Invasive Coronary Bypass Grafting Research Articles

Thirteen Years of Impactful, Minimally Invasive Coronary Surgery: Short- and Long-Term Results for Single and Multi-Vessel Disease

Objectives: Minimally invasive coronary surgery (MICS) via lateral thoracotomy is a less invasive alternative to the traditional median full sternotomy approach for coronary surgery. This study investigates its effectiveness for short- and long-term revascularization in cases of single and multi-vessel diseases. Methods: A thorough examination was performed on the databases of two cardiac surgery programs, focusing on patients who underwent minimally invasive coronary bypass grafting procedures between 2010 and 2023. The study involved patients who underwent either minimally invasive direct coronary artery bypass grafting (MIDCAB) for the revascularization of left anterior descending (LAD) artery stenosis or minimally invasive multi-vessel coronary artery bypass grafting (MICSCABG). Our assessment criteria included in-hospital mortality, long-term mortality, and freedom from reoperations due to failed aortocoronary bypass grafts post-surgery. Additionally, we evaluated significant in-hospital complications as secondary endpoints. Results: A total of 315 consecutive patients were identified between 2010 and 2023 (MIDCAB 271 vs. MICSCABG 44). Conversion to median sternotomy (MS) occurred in eight patients (2.5%). The 30-day all-cause mortality was 1.3% (n = 4). Postoperative AF was the most common complication postoperatively (n = 26, 8.5%). Five patients were reoperated for bleeding (1.6%), and myocardial infarction (MI) happened in four patients (1.3%). The mean follow-up time was six years (±4 years). All-cause mortality was 10.3% (n = 30), with only five (1.7%) patients having a confirmed cardiac cause. The reoperation rate due to graft failure or the progression of aortocoronary disease was 1.4% (n = 4). Conclusions: Despite the complexity of the MICS approach, the results of our study support the safety and effectiveness of this procedure with low rates of mortality, morbidity, and conversion for both single and multi-vessel bypass surgeries. These results underscore further the necessity to implement such programs to benefit patients.

Feasibility and safety of minimally invasive cardiac coronary artery bypass grafting surgery for patients with multivessel coronary artery disease: Early outcome and short-mid-term follow up results

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.

Minimally Invasive Coronary Bypass Grafting as a Standard Approach for Myocardial Revascularization

&#x0D; Background. Minimally invasive cardiac surgery is becoming more widespread.&#x0D; The aim of the study was to evaluate the outcomes in 343 consecutive patients with isolated multivessel coronary artery disease who underwent minimally invasive coronary revascularization.&#x0D; Materials and methods. From July 2017 to December 2019 we performed total coronary revascularization via left anterior minithoracotomy (TCRAT) in 343 consecutive patients with isolated multivessel coronary artery disease. In 83 (24.2%) of them we performed multiarterial revascularization using left internal mammary artery (LIMA) and T-shunt with left radial artery or right internal mammary artery (RIMA). Cardiopulmonary bypass (CPB), aortic cross-clamping and blood cardioplegia were used in all patients. The patients were divided into two groups, uniarterial and multiarterial, to compare and analyze perioperative parameters.&#x0D; Results. No cases of postoperative myocardial infarction, surgically induced infection, or conversion to sternotomy were observed in any of the study groups. Total perioperative mortality was 0.58% (2 patients). Total operation time (290.6±48 [205; 495] versus 259.4±53.3 [165; 590], p=0.0001) and aortic cross-clamping time (81.6±18.7 [40; 122] versus 67±18 [35; 146], p&lt;0.0001) were longer in patients with multiarterial revascularization compared to those with uniarterial revascularization. The patient’s mean age in the multiarterial group was 7.4 years less than in the uniarterial group. The mean hospital stay was 0.5 days shorter in the multiarterial group.&#x0D; Conclusions. The technique of minimally invasive coronary artery bypass grafting via left anterior thoracotomy avoids median sternotomy in 97.7% of patients. Both strategies for minimally invasive myocardial revascularization (multiarterial and uniarterial) are safe and effective with comparable perioperative outcomes and a total mortality of 0.58%.

