Minimally Invasive Direct Coronary Artery Bypass Research Articles

Hybrid total arterial minimally invasive off-pump coronary revascularization and percutaneous coronary intervention strategy for multivessel coronary artery disease: a cohort study with a median 11-year follow-up.

Hybrid coronary revascularization (HCR) is a treatment approach that combines the benefits of coronary artery bypass grafting (CABG) techniques such as minimally invasive direct coronary artery bypass (MIDCAB) or minimally invasive multivessel CABG (MICS-CABG) with percutaneous coronary intervention (PCI) for carefully selected patients with multivessel coronary artery disease (MV CAD). The extant body of research primarily concentrates on the comparison of outcomes between HCR and CABG or PCI. Furthermore, HCR is defined primarily as MIDCAB and PCI. Given the various criteria for HCR identified in the current body of literature, as well as several hybrid revascularization techniques, our primary goal was to analyse the characteristics and track the development of HCR patients operated on in our centre (Robert Bosch Hospital) over both short and long periods of time. Additionally, we sought to validate the practical challenges that arise during the implementation of an HCR methodology. This cohort study included 138 patients with MV CAD who had an HCR approach in conjunction with isolated total arterial off-pump MICS-CABG or MIDCAB between 2007 and 2018 at Robert Bosch Hospital in Stuttgart. Data on major adverse cardiac and cerebral events (MACCE), defined as all-cause mortality, myocardial infarction, repeat revascularization and stroke were gathered through a questionnaire. Long-term follow-up, with a mean duration of 8.7±0.3 years and a median duration of 11 years, was available for a significant majority of the patients (92.8%, n=128). The average age was 69.6±11.2 years, with 79% being male. The mean European System for Cardiac Operative Risk Evaluation score I additive (EuroSCORE I) additive was 7.6±10.2 and the mean SYNergy between PCI with TAXUS and Cardiac Surgery (SYNTAX) Score I was 22.9±9.4. A total of 97 MIDCAB surgeries and 41 MICS-CABG procedures were performed without any instances of conversion to sternotomy or cardiopulmonary bypass (CPB). A total of 70 patients, or 50.7% of the sample, received the planned PCI treatment. This percentage was substantially lower in the subgroup with chronic CAD, with just 27, equivalent to 39.1%. The observed 30-day death rate was 2.1% (3/138). During follow-up, 3 myocardial infarctions, 18 PCI repeats, no CABG, and 4 strokes occurred. From 128 followed-up patients, 28 died (21.9%), 7 of which were heart deaths (5.5%). Total MACCE was 36.7%. The survival rates at 3 and 5 years were 92% and 85% respectively. Patients who didn't get the planned PCI had a mean survival rate of 6.8-9.1 years, while those with completed hybrid treatment had a higher mean survival rate of 8.4-10.2 years. In selected individuals with MVCAD, current evidence suggests that HCR is a safe and effective coronary artery revascularization approach. After coronary bypass surgery, the attention going forward needs to be devoted toward the organization of the PCI step in the treatment process.

Early and late outcomes after minimally invasive direct coronary artery bypass vs. full sternotomy off-pump coronary artery bypass grafting.

