Invasive Coronary Artery Bypass Surgery Research Articles

低侵襲冠動脈外科手術の現在，そして未来へのパラダイムシフト

低侵襲冠動脈外科手術の現在，そして未来へのパラダイムシフト

Abstract P51: Trends in Utilization of Invasive Cardiac Procedures in North Carolina

Background: Concerns around utilization of coronary revascularization remain in the US. We aimed to understand the temporal trends and variation in invasive diagnostic cardiac catheterization (Cath), percutaneous intervention (PCI) and coronary artery bypass surgery (CABG) in North Carolina from 2003-2009. Methods: All Cath, PCI, and CABG procedures performed in North Carolina from 2003-2009 were identified using hospital-reported data submitted in a License Renewal Application by all catheterization labs for the North Carolina State Medical Facilities Plan. Rates of procedure use, ratios of PCI to Cath, CABG to Cath, and CABG to PCI were compared over time and between hospitals. Hospitals that performed at least 25 Cath, 25 PCI, and 25 CABG were included in the variation analysis. Results: From 2003-2009, there was an observed decline in the annual rate of all procedures, 16% for Cath, 9% for PCI, 27% for CABG. However, the ratio of PCI to diagnostic Cath over the time period increased by 10%, rising to 51% in 2009, while the ratio of CABG to Cath decreased by 10% (see Figure). Of the 119 hospitals in North Carolina, 21 hospitals reported performing more than 25 Cath, 25 PCI and 25 CABG each year from 2003-2009. Hospital level analysis also showed evidence of significant variation in the ratio of both PCI to Cath (10% to 90%, p<0.05) and CABG to Cath (5-35%, p<0.05). Conclusions: Although the use of all cardiac procedures declined, the ratio of PCI to Cath increased over the study period. There was significant variation in the mode of revascularization (CABG and PCI) across hospital systems in North Carolina. Further investigation into revascularization decisions is warranted. Figure.Trends in Volume and Rates of Diagnostic Cath, PCI, and CABG in North Carolina from 2003-2009.

Trends in the use of diagnostic coronary angiography, percutaneous coronary intervention, and coronary artery bypass graft surgery across North Carolina

Although variation in use of invasive coronary procedures has been shown, the relationship between invasive diagnostic cardiac catheterization (Cath) and subsequent revascularization with percutaneous coronary intervention (PCI) or coronary artery bypass surgery (CABG) is not known. We evaluated the temporal trends and variation in invasive Cath, PCI, and CABG across hospital systems in North Carolina. All Cath, PCI, and CABG procedures performed in North Carolina from 2003 to 2009 were identified using data reported in the annual North Carolina State Medical Facilities Plan. Rates and variation in procedure use, relative rates of PCI to Cath, CABG to Cath, and CABG to PCI were compared over the study period between hospitals that performed at least 25 Cath, 25 PCI, and 25 CABG procedures. The rates of all invasive procedures per 100,000 population declined: 24% for Cath, 16% for PCI, and 35% for CABG. However, the relative rate of PCI to Cath over the study period increased by 11%, whereas the relative rate of CABG to Cath decreased by 13%. Hospital level analysis showed significant variation in the relative rate of both PCI to Cath (10%-90%, P < .05) and CABG to Cath (5%-35%, P < .05). Although the use of all invasive cardiac procedures declined, the relative rate of PCI to Cath increased over the study period. There was also significant variation in the mode of revascularization (CABG and PCI) across hospital systems in North Carolina. Further research is needed to understand drivers of coronary revascularization.