Editorial introductions

Current Opinion in Cardiology was launched in 1985. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of cardiology is divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Alan BravermanAlan BravermanDr Braverman is a graduate of the University of Missouri-Kansas City School of Medicine, USA. He completed a residency in internal medicine and cardiology fellowship at Brigham and Women's Hospital and Harvard Medical School, USA, and served as Chief Medical Resident. In 1991, Dr Braverman joined the faculty at Washington University School of Medicine in St. Louis, USA, where he is currently the Alumni Endowed Professor in Cardiovascular Diseases. Dr Braverman is actively involved in the education of students, house staff and fellows at Washington University and serves as a Director of the Inpatient Cardiology Firm at Barnes-Jewish Hospital, USA. He has been awarded Teacher of the Year Award by the internal medicine residents on five occasions, the Clinical Teacher of the Year Award by the Washington University Medical Students Class of 2004, and the Benico Barzilai Teaching Award by the cardiology fellows in 2016, and the Hugh McCullough Award from the American Heart Association. In 2010, Dr Braverman was bestowed the E. Grey Dimond Take Wing Award from the University of Missouri-Kansas City. He is a Clinical Cardiologist and has a particular interest in diseases of the aorta, Marfan syndrome and hereditary aneurysm conditions. He is the Director of the Marfan Syndrome Clinic at Washington University in St. Louis and serves on the Professional Advisory Board and the Board of Directors of the Marfan Foundation. He has been awarded the Antoine Marfan Award from the Marfan Foundation in 2003. Dr Braverman is actively involved in clinical research on Marfan syndrome and related aortic diseases, including genetically triggered aortopathy, aortic dissection, and bicuspid aortic valve aortopathy. Marc RuelMarc RuelDr Marc Ruel is the Michael Pitfield Professor and Chair of the Division of Cardiac Surgery at the University of Ottawa Heart Institute, Canada. His areas of predilection include minimally invasive coronary and valve surgeries, heart transplantation, as well as complex and repeat cardiac operations. He co-developed and taught in several countries minimally invasive multivessel coronary bypass grafting -now frequently performed around the world- and introduced other novel cardiac surgical techniques on the international scene. Dr Ruel established a successful regenerative medicine research program in Ottawa, which has been continuously funded by national funding agencies for over 15 years. He was the recipient of many awards, including the Medal in Surgery from the Royal College of Physicians and Surgeons of Canada, and the Queen Elizabeth II Diamond Jubilee Medal. He led numerous studies and clinical trials on the outcomes of valve and coronary surgery. Dr Ruel has authored more than 300 publications, and written textbooks on Cardiac Surgery Techniques and on Cardiac Regeneration. He is the President-Elect of the Canadian Cardiovascular Society, the Canadian Director of the Society of Thoracic Surgeons, the past-Chairman of the Council on Cardio-Vascular Surgery and Anesthesia at the American Heart Association, and the Surgery Theme Editor for the journal Circulation. Peter H. StonePeter H. StonePeter H. Stone, MD, is a Professor of Medicine at Harvard Medical School, USA, Director of the Vascular Profiling Research Group, a Co-Director of the Center for Clinical Investigation, and Senior Physician at Brigham & Women's Hospital, USA. Dr Stone's research interests are in evaluating and managing patients with acute and chronic coronary artery disease. He is using new in-vivo methodologies to identify areas where human coronary disease will progress to determine if pre-emptive therapeutic strategies may avert adverse cardiac events. He received his undergraduate degree from Princeton University, USA, and his Medical Degree from Cornell University, USA. He completed internal medicine training at the University of California, San Francisco, USA, and then did a clinical cardiology fellowship at Pacific Medical Center in San Francisco, USA. He came to the Peter Bent Brigham Hospital as a Cardiology Research Fellow and he has remained at Brigham and Women's Hospital. He is past President of the Boston Chapter of the American Heart Association, past President of the International Society for Holter and Noninvasive Electrocardiology, and is a Fellow of the American College of Cardiology and the American Heart Association.

