross-clamping, and side-biting clamping for the performance of proximal aortic anastomoses) and the use of cardiopulmonary bypass. Adoption of off-pump CABG (OPCAB) is demonstrated to lower the risk of perioperative stroke, as well as reducing the risk of short-term mortality, renal failure, atrial fibrillation, bleeding, and length of intensive care unit stay. However, increased risk persists owing to the need for the tangential ascending aorta clamping to construct the proximal anastomosis. The concept of anaortic (aorta no-touch) OPCAB (anOPCAB) stems from eliminating ascending aorta manipulation, virtually abolishing the risk of embolism caused by aortic wall debris into the brain circulation. The adoption of anOPCAB has been shown to further decrease the risk of postoperative stroke, especially in higher-risk patients, entailing a step forward and a refinement of outcomes provided by the primeval OPCAB technique. Therefore, anOPCAB has been the recommended technique in patients with cerebrovascular disease and/or calcification or atheromatous plaque in the ascending aorta and should be preferred in patients with high-risk factors for neurological damage and stroke.

Coronary-Coronary bypass graft as a safe and an alternative technique for revascularization of coronary arteries

Coronary–coronary bypass graft was first performed by Rowland and Grooters. This technique can be performed between two segments of the same coronary artery using saphenous vein grafts or free arterial grafts in on/off-pump coronary artery bypass grafting, also can be an alternative safe technique in some cases as calcified ascending aorta, porcelain aorta and insufficient graft length. The coronary– coronary bypass graft can provide nearly the same flow rate as conventional coronary artery bypass graft, another advantage this technique is that we can use to decrease sternal and respiratory morbidity. we performed this technique to a 55-year-old woman to whom coronary angiography showed critical three-vessel disease, using a free segment of right internal mammary artery, combined to conventional coronary artery bypass graft. The postoperative course was uneventful with the absence of ischemic lesions and the grafts were patent at 6 months after procedure. Aim: This aim of this article is to describe this technique and suggest the ways that we can use it.

Robot-assisted coronary artery bypass surgery: a systematic review and meta-analysis of comparative studies

Robot-assisted coronary bypass (RCAB) surgery has been proposed as an alternative to conventional coronary artery bypass grafting (C-CABG) for managing coronary heart disease, but the evidence on its performance compared to other existing treatments is unclear. The aim of this study was to assess, through a systematic review of comparative studies, the safety and clinical effectiveness of RCAB compared to C-CABG and other minimally invasive approaches for the treatment of coronary heart disease. We conducted a systematic review of primary studies in the English-language literature comparing RCAB to existing treatment options (C-CABG, minimally invasive direct coronary artery bypass [MIDCAB] and port-access coronary artery bypass [PA-CAB]) following Cochrane Collaboration guidelines. Meta-analyses were performed where appropriate. We reviewed 13 studies: 11 primary studies of RCAB (v. C-CABG in 7, v. MIDCAB in 3 and v. PA-CAB in 1) and 2 multicentre database studies (RCAB v. non-RCAB). The overall quality of the evidence was low. Most studies showed no significant benefit of RCAB over other treatments in a majority of outcome variables. Meta-analyses showed that RCAB had lower rates of pneumonia or wound infection than C-CABG, and shorter intensive care unit length of stay than C-CABG or MIDCAB. Individual studies showed that RCAB had some better outcomes than C-CABG (ventilation time, transfusion, postoperative pain, hospital length of stay) or MIDCAB (transfusion, postoperative pain, time to return to normal activities, physical functioning and hospital length of stay). The review of the database studies showed that RCAB was statistically superior to non-RCAB approaches in postoperative pain, renal failure, transfusion, reoperation for bleeding, stroke and hospital length of stay; however, the difference between the 2 groups in several of these outcomes was small. Although the findings from this review of comparative studies of RCAB appear promising and suggest that RCAB may offer some benefits to patients, in the absence of randomized controlled trials, these results should be interpreted cautiously.

