Alternative Approaches to Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention, How Do They Compare?: A Systematic Review and Meta-Analysis

Coronary artery disease (CAD) is a leading cause of mortality worldwide. Severe symptomatic CAD is treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Alternative CABG (ACABG) approaches including thoracotomy, off-pump, total endoscopic, and robotic-assisted CABG are increasing in prevalence to address the increased early risk of CABG. This systematic review and meta-analysis aims to review the contemporary literature comparing outcomes after ACABG and PCI. Pubmed, Medline, and Embase were systematically searched by 2 authors for articles comparing the outcomes after ACABG and PCI. A total of 1154 articles were screened, and 11 were included in this review. The RevMan 5.4 software was used to perform a meta-analysis of the pooled data. Individual studies found rates of long-term survival, major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), and repeat revascularization either favored ACABG or did not differ significantly. Pooled estimates of the compiled data identified rates of MACCE, MI, and repeat revascularization favored ACABG. The results of this review demonstrated the favorable rates of long-term mortality, MACCE, MI, and repeat revascularization for ACABG in addition to similar short-term mortality and stroke when compared with PCI. Advancement of both CABG and PCI continues to improve patient outcomes. With the increasing prevalence of ACABG, similar studies will need to be undertaken with further direct comparisons between ACABG and PCI. Finally, hybrid revascularization should continue to be explored for its combined benefits of long-term outcomes, short-term safety, and ability to achieve complete revascularization.

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

Objectives

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.

Patients and methods

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.

Results

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).

Conclusion

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.

Long-term follow-up of patients with complex coronary artery disease treated with minimally invasive direct coronary artery bypass

BACKGROUND

Patients with complex coronary artery disease (CAD) may benefit from surgical myocardial revascularization but weighing the risk of peri-operative complications against the expected merit is difficult. Minimally invasive direct artery bypass (MIDCAB) procedures are less invasive, provide the prognostic advantage of operative revascularization of the left anterior descending artery and may be integrated in hybrid strategies. Herein, the outcomes between patients with coronary 1-vessel disease (1-VD) and patients with 2-VD and 3-VD after MIDCAB procedures were compared in this single-center study.

METHODS

Between 1998 and 2018, 1363 patients underwent MIDCAB at the documented institution. 628 (46.1%) patients had 1-VD, 434 (31.9%) patients 2-VD and 300 (22.0%) patients suffered from 3-VD. Data of patients with 2-VD, and 3-VD were pooled as multi-VD (MVD).

RESULTS

Patients with MVD were older (66.2 ± 10.9 vs. 62.9 ± 11.2 years; p < 0.001) and presented with a higher EuroScore II (2.10 [0.4; 34.2] vs. 1.2 [0.4; 12.1]; p < 0.001). Procedure time was longer in MVD patients (131.1 ± 50.3 min vs. 122.2 ± 34.5 min; p < 0.001). Post-operatively, MVD patients had a higher stroke rate (17 [2.3%] vs. 4 [0.6%]; p = 0.014). No difference in 30-day mortality was observed (12 [1.6%] vs. 4 [0.6%]; p = 0.128). Survival after 15 years was significantly lower in MVD patients (p < 0.01). Hybrid procedures were planned in 295 (40.2%) patients with MVD and realized in 183 (61.2%) cases. MVD patients with incomplete hybrid procedures had a significantly decreased long-term survival compared to cases with complete revascularization (p < 0.01).

CONCLUSIONS

Minimally invasive direct coronary artery bypass procedures are low-risk surgical procedures. If hybrid procedures have been planned, completion of revascularization should be a major goal.

