Invasive Direct Coronary Bypass Grafting Research Articles

Fractional Flow Reserve-Guided Hybrid Coronary Revascularization in Multi-Vessel Coronary Arteries Disease

Coronary artery bypass grafting without cardiopulmonary bypass (OPCABG) as a minimally invasive cardiac surgery (MICS) procedure has been used increasingly to treat coronary artery disease. We present our experience using off-pump minimally – invasive direct coronary artery bypass grafting (OPMIDCAB) and fractional flow reserve (FFR) – guided percutaneous coronary interventions (PCI) strategy for coronary revascularization.
 Purpose. Presentation of our experience in FFR – guided hybrid coronary revascularization in patients with multi – vessel coronary artery disease.
 Conclusion. A hybrid procedure that changes a conventional CABG of all stenotic arteries, into a FFR – guided PCI is an appealing way to minimize the risk of complex heart surgery, combining positive outcomes of CABG along with low stent restenosis and thrombosis rates compared to venous grafts.

Short-term clinical outcomes and long-term survival of minimally invasive direct coronary artery bypass grafting.

Minimally invasive direct coronary artery bypass (MIDCAB) grafting is regarded as an alternative to conventional coronary artery bypass grafting (CABG) through full sternotomy, particularly for patients with isolated proximal left anterior descending (LAD) artery stenosis deemed unsuitable for percutaneous coronary intervention. However, the technically demanding nature of the procedure and lack of long-term published outcomes have precluded its universal adoption. We report the comparative short-term outcomes and long-term survival of MIDCAB and conventional CABG through full sternotomy for grafting of isolated LAD. From February 1996 to October 2017, a total of 668 patients underwent MIDCAB (n=508) and full sternotomy (n=160) CABG for isolated proximal LAD stenosis. Their data were prospectively entered into the institutional cardiac surgery database (Patients Analysis & Tracking System; Dendrite Clinical Systems, Ltd, Oxford, England, United Kingdom) and analyzed retrospectively. Information on patient deaths was obtained from the institutional database and the National General Register Office for all patients. The two groups were comparable with respect to preoperative demographics and risk profile. MIDCAB was associated with longer operative time (177±32 versus 141±12 min; P=0.003). The two groups did not significantly differ with regard to other complications including operative mortality. At a mean follow-up of 12.95±0.47 years, survival was also similar. This large single centre study with longest follow-up validates the status of MIDCAB as an effective strategy for grafting of LAD. However, it fails to show superiority of the minimally invasive approach compared to conventional CABG through full sternotomy.

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.

Mid-Term Results of Minimally Invasive Direct Coronary Artery Bypass Grafting.

BackgroundMinimally invasive direct coronary artery bypass grafting (MIDCAB) has the advantage of allowing arterial grafting on the left anterior descending artery without a sternotomy incision. We present our single-center clinical experience of 66 consecutive patients.MethodsAll patients underwent MIDCAB through a left anterior small thoracotomy between August 2007 and July 2015. Preoperative, intraoperative, postoperative and follow-up data—including major adverse cardiovascular and cerebrovascular events (MACCE), graft patency, and the need for re-intervention—were collected.ResultsThe mean age of the patients was 69.4±11.1 years and 73% were male. There was no conversion to an on-pump procedure or a sternotomy incision. The 30-day mortality rate was 1.5%. There were no cases of stroke, although 2 patients had to be re-explored for bleeding, and 81.8% were extubated in the operating room or on the day of surgery. The median stay in the intensive care unit and in the hospital were 1.5 and 9.6 days, respectively. The median follow-up period was 11 months, with a 5-year overall survival rate of 85.3%±0.09% and a 5-year MACCE-free survival rate of 72.8%±0.1%. Of the 66 patients, 32 patients with 36 grafts underwent a postoperative graft patency study with computed tomography angiography or coronary angiography, and 88.9% of the grafts were patent at 9.7±10.8 months postoperatively.ConclusionMIDCAB is a safe procedure with low postoperative morbidity and mortality and favorable mid-term MACCE-free survival.