Conventional coronary artery bypass grafting

: It was in 1969 that Dr. René Favaloro first used a saphenous vein graft the way we use it today to perform an aorto-coronary bypass. Since then, there have been plenty of trials in the literature trying to prove the inferiority or not of conventional coronary artery bypass grafting. Left internal mammary artery to left anterior descending coronary artery anastomosis and saphenous vein grafts to other coronary artery targets performed through full median sternotomy in a safe, motionless and bloodless environment provided by cardiopulmonary bypass and cardioplegic arrest is typical of conventional coronary artery bypass grafting. Non-conventional approaches include bilateral internal mammary artery harvesting or total arterial revascularization instead of saphenous vein grafts, off-pump coronary artery bypass grafting avoiding the use of cardiopulmonary bypass machine and minimally invasive direct coronary artery bypass or hybrid coronary revascularization instead of full median sternotomy. However, conventional coronary artery bypass grafting appears non-inferior to any of the aforementioned approaches in terms of mortality and major morbidity. On the other hand, only highly selected patients can benefit from non-conventional approaches. Furthermore, experience is critical for achieving optimal outcomes with any of these approaches. High-volume centres with expert surgeons can offer the best results. Conventional coronary artery bypass grafting continuously competes with modern alternative approaches. However, which of these is the best remains a contentious affair.

Hybrid minimally invasive multivessel coronary artery bypass grafting to achieve complete myocardial revascularisation: the first clinical case

Aim. To report the first clinical case of the hybrid procedure combining off-pump minimally invasive multivessel coronary artery bypass grafting (MICS-CABG) and percutaneous coronary intervention (PCI) of the obtuse marginal (OM) artery to achieve complete myocardial revascularisation.Clinical case. Bilateral in situ skeletonised left internal mammary artery (IMA) grafting to the left anterior descending artery was performed, and a Y-shape anastomosis was created from the left IMA-right IMA to the circumflex branch. At 2 hours postoperatively, graft failure caused by subtotal stenosis at the graft was diagnosed. Reconstruction of the anastomosis improved the transit time flow measurement by 3.5 hours postoperatively. Acute myocardial infarction did not develop. On postoperative day 1, graft patency was assessed, and then the OM stent was placed. On postoperative day 8, the patient was discharged and referred to the outpatient centre for further treatment and rehabilitation. Hybrid revascularisation offers the advantages of both CABG and PCI; however, the technical complexity is a major limitation for its widespread use. This case reports the development of adverse events during the surgeon's training to perform this nonstandard technology. Timely diagnosis of the initial graft failure and surgical revision led to a successful and complication-free outcome and avoided prolonged patient rehabilitation.Conclusion. Hybrid revascularisation combining MICS-CABG and PCI with new-generation drug-eluting stents can be a worthwhile alternative to conventional multivessel CABG with minimal invasiveness and complete revascularisation. Received 5 June 2020. Revised 10 September 2020. Accepted 15 September 2020. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest.

Revascularization for Isolated Proximal Left Anterior Descending Artery Disease

Most studies of patients with isolated proximal left anterior descending (PLAD) coronary artery disease do not include all 3 procedural options: percutaneous coronary intervention (PCI), conventional coronary artery bypass graft (CABG) surgery, or minimally invasive CABG. New York's cardiac registries were used to identify patients who underwent revascularization for isolated PLAD disease between January 1, 2010, and November 30, 2016, in New York State. After exclusions, 14,327 patients, of whom 13,115 received PCI, 1001 of whom underwent CABG surgery, and 211 of whom underwent minimally invasive CABG were monitored through the end of 2017 to compare outcomes. Registry data were matched to vital statistics data to obtain deaths occurring after discharge and matched to claims data to obtain subsequent admissions for myocardial infarction and stroke. There were no significant differences in mortality or in mortality/myocardial infarction/stroke after 7 years (with median follow-up times in excess of 4 years) among the 3 procedures after adjusting fordifferences in patient risk factors. However, conventional CABG surgery was associated with a lower subsequent revascularization rate than PCI (adjusted hazard ratio, 0.45; 95% confidence interval, 0.35-0.58) and minimally invasive CABG surgery (adjusted hazard ratio, 0.46; 95% confidence interval, 0.32-0.66). Among patients with isolated PLAD disease undergoing any of 3 revascularization options (PCI, conventional CABG surgery, or minimally invasive CABG surgery), conventional CABG surgery was associated with lower subsequent revascularization rates, but there were no differences in mortality or mortality/myocardial infarction/stroke rates.

