An open randomized controlled trial of median sternotomy versus anterolateral left thoracotomy on morbidity and health care resource use in patients having off-pump coronary artery bypass surgery: The Sternotomy Versus Thoracotomy (STET) trial

Thoracoscopic-assisted, minimally invasive versus off-pump bypass grafting for single vessel coronary artery disease - A propensity matched analysis

OBJECTIVE

This study compared perioperative outcomes after off-pump revascularization through a thoracoscopic-assisted (non-robotic) minimally invasive approach (Endo-CAB) or sternotomy approach (OPCAB) for patients with single vessel left anterior descending (LAD) disease.

METHODS

In this retrospective, propensity matched cohort study, 266 consecutive patients were included in the Endo-CAB group (n = 136) and OPCAB group (n = 130). After propensity score matching 116 Endo-CAB and 116 OPCAB patients were compared. 'Textbook outcome' was defined as the absence of 30-day mortality, re-exploration for bleeding, postoperative ischemia, cardiac tamponade, cerebrovascular events, wound infection, new-onset arrhythmias, pneumonia, placement of chest drains and prolonged hospital stay (> 7 days). Multivariable regression analysis was performed to identify independent predictors for textbook outcome.

RESULTS

Textbook outcome occurred significantly more frequent in the Endo-CAB group compared to the OPCAB group (81.9% vs. 59.5%, p < 0.001). Patients undergoing Endo-CAB surgery had shorter hospital admission (3.0 [3.0-4.0] vs. 5.0 [4.0-6.0] days, p < 0.001), less blood loss (225 [150-355] vs. 450 [350-600] mL, p < 0.001). Other perioperative outcomes were comparable for both groups. Regression analysis demonstrated that Endo-CAB approach was an independent positive predictor for textbook outcome (OR 3.02, 95% CI 1.61-5.66, p < 0.001).

CONCLUSIONS

Our study suggests that patients undergoing Endo-CAB surgery have improved perioperative outcome resulting in higher rates of textbook outcome for the treatment of single vessel CAD. This technique could be widely available since routine thoracoscopic instruments are used.

Comparison of the Effects of Full Median Sternotomy vs. Mini-Incision on Postoperative Pain in Cardiac Surgery: A Meta-Analysis

INTRODUCTION

It is not yet clear whether cardiac surgery by mini-incision (minimally invasive cardiac surgery [MICS]) is overall less painful than the conventional approach by full sternotomy (FS). A meta-analysis is necessary to investigate polled results on this topic.

METHODS

PubMed®/MEDLINE, Cochrane CENTRAL, Latin American and Caribbean Health Sciences Literature (or LILACS), and Scientific Electronic Library Online (or SciELO) were searched for all clinical trials, reported until 2022, comparing FS with MICS in coronary artery bypass grafting (CABG), mitral valve surgery (MVS), and aortic valve replacement (AVR), and postoperative pain outcome was analyzed. Main summary measures were the method of standardized mean differences (SMD) with a 95% confidence interval (CI) and P-values (considered statistically significant when < 0.05).

RESULTS

In AVR, the general estimate of postoperative pain effect favored MICS (SMD 0.87 [95% CI 0.04 to 1.71], P=0.04). However, in the sensitivity analysis, there was no difference between the groups (SMD 0.70 [95% CI -0.69 to 2.09], P=0.32). For MVS, it was not possible to perform a meta-analysis with the included studies, because they had different methodologies. In CABG, the general estimate of the effect of postoperative pain did not favor any of the approaches (SMD -0.40 [95% CI -1.07 to 0.26], P=0.23), which was confirmed by sensitivity analysis (SMD -0.02 [95% CI -0.71 to 0.67], P=0.95).

CONCLUSION

MICS was not globally less painful than the FS approach. It seems that postoperative pain is more related to the degree of tissue retraction than to the size of the incision.

Multi-vessel coronary artery grafting: analyzing the minimally invasive approach and its safety

Introduction

At our institution, we perform off-pump coronary artery bypass (OPCAB) as a standard procedure. Moreover, patients with favorable coronary anatomy and condition are selected for minimally invasive cardiac surgery (MICS)-OPCAB. We retrospectively compared early outcomes, focusing on safety, between MICS-OPCAB and conventional off-pump techniques for multivessel coronary artery bypass grafting (CABG).

Methods

From August 2017 to September 2022, 1,220 patients underwent multivessel coronary artery grafting at our institution. They were divided into the MICS-OPCAB group (MICS group = 163 patients) and the conventional OPCAB group (MS group = 1057 patients). Propensity score matching (1 : 1 ratio) was applied to the MICS-OPCAB and MS groups (149 patients per group) based on 23 preoperative clinical characteristics.

Results

After matching, there were no significant differences in preoperative characteristics between the groups. The MICS group had a lower total graft number (2.3 ± 0.6 vs. 2.9 ± 0.8, p < 0.001) and fewer distal anastomoses (2.7 ± 0.8 vs. 3.2 ± 0.9, p < 0.001). There were no significant differences in hospital stay, intensive care unit stay, postoperative complications, and 30-day mortality. The MICS group had less drain output (MICS 350 ml [250-500], MS 450 ml [300-550]; p = 0.013). Kaplan-Meier analysis revealed no significant differences in postoperative MACCE (major adverse cardiac or cerebrovascular events)-free and survival rates between the groups (MACCE-free rate p = 0.945, survival rate p = 0.374).

Conclusion

With proper patient selection, MICS-OPCAB can provide good short to mid-term results, similar to those of conventional OPCAB.

Erector spinae plane block reduces opioid consumption and improves incentive spirometry volume after cardiac surgery: A retrospective cohort study

BACKGROUND

Effective postoperative pain management is vital in cardiac surgery to prevent opioid dependency and respiratory complications. Previous studies on the erector spinae plane (ESP) block have focused on single-shot applications or immediate postoperative outcomes. This study evaluates the efficacy of continuous ESP block vs conventional care in reducing opioid consumption and enhancing respiratory function recovery postcardiac surgery over 72 hours.

METHODS

A retrospective study at a tertiary hospital (January 2021-July 2022) included 262 elective cardiac surgery patients. Fifty-three received a preoperative ESP block, matched 1:1 with a control group (n = 53). The ESP group received 0.5% ropivacaine intraoperatively and 0.16% ropivacaine every 4 hours postoperatively. Outcomes measured were cumulative oral morphine equivalent (OME) dose within 72 hours postextubation, daily maximum numerical rating scale (NRS) ≥3, incentive spirometry volume, and %baseline performance, stratified by surgery type (sternotomy or thoracotomy).