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

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

623 Ultra fast track cardiac surgery and anaesthesia: A collaborative team approach

The advantages of minimally invasive coronary artery bypass grafting (CABG) surgery over conventional CABG include shorter recovery time, overall reduction in morbidity, blood transfusion, greater patient satisfaction, shorter hospital stay, and earlier return to work. In order to explore the opportunities within our practice to improve patient care while at the same time protecting our patients from harm and reducing costs to our financially challenged hospitals, we identified an opportunity to explore the option of bypassing the intensive care unit (ICU) in a highly selected group of patients undergoing minimally invasive coronary artery bypass surgery. This was accomplished through an extensive collaboration between nurses, administrators and physicians alike. A collaborative pathway was constructed for selection of suitable patients by the surgeon and anaesthesiologists based on the grounds of compatible coronary anatomy for minimally invasive coronary artery revascularization. Secondary factors included minimal systemic co-morbidity. A total of 14 patients underwent successful fast track cardiac surgery. There were 12 males and 2 females. They all received preoperative spinal injection of 15 mg of bupivacaine and 3 to 5 mcg/kg of preservative free morphine prior to their general anaesthesia. Using single lung ventilation they underwent Robotic-assisted CABG. Immediately after the revascularization they underwent cardiac catheterization to confirm patency of their graft and simultaneous percutaneous coronary intervention in 2 patients in the hybrid operating suite. Simultaneously, their anaesthetic and neuromuscular blockade was reversed achieving spontaneous respiration. Following clinical confirmation of return of spontaneous respiration, wakefulness and protective airway reflexes, the endotracheal tube was removed, and the patients were transferred to the post anaesthetic care unit (PACU). All patients were monitored in the PACU for 4 to 6 hours before being transferred to the postoperative ward. One patient had to return to the operating room for increase bleeding after 3 hours. He underwent uncomplicated exploration for chest wall bleeding. All patients had patent grafts, no post-operative complications and were extremely satisfied on discharge. Average length of stay in hospital was 3.1 ± 0.78 days. We believe Ultra fast track cardiac surgery is a safe and efficient way to conduct cardiac surgery in a highly selected group of patients. The importance of collaboration and a team based approach cannot be emphasized enough. We anticipate expanding this program within our own institution and look forward to evaluating the cost effectiveness of avoiding the ICU.

Long-Term Survival after Minimal Invasive Direct Coronary Artery Bypass (MIDCAB) Surgery in Patients with Low Ejection Fraction

: The long-term survival after minimal invasive direct coronary artery bypass (MIDCAB) surgery to any coronary territory in patients with ejection fraction of ≤30% was investigated for the first time in literature. : Seventy-three patients with primary MIDCAB and 89 patients with reoperative MIDCAB were studied including preoperative risk factors, operative details, early postoperative complications, and survival up to 10 years postoperatively. : Despite the high-risk profile of the patients, the MIDCAB approach for targeted revascularization resulted in excellent short-term results. Ventricular arrhythmia contributed to four of six early deaths. Survival at 5 years postoperatively was 62.5% for primary MIDCAB and 43.2% for reoperative MIDCAB and at 10 years was 36.9% and 29.5%, respectively. Functionally complete vascularization correlates with significantly better long-term survival particularly in primary MIDCAB procedures. : MIDCAB is a valuable option for targeted revascularization in high-risk patients with low ejection fraction and reoperation.

Facilitated anastomosis using a reverse thermo-sensitive polymer for temporary coronary occlusion in off-pump minimally invasive direct coronary artery bypass surgery☆

To evaluate the safety and efficacy of a novel, reverse thermo-sensitive polymer (LeGoo™) for its ability to provide temporary coronary occlusion and hemostasis during minimally invasive direct coronary artery bypass (MIDCAB) surgery. Between January 2009 and March 2009, 20 consecutive MIDCAB patients were studied. Ten patients received a conventional MIDCAB procedure using proximal vessel loops and CO2 blower (control group). The following 10 patients were operated by an otherwise identical procedure, except that intracoronary administration of LeGoo™ was used instead of vessel snares (LeGoo™ group). Left internal mammary artery (LIMA) bypass flow, peri- and postoperative events and perioperative creatinine kinase-MB fraction (CK-MB) release were prospectively analyzed. CO2-blower use was required in three of 10 of the LeGoo™ patients. Procedural time was identical, with a trend of shorter anastomosis time in the LeGoo™ group (12.3 vs. 10.7 min, P=0.11). LIMA-LAD flow was also not different (control 35.8 vs. LeGoo™ 42.5 ml/min, P=0.541). CK-MB values were not statistically different on postoperative days 1 and 2. However, the level of CK-MB 4 h postoperatively was lower in LeGoo™ patients (18.3±6.1 vs. 13.2±2.9 U/l, P=0.006). No major adverse cerebral or cardiovascular event occurred postoperatively and during follow-up of 317±21 days. Using LeGoo™ to achieve temporary coronary artery occlusion is easier to work with during MIDCAB due to the absence of vessel snares and less need of blowing to eliminate blood from the operative field. There were no negative postoperative events associated with the use of LeGoo™.

Long-Term Survival After Minimal Invasive Direct Coronary Artery Bypass (MIDCAB) Surgery in Patients With Low Ejection Fraction.