ІННОВАЦІЙНИЙ ПІДХІД – МІНІІНВАЗИВНЕ БАГАТОСУДИННЕ КОРОНАРНЕ ШУНТУВАННЯ В УМОВАХ ПЕРЕДНЬОЇ ТОРАКОТОМІЇ

Personal experience with minimally invasive multivessel coronary grafting through left anterior thoracotomy is described. Currently, we use this technique routinely, regardless of the number of grafts, quality, and location of coronary targets, left ventricular ejection fraction, age, gender, body mass index. Our aim was to develop minimally invasive coronary artery bypass grafting technique, which would be equally effective and safe as compared to the conventional coronary grafting technique; would be reproducible and be applied for every patient with isolated coronary artery disease. 220 patients were operated and then analyzed. In all patients, complete revascularization was performed. Mean number of grafts was 3.37± 0.68 per patient (range 2-5). Left internal mammary artery was used in 206 patients, right internal mammary artery - in 4 patients, radial artery - in 37 patients, vein grafts - in 193 patients. Complete arterial revascularization was performed in 29 patients. We had no mortality. Mean aortic cross-clamp time was 70.7 ± 18.7 min (range 31 - 146 min). Mean cardiopulmonary bypass time was 137.5 ± 31.9 min (range 71 - 339 min). Postoperatively, total drainage in the first 12 hours was 376.7 ± 205.4 ml, ventilation time was 2.6 ± 1.4 hours, ICU stay was 2.3 ± 1.2 days. Conclusion. Minimally invasive coronary bypass grafting is an effective and safe surgical method. Complete revascularization could be performed regardless of the number of grafts, left ventricle ejection fraction, quality and size of coronary vessels, or age of the patient.

Пластика аневризми лівого шлуночка при малоінвазивному багато- судинному коронарному шунтуванні

Пластика аневризми лівого шлуночка при малоінвазивному багато- судинному коронарному шунтуванні

Efficacy of oxycodone combined with thoracic paravertebral block for postoperative analgesia in patients undergoing minimally invasive direct coronary artery bypass grafting

Objective To evaluate the efficacy of oxycodone combined with thoracic paravertebral block (TPVB) for postoperative analgesia in patients undergoing minimally invasive direct coronary artery bypass grafting (MIDCABG). Methods Thirty-two American Society of Anesthesiologists physical status Ⅱ or Ⅲ patients of both sexes, aged 60-75 yr, weighing 50-85 kg, scheduled for elective MIDCABG under general anesthesia, were divided into 2 groups (n=16 each) using a random number table method: morphine plus TPVB group (group MT) and oxycodone plus TPVB group (group OT). Paravertebral catheter was placed at T4, 5 before induction of anesthesia to perform left thoracic paravertebral puncture, patients were tracheally intubated, and 0.375% ropivacaine 15 ml was injected followed by continuous infusion of 0.375% ropivacaine 5 ml/h until 0.5 h before the end of surgery.Both groups received patient-controlled analgesia (PCA) after surgery.The PCA solution contained 1 mg/ml morphine 60 ml in group MT or 1 mg/ml oxycodone 60 ml in group OT, and the PCA pump was set up to deliver a 1 mg bolus dose with a 10-min lockout interval and background infusion at 1 ml/h after a loading dose of 2 mg, with the maximum dose of 20 mg every 4 h. Pethidine 50 mg was intravenously injected as a rescue analgesic to maintain visual analog scale≤4.The intraoperative consumption of fentanyl, consumption of analgesics for PCA within 48 h after surgery, ratio of total to effective pressing times of PCA, consumption of analgesics for rescue analgesia, requirement for rescue analgesia, score of satisfactory analgesia, extubation time, duration of intensive care unit stay and length of hospital stay were recorded.The development of nausea and vomiting, pruritus, respiratory depression, atelectasis and somnolence was recorded within 72 h after surgery. Results Compared with group MT, the intraoperative consumption of fentanyl, consumption of analgesics for PCA, consumption of analgesics for rescue analgesia, requirement for rescue analgesia and ratio of total to effective pressing times of PCA were significantly decreased, the score of satisfactory analgesia was increased, the extubation time and duration of intensive care unit stay were shortened, and the incidence of nausea and vomiting, pruritus, respiratory depression and somnolence was decreased in group OT (P<0.05). Conclusion Oxycodone combined with TPVB provides safe and effective efficacy for postoperative analgesia in patients undergoing MIDCABG. Key words: Oxycodone; Analgesia, patient-controlled; Nerve block; Coronary artery bypass, off-pump