Minimally invasive direct coronary artery bypass grafting in a 17-year-old patient with left anterior descending coronary artery compression in follow-up after arterial switch operation.

Minimally invasive direct coronary artery bypass grafting in a 17-year-old patient with left anterior descending coronary artery compression in follow-up after arterial switch operation.

MINIMALLY INVASIVE CABG REDUCES TARGET VESSEL REVASCULARIZATIONS IN COMPARISON TO PCI WITHOUT INCREASED MAJOR ADVERSE EVENTS: A META-ANALYSIS OF RANDOMIZED TRIALS

Background: The trials comparing Minimally Invasive Direct Coronary Artery Bypass Graft (MIDCABG) with Percutaneous Coronary Intervention (PCI) for proximal Left Anterior Descending Artery (LAD) stenosis show conflicting results. Methods: The PubMed, EMBASE, and Cochrane Central Register of

Is the Future of Coronary Arterial Revascularization a Hybrid Approach?: The Canadian Experience Across Three Centers.

Hybrid coronary revascularization offers and combines the advantages of both surgical and percutaneous revascularization and eliminates at the same time the disadvantages of both procedures. The objective of this study was to assess graft and stent patency at 6 months, rate of bleeding, intensive care unit and hospital stay, rate of reintervention, and long-term clinical follow-up. From March 2004 to November 2015, a total of 203 patients underwent robotic-assisted minimally invasive direct coronary artery bypass graft of the left internal thoracic artery to the left anterior descending artery and PCI of a non-left anterior descending vessel in a single or two stage, at three different centers. Patients underwent 6-month angiographic follow-up. The mean ± SD clinical follow-up was 77.82 ± 41.4 months. Successful hybrid coronary revascularization occurred in 196 of the 203 patients. One hundred forty-six patients underwent simultaneous surgical and percutaneous intervention. Nineteen patients underwent PCI before surgery, and 38 patient underwent PCI after surgery. No in-hospital mortality occurred. The mean ± SD ICU stay was 1 ± 1 days and the mean ± SD hospital stay was 5 ± 2 days. Only 13.3% of the patients required a blood transfusion. Six-month angiographic follow-up has been performed in the 95 patients, and it demonstrated a left internal thoracic artery anastomotic patency of 97.9% and stent patency of 92.6%. A total of 77.8 ± 41.4-month clinical follow-up demonstrated 95.1% survival, 92.6% freedom from angina, and 90.7% freedom from any form of coronary revascularization. Hybrid coronary revascularization seems to be a promising and safe revascularization strategy. It provides selected patients with an alternative, functionally complete revascularization with minimal surgical trauma and good long-term clinical outcomes.

Mid-term Outcomes of Minimally Invasive Direct Coronary Artery Bypass Grafting

Mid-term Outcomes of Minimally Invasive Direct Coronary Artery Bypass Grafting

Robotic-enhanced coronary surgery in octogenarians.

Robotic-enhanced minimally invasive direct coronary artery bypass grafting surgery (RE-MIDCAB) is based on the use of a robotic console and instrumentation for the dissection of the left internal thoracic artery (LITA). The LITA to left anterior descending (LAD) artery anastomosis is subsequently constructed through a mini thoracotomy. The purpose of this study is to present our experience of RE-MIDCAB outcomes in elderly patients. From 2002 until 2015, 44 octogenarians (the mean age of 82.9 years) underwent RE-MIDCAB. The mean logistic EuroSCORE was 9.2. The majority of the patients were male with a medical history of hypertension, dyslipidaemia and previous coronary interventions. Of these patients 25% underwent RE-MIDCAB combined with percutaneous coronary intervention (PCI) for the treatment of multi-vessel disease (hybrid revascularization). All RE-MIDCABs and combined 'hybrid' PCI procedures were successfully completed. The mean intensive care unit (ICU) and hospital stay were 1.6 days and 10.9 days, respectively. There was 1 in-hospital mortality (2.3%). After an average follow-up period of 29.2 months, 5 patients required repeat revascularization procedures (9.1%). Mortality on follow-up was estimated at 25.6%. Our report suggests that considering the age and frailty of the octogenarian population, RE-MIDCAB is a feasible and safe procedure which is associated with acceptable mid-term results.