Minimally-invasive direct coronary artery bypass (MIDCAB) is a less-invasive alternative to full sternotomy off-pump coronary artery bypass (FS-OPCAB) revascularization of the left anterior descending artery (LAD). Some studies suggested that MIDCAB is associated with a greater risk of graft occlusion and repeat revascularization than FS-OPCAB LIMA-to-LAD grafting. Data comparing MIDCAB to FS-OPCAB with regard to long-term follow-up is scarce. We compared short- and long-term results of MIDCAB vs. FS-OPCAB revascularization over a maximum follow-up period of 10 years. From December 2009 to June 2020, 388 elective patients were included in our retrospective study. 229 underwent MIDCAB, and 159 underwent FS-OPCAB LIMA-to-LAD grafting. Inverse probability of treatment weighting (IPTW) was used to adjust for selection bias and to estimate treatment effects on short- and long-term outcomes. IPTW-adjusted Kaplan-Meier estimates by study group were calculated for all-cause mortality, stroke, the risk of repeat revascularization and myocardial infarction up to a maximum follow-up of 10 years. MIDCAB patients had less rethoracotomies (n = 13/3.6% vs. n = 30/8.0%, p = 0.012), fewer transfusions (0.93 units ± 1.83 vs. 1.61 units ± 2.52, p < 0.001), shorter mechanical ventilation time (7.6 ± 4.7 h vs. 12.1 ± 26.4 h, p = 0.005), and needed less hemofiltration (n = 0/0% vs. n = 8/2.4%, p = 0.004). Thirty-day mortality did not differ significantly between the two groups (n = 0/0% vs. n = 3/0.8%, p = 0.25). Long-term outcomes did not differ significantly between study groups. In the FS-OPCAB group, the probability of survival at 1, 5, and 10 years was 98.4%, 87.8%, and 71.7%, respectively. In the MIDCAB group, the corresponding values were 98.4%, 87.7%, and 68.7%, respectively (RR1.24, CI0.87-1.86, p = 0.7). In the FS group, the freedom from stroke at 1, 5, and 10 years was 97.0%, 93.0%, and 93.0%, respectively. In the MIDCAB group, the corresponding values were 98.5%, 96.9%, and 94.3%, respectively (RR0.52, CI0.25-1.09, p = 0.06). Freedom from repeat revascularization at 1, 5, and 10 years in the FS-OPCAB group was 92.2%, 84.7%, and 79.5%, respectively. In the MIDCAB group, the corresponding values were 94.8%, 90.2%, and 81.7%, respectively (RR0.73, CI0.47-1.16, p = 0.22). MIDCAB is a safe and efficacious technique and offers comparable long-term results regarding mortality, stroke, repeat revascularization, and freedom from myocardial infarction when compared to FS-OPCAB.

Five-Year Survival of Patients Treated with Minimally Invasive Direct Coronary Artery Bypass (MIDCAB) Compared with the General Swiss Population.

To evaluate the midterm follow-up and 5-year survival outcome of the minimally invasive direct coronary artery bypass (MIDCAB) procedure compared with the survival of the general Swiss population. Retrospective study on preoperative data, intraoperative data, and postoperative outcome of patients who underwent MIDCAB surgery between June 2010 and February 2019. To assess validity of this surgical therapy, outcomes were compared with survival data of a gender- and age-matched cohort of the general Swiss population taken from the database of the Swiss Federal Statistical Office. A total of 88 patients were included. Median (interquartile range [IQR[) age was 66 (56-75) years, and 27% (n = 24) were female. The median (IQR) length of the in-hospital stay was 7 (6-8) days. No postoperative stroke occurred. The 30-day mortality was 1.1% (n = 1). Reintervention for failed left internal mammary artery was needed in 1.1% (n = 1). The median (IQR) ejection fraction was 58% (47-60) preoperatively and remained stable during follow-up. The median (IQR) follow-up period was 3 (1.1-5.2) years. Five years postoperatively, 83% (confidence interval, 69-91) of the patients were alive, showing an overlap with the range of survival of the matched subcohort of the general Swiss population (range, 84-100%). Though suffering from coronary heart disease, patients after MIDCAB show almost equal survival rates as an equivalent subcohort corresponding to the general Swiss population matched on age and gender. Thus, our data show this treatment to be safe and beneficial.

Chronic post-thoracotomic pain syndrome in cardiothoracic surgery after minimally invasive coronary bypass surgery: prospective cohort study