Randomized clinical trial of surgical vs. percutaneous vs. hybrid revasculatization in multivessel coronary artery disease: 3 years follow-up (the HREVS Trial)

Abstract Aim Optimal revascularization strategy in multi-vessel (MV) coronary artery disease (CAD) eligible for percutaneous intervention (PCI) and surgery remains unresolved. We evaluated, in a randomized clinical trial, residual myocardial ischemia (RI) and clinical outcomes of MV-CAD revascularization using coronary artery bypass grafting (CABG), hybrid coronary revascularization (HCR) or MV-PCI. Materials and methods Consecutive MV-CAD patients (n=155) were randomized (1:1:1) to conventional CABG (LIMA-LAD plus venous grafts) or HCR (MIDCAB LIMA-LAD followed by PCI for remaining vessels) or MV-PCI (everolimus-eluting CoCr stents) under Heart Team agreement on equal technical and clinical feasibility of each strategy. The primary endpoint was SPECT at 12 months (primary endpoint of RI that the trial was powered for; a measure of revascularization mid-term efficacy and an independent predictor of long-term prognosis). The secondary endpoint was 3-year MACCE. Results Baseline characteristics were similar between the study arms. 5 (9.8%) patients in the HCR group required conversion to CABG. Data are given respectively for the CABG, HCR and MV-PCI arm. Incomplete revascularization rate was 8.0% vs. 7.7% vs. 5.7% (p=0.86). At 12 months, RI was 5 (2,9)% vs. 5 (3,7)% vs. 6 (3,10)% (median; Q1,Q3) with non-inferiority p values of 0.0006 (HCR vs. CABG) and 0.016 (MV-PCI vs. CABG). 3-year MACCE rate was similar (34.7% vs. 27.1% vs. 38%; p=0.18). Conclusion In patients with MV-CAD amenable to CABG, HCR, and MV-PCI, endpoints of residual myocardial ischemia at 12 months and 3-year MACCE were similar. ClinicalTrials: gov identifier: NCT01699048 Funding Acknowledgement Type of funding source: None

Robotic coronary artery surgery: Outcomes and pitfalls.

Coronary artery bypass grafting is one of the most commonly performed surgical procedures in cardiovascular surgery with a steadily evolving minimally invasive approach. Conventional coronary artery bypass grafting (CABG) is performed traditionally via midline sternotomy. Exciting advancements in technology and engineering over the last two decades have resulted in the transition from conventional to minimally invasive CABG including robotically assisted surgery. The minimally invasive techniques are continuously striving to promote coronary revascularization into the arena of minimally invasive surgery. Examination of 10 previously completed studies with relevant follow-up periods enables an insightful vision into the outcomes and pitfalls surrounding robot-assisted CABG (RACAB) as explored in this review. Studies indicate that RACAB is associated with decreased postoperative complications such as major adverse cardiac or cerebrovascular events without compromise in survival rates. Despite this, certain drawbacks such as incurring costs and technical complexity of the procedure cannot be dismissed. There exist patient-related benefits from minimally invasive techniques such as decreased certain postoperative complications. Furthermore, with experience and a specialized stepwise program, it is possible to perform the entire procedure from the console. However, certain pitfalls involving increased expenses, steep learning curve and the lack of proper haptic feedback currently withhold the worldwide expansion of RACAB and limit it to specialized institutions only.