Robot-assisted coronary artery bypass grafting improves short-term outcomes compared with minimally invasive direct coronary artery bypass grafting

Robot-assisted coronary artery bypass grafts (RACAB) utilizing the da Vinci surgical system are increasingly used and allow the surgeon to conveniently harvest internal mammary arteries (IMAs). The aim of this study was to compare the outcomes of off-pump RACAB and minimally invasive direct coronary artery bypass grafting (MIDCAB) in the short and medium term. We performed a retrospective review of 132 patients with single- or multiple-vessel coronary artery disease who underwent minimally invasive off-pump CABG (OPCAB) between May 2009 and May 2014. The patients were divided into two groups based on the surgical approach, MIDCAB and RACAB group. The anastomosis of the left internal mammary artery (LIMA) to the left anterior descending artery (LAD) was performed as regular OPCAB through the incision on the beating heart using regular stabilization devices (Genzyme Corporation). The preoperative, intraoperative, postoperative, and follow-up data, including major adverse cardiac and cerebrovascular events (MACCE), were compared. The preoperative data were similar. RACAB significantly shorten the intensive care unit (ICU) stay and postoperative compared with the MIDCAB group (P<0.05). There were 12 (19.7%) patients treated with a two-stage hybrid procedure in the MIDCAB group and 34 (47.9%) patients in the RACAB group (P=0.001). Thirty-day mortality was 1.6% in the MIDCAB group. There were 9 (14.7%) MIDCAB patients and 2 (2.8%) RACAB patients (P=0.013) that developed new arrhythmia. The two groups showed comparable mid-term survival (P=0.246), but the MACCEs were significantly different (P=0.038). RACAB may be a valuable alternative for patients requiring single or simple multi-vessel coronary artery bypass grafting (CABG). Although the mid-term mortality outcomes are similar, RACAB improves short-term outcomes and mid-term MACCE-free survival compared with MIDCAB.

Minimally invasive direct coronary artery bypass grafting with an improved rib spreader and a new-shaped cardiac stabilizer: results of 200 consecutive cases in a single institution.

BackgroundPerforming minimally invasive direct coronary artery bypass (MIDCAB) grafting via small chest incisions on a beating heart is challenging. We report our experiences of MIDCAB with the utilization of both an improved rib spreader to harvest the left internal mammary artery (LIMA) and a new-shaped cardiac stabilizer to facilitate LIMA-left anterior descending (LAD) coronary anastomosis.MethodsBetween May 2012 and June 2104, a total of 200 patients who were consecutively operated on in this period were enrolled in this study. Data reported included demographic information, preoperative clinical and cardiac status, LIMA harvest time, postoperative in-hospital outcomes, and 30-day mortality.ResultsThe average LIMA harvest time was 43 min. The mean age was 62.59 ± 10.19 years, and 45 of the 200 were females. The 30-day mortality was 0.5 % (one patient) due to perioperative myocardial infarction. Duration of mechanical ventilation and length of stay in intensive care unit was 9.27 ± 7.65 and 24.27 ± 17.85 h, respectively. The unit of packed RBC transfusion was 0.79 ± 1.58. Postoperative atrial fibrillation was observed in 14 (7 %) patients. There was no postoperative stroke, renal failure, or incision complication.ConclusionPerforming MIDCAB with the improved retractor and stabilizer utilized in this study showed favorable outcomes in terms of harvesting the LIMA, postoperative morbidities, and 30-day mortality.

Minimally invasive direct coronary artery bypass for left anterior descending artery revascularization - analysis of 300 cases.