BACKGROUND: No consensus has been established on the role of epidural anesthesia in relation to the prevention of chronic post-thoracotomic pain during minimally invasive coronary bypass surgery.&#x0D; OBJECTIVE: This study aimed to evaluate the effect of epidural anesthesia on the incidence of chronic post-thoracotomic pain syndrome after minimally invasive direct coronary artery bypass (MIDCAB) surgery.&#x0D; MATERIALS AND METHODS: The study included 87 patients who underwent MIDCAB surgery. In group 1, epidural anesthesia was performed before the induction of general anesthesia; in group 2, the operation was performed only under general anesthesia.&#x0D; RESULTS: The use of fentanyl for anesthesia varied: 0.5 (0.5; 0.6) mg in group 1 versus 3.5 (3.3; 3.6) mg in group 2 (p 0.01). The incidence of chronic post-thoracotomic pain in patients 3 months after surgery was higher in group 2 than in group 1 (39.1% vs 17.2%, p=0.005). The severity of pain at rest was 3 points (2; 3) in group 1 and 3 points (3; 3.5) in group 2 (p=0.018); however, during a deep breath, these differences became insignificant: 4 points (4; 4) in group 1 and 4 (4; 5) points in group 2 (p=0.453). At 6 months after surgery, chronic post-thoracotomic pain was present in 15.6% of the patients in group 1 and 34.8% in group 2 (p=0.011). After 6 months, the severity of pain at rest was 2.5 (2; 3) in group 1 and 3 (3; 3.75) in group 2 (p=0.01). No differences in cough were found: 4 (3.75; 4) points in group 1 and 4 (4; 4.5) points in group 2 (p 0.05).&#x0D; CONCLUSION: The use of epidural anesthesia led to a decrease in the incidence of chronic post-thoracotomic pain in patients undergoing MIDCAB surgery.

Minimally Invasive Direct Coronary Artery Bypass Versus Percutaneous Coronary Intervention for Isolated Left Anterior Descending Artery Stenosis: An Updated Meta-Analysis.

The optimal revascularization strategy for isolated left anterior descending (LAD) coronary artery lesion between minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI) remains controversial. This updated meta-analysis aims to compare the long- and short-term outcomes of MIDCAB versus PCI for patients with isolated LAD coronary artery lesions. The Pubmed, Web of Science, and Cochrane databases were searched for retrieving potential publications from 2002 to 2022. The primary outcome was long-term survival. Secondary outcomes were long-term target vessel revascularization (TVR), long-term major adverse cardiovascular events (MACEs), and short-term outcomes, including postoperative mortality, myocardial infarction (MI), TVR, and MACEs of any cause in-hospital or 30 days after the revascularization. Six randomized controlled trials (RCTs) and eight observational studies were included in this updated meta-analysis. In total, 1757 patients underwent MIDCAB and 15245 patients underwent PCI. No statistically significant difference was found between the two groups in the rates of long-term survival. MIDCAB had a lower long-term MACE rate compared with PCI. Besides, PCI resulted in an augmented risk of TVR. Postoperative mortality, MI, TVR, and MACEs were similar between the two groups. The updated meta-analysis presents the evidence that MIDCAB has a reduced risk of long-term TVR and MACEs, with no benefit in terms of long-term mortality and short-term results, in comparison with PCI. Large multicenter RCTs, including patients treated with newer techniques, are warranted in the future.

Postoperative results of minimally invasive direct coronary artery bypass procedure in 234 patients.

Minimally invasive approach in cardiac surgery has gained popularity. In order to reduce surgical trauma in coronary surgery minimally invasive direct coronary artery bypass (MIDCAB) has already been established. This technique has been introduced for revascularisation of isolated left anterior descending (LAD). It can also be performed for hybrid revascularisation procedure in multi-vessel disease. From 2017 to 2021, 234 patients received MIDCAB operation in our heartcenter 73% were male. Most of the patients had two or three vessel disease (74%). The average age of the patients was 66 ± 12 years mean. The left internal mammary artery (LIMA) was anastomosed to the LAD through left minithoracotomy approach. Multi-vessel MIDCAB (MV-MIDCAB) including two anastomoses (T-graft to LIMA with additional saphenous vein graft) was done in 15% (n = 35). The average operation time was 2.3 ± 0.8 h mean. The 30-day mortality was 1.7% (n = 4). The average amount of packed red blood cells (pRBC) that was given intra- and postoperatively was 0.4 ± 0.8 units mean. The mean intensive care unit stay (ICU) was 1 ± 1.2 days. Three patients (1.3%) had wound infection postoperatively. The rate of neurologic complications was 0.4% (n = 1). Two patients (0.9%) had myocardial infarction and received coronary re-angiography perioperatively including stent implantation of the right coronary artery. The MIDCAB procedure is a safe and less traumatic procedure for selected patients with proximal LAD lesions. It is also an option for hybrid procedure in multi-vessel disease. The ICU stay and application of pRBC's are low. Our MIDCAB results show a good postoperative clinical outcome. However, follow-up data are necessary to evaluate long-term outcome.