Minimally invasive direct coronary bypass surgery via distal mini-sternotomy

Minimally invasive direct coronary artery bypass grafting (MIDCAB) was developed to decrease perioperative morbidity, some of which may be related to the use of cardiopulmonary bypass and to cross-clamping of the aorta. We report our initial experience with multivessel MIDCAB via distal mini-sternotomy (DIMS). DIMS is performed to gain access to the left and right internal thoracic arteries and to reach the left anterior descending coronary artery (LAD), diagonal branches, and right coronary artery (RCA). Between January 2016 and January 2017, 12patients with significant coronary artery disease of the LAD and the RCA underwent multivessel, all-arterial MIDCAB through adistal midline skin incision from the fourth intercostal space to the xyphoid process, with L‑ or T‑shaped division of the sternum. The mean age of the patients was 61.5 ± 5.2years (range: 52-71years). We performed all-arterial revascularization using the left internal mammary artery in 12patients, the radial artery in ten, and the right internal mammary artery in twopatients. The mean number of grafts per patient was 2.08 ± 0.4 (range: 2-3). The mean length of the skin incision was 8.5 ± 1.3 cm (range: 7-11 cm). There was no perioperative ischemia, postoperative bleeding, or arrhythmia events. No postoperative cognitive dysfunction occurred. The mean hospital stay was 5.6days. No major adverse cardiac events (MACE) occurred at the 12-month follow-up. At follow-up, all patients were in New York Heart Association classI and there were no wound complications. Although MIDCAB-DIMS is technically more demanding than conventional procedures and our experience is limited, we conclude that this technique can be used safely in selected patients, with promising 12-month follow-up results.

Minimally invasive cardiac surgery coronary artery bypass grafting (MICS CABG): a review of technique and literature

Minimally invasive cardiac surgery has emerged as a safe alternative to standard cardiac surgery. Minimally invasive coronary surgery (MICS CABG) is developed to allow adequate exposure and complete revascularization in CABG from a small thoracotomy incision without cardiopulmonary bypass. The literature of the technique and evidence of the MICS CABG procedure is reviewed. In its earlier phase, MICS CABG required the adherence to a number of absolute and relative contraindications. The technique continues to evolve, and in addition to multi-vessel revascularization, bilaterally internal thoracic artery take down are currently feasible to allow for multi-arterial grafting. The success of an MICS CABG procedure also requires cooperation between the surgeon, anesthesiologist, and perfusionist and diligent management of hemodynamics. To date, 11 articles have been published on experiences with MICS CABG. MICS CABG is a safe alternative to sternotomy CABG in early and long-term post-operative mortality and morbidity, and has significantly shorter length of hospital stay and earlier post-operative physical recovery compared to sternotomy CABG. Evidences are emerging that MICS CABG maintains equivocal safety profile to sternotomy CABG, while providing superior morbidity profile and post-operative recovery. Further randomized control trials involving the comparison between MICS CABG and PCI or traditional CABG would widen the applicability and utilization of the procedure.

