Multivessel Arterial Revascularization via Left Anterior Thoracotomy

Minimally Invasive CABG Is The Future: Pro

Coronary artery bypass grafting (CABG) remains one of the most commonly performed operations worldwide. However, most CABG operations performed today are as invasive -apart from saphenous vein harvesting- as they were 50 years ago. While heart valve operations have become less invasive, CABG faces formidable challenges in doing so. Valve surgery requires a single surgical exposure to the valve intervened on, but less invasive CABG necessitates multiple surgical exposures to harvest internal thoracic artery conduits, source their inflow plus that of other grafts, and expose each coronary target to be grafted -including anterior, lateral, posterior, and inferior vessels. In this article, we rationalize why we believe that conventional CABG remains unduly invasive, associated with morbidity and prolonged recovery, and why less invasive CABG in its many forms, which we describe, represents a safe, practical, diffusible, and less invasive alternative to sternotomy CABG. Centers of excellence in coronary artery surgery should dedicate resources and expertise to developing high-quality, safe, durable, and advanced forms of lesser invasive CABG.

Minimally Invasive Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease: A Systematic Review

OBJECTIVE

We conducted a systematic review of all available evidence on the feasibility and safety of minimally invasive coronary artery bypass grafting (MICS CABG) in patients with multivessel coronary artery disease (CAD).

METHODS

A systematic literature search in PubMed, MEDLINE via Ovid, Embase, Scopus, and Web of Science was performed to identify all relevant studies evaluating outcomes of MICS CABG among patients with multivessel CAD and including at least 15 patients with no restriction on the publication date.

RESULTS

A total of 881 studies were identified, of which 26 studies met the eligibility criteria. The studies included a total of 7,556 patients. The average patient age was 63.3 years (range 49.5 to 69.0 years), male patients were an average of 77.8% (54.0% to 89.8%), and body mass index was 29.8 kg/m2 (24.5 to 30.1 kg/m2). Early mortality and stroke were on average 0.6% (range 0% to 2.0%) and 0.4% (range 0% to 1.3%), respectively. The average number of grafts was 2.8 (range 2.1 to 3.7). The average length of hospital stay was 5.6 days (range 3.1 to 9.3 days).

CONCLUSIONS

MICS CABG appears to be a safe method in well-selected patients with multivessel CAD. This approach is concentrated at dedicated centers, and there is no widespread application, although it has potential to be widely applicable as an alternative for surgical revascularization. However, large randomized controlled studies with longer follow-up are still required to compare the outcomes with conventional CABG and other revascularization strategies.

New approach to the mitral valve through the left anterior minithoracotomy for combined valve and coronary surgical procedures

Objective

We have developed a new technique for accessing the mitral valve through the left anterior minithoracotomy. This approach has been used in patients requiring both mitral valve surgery and coronary artery bypass grafting.

Methods

From October 2020 to September 2022, we performed 24 concomitant mitral valve procedures and coronary artery bypass grafting through the left anterior minithoracotomy. The average age of the patients was 65.5 years, and the mean left ventricular ejection fraction was 44.5%. Computed tomography angiography was routinely performed preoperatively. The surgical technique included a left anterior minithoracotomy in the fourth intercostal space, peripheral cardiopulmonary bypass, aortic crossclamping using a transthoracic clamp through the additional port in the left second intercostal space, the administration of cold blood cardioplegia, a right atrial transseptal approach to the mitral valve, and special surgical exposure maneuvers. These maneuvers were designed to displace the heart into the left pleural space by pulling the inferior vena cava tape and the ascending aorta tape to the left. Conventional mitral valve surgical techniques were used. The mitral valve repair or replacement was performed after the distal anastomoses to the right and circumflex coronary system were completed. Subsequently, after the mitral valve procedure, coronary anastomosis to the left anterior descending artery was performed.

Results

The mitral valve was effectively visualized, and a planned procedure was successfully completed in all patients. There was no need for conversion to a sternotomy. mitral valve repair was performed in 22 patients (91.7%), and mitral valve replacement was performed in 2 patients (8.3%). Conventional surgical instruments were used in 10 cases (41%), and long-shafted instruments were used in 14 cases (59%). A knot-pusher was required in 9 cases (37.5%). A computed tomography distance from the skin level to the mitral valve posterior annulus of more than 14 cm was identified as a technical difficulty marker, necessitating the use of long-shafted instruments. Concomitant complete revascularization was achieved in all cases. The mean number of distal anastomoses was 2.54 ± 0.7 (1; 4). Total operation time was 341 ± 41 (285; 420) minutes, cardiopulmonary bypass time was 231 ± 38 (172; 316) minutes, and the crossclamp time was 127 ± 23 (80; 169) minutes. Patients had a mean intensive care unit stay of 1.87 ± 0.69 (1; 4) days, and their total hospital stay averaged 6.54 ± 1.86 (4; 10) days. There were no reoperations due to bleeding, no occurrences of strokes, and no other major complications. There were no instances of hospital mortality or mortality within 30 days after the procedures.