Surgeon-Guided Robotic Arm Facilitates LIMA Takedown in MIDCAB Surgery.

Left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery bypass has been scientifically proven to have the best patency and long-term results in myocardial revascularization. The latest guidelines suggest minimally invasive LIMA to LAD is the optimal therapy for isolated proximal LAD lesions. The start of a minimally invasive direct coronary artery bypass (MIDCAB) program can be quite challenging as robotic surgery demands high starting costs, while normal thoracoscopic techniques have a longer surgeon learning curve. In this article, we describe to the best of our knowledge the first use of surgeon-guided wristed instruments in LIMA harvesting for MIDCAB surgery. It allows for a facilitated LIMA harvest like in robotic surgery with the comfort of a surgeon constantly standing by the patient, allowing for a faster response time in case of an emergency or the need for instrument exchange. These features result in shorter operating times, lower costs compared with robotic surgery, and faster adoption of this technique for centers just starting MIDCAB surgery.

Minimally Invasive Direct Coronary Artery Bypass: An Evolving Paradigm Over the Past 25 Years.

We have routinely utilized minimally invasive direct coronary artery bypass (MIDCAB) for revascularization of the left anterior descending (LAD) coronary artery. We examined how this procedure has evolved. A retrospective review was undertaken of 2,283 consecutive patients who underwent MIDCAB between 1997 and 2021. Patients were divided into 3 groups: group A from 1997 to 2002 (n = 751, 32.9%), group B from 2003 to 2009 (n = 452, 19.8%), and group C from 2009 to 2021 (n = 1,080, 47.3%). Risk profiles and short-term outcomes were analyzed for the entire cohort and for 293 propensity-matched patients drawn from each group. The left internal mammary artery was harvested open in group A but with robotic assistance in group C. Thirty-day mortality was higher in group A versus group C (12 deaths, 1.6% vs 5 deaths, 0.5%, P = 0.044); this difference was negated after propensity matching. Group A had more comorbidities than group C, including peripheral vascular disease (17.7% vs 10.0%, P < 0.001), congestive heart failure (39.6% vs 18.0%, P < 0.001), and a history of stroke (17.9% vs 10.0%, P < 0.001), although diabetes mellitus was more common in group C (51.4% vs 31.0%, P < 0.001). Stroke was greater in group A (1.2% vs 0.0% vs 0.2%, respectively, P = 0.004), as was the need for prolonged ventilation (3.6% vs 0.2% vs 0.9%, respectively, P < 0.001), before and after propensity matching. MIDCAB patients had less comorbidities than in the past. Robot-assisted MIDCAB was associated with lower stroke risk.

LIMA to LAD grafting returns patient survival to age-matched population: 20-year outcomes of MIDCAB surgery.

OBJECTIVESPrevious studies have demonstrated the safety and excellent short-term and mid-term survival after minimally invasive direct coronary artery bypass (MIDCAB). We reviewed the long-term outcomes up to 20 years, including overall survival and freedom from reintervention.METHODSConsecutive patients who underwent MIDCAB between February 1997 and August 2020 were identified. Demographic details, operative information and long-term outcomes were obtained. The Australian National Death Index database was accessed to obtain long-term mortality data.RESULTSA total of 271 patients underwent an MIDCAB procedure during the study period. There were no intraoperative deaths and only one 30-day mortality (0.4%). The mean length of follow-up was 9.82 ± 8.08 years. Overall survival at 5-, 10-, 15- and 20-year survival was 91.9%, 84.7%, 71.3% and 56.5%, respectively. Patients with single-vessel disease [left anterior descending artery (LAD) only] had significantly better survival compared to patients with multivessel disease (P = 0.0035). During long-term follow-up, there were no patients who required repeat revascularization of the LAD territory. Sixty-nine patients died with the cause of death in 15 patients (21.7%) being attributable to ischaemic heart disease. An analysis comparing the isolated LAD disease MIDCAB cohort survival with the expected survival among an age/gender/year matched sample of the Australian reference population, using the standardized mortality ratio, demonstrated that the rate of survival returned to that of the reference population (standardized mortality ratio = 0.94).CONCLUSIONSMIDCAB is a safe and effective revascularization strategy which can be successfully performed in a carefully selected patient population with low morbidity and excellent long-term results. The survival of MIDCAB patients returns to that of their age/gender/year-matched counterparts within the normal population and hence should be offered as an alternative to coronary stenting when counselling patients with ischaemic heart disease.