RESULTS

Significant OME reduction was observed in the ESP group (sternotomy: median decrease of 113 mg, 95% CI: 60-157.5 mg, p < 0.001; thoracotomy: 172.5 mg, 95% CI: 45-285 mg, p = 0.010). The ESP group also had a lower risk of daily maximum NRS ≥3 (adjusted OR sternotomy: 0.22, p < 0.001; thoracotomy: 0.07, p < 0.001), a higher incentive spirometry volumes (sternotomy: mean increase of 149 mL, p = 0.019; thoracotomy: 521 mL, p = 0.017), and enhanced spirometry %baseline (sternotomy: mean increase of 11.5%, p = 0.014; thoracotomy: 26.5%, p < 0.001).

CONCLUSION

Continuous ESP block was associated with a reduction of postoperative opioid requirements, lower instances of pain scores ≥3, and improve incentive spirometry performance following cardiac surgery. These benefits appear particularly prominent in thoracotomy patients. Further prospective studies with larger sample size are required to validate these findings.

Long-term survival, cardiovascular, and functional outcomes after minimally invasive coronary artery bypass grafting in 566 patients

OBJECTIVE

Sternotomy has been the gold standard incision for surgical revascularization but may be associated with chronic pain and sternal malunion. Minimally invasive coronary artery bypass grafting allows for complete surgical revascularization through a small thoracotomy in selected patients. There is a paucity of long-term data, particularly functional outcomes, for patients who underwent minimally invasive coronary artery bypass grafting.

METHODS

Patients (N = 566) who underwent minimally invasive coronary artery bypass grafting at a single institution over a 17-year period were prospectively followed. The primary outcome was survival. At late follow-up, patients were contacted for a questionnaire on functional outcomes. Multivariable Cox proportional hazard model identified correlates of the primary outcome.

RESULTS

Clinical follow-up was complete for 100% of patients (mean 7.0 ± 4.4 years); a follow-up questionnaire was also completed for 83.9% (N = 427) of live patients. Fifty percent of patients (N = 283) had undergone multivessel grafting. At 12 years, survival for the entire cohort was 82.2% ± 2.6%. On late follow-up questionnaire, 12 patients (2.8%) had greater than Canadian Cardiovascular Score Class II angina and 19 patients (4.5%) had greater than New York Heart Association Class II symptoms. More than 98% of patients did not have pain related to the incision site. Cox proportional hazards analysis identified older age, peripheral vascular disease, prior myocardial infarction, left ventricular dysfunction, cancer in the past 5 years, intraoperative transfusion, and hybrid revascularization as correlates of mortality during follow-up.

CONCLUSIONS

Minimally invasive coronary artery bypass grafting is a safe and durable alternative to sternotomy coronary artery bypass grafting in selected patients, with excellent short- and long-term outcomes, including for multivessel coronary disease. At long-term follow-up, the proportion of patients with significant symptoms and incisional pain was low.

Pectoral Fascial Plane Versus Paravertebral Blocks for Minimally Invasive Mitral Valve Surgery Analgesia

OBJECTIVES

This study examined the postoperative analgesic efficacy of single-injection pectoral fascial plane (PECS) II blocks compared to paravertebral blocks for elective robotic mitral valve surgery.

DESIGN

A single-center retrospective study that reported patient and procedural characteristics, postoperative pain scores, and postoperative opioid use for patients undergoing robotic mitral valve surgery.

SETTING

This investigation was performed at a large quaternary referral center.

PARTICIPANTS

Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2016, to August 14, 2020, for elective robotic mitral valve repair who received either a paravertebral or PECS II block for postoperative analgesia.

INTERVENTIONS

Patients received an ultrasound-guided, unilateral paravertebral or PECS II nerve block.

MEASUREMENTS AND MAIN RESULTS

One hundred twenty-three patients received a PECS II block, and 190 patients received a paravertebral block during the study period. The primary outcome measures were average postoperative pain scores and cumulative opioid use. Secondary outcomes included hospital and intensive care unit lengths of stay, need for reoperation, need for antiemetics, surgical wound infection, and atrial fibrillation incidence. Patients receiving the PECS II block required significantly fewer opioids in the immediate postoperative period than the paravertebral block group, and had comparable postoperative pain scores. No increase in adverse outcomes was noted for either group.

CONCLUSIONS

The PECS II block is a safe and highly effective option for regional analgesia for robotic mitral valve surgery, with demonstrated efficacy comparable to the paravertebral block.

Erector Spinae Plane Catheter Analgesia in Minimally Invasive Mitral Valve Surgery: A Retrospective Case-Control Study for Inclusion in an Enhanced Recovery Program

Background. A retrospective case-control study was conducted to assess the feasibility of erector spinae plane (ESP) block as part of a multimodal enhanced recovery program for patients undergoing minimally invasive mitral valve replacement surgery. Methods. This retrospective analysis was conducted at a single center between January and August 2019. 61 patients were included; 23 received ESP and 38 did not. Erector spinae catheters (ESCs) were placed preoperatively, using a loading dose of 30 mL .5% ropivacaine, followed by an infusion of .2% ropivacaine at 10 mL/h throughout the study period. Primary outcome was 48-hour opioid consumption. Secondary outcomes included intraoperative morphine equivalents, extubation within 24 hours, reintubation, ICU length of stay and hospital length of stay and 30-day mortality. Results. Median [inter-quartile range] of the postoperative morphine milligram equivalents (MMEs) in the first 48 hours was 70[45-121] MMEs in the ESC) group, and 109[70-148] MMEs in the no ESC group (P-value = .16). No significant difference was observed in intraoperative morphine equivalents, extubation within 24 hours or ICU length of stay. The ESC group had shorter hospital length of stay (6.0 vs 7.0 days, P-value = .043). Conclusion. This study found a statistically insignificant, though potentially clinically significant reduction in postoperative opioid consumption. A reduced hospital length of stay as well as an acceptable safety profile was also observed in the ESC group. An adequately powered, prospective trial is warranted to accurately assess the potential role for ESP catheters for patients undergoing minimally invasive mitral valve surgery.

Effect of high-flow nasal therapy on patient-centred outcomes in patients at high risk of postoperative pulmonary complications after cardiac surgery: a study protocol for a multicentre adaptive randomised controlled trial

BACKGROUND

High-flow nasal therapy is a non-invasive form of respiratory support that delivers low-level, flow dependent positive airway pressure. The device can be better tolerated by patients than alternatives such as continuous positive airway pressure. The primary objective is to determine if prophylactic high-flow nasal therapy after tracheal extubation can result in an increase in the number of days alive and at home within the first 90 days after surgery, when compared with standard oxygen therapy. The co-primary objective is to estimate the incremental cost-effectiveness and cost-utility of high-flow nasal therapy vs standard oxygen therapy at 90 days, from the view-point of the public sector, the health service and patients.