Minimal-Access Coronary Revascularization: Past, Present, and Future

Minimal-access cardiac surgery appears to be the future. It is increasingly desired by cardiologists and demanded by patients who perceive superiority. Minimal-access coronary artery revascularisation has been increasingly adopted throughout the world. Here, we review the history of minimal-access coronary revascularization and see that it is almost as old as the history of cardiac surgery. Modern minimal-access coronary revascularization takes a variety of forms-namely minimal-access direct coronary artery bypass grafting (MIDCAB), hybrid coronary revascularisation (HCR), and totally endoscopic coronary artery bypass grafting (TECAB). It is noteworthy that there is significant variation in the nomenclature and approaches for minimal-access coronary surgery, and this truly presents a challenge for comparing the different methods. However, these approaches are increasing in frequency, and proponents demonstrate clear advantages for their patients. The challenge that remains, as for all areas of surgery, is demonstrating the superiority of these techniques over tried and tested open techniques, which is very difficult. There is a paucity of randomised controlled trials to help answer this question, and the future of minimal-access coronary revascularisation, to some extent, is dependent on such trials. Thankfully, some are underway, and the results are eagerly anticipated.

Twenty-year outcomes of minimally invasive direct coronary artery bypass surgery: The Leipzig experience

OBJECTIVE

Minimally invasive direct coronary artery bypass (MIDCAB) surgery involving left anterior descending coronary artery grafting with the left internal thoracic artery through a left anterior small thoracotomy is being routinely performed in some specified centers for patients with isolated complex left anterior descending coronary artery disease, but very few reports regarding long-term outcomes exist in literature. Our study was aimed at assessing and analyzing the early and long-term outcomes of a large cohort of patients who underwent MIDCAB procedures and identifying the effects of changing trends in patient characteristics on early mortality.

METHODS

A total of 2667 patients, who underwent MIDCAB procedures between 1996 and 2018, were divided into 3 groups on the basis of the year of surgery: group A, 1996-2003 (n = 1333); group B, 2004-2010 (n = 627) and group C, 2011-2018 (n = 707). Groupwise characteristics and early postoperative outcomes were compared. Long-term survival for all patients was analyzed and predictors for late mortality were identified using Cox proportional hazards methods.

RESULTS

The mean age was 64.5 ± 10.9 years and 691 (25.9%) patients were female. Group C patients (log EuroSCORE I = 4.9 ± 6.9) were older with more cardiac risk factors and comorbidities than groups A (log EuroSCORE I = 3.1 ± 4.5) and B (log EuroSCORE I = 3.5 ± 4.7). Overall and groupwise in-hospital mortality was 0.9%, 1.0%, 0.6%, and 1.0% (P = .7), respectively. Overall 10-, 15-, and 20-year survival estimates for all patients were 77.7 ± 0.9%, 66.1 ± 1.2%, and 55.6 ± 1.6%, respectively.

CONCLUSIONS

MIDCAB can be safely performed with very good early and long-term outcomes. In-hospital mortality remained constant over the 22-year period of the study despite worsening demographic profile of patients.

Minimally invasive off-pump anaortic coronary artery bypass (MACAB)

BACKGROUND

Minimally invasive direct coronary artery bypass has enabled coronary artery bypass graft to compete with the appeal of less invasive percutaneous coronary procedures. Favorable results of coronary artery bypass surgery performed without the use of cardiopulmonary bypass and without touching the aorta (anOPCAB) have enabled the development and use of minimally invasive methods.

METHODS

Between 2016 and 2021, 112 patients underwent multivessel coronary bypass surgery performed using a minimally invasive method through a small thoracotomy in the left chest with off-pump, anaortic, and all-arterial grafts (Minimally Invasive Off-Pump Anaortic Coronary Artery Bypass [MACAB]). Patient data were collected and retrospectively analyzed. Eight series from the literature using the multivessel mini-OPCAB and MACAB technique were also evaluated.

RESULTS

Collectively, from the literature, 2729 patients underwent an average of 2.4 bypasses with an early mortality rate of 0.7% and a stroke rate of 0.16%. In our MACAB case series, 112 patients underwent an average of 2.9 bypasses with a mortality rate of 1.8% and a stroke rate of 0%.

CONCLUSION

MACAB can be performed safely by experienced surgeons and reduces neurological injury and surgical trauma and may be a good alternative for multivessel stenting. Simulation systems are essential for its dissemination, and teams dedicated to coronary surgery-with subspecialty expertise-are necessary to achieve good outcomes.