Comparison of Early Outcome of Off-pump and Conventional Coronary Artery Bypass Graft Surgery in Patients with Multivessel Coronary Artery Disease and Left Ventricular Dysfunction

Introduction: Left ventricular dysfunction is an important predictor of in-hospital mortality. Due to the theoretical and practical advantages to avoid the harmful effects of cardiopulmonary bypass (CPB), many cardiac surgeons are using Off-pump Coronary Artery Bypass (OPCAB)as an effective alternative to conventional CABG (CCAB) even in patients with reduced left ventricular (LV)ejection fraction. Objectives: This study performed in the National Institute of Cardiovascular Diseases (NICVD) evaluated the early outcomes of OPCAB in terms of mortality and major post-operative morbidities and compared them with that of CCAB in patients with multivessel coronary artery diseases and reduced left ventricular (LV) function.&#x0D; Methods: Total 120 patients with multivessel coronary artery disease with reduced left ventricular ejection fraction (d”50%)were allocated into two groups: a) 60 patients who underwent OPCAB and b) another 60 patients who underwent conventional CABG between January 2013 and December 2015. Pre-operative, peroperative and early post-operative variables were recorded, compiled and compared.&#x0D; Results: All risk factors and co-morbidities were homogenously distributed between the two groups. Majority of the patients had triple vessel disease. Nearly three-quarter (73.3%) of patients in OPCAB group and 80% in CCAB group received 3 grafts (p=0.470). The mean total operative time (268.5 ± 33.5vs. 296.3 ± 34.8minutes, p &lt; 0.001), intubation times(8.6±0.3 vs. 12.3±0.5 hours, p&lt;0.001), blood losses (377.8378 ± 45 ml vs. 602 ± 60 ml, p &lt; 0.001); requirements for blood and blood products (689.7±21.1 vs. 1199.3±34.5ml, p &lt; 0.0010),intensive care unit stays (31.7±0.9 hours versus 41.6±1.5 hours; p&lt;0.001) and hospital stays (8.2 ± 0.2days vs.10.3 ± 0.3days, p &lt; 0.001)were all significantly lower in the OPCAB group.&#x0D; Conclusion: OPCAB is a safe and effective operative revascularization procedure for patients with multivessel coronary artery disease and left ventricular dysfunction and is associated with reduced morbidity. However, a larger and omized trial with long-term followup may show the real benefits of OPCAB.&#x0D; Bangladesh Heart Journal 2020; 35(1) : 20-27

Off-pump versus conventional coronary artery bypass grafting for the revascularization of posterior wall arteries

Off-pump versus conventional coronary artery bypass grafting for the revascularization of posterior wall arteries

On-pump beating-heart coronary artery bypass grafting in high-risk patients: A systematic review and meta-analysis.

Operative technique for surgical myocardial revascularization in high-risk patients remains an argument of debate. On-pump coronary artery bypass graft (CABG) with cardioplegic arrest and off-pump CABG have intrinsic limitations. The hybrid approach of on-pump beating-heart CABG (OPBHC) has been proposed over the years with conflicting results. This systematic review and meta-analysis intends to summarize the contemporary literature. A literature search was conducted through major electronic databases. The systematic review provided a total of 279 articles, of those 17 studies were included in the present study. Compared with on-pump CABG, OPBHC patients showed a preoperative higher risk profile but had reduced early mortality (risk ratio [RR], 0.59, 95% CI, 0.36-0.97) and reduced postoperative stroke (RR, 0.60, 95% CI, 0.39-0.91). Also, interesting trends towards reduced postoperative intra-aortic balloon pump use (RR, 0.56, 95% CI, 0.31-1.01) and myocardial infarction (RR, 0.48, 95% CI, 0.22-1.07) were observed. Baseline characteristics and postoperative complications were similar between OPBHC and off-pump CABG, but limited data are available. The risk of incomplete revascularization in OPBHC is lower than off-pump CABG (RR, 0.53, 95% CI, 0.33-0.87) but higher than conventional on-pump CABG (RR, 1.71, 95% CI, 1.23-2.39). OPBHC is an effective technique to perform surgical revascularization in high-risk patients as preventing haemodynamic deterioration and guaranteeing adequate end-organ perfusion. OPBHC represents an alternative technique to on-pump and off-pump CABG, in those cases in which complications deriving from cardioplegic arrest or manipulation of the heart are more likely. For these reasons, OPBHC might be useful in patients with recent myocardial infarction or with left ventricular dysfunction.