: The long-term survival after minimal invasive direct coronary artery bypass (MIDCAB) surgery to any coronary territory in patients with ejection fraction of ≤30% was investigated for the first time in literature. : Seventy-three patients with primary MIDCAB and 89 patients with reoperative MIDCAB were studied including preoperative risk factors, operative details, early postoperative complications, and survival up to 10 years postoperatively. : Despite the high-risk profile of the patients, the MIDCAB approach for targeted revascularization resulted in excellent short-term results. Ventricular arrhythmia contributed to four of six early deaths. Survival at 5 years postoperatively was 62.5% for primary MIDCAB and 43.2% for reoperative MIDCAB and at 10 years was 36.9% and 29.5%, respectively. Functionally complete vascularization correlates with significantly better long-term survival particularly in primary MIDCAB procedures. : MIDCAB is a valuable option for targeted revascularization in high-risk patients with low ejection fraction and reoperation.

A xiphoid approach for minimally invasive coronary artery bypass surgery.

The premise for adopting minimally invasive cardiac surgery techniques for myocardial revascularization is to reduce the patient's morbidity without compromising the efficacy of conventional coronary artery bypass. However, opening the pleura has been a limitation of using these approaches. We used the xiphoid approach as an alternative to opening the pleura and to minimize pain after minimally invasive coronary artery bypass surgery. We review our surgical experience in 55 patients who underwent minimally invasive direct coronary artery bypass (MIDCAB) surgery through a xiphoid approach between October 1997 and August 1999. Thoracoscopy (n = 31) or direct vision (n = 24) were used for internal mammary artery (IMA) harvesting. Mean patient age was 67 +/- 10 years and 65% were men. The mean Parsonnet score was 23 +/- 10. Performed anastomoses included left IMA (LIMA) to the left anterior descending (LAD) artery (n = 53), LIMA-to-LAD and saphenous vein graft from the LIMA to the right coronary artery (n = 1), and LIMA-to-LAD and right IMA (RIMA) to right coronary artery (n = 1). Postoperative complications included atrial fibrillation (12%), acute noninfectious pericarditis (12%), and acute renal failure (5%). Mean postoperative length of stay was 4 +/- 2 days. Angiography was performed in 16 patients and demonstrated excellent patency of the anastomoses. There was no operative mortality. Actuarial survival was 98% in a mean follow-up period of 11 +/- 5 months. Minimally invasive coronary artery bypass can be performed safely through a xiphoid approach with low morbidity, mortality, and a relatively short hospital stay.

Comparing MIDCAB surgery and stenting for isolated proximal left anterior descending stenosis

Isolated proximal left anterior descending (LAD) coronary artery stenosis is of prognostic relevance. Proximal stenosis location carries specific features for revascularization either by percutaneous coronary intervention (PCI) or coronary artery bypass grafting. Previous randomized clinical trials comparing bare-metal stenting with minimally invasive direct coronary artery bypass (MIDCAB) surgery in patients with isolated proximal LAD lesions demonstrated a significantly higher reintervention rate for bare-metal stenting than for MIDCAB, and similar results with both options for mortality and reinfarction. However, with the introduction of drug-eluting stents a highly significant reduction in restenosis has been demonstrated. There is only one trial in a limited number of patients comparing PCI with drug-eluting stenting and MIDCAB surgery and it demonstrated noninferiority of PCI with regard to major adverse cardiac events. This article summarizes the current evidence regarding the treatment of isolated...

Facilitated anastomosis using a reverse thermo-sensitive polymer for temporary coronary occlusion in minimally invasive direct coronary artery bypass (MIDCAB) surgery

Objective: To evaluate the safety and efficacy of a reverse thermosensitive novel polymer (LeGoo™) for its ability to allow temporary coronary occlusion and hemostasis while performing LIMA-to-LAD anastomosis during MIDCAB surgery.

Coronary Artery Bypass Graft Versus Drug-Eluting Stent for High-Risk Proximal Left Anterior Descending Stenosis

Determining how to treat a patient with symptomatic isolated proximal left anterior descending coronary artery disease may present a challenge. Previous randomized trials comparing percutaneous coronary intervention (PCI) with bare metal stents with minimally invasive direct coronary artery bypass surgery demonstrated significantly higher reintervention rates for stenting, with similar mortality and reinfarction rates. However, current evidence suggests that the use of drug-eluting stents may reduce the need for repeat revascularization. Also, in recent studies there were fewer periprocedural complications in patients undergoing PCI, with similar death and reinfarction rates. Moreover, the quality of life for patients who have received drug-eluting stents is similar to that of patients who have undergone minimally invasive direct coronary artery bypass surgery. Therefore, PCI with drug-eluting stents is the current treatment of choice for patients with isolated proximal left anterior descending coronary artery disease, unless they have complex lesions or repeated in-stent restenosis. In this article, the current treatment options are reviewed and outlined.