Editorial introductions

Current Opinion in Cardiology was launched in 1985. It is part of a successful series of review journals whose unique format is designed to provide a systematic and critical assessment of the literature as presented in the many primary journals. The field of cardiology is divided into 14 sections that are reviewed once a year. Each section is assigned a Section Editor, a leading authority in the area, who identifies the most important topics at that time. Here we are pleased to introduce the Section Editors for this issue. SECTION EDITORS Alan C. BravermanAlan C. BravermanDr Braverman is a graduate of the University of Missouri-Kansas City School of Medicine, USA. He completed a residency in internal medicine at Brigham and Women's Hospital and Harvard Medical School, USA, and served as Chief Medical Resident. Dr Braverman also completed cardiology fellowship training at Brigham and Women's Hospital. In 1991, Dr Braverman joined the faculty at Washington University School of Medicine in St. Louis, Missouri, where he is currently the Alumni Endowed Professor in Cardiovascular Diseases. Dr Braverman is actively involved in the education of students, house staff and fellows at Washington University and serves as Director of the Inpatient Cardiology Firm at Barnes-Jewish Hospital, USA. He has been awarded Teacher of the Year Award by the internal medicine residents on five occasions, the Clinical Teacher of the Year Award by the Washington University Medical Students Class of 2004, and the Benico Barzilai Teaching Award by the cardiology fellows in 2016. In 2010, Dr Braverman was awarded the E. Grey Dimond Take Wing Award from the University of Missouri-Kansas City. Dr Braverman is a Clinical Cardiologist and has a particular interest in diseases of the aorta and Marfan syndrome and related disorders. He is the Director of the Marfan Syndrome Clinic at Washington University in St. Louis and serves on the Professional Advisory Board of the National Marfan Foundation. Dr Braverman is actively involved in clinical research on Marfan syndrome and related aortic diseases, including genetically triggered aortopathy and bicuspid aortic valve disease. Marc RuelMarc RuelDr Marc Ruel is the Michael Pitfield Chair, Professor, and Head of the Division of Cardiac Surgery at the University of Ottawa Heart Institute. Dr Ruel's areas of predilection include minimally invasive coronary and valve surgeries, heart transplantation, as well as complex and repeat cardiac operations. He co-developed and taught in many countries minimally invasive multivessel coronary bypass grafting -now frequently performed around the world-, and introduced several other novel cardiac surgical techniques on the international scene. Dr Ruel established a successful regenerative medicine research program in Ottawa, which has been continuously funded by national funding agencies for more than 15 years. He was the recipient of many awards, including the Medal in Surgery from the Royal College of Physicians and Surgeons of Canada, and the Queen Elizabeth II Diamond Jubilee Medal. He led multiple studies and clinical trials on the outcomes of valve and coronary surgery. Dr Ruel has authored nearly 300 publications, and written textbooks on Cardiac Surgery Techniques and on Cardiac Regeneration. He is the Chairman of the Council on Cardio-Vascular Surgery and Anesthesia at the American Heart Association, the Surgery Theme Editor for the journal Circulation, and he also serves on the executive of the Canadian Cardiovascular Society, the American Association for Thoracic Surgery, and the International Society for Minimally Invasive Cardiothoracic Surgery. Peter H. StonePeter H. StonePeter H. Stone, MD, is a Professor of Medicine at Harvard Medical School, USA, Director of the Vascular Profiling Research Group, a co-Director of the Center for Clinical Investigation, and Senior Physician at Brigham & Women's Hospital (BWH), USA. Dr Stone's research interests are in evaluating and managing patients with acute and chronic coronary artery disease. He is using new in-vivo methodologies to identify areas where human coronary disease will progress to determine if pre-emptive therapeutic strategies may avert adverse cardiac events. He also directs the BWH Research Ambulatory ECG (Holter) Core Laboratory to investigate the significance of myocardial ischemia and heart rate variability in patients with coronary syndromes. He received his undergraduate degree from Princeton University, and his Medical Degree from Cornell University. He completed internal medicine training at the University of California, San Francisco, and then did a clinical cardiology fellowship at Pacific Medical Center in San Francisco. He came to the Peter Bent Brigham Hospital as a Cardiology Research Fellow and he has remained at BWH. He is past President of the Boston Chapter of the American Heart Association, past President of the International Society for Holter and Noninvasive Electrocardiology, and is a Fellow of the American College of Cardiology and the American Heart Association.

Continuous Procedural Full-Lung Ventilation During Minimally Invasive Coronary Bypass Grafting

In the past, minimally invasive cardiac surgery (MICS)- coronary artery bypass graft surgery (CABG) alternatives have been introduced that dramatically reduce the invasiveness of standard operative procedures while still showing excellent clinical outcomes. However, in patients with high morbidity, reduced lung function impeding single-lung ventilation is one of the major concerns for MICS-CABG procedures, although those patients might reap the largest benefit from a procedure of reduced invasiveness. Here, we describe a simple surgical technique-the fan technique-that allows for continuous full-lung ventilation with unimpeded surgical view during common MICS-CABG procedures. To evaluate the procedural feasibility of this technique, we analyzed intraoperative ventilation measurements of 22 consecutive MICS-CABG patients in whom the fan technique was used. This study demonstrates a significant improvement of standard respiratory measurements during procedural full-lung ventilation using the fan technique as compared with conventional single-lung ventilation (ventilation pressure 21.4 ± 3.2 versus 26.6 ± 3 mbar, p < 0.001; respiratory rate 13.1 ± 1.4 versus 14.4 ± 2.2 breaths per minute, p < 0.001; minute volume 7.4 ± 1.1 versus 6.2 ± 1 L/min, p < 0.0001; Pao2 during ventilation 294.9 ± 74.6 versus 153.2 ± 71 mm Hg, p < 0.0001). The presented technique may not only enable us to perform MICS-CABG procedures in patients not suitable for single-lung ventilation owing to reduced pulmonary function, but also may soon also become a standard procedure for MICS-CABG surgery, especially with regard to procedures involving complex and time-consuming multivessel revascularizations. However, further studies are strongly warranted to assess whether the fan technique may also decrease postoperative pulmonary complications and benefit clinical outcome indicators.