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

OBJECTIVES

Thoracoscopic 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.

METHODS

Retrospective 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.

RESULTS

Twenty-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].

CONCLUSIONS

In 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 direct coronary artery bypass after percutaneous coronary intervention

OBJECTIVES

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.

METHODS

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).

RESULTS

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-PCI group 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).

CONCLUSIONS

The previous LAD-PCI may deteriorate the outcomes of MIDCAB in patients with isolated LAD disease.

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.

Advances in revascularization of the left coronary artery

Ischaemic heart disease is the most common cardiovascular disease worldwide, and it contributes to a significant source of morbidity and mortality internationally. It can be asymptomatic for many years and present suddenly with acute coronary syndrome or can be progressive with angina and eventual acute myocardial infarction. Diseases of the left coronary system can be drastic and fatal if not managed correctly. With ongoing increase in the practice of percutaneous intervention; patient demographics for conventional coronary artery bypass grafting surgery have more risk factors than before. Conventional bypass surgery has also evolved to include minimally invasive and hybrid techniques. Although some evidence supports each approach, controversies remain.

Minimally invasive and robotic coronary artery bypass grafting-a 25-year review

During the mid-1990s cardiac surgery started exploring minimally invasive methods for coronary artery bypass grafting (CABG) and has over a 25-year period developed highly differentiated and less traumatic operations. Instead of the traditional sternotomy mini-incisions on the chest or ports are placed, surgery on the beating heart is applied, sophisticated remote access heart lung machine systems as well as videoscopic units are available, and robotic technology enables completely endoscopic approaches. This review describes these methods, reports on the cumulative intra- and postoperative outcome of these procedures, and gives an integrated view on what less invasive coronary bypass surgery can achieve. A total of 74 patient series published on the topic between 1996 and 2019 were reviewed. Six main versions of minimal access and robotically assisted CABG were applied in 11,135 patients. On average 1.3±0.6 grafts were placed and the operative time was 3 hours 42 min ± 1 hour 15 min. The procedures were carried out with a hospital mortality of 1.0% and a stroke rate of 0.6%. The revision rate for bleeding was 2.5% and a renal failure rate of 0.9% was noted. Wound infections occurred at a rate of 1.2% and postoperative hospital stay was 5.6±2.2 days. It can be concluded that less invasive and robotically assisted versions of coronary bypass grafting are carried out with an adequate safety level while surgical trauma is significantly reduced.

State-of-the-Art Coronary Artery Bypass Grafting: Patient Selection, Graft Selection, and Optimizing Outcomes

Despite the progressive expansion of clinical indications for percutaneous coronary intervention and the increasingly high risk profile of referred patients, coronary artery bypass grafting (CABG) remains the mainstay in multivessel disease, providing good long-term outcomes with low complication rates. Multiple arterial grafting, especially if associated with anaortic techniques, might provide the best longer-term outcomes. A surgical approach individualized to the patients' clinical and anatomic characteristics, and surgeon and team experience, are key to excellent outcomes. Current evidence regarding patient selection, indications, graft selection, and potential strategies to optimize outcomes in patients treated with CABG is summarized.

Short and long-term results of endoscopic atraumatic coronary artery off-pump bypass grafting in patients with left anterior descending artery stenosis

BACKGROUND

To perform a retrospective analysis of patients who underwent endoscopic atraumatic coronary artery off-pump bypass grafting (EACAB) in a single center over a period of 11 years.

METHODS

Data was acquired from the hospital registry and patient medical records. In order to determine changes in clinical profile, patients were subdivided into three groups regarding year of surgery: 1998-2002 (group 1), 2003-2005 (group 2), 2006-2009 (group 3). In-hospital analysis up to 30 days and long-term observation were conducted.