METHODS

This is an adaptive, multicentre, international parallel-group, randomised controlled trial with embedded cost-effectiveness analysis comparing the use of high-flow nasal therapy with control in patients at high risk of respiratory complications following cardiac surgery. Participants will be randomised before tracheal extubation and allocated either high-flow nasal therapy or standard oxygen therapy for a minimum of 16 h immediately post extubation. Participants will be followed up until 90 days after surgery. The total sample size needed to detect a 2-day increase in DAH90 with 90% power with an intention to treat analysis is 850 patients. The adaptive design includes an interim sample size re-estimation which will provide protection against deviations from the original sample size assumptions made from the single-centre pilot study and will allow for a maximum sample size increase to 1152 patients.

DISCUSSION

Evidence to support routine use of high-flow nasal therapy will inform the development of effective enhanced recovery care bundles. Reducing complications should reduce length of stay and re-admission to hospital and provide an important focus for cost reduction. However; high-quality studies evaluating the clinical and cost effectiveness of high-flow nasal therapy after cardiothoracic surgery are lacking.

TRIAL REGISTRATION

The study has been registered with ISRCTN ( ISRCTN14092678 , 13/05/2020) Clinicaltrials.gov Registration Pending.

The effect of continuous intercostal nerve block vs. single shot on analgesic outcomes and hospital stays in minimally invasive direct coronary artery bypass surgery: a retrospective cohort study

BACKGROUND

Minimally invasive direct coronary artery bypass (MIDCAB) grafting surgery is accompanied by severe pain. Although continuous intercostal nerve block (CINB) has become one of the multimodal analgesic techniques in single port thoracoscopic surgery, its effects on MIDCAB are unclear. The purpose of this study was to compare the effects of CINB and single shot on analgesic outcomes and hospital stays in patients undergoing MIDCAB in a real-world setting.

METHODS

A retrospective cohort study was carried out at Peking University Third Hospital, China. Two hundred and sixteen patients undergoing MIDCAB were divided into two groups: a CINB group and a single block (SI) group. The primary outcome was postoperative maximal visual analog scale (VAS); secondary outcomes included the number of patients with maximal VAS ≤ 3, the demand for and consumed doses of pethidine and tramadol, and the length of intensive care unit (ICU) and hospital stays. The above data and the area under the VAS curve in the 70 h after extubation for the two subgroups (No. of grafts = 1) were also compared.

RESULTS

The maximum VAS was lower in the CINB group, and there were more cases with maximum VAS ≤ 3 in the CINB group: CINB 52 (40%) vs. SI 17 (20%), P = 0.002. The percentage of cases requiring tramadol and pethidine was less in CINB, P = 0.001. Among all patients, drug doses were significantly lower in the CINB group [tramadol: CINB 0 (0-100) mg vs. SI 100 (0-225) mg, P = 0.0001; pethidine: CINB 0 (0-25) mg vs. SI 25 (0-50) mg, P = 0.0004]. Further subgroup analysis showed that the area under the VAS curve in CINB was smaller: 28.05 in CINB vs. 30.41 in SI, P = 0.002. Finally, the length of ICU stay was shorter in CINB than in SI: 20.5 (11.3-26.0) h vs. 22.0 (19.0-45.0) h, P = 0.011.

CONCLUSIONS

CINB is associated with decreased demand for rescue analgesics and shorter length of ICU stay when compared to single shot intercostal nerve block. Additional randomized controlled trial (RCT) is needed to support these findings.

Persistent and acute postoperative pain after cardiac surgery with anterolateral thoracotomy or median sternotomy: A prospective observational study

OBJECTIVE

The primary objective of this study was to compare the association between cardiac surgical approach (thoracotomy vs. sternotomy) and incidence of persistent postoperative pain at 3 months. Secondary objectives were the incidence and intensity of persistent pain at 6 and 12 months, acute postoperative pain, analgesic requirement and its side effects.

DESIGN

Single-center, prospective, observational study. Recruitment between December 2017 and August 2018.

SETTING

Perioperative care at university-affiliated tertiary care centre.

PATIENTS

202 adults scheduled for cardiac surgery. Patients with chronic pain or behavioural disorder were excluded.

INTERVENTIONS

Thoracotomy (n = 106) and sternotomy (n = 96).

MEASUREMENTS

Pain scores and pain medication requirements from extubation until hospital discharge. Persistent postoperative pain was assessed using a telephone questionnaire.

MAIN RESULTS

Incidence and intensity of pain was not significantly different between thoracotomy or sternotomy either in the short- or in the long-term follow-up. Incidence of persistent postoperative pain showed no differences between groups (30.2 vs 22.9% at 3 months (p = 0.297), 10.4 vs 7.3% at 6 months (p = 0.364) and 7.5 vs 7.3% at 12 months (p = 0.518) in thoracotomy and sternotomy group). A significant decrease of pain incidence was observed between 3 and 6 months (p < 0.001) but not between 6 and 12 months (p = 0.259) in both groups. ANOVA of repeated measures adjusted for confounding variable showed a decrease of acute pain intensity over time (p = 0.001) with no difference between groups (p = 0.145). Acute pain medication requirements were not different between the groups (p = 0.237 for piritramide and p = 0.743 for oxycodone) with no difference in their side effects.

CONCLUSIONS

Our study showed no difference in short- or long-term pain in patients undergoing anterolateral thoracotomy or median sternotomy. Both groups showed a decrease in persistent postoperative pain incidence between 3 and 6 months without any significant changes at 12 months.