Predictors and Outcomes of Sternotomy Conversion and Cardiopulmonary Bypass Assistance in Minimally Invasive Coronary Artery Bypass Grafting.

This work's objective was to identify the determinants of conversion of minimally invasive coronary artery bypass grafting to sternotomy, with and without cardiopulmonary bypass assistance, and to compare clinical outcomes in patients who needed conversion. This is a prospectively collected data on patients who underwent minimally invasive coronary bypass done by a single surgeon from February 2005 to September 2014. Statistical analyses were expressed as mean values ± standard deviation or proportions. The total number of patients was 266, with an average age of 62 years. The median number of grafted territories was 2, higher in those with pump assistance (median, 3 grafts; P ≤ 0.01). Predictors for use of cardiopulmonary bypass included diabetes, 3-vessel disease, left circumflex involvement, and small target vessels (P < 0.05). The rate for sternotomy conversion was 3.8%. Risk factors for conversion to sternotomy included smoking, preoperative bradycardia (<50 beats per minute), low intraoperative ejection fraction, inability to tolerate one-lung ventilation, inadequate surgical exposure, and hemodynamic instability. Postoperative complications included superficial thoracotomy infection (3%), sternotomy infection (10%), new atrial fibrillation (3%), and need for blood transfusion (14%). Twelve patients (5%) developed left-sided pleural effusion that required drainage. There were no perioperative deaths, major adverse cardiac event, or stroke. Minimally invasive coronary bypass grafting with conversion to sternotomy and use of cardiopulmonary bypass is safe. Conversions may be alleviated by an effort to optimize modifiable risk factors and the adequacy of surgical exposure. These data may help develop objective selection criteria to identify patients who are excellent candidates for the procedure.

左前胸部小切開にてオフポンプ3 枝MICS CABG を施行した1 治験例

今回，左前胸部第4 肋間小開胸によりMICS CABG（minimally invasive cardiac surgery coronary artery bypass grafting）を行い良好な結果を得たので文献的考察を含めて報告する．症例は68 歳女性．登坂時に胸痛を自覚し近医受診．冠動脈造影検査にて左主幹部50％病変を含む3 枝病変と診断され手術となった．左主幹部の病変は50％の狭窄であり血流が多いことが考えられたので，回旋枝には大伏在静脈を用いる方針とした．その結果よりインフォームドコンセントを行い左小開胸によるMICS CABG を施行した．手術は左第4 肋間開胸によるアプローチで施行．左内胸動脈を採取と同時に下肢から小切開にて大伏在静脈も採取した．開胸部から上行大動脈を部分遮断下し，2 本の大伏在静脈を上行大動脈にそれぞれ吻合した．その後スタビライザーとハートポジショナーを用いて左前下行枝にLITA を，回旋枝，右後下行枝にSVG を吻合した．手術は人工心肺を用いず無輸血にて終了した．術後経過は良好であり冠動脈CT 検査にて全てのグラフトの開存を確認し，術後第12 病日に退院となった．本法は人工心肺を用いず，かつ胸骨正中切開を行わない術式であり，冠動脈バイパス術の新たなオプションとして極めて有用であると考えられた．

Сравнительный анализ результатов миниинвазивной реваскуляризации миокарда, коронарного шунтирования на работающем сердце и с искусственным кровообращением

Сравнительный анализ результатов миниинвазивной реваскуляризации миокарда, коронарного шунтирования на работающем сердце и с искусственным кровообращением

Compliance with pharmacological treatment among patients after minimally invasive coronary bypass grafting