Awake CABG on Beating Heart Under High Thoracic Epidural Anesthesia First Time in BSMMU

Minimally invasive Coronary Artery Bypass Surgery (CABG) using Thoracic Epidural' Anesthesia (TEA) is nowadays considered to be a safe surgical strategy. The objective of TEA is to achieve somatosensory and motor block at TI to T8 level so that CABG can be done in - awake patient. In June 2006 when a 40 year old patient came to us in University Cardiac Centre (UCC) at BSMMU with double-vessel disease for CABG surgery, we considered it an opportunity to try this operation under only high thoracic epidural anesthesia without incubation. After taking the patient's consent, we proceeded to perform the awake CABG on beating heart (ACAS) - an operation attempted for the first time in BSMMU. The patient received TEA via an epidural catheter placed at the level of T1 -T2. Total arterial myocardial revascularization on was performed after sternotomy. The patient well tolerated all phases of the operation. Additional analgesics and sedatives required only during the sternotomy and sternal retraction. The patient's Blood Pressure (BP), SPO2, ABG, ETCO2, ECG, and all other parameters were within normal range throughout the whole procedure. The effect of movement of the chest wall and heart during spontaneous respiration did not affect the conduction of the surgery. The postoperative course was uneventful, and we were able to release the patient from the ICU on the second POD. Journal of BSA, Vol. 20, No. 2, July 2007 p.70-72

Comparison of Minimally Invasive Direct Coronary Artery Bypass Surgery with Implantation of Drug-Eluting Stents in Patients with Left Anterior Descending Coronary Artery Disease

: Bypass surgery and percutaneous coronary interventions improve the clinical status of patients with left anterior descending coronary artery disease. However, these techniques differ in invasiveness and in the need for subsequent reinterventions. The development of minimally invasive direct coronary artery bypass (MIDCAB) surgery and of drug-eluting stents (DES) offers perspectives to close this gap. : We compared the long-term clinical outcome of 308 patients after revascularization for isolated left anterior descending coronary artery disease. One hundred fifty-four patients were treated with MIDCAB and 154 with percutaneous coronary interventions and DES implantation. : Both groups were similar in age (63 ± 13 and 62 ± 10 years), Euroscore (3.3 ± 2.8 and 3.4 ± 2.6), and mean duration of follow-up (30 ± 17 and 24 ± 10 months). Two-year survival was similar after MIDCAB and after DES (97.4% and 94.8%). During follow-up, four patients (2.6%) of the MIDCAB group and 21 patients (13.6%) of the DES group needed subsequent revascularization of the target vessel (P = 0.001). Revascularization of a nontarget vessel was needed in 11 patients (7%) of the MIDCAB group and in 17 patients (11%) of the DES group (NS). Neurologic complications included two transient ischemic accidents and two strokes in the MIDCAB group but three fatal cerebral hemorrhages and one stroke in the DES group. Major adverse coronary and cerebrovascular events rates were 14% in the MIDCAB and 31% in the DES group. : MIDCAB and DES implantation showed similar rates of mortality but a higher reintervention rate after DES. Anticoagulation implications remain critical for the future of DES.

Robotic Right Gastroepiploic Artery Harvesting

: Robotic surgery promises to extend the capabilities of the minimally invasive surgeon, and many surgical specialties are applying this new technology. However, there is no report of robotic harvesting of the right gastroepiploic artery (rGEA). We evaluated the possibility of video-endoscopic dissection of the rGEA using the da Vinci surgical system for use in minimally invasive coronary artery bypass surgery. : The procedure was performed on a porcine rGEA harvesting model using the Tuebingen MIS-Trainer and a pig model. In the pig model, a pneumoperitoneum (maximal pressure, 12 mm Hg) was established after the insertion of a 12-mm trocar (camera) using the open method. The surgical cart was positioned at the head of the pig. A 30-degree three-dimensional camera, using two parallel-arranged three-chip cameras, was inserted and mounted on the middle 12-mm trocar. Under direct visualization, the two lateral surgical arm trocars were then placed at both sides of the camera port. We mounted a permanent cautery hook and Cadiere forceps on the right and left surgical arm, respectively. : We performed harvesting of the rGEA with the permanent cautery hook and Cadiere forceps mounted on the surgical arms. The rGEA were easily visualized and dissection with complete mobilization was achieved without injury in both models. The bleeding from the branch of the rGEA was prevented by use of the permanent cautery hook in the pig model. : We have preliminarily established, in pig, the feasibility of robotic rGEA harvesting without laparotomy, avoiding the risks of abdominal complications and expanding its use for all patients. However, further studies need to be undertaken to prove its practical feasibility in humans using the da Vinci surgical system to make it an effective operation.