Esophagectomy combined with off-pump coronary artery bypass grafting through left posterolateral incision is safe and feasible for esophageal cancer associated with coronary artery disease

Controversy still exists as to whether surgical treatment has any impact on the long-term survival of esophageal cancer (EC) patients with coronary artery disease treated with curative esophagectomy combined with off-pump coronary artery bypass grafting (OPCABG). Therefore, the aim of this study was to introduce and assess the effect of esophagectomy combined with OPCABG on both short- and long-term outcomes. From January 2010 to January 2015, 1428 EC or esophagogastric junction cancer patients underwent surgical treatment at Henan Chest Hospital, Zhengzhou, China. The clinical data of 25 patients who underwent EC resection through a left thoracotomy following OPCABG and the perioperative characteristics and follow-up results were analyzed. The majority of the patients were male, and the EC stage was predominantly cT2N0-1M0 II. The most common pathological types were squamous cell carcinoma. The EC surgeries consisted of 15 chest anastomosis procedures and 10 cervical anastomosis procedures with aortocoronary graft implantation (mean: 2.36 grafts per patient). The mean total operative time was 330.8 ± 83.5 minutes. The median intensive care unit and hospital lengths of stay were 1.72 and 21.16 days, respectively. Resection without macroscopic residual disease (R0) was achieved in all of the patients. The most frequent complications included pulmonary infections (24%), arrhythmias (24%), pleural effusion (12%), and esophageal anastomotic leakage (8%). There were no postoperative deaths or myocardial infarctions within 30 days after the surgery. The overall 1-, 3-, and 5-year survival rates were 88%, 40%, and 24%, respectively, with a median survival time of 43 months. In the short-term, radical resection of EC following OPCABG is a safe and feasible treatment with low postoperative mortality rates. In the long-term, simultaneous surgery is acceptable and is associated with favorable overall and disease-free survival.

Left thoracotomy approach for off-pump coronary artery bypass grafting surgery: 15 years of experience in 2500 consecutive patients

OBJECTIVES

Our goal was to describe the experience at 2 centres with off-pump coronary artery bypass grafting using a left thoracotomy.

METHODS

From January 2002 to December 2017, a total of 2528 consecutive patients (578 women, mean age 62.3 ± 9.1 years) were operated on using this technique. Data were collected prospectively and analysed retrospectively.

RESULTS

There were no conversions to median sternotomy and 6 patients (0.2%) were converted to on-pump CABG. The mean number of grafts per patient was 2.8 ± 0. 9. The 30-day mortality rate was 1.0% (25 patients). Most patients were extubated in the operating theatre (97.3%), and 47 patients (1.9%) needed re-exploration for bleeding. Seven patients (0.3%) experienced a cerebrovascular event; 4 (0.3%) had a postoperative myocardial infarction; and 84 (3.4%) had new-onset atrial fibrillation. A total of 1510 patients (61.1%) were discharged from the hospital in the first 48 h after surgery. Long-term survival rates were 98.8%, 93.6% and 69.1% at 1, 5 and 10 years, respectively (central image). During the follow-up period, 60 patients (2.9%) were re-examined for recurrence of angina with a new coronary angiogram; of those, 24 (1.2%) required percutaneous coronary intervention and 11 (0.5%) had redo surgery.

CONCLUSIONS

A left thoracotomy is a safe alternative to a median sternotomy for coronary artery bypass grafting on the beating heart, with low early complications and good mid- and long-term results.

Review of Contemporary Techniques for Minimally Invasive Coronary Revascularization

Minimally invasive coronary revascularization techniques aim to avoid median sternotomy with its associated complications, while facilitating recovery and maintaining the benefits of surgical revascularization. The 3 most common procedures are minimally invasive coronary artery bypass grafting, totally endoscopic coronary artery bypass, and hybrid coronary revascularization. For a variety of reasons, including cost and technical difficulty, not many centers are routinely performing minimally invasive coronary revascularization. Nevertheless, many studies have assessed the safety and efficacy of each of these procedures in different clinical contexts. Thus far results have been promising, and with the evolution of procedural techniques, these approaches have the potential to redefine coronary revascularization in the future. This review highlights the current state of minimally invasive coronary revascularization techniques by exploring their benefits, identifying barriers to their adoption, and discussing future potential paradigms.

Multivessel Arterial Revascularization via Left Anterior Thoracotomy

To present the technique and to evaluate the outcomes of the multivessel minimally invasive coronary revascularization through the left anterior thoracotomy. From July 2017 to March 2019 in 229 consecutive patients with isolated multivessel coronary artery disease we performed complete coronary revascularization through the left anterior minithoracotomy (6-8 cm skin incision). In 47 of them we performed multiarterial revascularization using left internal mammary artery and T-shunt with left radial artery or right internal mammary artery. Cardiopulmonary bypass (CPB), Chitwood clamp and blood cardioplegia were used in all patients. Heart strings, encircling tapes and Chitwood clamp were used to reduce the distance from skin to coronary targets. Usual coronary instruments were used. The perioperative outcomes of multiarterial graft strategy group were compared with uniarterial graft strategy group. There were no mortality, no perioperative myocardial infarcts, and no conversion to sternotomy with either graft strategy groups. The mean number of distal anastomoses, CPB time, and total hospital stay were not different between the groups. Aortic cross-clamp time ((83.8 ± 17.4 (45;121) vs 67.8 ± 17.4 (35;146), P < 0.0001) and total operation time (283.5 ± 45 (205;495) vs 254.3 ± 48.6 (175;590), P = 0.0003) were longer in patients with multiarterial revascularization compared to uniarterial revascularization using left internal mammary artery and veins. Multivessel coronary bypass grafting using CPB and cardioplegia can be routinely performed minimally invasively through the left anterior thoracotomy. In selected patients multiarterial revascularization could be done with excellent procedural outcomes.

Comparison of Minimally Invasive Direct Coronary Artery Bypass and Percutaneous Coronary Intervention Using Second-Generation Drug-Eluting Stents for Coronary Artery Disease - Propensity Score-Matched Analysis

BACKGROUND

Some studies comparing minimally invasive direct coronary artery bypass (MIDCAB) and percutaneous coronary intervention (PCI) have reported MIDCAB's superiority, but they did not investigate contemporary PCI with newer generation drug-eluting stents (DES). We compared clinical outcomes after MIDCAB with previously reported outcomes after PCI with second-generation DES.Methods and Results:We retrospectively reviewed the records of patients treated with MIDCAB. Baseline characteristics and clinical outcomes after MIDCAB were compared with those for left anterior descending artery disease treated via PCI. The primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE), a composite of cardiovascular death, non-fatal myocardial infarction, ischemic stroke, and target vessel revascularization (TVR). A propensity score-matching (PSM) analysis was conducted to adjust for between-group differences in baseline characteristics. We analyzed 77 patients treated with MIDCAB and 2,206 treated with PCI. The MIDCAB group was older and had more severe coronary disease and a higher incidence of left ventricular dysfunction. Over a 3-year follow-up, the PCI group had favorable MACCE outcomes. After PSM, there were no between-group differences in MACCE (MIDCAB, 15.6% vs. PCI, 23.4%; hazard ratio [HR], 0.80; 95% CI: 0.38-1.68, P=0.548) or TVR (MIDCAB, 2.6% vs. PCI, 5.2%; HR, 0.51; 95% CI: 0.10-3.09, P=0.509).

CONCLUSIONS

Clinical outcomes were similar between MIDCAB and PCI using second-generation DES over 3 years of follow-up.