IntroductionMinimally invasive direct coronary artery bypass (MIDCAB) grafting is performed via small, left anterolateral thoracotomy. The left internal mammary artery was grafted to the left anterior descending (LAD) artery in 300 consecutive patients.AimIn-hospital results were evaluated and compared with the conventional, off-pump coronary artery bypass graft procedure.Material and methodsOne hundred and sixty-three (54.33%) of 300 patients underwent staged hybrid coronary revascularization, 93 (31%) were treated for a single LAD lesion, and 44 (14.67%) were treated for multi-vessel disease with reasonably incomplete revascularization. Major in-hospital cardiac adverse events and postoperative data were compared between groups.ResultsPreoperative data were similar between groups. However, the difference in left ventricular ejection fraction (p < 0.001) was significant. No conversions to sternotomy occurred during the primary MIDCAB procedures. Shorter operation time (p < 0.001), shorter postoperative mechanical ventilation time (p < 0.001), shorter intensive care unit stay (p < 0.001), and less red blood cell transfusion (p < 0.001) were noted in the MIDCAB group. Postoperative coronary angiography conducted in the MIDCAB group within one week after the operation showed that 2 of 163 patients developed graft occlusion. These patients underwent conventional CABG and recovered well. No significant differences were observed in postoperative MI, delayed wound healing or 30-day in-hospital mortality between the two groups.ConclusionsThe use of a chest wall lifting system and modified stabilizer makes the MIDCAB procedure safer and easier. The MIDCAB procedure is demonstrated to be a feasible and minimally invasive alternative for patients with coronary artery disease involving LAD lesions.

Subxiphoid (sternal sparing) approach for minimal access coronary artery bypass grafting

Background Coronary artery bypass grafting (CABG) is one of the commonest cardiothoracic surgical procedures carried out in today’s day and age. Traditionally, the midline sternotomy approach was in vogue, and CABG would be done on cardiopulmonary bypass. With further advances and expertise, various procedural modifications have been made including off-pump CABG and minimally access procedures which include minimally invasive direct coronary artery bypass (MIDCAB) grafting and partial sternotomy techniques. Subxiphoid CABG is a sparingly used novel approach but nonetheless an excellent choice in many cases.

MIDCAB or PCI for Single LAD Lesions A Systematic Review with Meta-Analysis of 3,491 Patients

Aims: The present systematic review with meta-analysis aims to determine the current evidence for minimally invasive direct coronary artery bypass grafting (MIDCAB) or percutaneous coronary intervention (PCI) for revascularization of the left anterior descending artery (LAD). Both techniques are established therapeutic options. Internal mammary artery grafts (IMA) have proven survival benefits and 10 year patency rates greater than 90% after LAD revascularization. However, due to lower costs, quicker recovery and lesser invasiveness PCI with stenting is currently the most common used treatment for isolated LAD stenosis.

Two-stage Minimally Invasive Direct Coronary Artery Bypass Grafting in a Cancer Patient: LITA-LAD Bypass and Concomitant Transabdominal GEA-PD Bypass and Right-sided Colectomy

Two-stage Minimally Invasive Direct Coronary Artery Bypass Grafting in a Cancer Patient: LITA-LAD Bypass and Concomitant Transabdominal GEA-PD Bypass and Right-sided Colectomy

Robot-assisted cardiac surgery.

Recognition of the significant advantages of minimizing surgical trauma has resulted in the development of minimally invasive surgical procedures. Endoscopic surgery offers patients the benefits of minimally invasive surgery, and surgical robots have enhanced the ability and precision of surgeons. Consequently, technological advances have facilitated totally endoscopic robotic cardiac surgery, which has allowed surgeons to operate endoscopically rather than through a median sternotomy during cardiac surgery. Thus, repairs for structural heart conditions, including mitral valve plasty, atrial septal defect closure, multivessel minimally invasive direct coronary artery bypass grafting (MIDCAB), and totally endoscopic coronary artery bypass graft surgery (CABG), can be totally endoscopic. Robot-assisted cardiac surgery as minimally invasive cardiac surgery is reviewed.

Ultra-minimally invasive cardiac surgery: robotic surgery and awake CABG.