Conclusions

Mitral valve repair or replacement through the left anterior thoracotomy and transseptal approach is a valuable and effective technique that can be used for concomitant procedures performed through a single minithoracotomy incision in selected patients.

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

OBJECTIVES

Minimally invasive coronary surgery (MICS) via lateral thoracotomy is a less invasive alternative to the traditional median full sternotomy approach for coronary surgery. This study investigates its effectiveness for short- and long-term revascularization in cases of single and multi-vessel diseases.

METHODS

A thorough examination was performed on the databases of two cardiac surgery programs, focusing on patients who underwent minimally invasive coronary bypass grafting procedures between 2010 and 2023. The study involved patients who underwent either minimally invasive direct coronary artery bypass grafting (MIDCAB) for the revascularization of left anterior descending (LAD) artery stenosis or minimally invasive multi-vessel coronary artery bypass grafting (MICSCABG). Our assessment criteria included in-hospital mortality, long-term mortality, and freedom from reoperations due to failed aortocoronary bypass grafts post-surgery. Additionally, we evaluated significant in-hospital complications as secondary endpoints.

RESULTS

A total of 315 consecutive patients were identified between 2010 and 2023 (MIDCAB 271 vs. MICSCABG 44). Conversion to median sternotomy (MS) occurred in eight patients (2.5%). The 30-day all-cause mortality was 1.3% (n = 4). Postoperative AF was the most common complication postoperatively (n = 26, 8.5%). Five patients were reoperated for bleeding (1.6%), and myocardial infarction (MI) happened in four patients (1.3%). The mean follow-up time was six years (±4 years). All-cause mortality was 10.3% (n = 30), with only five (1.7%) patients having a confirmed cardiac cause. The reoperation rate due to graft failure or the progression of aortocoronary disease was 1.4% (n = 4).

CONCLUSIONS

Despite the complexity of the MICS approach, the results of our study support the safety and effectiveness of this procedure with low rates of mortality, morbidity, and conversion for both single and multi-vessel bypass surgeries. These results underscore further the necessity to implement such programs to benefit patients.

New approach for combined aortic valve and coronary procedures through the left anterior minithoracotomy

OBJECTIVES

We have developed a novel technique for accessing the aortic valve (AoV) through the left anterior minithoracotomy (LAmT). This approach has been used in patients requiring both AoV surgery and coronary artery bypass grafting (CABG).

METHODS

From April 2023 to July 2023, we performed 6 concomitant AoV procedures and CABG through the LAmT. The mean age was 71.5 [standard deviation (SD): 5.8; 64; 82] years, and the mean left ventricular ejection fraction was 53% (SD: 12.1; 30; 60). Surgical technique includes LAmT in the fourth intercostal space, peripheral cardiopulmonary bypass, aortic cross-clamping using transthoracic clamp, cold blood cardioplegia, conventional oblique aortotomy and special surgical exposure manoeuvres, aimed to position the ascending aorta and AoV close to the surgical incision.

RESULTS

AoV was effectively visualized and the procedure was performed as planned in all 6 patients. No conversion to sternotomy was required. AoV replacement with biological prosthesis was performed in 6 (100%) patients. Conventional surgical instruments were used in all cases. The long-shafted instruments were not required. Knot-pusher was used in 4 (67%)cases. Concomitant complete revascularization was achieved in all cases. The mean number of distal anastomosis was 2.0 (SD: 0.6; 1; 3). Total operation time was 371 (SD: 43; 300; 420) min, cardiopulmonary bypass time was 253 (SD: 36; 193; 284) min and cross-clamp time was - 162 (SD: 29; 128; 214) min. intensive care unit stay was-1.5 (SD: 0.55; 1; 2) days, total hospital stay was-7.3 (SD: 1; 6; 9) days. There were no revisions for bleeding, no strokes or other major complications, and no hospital or 30-days mortality.

CONCLUSIONS

The simultaneous performance of AoV replacement and multivessel CABG through a single left anterior thoracotomy is technically feasible and can be carried out by experienced surgeons. However, a larger number of cases are required to fully comprehend the potential limitations of this procedure.

Robot-Assisted Minimally Invasive Multivessel Coronary Bypass Guided by Computerized Tomography

OBJECTIVE

Robot-assisted minimally invasive coronary bypass surgery is one of the least invasive approaches that offers multivessel revascularization and accelerated recovery. We investigated the benefits of computed tomography angiography (CTA) guidance in robotic coronary bypass (RCAB) by analyzing perioperative outcomes.

METHODS

Between April 2022 and April 2023, 60 consecutive patients who underwent RCAB under preoperative CTA guidance were included. The intercostal space of the minithoractomy incision was determined based on the distance from the thoracotomy site to the midsection of the left anterior descending artery (LAD) on preoperative CTA. Peripheral vascular findings on preoperative CTA guided the decision for the cannulation site. Perioperative parameters and early outcomes were evaluated.