RESULTS

The study cohort consisted of 714 patients (581 male). Procedural success accounted for 99% of all patients. No mortality was observed up to 30 days. Complications in the early period included pleural effusion (7.6%), cardiac arrhythmias (3.6%), bleeding related revision (2.7%) and wound infection (1.6%). Mean follow-up was 6 years (2132 ± 1313 days; median: 1918.5). Nineteen (2.7%) patients died, of which 52.6% (10 patients) were due to heart related conditions. Overall frequency of major adverse cerebral and cardiovascular events (MACCE) was 10.8% (77 patients). The Kaplan-Meyer analysis defined survival rate and event-free survival in long-term observation of 96.1% and 85.3%, respectively. Ejection fraction (EF) < 50% was the only independent factor of mortality (OR: 3.35). Regarding cumulative MACCE, older age (OR: 1.72), lower EF (OR: 3.03), the history of percutaneous coronary intervention (OR: 2.13) and higher New York Heart Association class (OR: 2.63) influenced the incidence rate.

CONCLUSIONS

The presented short and very long-term results confirm that EACAB is an efficient alternative for patients requiring revascularization of the left anterior descending artery. The elimination of cardiopulmonary bypass significantly reduces the number of complications.

Bioresorbable Vascular Scaffold Compared With Minimally Invasive Bypass Surgery for the Left Anterior Descending Coronary Artery Disease: 12-Month Follow up

THE AIM

Evaluates long-term clinical outcomes of percutaneous coronary intervention (PCI) with bioresorbable vascular scaffold (BVS) versus minimally invasive direct coronary artery bypass (MIDCAB) surgery for the treatment of left anterior descending (LAD) lesions.

METHODS AND RESULTS

In this single-center study were included 130 patients with stable angina and significant (≥ 70 %) LAD disease. Patients were randomly assigned in a 1:1 ratio to PCI with everolimus-eluting BVS (n=65) or MIDCAB (n=65). The primary end-point was major adverse cerebro-cardiovascular events (MACCE) and secondary was scaffold (graft) thrombosis at 1 year. The groups of patients were comparable for all baseline demographic, clinical and angiographic parameters. MACCE at 12 month occurred in 9.2 % of patients in the BVS group and in 4.6 % of patients in the MIDCAB group (p=0.3). There was no significant difference between the groups in rates of all cause death (1.5 % vs 1.5 %, p=1.0), myocardial infarction (3.1 % vs. 6.1 %, p=0.4), any revascularization (1.5 % vs. 6.1 %, p=0.1) and scaffold (graft) thrombosis (1.5 % vs. 1.5 %, p=1.00).

CONCLUSION

At 12-month follow up, there was no significant difference in the rate of MACCE between PCI by BVS and MIDCAB in patients with isolated LAD lesions.

Minimally invasive direct coronary artery bypass graft surgery versus percutaneous coronary intervention of the LAD: costs and long-term outcome

OBJECTIVE

Outcomes and treatment costs for coronary artery disease involving the left anterior descending coronary artery (LAD) are influenced by the type of treatment, which can be either isolated minimally invasive revascularization of the LAD using the internal thoracic artery (ITA) (MIDCAB) or percutaneous coronary intervention (PCI) on the LAD. This retrospective study sought to evaluate long-term survival, freedom from re-intervention and cost analysis after MIDCAB compared to PCI on the LAD.

METHODS

Between 2006 and 2012, from a total of 561 patients, 106 consecutive patients with LAD stenosis underwent a MIDCAB procedure whereas 100 patients underwent elective PCI. Urgent and emergent cases were excluded from the present study (n = 355). Detailed analysis of the outcome data was performed for both groups. A Kaplan-Meier survival estimation with up to 10-year follow-up was applied for both groups for survival analysis and freedom from re-intervention.