Assessment of Physical Activity by Wearable Technology During Rehabilitation After Cardiac Surgery: Explorative Prospective Monocentric Observational Cohort Study

Background

Wearable technology is finding its way into clinical practice. Physical activity describes patients’ functional status after cardiac surgery and can be monitored remotely by using dedicated trackers.

Objective

The aim of this study was to compare the progress of physical activity in cardiac rehabilitation by using wearable fitness trackers in patients undergoing coronary artery bypass surgery by either the conventional off-pump coronary artery bypass (OPCAB) or the robotically assisted minimally invasive coronary artery bypass (RA-MIDCAB). We hypothesized faster recovery of physical activity after RA-MIDCAB in the first weeks after discharge as compared to OPCAB.

Methods

Patients undergoing RA-MIDCAB or OPCAB were included in the study. Each patient received a Fitbit Charge HR (Fitbit Inc, San Francisco, CA) physical activity tracker following discharge. Rehabilitation progress was assessed by measuring the number of steps and physical activity level daily. The physical activity level was calculated as energy expenditure divided by the basic metabolic rate.

Results

A total of 10 RA-MIDCAB patients with a median age of 68 (min, 55; max, 83) years and 12 OPCAB patients with a median age of 69 (min, 50; max, 82) years were included. Baseline characteristics were comparable except for body mass index (RA-MIDCAB: 26 kg/m²; min, 22; max, 28 versus OPCAB: 29 kg/m²; min, 27; max, 33; P<.001). Intubation time (P<.05) was significantly lower in the RA-MIDCAB group. A clear trend, although not statistically significant, was observed towards a higher number of steps in RA-MIDCAB patients in the first week following discharge.

Conclusions

RA-MIDCAB patients have an advantage in recovery in the first weeks of revalidation, which is reflected by the number of steps and physical activity level measured by the Fitbit Charge HR, as compared to OPCAB patients. However, unsupervised assessment of daily physical activity varied widely and could have consequences with regard to the use of these trackers as research tools.

Initiation and modification of minimally invasive coronary artery bypass grafting

Minimally invasive coronary artery bypass grafting (MICS CABG) via a small left thoracotomy has been proposed as an alternative to standard coronary artery bypass grafting. However, this technique is still limited to skillful surgeons. Off-pump multi-vessel bypass grafting and the use of bilateral internal thoracic arteries are particularly challenging via a small thoracotomy, while they are widely performed via a full median sternotomy. The purpose of this review is to serve as a guide for the proper introduction of MICS CABG in the current era. We examine the advances, current techniques, outcomes and learning curves of MICS CABG and discuss the safe introduction.

Evolution of Minimally Invasive Coronary Artery Bypass Grafting: Learning Curve

OBJECTIVE

Minimally invasive coronary surgery approach for coronary artery bypass grafting is a safe and reproducible procedure for multivessel revascularization. This study reviewed a single surgeon's experience with minimally invasive coronary surgery coronary artery bypass grafting, including operative time, number of bypasses, and conversion to sternotomy.

METHODS

A prospective database of consecutive minimally invasive coronary surgery coronary artery bypass grafting procedures from 2005 to 2013 was reviewed. A small anterolateral left thoracotomy allowed left internal mammary artery harvest, proximal anastomoses on the ascending aorta, and distal coronary anastomoses. Early cases were compared with the later cases, focusing on grafting strategies that led to a standardized approach with Propensity Score Matching analysis.

RESULTS

Seven hundred consecutive cases were divided into early (1-200) and late (201-700) groups. In the late group, the number of triple-vessel disease patients trended higher (50% vs. 57%, P = 0.0674) and the number of bypasses increased (2.3 ± 0.8 vs. 2.7 ± 1.0, P < 0.0001). Conversion to sternotomy significantly decreased between the groups (6% vs. 0.6%, P < 0.0001). There was no difference in rate of postoperative complications between the groups except for prolonged intubation (10% vs. 5%, P = 0.0236) and shortened length of stay (5.9 ± 6.7 vs. 5.5 ± 6.0, P = 0.0268). Propensity score matching analysis (n = 177) was significant for total bypass performed and time per bypass (P < 0.05). The late group was further divided into subgroups of one hundred each (subgroup 1 through 5). Operative times differed significantly (subgroup 1: 249 ± 71.2, subgroup 2: 259 ± 85.8, subgroup 3: 244 ± 71.0, subgroup 4: 270 ± 58.4, and subgroup 5: 246 ± 47.9, P < 0.005).

CONCLUSIONS

As experience with minimally invasive coronary surgery coronary artery bypass grafting increased, the ideal sequence of steps to optimize surgical outcome was defined. The number of bypassed vessels increased and the operative time and conversion to sternotomy decreased.

Does minimally invasive coronary artery bypass improve outcomes compared to off-pump coronary bypass via sternotomy in patients undergoing coronary artery bypass grafting?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In patients undergoing off-pump coronary artery bypass grafting, for single or multivessel disease, does minimally invasive direct coronary artery bypass (MIDCAB) or off-pump coronary artery bypass (OPCAB) provide the superior outcome including a reduction in morbidity and mortality?'. A total of 187 papers were found using the reported search, of which 12 represented the best evidence to answer the clinical question. The authors, date, journal and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. It was found that compared to OPCAB, MIDCAB surgery can offer decreased intensive care unit length of stay (4.5-57.4 h vs 5.2-52.7 h) and total hospital length of stay (4.5-8.5 days vs 5.2-12 days), with 1 paper showing a decrease in mortality at 1 year (3% vs 14%). However, there were several papers that showed significant risks with MIDCAB surgery in patients with either single or multivessel disease. These include increased risk of incomplete revascularization (29% vs 0%), significant early complications (22.5 vs 0%), urgent reintervention (16% vs 0%), repeat revascularization events (12.2% vs 3.7%), progression of native disease (4.8% vs 0.9%), rehospitalization by 3 months (20% vs 2%) and postoperative infarction (2.9% vs 1.45%). These risks did not translate to an increase in early mortality (0-1% vs 0-1.6%) or late mortality (0-3% vs 0-14%) in papers that included mid-term follow up. However, they do represent significant potential risks that cannot be overlooked when considering the use of MIDCAB. We conclude that MIDCAB is associated with greater morbidity and reintervention compared to OPCAB via sternotomy, but both techniques are equivalent in terms of operative and mid-term mortality.