RESULTS

The mean age of the patients was 62.3 ± 10.5 years, and 51 patients were male (85.0%). The mean number of revascularized vessels was 2.9 ± 1.1. Left thoracotomy guided by CTA measurements was performed in the fourth intercostal space in 37 patients (61.7%) and in the third intercostal space in the remaining patients. Axillary cannulation was performed in 28 (46.7%) patients because of prohibitive findings in the iliac vessels and aorta. All target coronary arteries with an indication for bypass were revascularized with CTA-guided RCAB. The left internal mammary artery (LIMA) was anastomosed to the LAD in all patients, and the LIMA was anastomosed sequentially to the diagonal artery in 17 patients (28.3%). No operative mortality or cerebrovascular event was observed. One patient underwent reoperation due to bleeding.

CONCLUSIONS

Robot-assisted minimally invasive multiple-vessel coronary bypass under preoperative CTA guidance is safe and can be performed with excellent results.

Left anterior minithoracotomy as a first-choice approach for isolated coronary artery bypass grafting and selective combined procedures

OBJECTIVES

Our goal was to describe the technique for and evaluate the results of the isolated coronary artery bypass grafting or combined grafting procedures with mitral valve repair/replacement and/or left ventricle aneurysm repair performed through a single left anterior minithoracotomy.

METHODS

Perioperative data of all patients who required isolated or combined coronary grafting from July 2017 to December 2021 were observed. The focus was on 560 patients who underwent isolated or combined multivessel coronary bypass using the "Total Coronary Revascularization via left Anterior Thoracotomy" technique. The main perioperative outcomes were analysed.

RESULTS

A left anterior minithoracotomy was used in 521 (97.7%) out of 533 patients who required isolated multivessel surgical coronary revascularization and in 39 (32.5%) out of 120 patients who required combined procedures. In 39 patients, multivessel grafting was combined with 25 mitral valve and 22 left ventricular procedures. Mitral valve repair was performed through the aneurysm (n = 8) or through the interatrial septum (n = 17). Perioperative outcomes in isolated and combined groups were next: aortic cross-clamp time-71.9 (SD: 19.9) and 120 (SD: 25.8) min; cardiopulmonary bypass time-145.7 (SD: 33.5) and 216 (SD: 45.8) min; total operating time-269 (SD: 51.8) and 324 (SD: 52.1) min; intensive care unit stay-2 (2-2) and 2 (2-2) days; total hospital stay-6 (5-7) and 6 (5-7) days; and total 30-day mortality was 0.54 and 0%, respectively.

CONCLUSIONS

A left anterior minithoracotomy can be effectively used as a first-choice approach to perform isolated multivessel coronary grafting and can be combined with mitral valve and/or left ventricular repair. Experience with isolated coronary grafting through an anterior minithoracotomy is required to achieve the satisfactory results in combined procedures.

Reasons for Conversion and Adverse Intraoperative Events in Robotically Enhanced Minimally Invasive Coronary Artery Revascularization

OBJECTIVE

The transition from sternotomy access to minimally invasive coronary artery bypass grafting is associated with steep learning curves. This study reports the reasons for sternotomy conversions from robotically enhanced minimally invasive direct coronary artery bypass grafting (RE-MIDCAB) and describes potential risk reduction strategies.

METHODS

The perioperative data of 759 RE-MIDCAB patients (mean age 65.9 ± 10 years, 25.5% female, 30.2% multivessel disease) operated between July 1, 2002 and November 30, 2018 were reviewed for the reasons of conversion and adverse intraoperative events. Hybrid revascularization was planned in 204 (26.9%) patients.

RESULTS

Sternotomy conversion occurred in 30 (4.0%) patients. Lung adhesions and unsuccessful single-lung ventilation prohibited safe RE-MIDCAB internal thoracic artery (ITA) harvesting in 11 (36.7%) and 1 (3.3%) patients, respectively. ITA dysfunction (n = 11, 36.7%) and inadequate target vessel visualization (n = 3, 10.0%) were among the anatomical reasons for conversions. Adverse intraoperative events included ventricle perforation (n = 1, 3.3%) and sustained ventricular arrhythmia (n = 1, 3.3%). The in-hospital mortality and mean length of hospitalization for sternotomy conversion were 3.3% (n = 1 of 30) and 13.4 ± 14.5 days, respectively. Perioperative morbidities included pneumonia (n = 4, 13.3%). Premorbid renal dysfunction predicted sternotomy conversion at the 5% level of significance.

CONCLUSIONS

RE-MIDCAB provides an attractive surgical platform for primary- or hybrid coronary artery procedures. The progressive increase in patient risk profiles, strict quality control, and focus on clinical governance require awareness of reasons that potentially contribute RE-MIDCAB to sternotomy conversion to ensure safe and sustainable programs.