Comparison of Minimally Invasive Direct Coronary Artery Bypass Surgery with Implantation of Drug-Eluting Stents in Patients with Left Anterior Descending Coronary Artery Disease

Comparison of Minimally Invasive Direct Coronary Artery Bypass Surgery with Implantation of Drug-Eluting Stents in Patients with Left Anterior Descending Coronary Artery Disease

Randomized Comparison of Minimally Invasive Direct Coronary Artery Bypass Surgery Versus Sirolimus-Eluting Stenting in Isolated Proximal Left Anterior Descending Coronary Artery Stenosis

The purpose of this randomized study was to compare sirolimus-eluting stenting (SES) with minimally invasive direct coronary artery bypass (MIDCAB) surgery for patients with isolated proximal left anterior descending (LAD) coronary artery disease. Bare-metal stenting is inferior to MIDCAB surgery in patients with isolated proximal LAD lesions due to a higher reintervention rate with similar results for mortality and reinfarction. SES are effective in restenosis reduction. A total of 130 patients with significant proximal LAD coronary artery disease were randomized to either SES (n = 65) or MIDCAB surgery (n = 65). The primary clinical end point was noninferiority in freedom from major adverse cardiac events (MACE), such as cardiac death, myocardial infarction, and the need for target vessel revascularization within 12 months. Follow-up was completed for all patients. MACE occurred in 7.7% of patients after stenting, as compared with 7.7% after surgery (p = 0.03 for noninferiority). The individual components of the combined end point revealed mixed results. Although noninferiority was revealed for the difference in death and myocardial infarction (1.5% vs. 7.7%, noninferiority p < 0.001), noninferiority was not established for the difference in target vessel revascularization (6.2% vs. 0%, noninferiority p = 0.21). Clinical symptoms improved significantly in both treatment groups in comparison with baseline, and the percentage of patients free from angina after 12 months was 81% versus 74% (p = 0.49). In isolated proximal LAD disease, SES is noninferior to MIDCAB surgery at 12-month follow-up with respect to MACE at a similar relief in clinical symptoms.

Revascularization of Left Anterior Descending Artery With Drug-Eluting Stents: Comparison With Minimally Invasive Direct Coronary Artery Bypass Surgery

Revascularization of Left Anterior Descending Artery With Drug-Eluting Stents: Comparison With Minimally Invasive Direct Coronary Artery Bypass Surgery

Endoscope-Assisted Minimally Invasive Surgery for Coronary Artery Bypass

Objective: Cardiac surgeons began in this decade to apply the endoscopes in their practices. Endoscopic graft harvest for coronary artery bypass surgery (CABG) has become the routine practice in many institutes. However, endoscopic harvest of the left internal mammary artery (LIMA) has remained a technical challenge. Methods: From April 2002 to April 2004, 40 patients underwent minimally invasive direct CABG using LIMA to left anterior descending (LAD) artery bypass. Twentyone of them had endoscopic harvest of LIMA. Results: There was neither early nor late operative mortality. Endoscopic LIMA harvest time ranged from 38 to 125 minutes (mean 56 minutes). All harvested LIMAs had a burst flow while being cut from the distal end. The length of thoracotomy was 5 to 8 cm (mean 6.2 cm).Ten patients were extubated immediately. One patient had hemothorax which required chest tube insertion. The intensive care unit (ICU) ventilation time was 0 to 40 hours (mean 7 hours). The ICU stay and hospital stay were 1.3±0.3 and 6.2±1.5 days, respectively. Conclusions: Endoscope-assisted LIMA harvest is a feasible technique. The learning curve, however, shows that this approach reduces wound length, recovery time, and helps extend the graft length to facilitate the anastomosis. It provides patients with an alternative choice to have a satisfactory conduit in a minimally invasive way.

Baseline flow in coronary bypass conduits on-pump and off-pump via reversed-J inferior sternotomy

Aims: Minimally invasive coronary artery bypass surgery is a well established procedure for revascularisation of patients with limited coronary artery disease. The aim of the study was to measure the blood flow in coronary artery bypass conduits and to compare the results between on-pump and off-pump MIDCAB-surgery.