We sought to evaluate patients' adherence to optimal pharmacotherapy as recommendedby the European Society of Cardiology, together with the assessment of potential clinical determinants of medical non-compliance in a large cohort of patients after endoscopic atraumatic coronary artery bypassing (EACAB). This cross sectional study was conducted in a group of 706 individuals who underwent EACAB between April 1998 and December 2010. Data covering current pharmacological treatment with antiplatelet agents, beta-blockers (BB) (or heart rate lowering calcium channel blockers [CCB] in case of intolerance and/or poor efficacy of beta-blockade), angiotensin-converting enzyme (ACE) inhibitors (or angiotensin receptor blockers [ARB]) and statins was acquired. Mean duration of observation after the surgery was 2132 ± 1313 days. Complete follow-up data has been obtained from 415 living patients (341 males). Amongst them, 353 (85%) received antiplatelet agents, while BB or CCB were routinely ingested by 349 (84%) patients. Statins were used by 310 (74.7%) individuals and 274 (66%) subjects took ACE inhibitors or ARB. Baseline demographic and clinical features, including major co-morbidities had no impact on patients' compliance with all investigated medications. There was no clear association between adherence to treatment and risk of rehospitalization or occurrence of major cerebral and cardiovascular events. EACAB patients' compliance with pharmacotherapy guidelines is insufficient and is unrelated to demographic and clinical features of the subjects. Multidisciplinary approach involving health education, enhancement in prescription drug affordability and a better rapport between doctors and patients should be incorporated into clinical practice to overcome therapeutic disobedience.

Robotic internal thoracic artery harvesting and the mid-term follow up of arterial graft patency

To summarize our experience of robotic internal thoracic artery (ITA) skeletonized harvesting in Asian patients and evaluate the learning curves of robotic ITA harvesting and ITA graft patency. A total of 200 patients underwent totally robotic ITA takedown at our department from April 2007 to August 2012. ITA was harvested in a skeletonized fashion and learning curve estimated. Coronary artery bypass grafting was completed in minimally invasive direct coronary artery bypass graft (MIDCAB) or totally endoscopic coronary bypass graft on beating heart (BH-TECAB) manners after robotic ITA harvesting. The coronary angiography or 64-MSCT was performed to evaluate the patency of ITA graft before discharge and at Year 1-5 postoperatively. One patient underwent median sternotomy for severe plural adhesion. Left ITA (LITA, n = 190), right ITA (RITA, n = 5) and double-ITA (n = 4) were harvested. The mean duration of single ITA harvesting was 18-70 (35.8 ± 10.7) min. A significant learning curve was observed: y (min) = 58.0 - 5.3×ln(x) (r(2) = 0.33, P < 0.01). ITA patency was 98.1% at Year 1 and 97.8% at Year 2 postoperatively respectively. And there was no recurrence of ITA occlusion at Years 3-5. Robotic ITA takedown is a prerequisite for totally endoscopic coronary bypass graft and can be performed safely and within an acceptable time after overcoming a learning curve. ITA graft patency has comparable outcomes of conventional surgery.

Comparison of arterial and venous coronary artery bypass flow measurements using 3-T magnetic resonance phase contrast imaging

Comparison of arterial and venous coronary artery bypass flow measurements using 3-T magnetic resonance (MR) phase contrast in correlation with intraoperative Doppler flow measurements. Fifty-six coronary bypasses (right coronary artery n=18, left internal mammary artery to left anterior descending artery n=16, marginal artery n=7, circumflex artery n=7, diagonal artery n=6, left anterior descending artery n=1, and right internal mammary artery to right coronary artery n=1) were studied in 27 asymptomatic patients. In this prospective study, each bypass was studied intra-operatively using Doppler flow measurement. Within one week post surgery, patients were studied using a 3-T MR scanner (Magnetom Verio, Siemens, Erlangen, Germany) using velocity encoded phase-contrast flow measurements. Intraoperative Doppler flow measurements demonstrated regular flow patterns in all vascular territories supplied. All bypasses were patent on MRI and flow measurement results were as follows: median flow 60ml/min (interquartile range (IQR): 37.5-78.5ml/min). For comparison, the corresponding median intraoperative flow was 58ml/min (IQR: 41-80ml/min) (p<0.001; R=0.44). Linear regression analysis demonstrated a significant correlation for venous bypasses (p=0.0002; R=0.48), but not for arterial bypasses (p=0.09; R=0.24). This study demonstrated that MR flow measurements of venous bypass grafts agreed more with Doppler than arterial bypass grafts. However, bypass patency was confirmed for all patients. In the future, this technique may be used for non invasive coronary bypass graft follow-up.