Unilateral left-sided thoracoscopic ablation of atrial fibrillation concomitant to minimally invasive bypass grafting of the left anterior descending artery.

OBJECTIVESThoracoscopic ablation for atrial fibrillation (AF) and minimally invasive direct coronary artery bypass (MIDCAB) with robot-assisted left internal mammary artery (LIMA) harvesting may represent a safe and effective alternative to more invasive surgical approaches via sternotomy. The aim of our study was to describe the feasibility, safety and efficacy of a unilateral left-sided thoracoscopic AF ablation and concomitant MIDCAB surgery.METHODSRetrospective analysis of a prospectively gathered cohort was performed of all consecutive patients with AF and at least a critical left anterior descending artery (LAD) stenosis that underwent unilateral left-sided thoracoscopic AF ablation and concomitant off-pump MIDCAB surgery in the Maastricht University Medical Centre between 2017 and 2021.RESULTSTwenty-three patients were included [age 69 years (standard deviation = 8), paroxysmal AF 61%, left atrial volume index 42 ml/m2 (standard deviation = 11)]. Unilateral left-sided thoracoscopic isolation of the left (n = 23) and right (n = 22) pulmonary veins and box (n = 21) by radiofrequency ablation was succeeded by epicardial validation of exit- and entrance block (n = 22). All patients received robot-assisted LIMA harvesting and off-pump LIMA-LAD anastomosis through a left mini-thoracotomy. The perioperative complications consisted of one bleeding of the thoracotomy wound and one aborted myocardial infarction not requiring intervention. The mean duration of hospital stay was 6 days (standard deviation = 2). After discharge, cardiac hospital readmission occurred in 4 patients (AF n = 1; pleural- and pericardial effusion n = 2, myocardial infarction requiring the percutaneous intervention of the LIMA-LAD n = 1) within 1 year. After 12 months, 17/21 (81%) patients were in sinus rhythm when allowing anti-arrhythmic drugs. Finally, the left atrial ejection fraction improved postoperatively [26% (standard deviation = 11) to 38% (standard deviation = 7), P = 0.01].CONCLUSIONSIn this initial feasibility and early safety study, unilateral left-sided thoracoscopic AF ablation and concomitant MIDCAB for LIMA-LAD grafting is a feasible, safe and efficacious for patients with AF and a critical LAD stenosis.

Minimally invasive surgery or stenting for left anterior descending artery disease - meta-analysis.

Minimally invasive direct coronary artery bypass (MIDCAB) surgery and percutaneous coronary intervention (PCI) are both well-established minimally invasive revascularization strategies in patients with proximal left anterior descending (LAD) lesions. We aimed to evaluate the 20-years’ experience by performing a systematic review and meta-analysis comparing MIDCAB versus PCI in adults with proximal LAD disease. We searched MEDLINE, EMBASE and Cochrane on October 1st, 2021 for articles published in the year 2000 or later. The primary outcome was all-cause mortality. Secondary outcomes included cardiac mortality, repeat target vessel revascularization (rTVR), myocardial infarction (MI), and cerebrovascular accident (CVA). Outcomes were analysed at short-term, mid-term, and long-term follow-up. Random effects meta-analyses were performed. Events were compared using risk ratios (RR) with 95% confidence intervals (CI). Our search yielded 17 studies pooling 3847 patients. At short-term follow-up, cardiac mortality was higher with MIDCAB than with PCI (RR 7.30, 95% CI: 1.38 to 38.61). At long-term follow-up, MIDCAB showed a decrease in all-cause mortality (RR 0.66, 95% CI: 0.46 to 0.93). MIDCAB showed a decrease in rTVR at mid-term follow-up (RR 0.16, 95% CI: 0.11 to 0.23) and at long-term follow-up (RR 0.25, 95% CI: 0.17 to 0.38). MI and CVA comparisons were not significant. In conclusion, in patients with proximal LAD lesions, MIDCAB showed a higher short-term mortality in the RCTs, but the cohort studies suggested a lower all-cause mortality at long-term follow-up. We confirm a decreased rTVR at mid-term follow-up in the RCTs and long-term follow-up in the cohort studies.