Factors causing prolonged mechanical ventilation and peri-operative morbidity after robot-assisted coronary artery bypass graft surgery

Robot-assisted coronary artery bypass graft [robot-assisted (coronary artery bypass grafting (CABG)] surgery is the latest treatment for coronary artery disease. However, the surgery extensively affects cardiac and pulmonary function, and the risk factors associated with peri-operative morbidity, including prolong mechanical ventilation (PMV), have not been fully examined. In this retrospective cohort study, a total of 382 patients who underwent robot-assisted internal mammary artery harvesting with mini-thoracotomy direct-vision bypass grafting surgery (MIDCABG) from 2005 to 2012 at our tertiary care hospital were included. The definition of PMV was failure to wean from mechanical ventilation more than 48 h after the surgery. Risk factors for PMV, and peri-operative morbidity and mortality were analyzed with a multivariate logistic regression model. Forty-three patients (11.3%) developed PMV after the surgery, and the peri-operative morbidity and mortality rates were 38 and 2.6%, respectively. The risk factors for PMV were age, left ventricular ejection fraction (LVEF), the duration of one-lung ventilation for MIDCABG (beating time), and peak airway pressure at the end of the surgery. Furthermore, age and anesthesia time were found to be independent risk factors for peri-operative morbidity, whereas age, LVEF, and anesthesia time were the risk factors for peri-operative mortality. These findings may help physicians to properly choose patients for this procedure, and provide more attention to patients with higher risk after surgery to achieve better clinical outcomes.

Minimally invasive coronary artery bypass as a safe method of surgical revascularization. The step towards hybrid procedures

INTRODUCTION

Coronary artery disease is nowadays responsible for approximately 15% of hospitalizations in Poland. Minimally invasive coronary artery bypass (MIDCAB) represents an attractive alternative to a sternotomy, and at the same time provides better life quality and facilitates quick rehabilitation.

AIM

To evaluate whether MIDCAB can be performed with similar early and mid-term results as off-pump coronary artery bypass (OPCAB) and therefore can be considered as a safe stage in hybrid revascularization.

MATERIAL AND METHODS

In a retrospective cohort study, we analyzed 73 consecutive patients who underwent coronary artery bypass grafting (left internal mammary artery to left anterior descending artery) between 2013 and 2016 in the Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Krakow. Thirty-eight (52.1%) MIDCAB and 35 (47.9%) OPCAB patients were enrolled.

RESULTS

Short-term results did not significantly differ between groups and similar 30-day mortality was observed (MIDCAB 2.6% vs. OPCAB 2.9%, p = 1). The median follow-up period was 21 months. There were no statistical differences in terms of overall survival or cardiac mortality between groups (94.7% vs. 88.6%, p = 0.42; 2.6% vs. 2.9%, p = 1, respectively). The rate of hospitalization due to cardiac causes was similar in both groups (7.9% vs. 5.1%, p = 1) and there were no differences in current exacerbation of angina or heart failure, with median NYHA class I and CCS class I in both groups.

CONCLUSIONS

Despite higher technical difficulty, MIDCAB procedures can be performed with similar safety results as OPCAB procedures. No differences in terms of mortality, repeat revascularization or recurrent angina are observed.

Diagnostic and therapeutic medical devices for safer blood management in cardiac surgery: systematic reviews, observational studies and randomised controlled trials

Background

Anaemia, coagulopathic bleeding and transfusion are strongly associated with organ failure, sepsis and death following cardiac surgery.

Objective

To evaluate the clinical effectiveness and cost-effectiveness of medical devices used as diagnostic and therapeutic tools for the management of anaemia and bleeding in cardiac surgery.

Methods and results

Workstream 1 – in the COagulation and Platelet laboratory Testing in Cardiac surgery (COPTIC) study we demonstrated that risk assessment using baseline clinical factors predicted bleeding with a high degree of accuracy. The results from point-of-care (POC) platelet aggregometry or viscoelastometry tests or an expanded range of laboratory reference tests for coagulopathy did not improve predictive accuracy beyond that achieved with the clinical risk score alone. The routine use of POC tests was not cost-effective. A systematic review concluded that POC-based algorithms are not clinically effective. We developed two new clinical risk prediction scores for transfusion and bleeding that are available as e-calculators. Workstream 2 – in the PAtient-SPecific Oxygen monitoring to Reduce blood Transfusion during heart surgery (PASPORT) trial and a systematic review we demonstrated that personalised near-infrared spectroscopy-based algorithms for the optimisation of tissue oxygenation, or as indicators for red cell transfusion, were neither clinically effective nor cost-effective. Workstream 3 – in the REDWASH trial we failed to demonstrate a reduction in inflammation or organ injury in recipients of mechanically washed red cells compared with standard (unwashed) red cells.

Limitations

Existing studies evaluating the predictive accuracy or effectiveness of POC tests of coagulopathy or near-infrared spectroscopy were at high risk of bias. Interventions that alter red cell transfusion exposure, a common surrogate outcome in most trials, were not found to be clinically effective.

Conclusions

A systematic assessment of devices in clinical use as blood management adjuncts in cardiac surgery did not demonstrate clinical effectiveness or cost-effectiveness. The contribution of anaemia and coagulopathy to adverse clinical outcomes following cardiac surgery remains poorly understood. Further research to define the pathogenesis of these conditions may lead to more accurate diagnoses, more effective treatments and potentially improved clinical outcomes.

Study registration

Current Controlled Trials ISRCTN20778544 (COPTIC study) and PROSPERO CRD42016033831 (systematic review) (workstream 1); Current Controlled Trials ISRCTN23557269 (PASPORT trial) and PROSPERO CRD4201502769 (systematic review) (workstream 2); and Current Controlled Trials ISRCTN27076315 (REDWASH trial) (workstream 3).

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 5, No. 17. See the NIHR Journals Library website for further project information.

Meta-analysis of interleukin 6, 8, and 10 between off-pump and on-pump coronary artery bypass groups

This study aimed to evaluate the role of off-pump coronary artery bypass (CAB) surgery on the decrease of postoperative inflammatory responses in patients. We systematically searched databases of PubMed and Embase to select the related studies. Interleukin (IL) 6, 8, and 10 were used as outcomes and pooled analysis was performed using R 3.12 software. Standardized mean differences (SMDs) and their 95% confidence intervals (95% CIs) were considered as effect estimates. A total of 27 studies, including 1340 participants, were recruited in this meta-analysis. The pooled analyses showed that postoperative concentration of IL-10 at 12 hours was significantly lower in off-pump CAB group compared to on-pump CAB group (SMD = -1.3640, 95% CI = -2.0086--0.7193). However, no significant differences were found in pre and postoperative concentrations of IL-6 and 8 between off-pump and on-pump CAB groups. These results suggest that there is no advantage of off-pump CAB surgery in the reduction of inflammation compared to on-pump CAB surgery.