A meta-analysis of randomized control trials comparing minimally invasive direct coronary bypass grafting versus percutaneous coronary intervention for stenosis of the proximal left anterior descending artery

Percutaneous intervention (PCI) and minimally invasive direct coronary bypass grafting (MIDCAB) are both well-accepted treatment options for isolated high-grade stenosis of proximal left anterior descending coronary artery. Small studies comparing the two modalities have yielded conflicting results. We performed a meta-analysis of randomized control trials to compare percutaneous intervention with minimally invasive coronary bypass grafting for isolated proximal left anterior descending artery stenosis. Five randomized trials with a total of 711 patients and average follow-up of 2.3 years were included in the analysis; 380 patients received stents and 331 underwent surgery. Only one trial used drug eluting stents. There were a small number of events overall in each trial. Difference between mortality was 12 events versus 15 between the PCI versus MIDCAB group. Similarly, the difference in myocardial infarction was 14 versus 10, and target vessel revascularization was 56 versus 19. The relative risk for stenting versus MIDCAB was 0.96 [(95% CI: 0.47, 1.99), p=0.92, I(2)=17.5%], for mortality and myocardial infarction, 0.77 [(95% CI: 0.30, 2.01), p=0.60, I(2)=10.4%] for mortality and 1.81 [(95% CI: 0.80, 4.06), p=0.15, I(2)=65.9%] for the composite end point of mortality, myocardial infarction and target vessel revascularization. Excluding the trial with drug eluting stents the relative risk for the composite outcome of mortality, myocardial infarction and target vessel revascularization was significantly higher for PCI [RR=2.27 (95% CI: 1.32, 3.90), p=0.003, I(2)=18.9%]. Overall mortality and myocardial infarction rates are similar for bare metal stents versus MIDCAB, but surgery was associated with significantly lower rates of repeat revascularization. The number of randomized patients and events were small. The effect of drug eluting stents might close the gap of repeat revascularization compared to MIDCAB for this disease.

Robot Assisted Left Internal Thoracic Artery Harvesting in Minimally Invasive Direct Coronary Artery Bypass: Report of a Case

Coronary artery bypass grafting (CABG) is usually performed through a sternotomy. Minimally invasive direct coronary artery bypass grafting (MIDCABG) has been used recently in a select group of patients with severe lesions of the left anterior descending (LAD) coronary artery. CABG has been proven difficult to adapt to a totally endoscopic approach because of the inability to perform a precision microvascular-sutured coronary anastomosis with conventional endoscopic instrumentation. The Da Vinci telemanipulation system has six degrees of freedom and allows free orientation in space and a remote, tremor-free, three-dimensional visual image. We report hereby a 76-year-old male who suffered from substernal chest pain that radiated to the left shoulder for one day. Coronary angiography confirmed coronary artery disease with 90% occlusion of the LAD coronary artery. The patient volunteered to receive the operation. Robotically assisted left internal thoracic artery (LITA) harvesting and direct off-pump anastomosis to the LAD through small thoracotomy incisions were performed safely. The patient improved clinically and was free of angina at the six-month follow-up. We describe an alternative procedure for one-vessel disease using robotic takedown of the LITA and off-pump anastomosis to the LAD artery through small incisions. This procedure is associated with minimal blood loss and ventilatory requirements, and short stays in the intensive care unit and hospital.

Stress Doppler echocardiography of the internal thoracic artery - a new non-invasive approach for functional assessment after minimally invasive coronary bypass grafting

Minimally invasive surgery for coronary revascularization using the left internal thoracic artery (ITA) has gained increasing interest. For control of graft function the established transcutaneous color-Doppler echocardiography in combination with a stress-test was performed to test the ability of this novel technique. Twenty-one patients having received a single ITA-graft were evaluated early postoperatively at rest and during isometric stress test with a handgrip exercise. Compared to the right internal thoracic artery, the mainly systolic flow is changed to a wide diastolic component when the left ITA is anastomosed to the coronary artery. The peak systolic/peak diastolic velocity ratio changed from 4.5+/-1.9 to 1.4+/-0.47 (P<0.0001). During stress reaction with the isometric handgrip maneuver the grafted ITA showed a significant increase of the mean diastolic flow (29.1+/-13.3 to 44.3+/-14.7 cm/s, P<0.0001) and total blood flow (124.8+/-55.4 ml/min to 176.6+/-71.7 ml/min), which may demonstrate an efficient bypass function. We conclude, that the noninvasive measurement of ITA-graft function with Doppler-ultrasound may be a clinically useful method to assess the functional status after minimally invasive coronary artery bypass grafting. In combination with the hand-grip test it represents a valid new technique with the potential to estimate graft patency.