Minimally invasive direct coronary artery bypass after percutaneous coronary intervention.

Minimally invasive direct coronary artery bypass (MIDCAB) with the left internal thoracic artery (LITA) provides excellent long-term results for isolated left anterior descending coronary artery (LAD) disease. We tried to evaluate the impact of the previous percutaneous coronary intervention (p-PCI) for LAD on the clinical outcomes of MIDCAB in this study. A total of 197 patients with isolated LAD disease underwent MIDCAB in our center from February 2009 to May 2020. 51 patients had the p-PCI for LAD and 146 patients did not. The primary outcome was the major adverse cardiovascular event (MACE). The incidences of the perioperative outcomes were comparable between the two groups (p > .05). The median follow-up time was 48.0 months (interquartile range, 25.9-85.5 months). The incidences of MACE (p < .001) and myocardial infarction or recurrent angina (p < .001) were significantly higher in the p-PCIgroup than those in the non-PCI group. The estimated 5-year freedom from MACE in the p-PCI group was significantly lower (56.1%, 95% confidence interval [CI]: 41.2%-71.0% vs. 83.4%, 95% CI: 76.7%-90.1%, p < .001). The previous LAD-PCI (hazard ratio [HR]: 2.664, 95% CI: 1.471-4.822, p = .001) and the history of peripheral arterial disease (HR: 3.145, 95% CI: 1.085-9.113, p = .035) were the independent predictors of MACE. The p-PCI group had a higher diseased graft rate than the non-PCI group (10.9% vs. 2.3%, p = .046). The previous LAD-PCI may deteriorate the outcomes of MIDCAB in patients with isolated LAD disease.

Left Internal Mammary Artery to Left Anterior Descending Artery. An Alternative for old, High-Risk, Multivessel, Coronary Artery Disease Patients and an Approach for Hybrid Revascularization

In 1997, the first ambulatory off-pump left internal mammary artery (LIMA) to left anterior descending artery (LAD) anastomosis was performed via xiphoid approach, an intervention known today as the MINI-OPCAB operation. This operation has been performed in more than 150 patients around the world for the management of single and multiple vessel coronary artery disease, and 70 of those cases underwent the procedure in our Foundation from 1997 to 2021, showing no operative mortality or reintervention rates, low conversion rates, early hospital discharge, and 100% graft patency at the follow-ups. The minimally invasive direct coronary artery bypass (MIDCAB) procedure was introduced in 1994 by Benetti from Argentina, and was developed based on our previous experience performing off-pump coronary surgery by manipulating the ascending aorta through a left-sided small thoracotomy. Although it represents one of the most common minimally invasive procedures done worldwide, the original technique is not easy to reproduce, and in most cases the pleura is opened, which increases patients pain, morbidity, hospital length of stay, and hinders the realization of immediate hybrid revascularization after the procedure. The latest minimally invasive approaches for CABG include robotic-assisted procedures, in which the IMAs are harvested using robotic technology or the whole procedure is done using robotic technology. This approach has shown adequate short-term clinical results, however, there are no studies available reporting the procedure’s long-term results. Conclusion: The MINI-OPCAB operation is a friendly approach to perform Minimally Invasive Coronary Bypass Surgery in old, high-risk, multivessel coronary artery disease patients, and it represents a good intervention alternative for the majority of cardiac surgeons and cardiac specialized centers. We also consider this approach as ideal for patients who further require Hybrid Revascularization; however, more experience is needed to validate this initials results.