Perioperative outcomes in minimally invasive direct coronary artery bypass versus off-pump coronary artery bypass with sternotomy

Introduction

Surgical treatment of isolated left anterior descending coronary artery disease can be performed with either minimally invasive direct coronary artery bypass via a left anterior thoracotomy (MIDCAB) or off-pump coronary artery bypass via a median sternotomy (OPCAB).

Aim

To compare the perioperative outcomes of patients undergoing MIDCAB or OPCAB surgery.

Material and methods

Patients who underwent either MIDCAB or OPCAB for isolated left anterior descending (LAD) coronary artery disease between October 2013 and December 2015 were retrospectively evaluated. Operations were carried out by the same surgical team. Preoperative, intraoperative and postoperative data of the patients were recorded for analyses.

Results

Twenty-three patients (7 females, 16 males) underwent MIDCAB surgery, and 24 patients (4 female, 20 males) underwent OPCAB surgery. The two groups were comparable regarding preoperative patient characteristics. Duration of mechanical ventilation (5.1 ±0.7 h vs. 6.6 ±0.9 h), intensive care unit stay (19.4 ±2.5 h vs. 45.8 ±5.4 h) and hospital stay (4.3 ±0.4 days vs. 5.6 ±0.8 days) were significantly shorter in the MIDCAB group (p < 0.01). Patients in the OPCAB group required significantly more blood transfusions (1.83 ±0.38 units vs. 0.17 ±0.38 units) and fresh frozen plasma use (2.33 ±0.96 units vs. 0.69 ±0.76 units) (p < 0.01). Conversion to sternotomy was not required in the MIDCAB group. There was no mortality, conversion to cardiopulmonary bypass or serious complication in either group.

Conclusions

We believe that the MIDCAB technique is more advantageous than the OPCAB technique in the treatment of patients with a critical LAD lesion.

First-in-Man Transcervical Surgical Aortic Valve Replacement Using the CoreVista System

OBJECTIVE

This study aimed to evaluate a novel device system for surgical aortic valve replacement (SAVR) using a unique new less invasive access approach. The hypothesis is that SAVR can be performed through a short transverse incision in the neck, similar to that used for transcervical thymectomy avoiding chest disruption.

METHODS

A new device system was developed to provide retraction, step-by-step illumination, and on-screen visualization for the new approach. Preliminary feasibility studies were performed in cadavers. Comprehensive risk analysis was performed, and training was implemented in Thiel preserved cadavers. For the first-in-man clinical case, a 63-year-old woman with symptomatic critical aortic stenosis (The Society of Thoracic Surgeons risk, 11%) and heavily calcified aortic valve was selected. A short transverse incision was made in the neck; the device was introduced, and the sternum was elevated; femorofemoral cardiopulmonary bypass was established; substernal dissection was guided by the sequenced illumination, and high-definition visualization was provided by the device, allowing for optimal exposition of the aorta and aortic valve; and a 23-mm Medtronic ENABLE sutureless valve prosthesis was implanted. Procedure success was evaluated according to the standardized composite end point definition of "device success" proposed by the Valve Academic Research Consortium.

RESULTS

Access, delivery, and deployment of the valve prosthesis were successful. The correct position and intended performance of the valve were demonstrated (mean gradient, 6 mm Hg; aortic valve area, 2.5 cm) with the absence of moderate or severe prosthetic aortic regurgitation. Only one valve prosthesis was used.

CONCLUSIONS

Transcervical SAVR with sutureless valve is feasible using this novel access system. The new approach has potential to offer patients substantially shorter stay and fewer, less serious complications, as has been observed in transcervical thymectomy. Further studies are merited.

Minimally invasive compared to conventional approach for coronary artery bypass grafting improves outcome

INTRODUCTION

Minimally invasive (MI) cardiac surgery is a rapidly gaining popularity, globally as well as in India. We aimed to compare the outcome of MI to the conventional approach for coronary artery bypass graft (CABG) surgery.

METHODS

This prospective, comparative study was conducted at a tertiary care cardiac surgical center. All patients who underwent CABG surgery via MI approach (MI group) from July 2015 to December 2015 were enrolled and were compared against same number of EuroSCORE II matched patients undergoing CABG through conventional mid-sternotomy approach (CON group). Demographic, intra- and post-operative variables were collected.

RESULTS

In MI group, duration of the surgery was significantly longer (P = 0.029). Intraoperative blood loss lesser (P = 0.002), shorter duration of ventilation (P = 0.002), shorter Intensive Care Unit stay (P = 0.004), shorter hospital stay (P = 0.003), lesser postoperative analgesic requirements (P = 0.027), and lower visual analog scale scores on day of surgery (P = 0.032) and 1 st postoperative day (P = 0.025). No significant difference in postoperative blood loss, blood transfusion, or duration of inotrope requirement observed. There was no conversion to mid-sternotomy in any patients, 8% of patients had desaturation intraoperatively. There was no operative mortality.

CONCLUSION

MI surgery is associated with lesser intraoperative blood loss, better analgesia, and faster recovery.

Minimally invasive cardiac surgery: A systematic review and meta-analysis

BACKGROUND

Minimally invasive (MI) cardiac surgery was introduced to reduce problems associated with a full sternotomy. This meta-analysis aimed to investigate the effects of minimally invasive cardiac surgery on a range of clinical outcomes.

METHODS

To identify potential studies (randomised/prospective clinical trials) systematic searches were carried out. The search strategy included the concepts of "minimally invasive" OR "MIDCAB" AND "coronary artery bypass grafting" OR "cardiac surgery". This was followed by a meta-analysis investigating cross-clamp time, cardiopulmonary bypass (CPB) time, operation time, ventilation time, intensive care unit (ICU) stay, hospital stay, incidence of myocardial infarction and of stroke/neurologic complications.

RESULTS

Eight studies (9 intervention groups), totalling 596 participants were analysed. MI cardiac surgery was associated with a shorter ICU stay mean difference (MD) -0.7days (95% confidence interval (CI) -1.23 to -0.18, p=0.009) and longer cross-clamp MD 6.7min (95% CI 1.24 to 12.17, p=0.02), CPB MD 26.68min (95% CI 10.31 to 43.05, p=0.001), and operation times MD 55.03min (95% CI 22.76 to 87.31, p=0.0008). However no differences were found in the ventilation time MD -3.94h (95% CI -8.09 to 0.21, p=0.06), length of hospital stay MD -1.14days (95% CI -3.11 to 0.83, p=0.26) and in the incidence of myocardial infarction odds ratio (OR) 1.97 (95% CI 0.49 to 7.9, p=0.34) or stroke/neurologic complications OR 0.67 (95% CI 0.11 to 4.05, p=0.66).