The recognition of the significant advantages of minimizing surgical trauma has resulted in the development of minimally invasive surgical procedures. Endoscopic surgery confers the benefits of minimally invasive surgery upon patients, and surgical robots have enhanced the ability and precision of surgeons. Consequently, technological advances have facilitated totally endoscopic robotic cardiac surgery, which has allowed surgeons to operate endoscopically, rather than through a median sternotomy, during cardiac surgery. Thus, repairs for structural heart conditions, including mitral valve plasty, atrial septal defect closure, multivessel minimally invasive direct coronary artery bypass grafting and totally endoscopic coronary artery bypass graft surgery (CABG), can be totally endoscopic. On the other hand, general anesthesia remains a risk in patients who have severe carotid artery stenosis before surgery, as well as in those with a history of severe cerebral infarction or respiratory failure. In this study, the potential of a new awake CABG protocol using only epidural anesthesia was investigated for realizing day surgery and was found to be a promising modality for ultra-minimally invasive cardiac surgery. We herein review robot-assisted cardiac surgery and awake off-pump coronary artery bypass grafting as ultra-minimally invasive cardiac surgeries.

Mid-Term Outcomes of Minimally Invasive Direct Coronary Artery Bypass Grafting.

Minimally invasive direct coronary artery bypass grafting (MIDCAB) has gained wide acceptance for the treatment of single vessel disease of the left anterior descending artery (LAD). Here, we present our single center experience of 152 consecutive patients. All patients underwent MIDCAB through a left anterior minithoracotomy between January 1, 2009, and December 31, 2012. Preoperative, intraoperative, postoperative, and follow-up data including major adverse cardiac and cerebrovascular events (MACCE) and need for re-intervention were collected. Mean age was 64.4 ± 11 years, median additive EuroSCORE 3 (0-11), 84% were male. All except one patient were successfully operated without cardiopulmonary bypass. Seven patients with unexpected severely calcified LADs were converted to sternotomy (4.6%); 91.3% were extubated in the operating room or on the day of surgery. Median stay at the intensive care unit and in hospital were 1 (0-97) and 7 (1-49) days, respectively. Thirty-day mortality was 1.9%. There was no stroke. Five patients (3.2%) had to be re-explored for bleeding and 95% received no transfusion. Median follow-up was 24 months (0-97) and complete in 93.3% with overall survival of 92.4 ± 0.2% and MACCE-free survival of 96.1 ± 1.7%. Two patients had a re-intervention of the LAD. MIDCAB is a safe procedure with low postoperative morbidity, mortality, and favorable mid-term MACCE-free survival in selected patients that should be discussed in a heart team setting to evaluate the "ideal" individual treatment option.

Minimally invasive direct coronary bypass grafting versus percutaneous coronary intervention for single-vessel disease: a meta-analysis of 2885 patients.

Percutaneous coronary intervention (PCI) and minimally invasive direct coronary artery bypass (MIDCAB) grafting are both established therapeutic options for single-vessel disease of the left anterior descending artery (LAD). The present systematic review with meta-analysis aims to determine the current strength of evidence for or against PCI and MIDCAB for revascularization of the LAD. Therefore, we performed a meta-analysis of randomized, controlled trials (RCTs) and observational trials (OTs) that reported clinical outcome after isolated LAD revascularization. Analysed postoperative outcomes included major adverse cardiac and cerebrovascular events (MACCEs), all-cause mortality, myocardial infarction and stroke. Pooled treatment effects [odds ratio (OR) or weighted mean difference (WMD), 95% confidence intervals (95% CI)] were assessed using a fixed- or random-effects model. A total of 2885 patients from 12 studies (6 RCTs, 6 OTs) were identified after a literature search of major databases using a predefined list of keywords. PCI of the LAD was performed in 60.7% (n = 1751) and MIDCAB in 39.3% of patients (n = 1126). Pooled-effect estimates revealed an increased incidence for MACCEs after PCI (OR 1.98; 95% CI 1.45-2.69; P < 0.0001) 6 months after the procedure. Especially, PCI was particularly associated with an increased odds for target vessel revascularization (OR 2.11; 95% CI 1.00-4.47; P = 0.0295). No differences with regard to stroke, myocardial infarction and all-cause mortality were observed between both revascularization strategies. Patients after PCI had a shorter length of hospital stay (WMD -3.37 days; 95% CI (-)4.92 to (-)1.81; P < 0.0001). In conclusion, the present systematic review underscores the superiority of MIDCAB over PCI for treatment of single-vessel disease of the LAD.