Redo MIDCAB in a Septuagenarian in our Setting, Fantasy or Fact? - A Case Report

Worldwide growth in elderly population has led to an upsurge in the number of septuagenarian (&gt;70 years of age) patients requiring surgical treatment for coronary artery disease. Elective coronary artery bypass grafting (CABG) in the older patients are associated with acceptable risks of adverse events and should be undertaken for appropriate indications without unnecessary hesitation. Redo coronary surgeries carries one of the highest mortality rates amongst redo cardiac surgeries, both separately or in combination with other pathologies. As a result, minimally-invasive direct coronary artery bypass (MIDCAB), was preferred to avoid the complications of re-sternotomy. We hereby present a case report of a septuagenarian patient with post CABG (2014) unstable angina with old myocardial infarction (extensive anterior) who was treated successfully, by us and to our best knowledge in the published articles this is probably the first time, a re-do MIDCAB technique has been implemented in our country. Bangladesh Heart Journal 2021; 36(2): 145-150

Demographic and Surgical Profile of the Patients Underwent Minimally Invasive Cardiac Surgery in a Rural Center of Bangladesh

Background: Ever Since its inception , minimally invasive cardiac surgery is growing rapidly for better convenience and superb post operative outcome. As newer instruments, surgical technique and operative exposure are increasing more and more patients are demanding minimally invasive cardiac surgery. Objective: The study was conducted to evaluate the various pre operative and peroperative factors in minimally invasive cardiac surgery. Materials and Methods: A retrospective observational study on the patients who underwent minimally invasive cardiac surgery in the department of cardiovascular and thoracic surgery, Khwaja Yunus Ali Medical College, Sirajganj, Bangladesh from January 2016 to December 2020. Results: A total of 40 cases were operated through minimally invasive cardiac surgery in our department. Maximum number of cases was Atrial septal defect(ASD), and minimally invasive direct coronary artery bypass (MIDCAB). About 62.50% were female, majority of patients were in the range of 11-15 years. Right anterolateral thoracotomy was done in 27 cases and left anterolateral thoracotomy in 10 cases. The maximum number of cannulation done in femoral artery and femoral vein, followed by direct superior vena caval cannulation and only a single percutaneous superior venacaval cannulation through internal jugular vein. In 14 cases the length of incision was in the range of 3-4 cm and 12 cases in 4-5cm. Conclusion: Minimally invasive cardiac surgery is now becoming more demanding. As more and more centers are opening the door to newer technology, common people are also becoming conscious about its excellent post operative outcome. KYAMC Journal.2021;12(02): 71-74

Echniques for Robotic-Assisted Surgical Myocardial Revascularization

The two current strategies for robotic-assisted, surgical myocardial revascularization are minimally invasive direct coronary artery bypass (MIDCAB) and totally endoscopic coronary artery bypass grafting (TECAB). We discuss the rationale underlying the benefits of robotic assistance in surgical myocardial revascularization, and detail the technical steps to safely and effectively perform these two procedures.

Minimally Invasive Direct Coronary Artery Bypass in High-Risk Patients with Multivessel Disease.

High-risk patients with multivessel disease (MVD) including a complex stenosis of the left anterior descending coronary may not be ideal candidates for guideline compliant therapy by coronary artery bypass grafting (CABG) regarding invasiveness and perioperative complications. However, they may benefit from minimally invasive direct coronary artery bypass (MIDCAB) grafting and hybrid revascularization (HCR). A logistic European system for cardiac operative risk evaluation score (logES) >10% defined high risk. In high-risk patients with MVD undergoing MIDCAB or HCR, the incidence of major adverse cardiac and cerebrovascular events (MACCEs) after 30 days and during midterm follow-up was evaluated. Out of 1,250 patients undergoing MIDCAB at our institution between 1998 and 2015, 78 patients (logES: 18.5%; age, 76.7 ± 8.6 years) met the inclusion criteria. During the first 30 days, mortality and rate of MACCE were 9.0%; early mortality was two-fold overestimated by logES. Complete revascularization as scheduled was finally achieved in 64 patients (82.1%). Median follow-up time reached 3.4 (1.2-6.5) years with a median survival time of 4.7 years. Survival after 1, 3, and 5 years was 77, 62, and 48%. In high-risk patients with MVD, MIDCAB is associated with acceptable early outcome which is better than predicted by logES. Taking the high-risk profile into consideration, midterm follow-up showed satisfying results, although scheduled HCR was not realized in a relevant proportion. In selected cases of MVD, MIDCAB presents an acceptable alternative for high-risk patients.