CONCLUSIONS

Minimally invasive cardiac surgery is as safe as conventional surgery and could reduce costs due to a shorter period spent in ICU.

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

BACKGROUND

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Trial protocol for a randomised controlled trial of red cell washing for the attenuation of transfusion-associated organ injury in cardiac surgery: the REDWASH trial

Introduction

It has been suggested that removal of proinflammatory substances that accumulate in stored donor red cells by mechanical cell washing may attenuate inflammation and organ injury in transfused cardiac surgery patients. This trial will test the hypotheses that the severity of the postoperative inflammatory response will be less and postoperative recovery faster if patients undergoing cardiac surgery receive washed red cells compared with standard care (unwashed red cells).

Methods and analysis

Adult (≥16 years) cardiac surgery patients identified at being at increased risk for receiving large volume red cell transfusions at 1 of 3 UK cardiac centres will be randomly allocated in a 1:1 ratio to either red cell washing or standard care. The primary outcome is serum interleukin-8 measured at 5 postsurgery time points up to 96 h. Secondary outcomes will include measures of inflammation, organ injury and volumes of blood transfused and cost-effectiveness. Allocation concealment, internet-based randomisation stratified by operation type and recruiting centre, and blinding of outcome assessors will reduce the risk of bias. The trial will test the superiority of red cell washing versus standard care. A sample size of 170 patients was chosen in order to detect a small-to-moderate target difference, with 80% power and 5% significance (2-tailed).

Ethics and dissemination

The trial protocol was approved by a UK ethics committee (reference 12/EM/0475). The trial findings will be disseminated in scientific journals and meetings.

Trial registration number

ISRCTN 27076315.

Translation, adaptation and validation of the Coronary Revascularization Outcome Questionnaire into Greek

BACKGROUND AND AIMS

Evaluating the impact of coronary revascularization on patients' health related quality of life with a patient-based and disease-specific tool is important for drawing conclusions about treatment and outcomes. This study reports on the translation, adaptation and psychometric evaluation of a Greek version of the Coronary Revascularization Outcome Questionnaire (CROQ-Gr).

METHODS

A total of 609 (81.7% male) patients who had undergone coronary revascularization (percutaneous coronary intervention or coronary artery bypass grafting) were recruited from four hospitals in Athens. After translating the CROQ into Greek, a preliminary qualitative study and a pilot quantitative study were conducted. A full psychometric evaluation was carried out on the main study's data.

RESULTS

The psychometric evaluation demonstrated that the CROQ-Gr is acceptable to patients (high response rate, low missing data) and has a good level of reliability (internal consistency >0.70, test-retest reliability >0.90) and validity (both content and construct validity).

CONCLUSIONS

The results of this study show the CROQ-Gr to be a psychometrically rigorous patient-based measure of outcomes of coronary revascularization. It would be appropriate for use in evaluative research as well as a routine clinical tool to aid cardiologists in monitoring the outcomes of care.

Sternal force distribution during median sternotomy retraction

BACKGROUND

Median sternotomy is the access of choice in cardiac surgery. Sternal retractors exert significant forces on the thoracic cage and might cause considerable damage. The aim of this study was to determine the effects of retractor shape on local force distribution to obtain criteria for retractor design.

METHODS

Two types of sternal retractors (straight [SSR] and curved [CSR]) were equipped with force sensors. Force distribution, total force, and displacement were recorded to a spread width of 10 cm in 18 corpses (11 males and 7 females; age, 62 ± 12 years). Both retractors were used in alternating sequence in 4 iterations in every corpse. Data were compared with respect to the different retractor blade shapes.

RESULTS

Maximum total forces for full retraction of both retractors resulted in 349.4 ± 77.9 N. Force distribution during the first retraction for the cranial/median/caudal part of the sternum was 101.5 ± 43.9/29.1 ± 33.9/63.0 ± 31.4 N for the SSR and 38.7 ± 41.3/80.9 ± 64.5/34.0 ± 25.8 N for the CSR, respectively. During the 4 spreading cycles, the average force decreased from 224.6 ± 61.3 N in the first to 110.8 ± 39.8 N in the fourth iteration. The mean total force for the first retraction revealed 226.4 ± 71.9 N for the CSR and 222.8 ± 52.9 N for the SSR.

CONCLUSIONS

The shape of sternal retractors considerably influences the force distribution on the sternal incision. In the SSR, forces on the cranial and caudal sternum are significantly higher than in the median section, whereas in the CSR, forces in the median section are highest.

Does a minimally invasive approach result in better pulmonary function postoperatively when compared with median sternotomy for coronary artery bypass graft?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Does a minimally invasive approach result in better pulmonary function postoperatively when compared with median sternotomy for coronary artery bypass graft?'. Procedures such as limited sternotomy and minimally invasive direct coronary artery bypass (MIDCAB) though a minithoracotomy were regarded as minimally invasive. Overall, 681 papers were found, of which eight represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, evidence level, relevant outcomes and results of these papers were tabulated. Three randomized, controlled trials (RCT) were included: One study suggested that ministernotomy dividing the corpus sterni (n = 50) offers no advantage over standard sternotomy (n = 50) during the first 10 postoperative days. Two further studies reported on minithoracotomy: one trial presented data suggesting that minithoracotomy (n = 21) is as safe as standard sternotomy with (n = 18) or without (n = 19) cardiopulmonary bypass, but without the benefit ascribed to the minimally invasive incision. A two-centre report investigated pulmonary function as a secondary outcome and claimed that minithoracotomy worsens FEV1 and FVC. The study was not powered to detect these differences as pulmonary function data were available only for one of the centres. Five non-randomized reports were also included in this analysis: These investigated outcomes after minithoracotomy or limited sternotomy compared with standard sternotomy. Patient groups were small, involving <20 subjects per group. Non-randomized studies suggested a benefit to postoperative lung function in using thoracotomy. One of these reports included only patients with severe chronic obstructive pulmonary disease (COPD) (FEV1 <70% of predicted) and detected benefits in selected patients undergoing MIDCAB. A further study was in agreement with the above statement in patients without COPD. MIDCAB may be more painful initially, but results in quicker recovery of lung function. Demonstrating the benefits of ministernotomy compared with the standard sternal incision was less clear. One paper demonstrates better outcomes when compared with standard sternotomy, while another reports no difference. We conclude that non-randomized studies support the hypothesis that minimally invasive coronary artery bypass benefits postoperative lung function in patients with known respiratory problems.