Postoperative Atrial Fibrillation after Minimally Invasive Direct Coronary Artery Bypass: A Single-Center, 5-Year Follow-Up Study.

To evaluate the risk factors and explore the mid-term outcomes of postoperative atrial fibrillation (POAF) after minimally invasive direct coronary artery bypass (MIDCAB). A total of 165 patients, who underwent isolated MIDCAB from 2012 to 2015, were enrolled in the study and retrospectively reviewed. Patients with preoperative arrhythmia, concomitant surgical procedures were excluded. All patients were continuously monitored for POAF until discharge, and two groups were formed: the non-POAF group (140 patients, 71.4% men, mean age 58.83±10.3 years) and the POAF group (25 patients, 84.0% men, mean age 64.52±9.0 years). Early and mid-term outcomes were evaluated, perioperative factors associated with POAF were analyzed with a binary logistic regression model, and the relationship between POAF and major adverse cardiac event (MACE) was analyzed with Cox regression model. The incidence of POAF in this study was 15.15%. Patients in the POAF group had a significant higher risk of re-entry to ICU (2 cases: 2 cases=8.0%: 1.4%, P = 0.049), renal failure (2 cases: 1 case=8.0%: 0.7%, P = 0.018), and death (1 case: 0 case=4.0%: 0%, P = 0.018). Binary logistic regression showed gender (male), age were independent risk factors of POAF (P = 0.038, 95% confidence interval 1.082-16.286; P = 0.011, 95% confidence interval 1.015-1.117, respectively), preoperative ACEI or ARB usage was a protective factor of POAF (P = 0.010, 95% confidence interval 0.113-0.748). With a 5-year follow up, the overall MACE rate showed no statistical difference between the two groups (P = 0.067). POAF after MIDCAB was related to postoperative morbidities, such as re-entry to ICU, renal failure, and death. Gender (male) and age were independent risk factors, while preoperative ACEI or ARB usage was a protective factor. POAF has not associated the occurrence of MACE with a mid-term follow-up.

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

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

Implementation of a beating heart system for training in off-pump and minimally invasive coronary artery bypass

BackgroundSeveral training devices have been developed to train anastomotic skills in off-pump coronary artery bypass grafting (OPCAB). However, assessment of trainees’ improvement remains challenging. The goal of this study was to develop a new practical scoring chart and investigate its reliability and utility for anastomotic skills in OPCAB and minimally invasive direct coronary artery bypass (MIDCAB).MethodsA training device was used, which included a beating heart model installed in a dedicated box. A soft plastic tube was used as the left anterior descending artery, and a porcine ureter was used as the left internal mammary artery. Five cardiac surgery fellows (Fellows, > 5 year of surgical experience) and five residents or medical students (Residents, ≤ 5 year of surgical experience) were enrolled for this study. Before and after training, skills were evaluated using a scoring chart that took into account anastomotic time, leakage, shape, flow measurement, and self-estimation.ResultsMean total score of all trainees was 15.4 ± 4.0 at pre-training and 18.5 ± 2.4 at post-training (P = 0.05). Before training, there was a significant difference in the total score between Fellows and Residents (18.6 ± 2.2 vs 12.2 ± 2.4 points, P = 0.002), which disappeared after training (19.4 ± 2.5 vs 17.6 ± 2.2 points, P = 0.262). Residents benefitted from training with improvements in their time, total score, score for time, score for flow and subtraction score; however, these effects were not seen in Fellows. The most evident training effect was improvement of self-estimation, which was also seen in Fellows.ConclusionsResidents were most likely to derive benefit from these training models with regard to both efficiency and quality. Training models seem to have an important role in making surgeons feel more comfortable with the procedure.