RESULTS

There were no statistically significant differences in terms of clinically relevant baseline characteristics. The outcome in the MIDCAB group was superior regarding long-term overall survival, accounting for 100% versus 92.8% at 1 year, 98.5% versus 82.1% at 6 years and 79.6% versus 61.5% at 10 years (Log Rank (Mantel-Cox) p = 0.011) and freedom from re-intervention at 10 years (97.2% vs. 86.7%, Log Rank (Mantel-Cox) p = 0.001). Intensive care unit (ICU) stay (p = 0.020) and total hospital stay (p<0.001) were significantly longer in the MIDCAB group, which was also associated with higher in-hospital costs (10,879 € vs. 4009 €, p<0.001).

CONCLUSIONS

Whereas patients undergoing MIDCAB remained longer on ICU and in hospital, causing higher costs, this procedure was associated with a significantly lower incidence of repeat revascularization and significantly lower mortality compared to PCI on the LAD.

Minimally invasive coronary artery bypass grafting

Minimally invasive cardiac surgery (MICS)-CABG is a technique that at its core has patient comfort, early return to routine activities, meeting patient expectations for less invasive options, and maintaining the highest possible standards of care and outcomes. The technique requires not only surgical dexterity but also integration of significant technological advancements in patient care. At a time when percutaneous interventions are often prescribed on the pretext of increased patient comfort and demand, minimally invasive myocardial revascularization becomes even more relevant. Minimally invasive myocardial revascularization is ever evolving and encompasses both small-incision open techniques as well as endoscopic-assisted procedures. The success of the procedure depends not only on the learning curve and familiarity with the technology but also on appropriate patient selection. Mere feasibility of the technique is not sufficient, and the results have to be comparable with the long-established techniques of conventional coronary artery bypass grafting both in terms of early morbidity and mortality as well as long-term outcomes. In this review, we discuss patient selection and technical aspects of minimally invasive coronary artery bypass grafting. We also provide an evidence-based comparison to early and long-term outcomes with conventional coronary artery bypass grafting. Finally, we review the uptake and outcomes of minimally invasive revascularization in the Indian subcontinent.

Long-Term Outcome of Patients Undergoing Minimally Invasive Direct Coronary Artery Bypass Surgery: A Single-Center Experience

OBJECTIVE

The primary objective was to investigate the long-term survival of patients who underwent single-vessel coronary revascularization with minimally invasive direct coronary artery bypass surgery with or without hybrid revascularization. The secondary outcome measures were repeat revascularization either by coronary artery bypass grafting or by percutaneous coronary intervention and the incidence of myocardial infarction or recurrent angina.

METHODS

This is a retrospective study of prospectively collected data of patients who underwent minimally invasive direct coronary artery bypass procedure in our center between January 2001 and December 2015. Procedures were performed either through small left anterolateral thoracotomy or lower midline sternotomy.

RESULTS

A total of 182 patients were identified: 100 underwent minimally invasive direct coronary artery bypass to the left anterior descending artery and 82 underwent hybrid revascularization (percutaneous coronary intervention to coronary arteries other than the left anterior descending artery along with minimally invasive direct coronary artery bypass to the left anterior descending artery). The mean ± SD age was 62 ± 10.1 years. Preoperatively 82% were male, and 72.5% patients had good left ventricular function. The median follow-up period was 10.9 years. There was no in-hospital or 30-day mortality. The 10-year actuarial survival was 84.8%. Freedom from repeat revascularization was 98.9% at 1 year and 89.9% at 10 years. At follow-up, freedom from myocardial infarction was 96.7% whereas freedom from angina was 92.9%.

CONCLUSIONS

Within the limitations imposed by retrospective analyses, our study demonstrates excellent long-term outcome in patients undergoing minimally invasive direct coronary artery bypass with or without hybrid revascularization. For isolated left anterior descending artery disease minimally invasive direct coronary artery bypass should be considered, whereas hybrid revascularization (percutaneous coronary intervention and minimally invasive direct coronary artery bypass) should be considered for multivessel disease.

Minimally Invasive Cardiac Surgery in China: Multi-Center Experience

BACKGROUND To the best of our knowledge, there is no nationwide data available on the development of minimally invasive cardiac surgery (MICS) in China. The purpose of this study was to report the results of MICS in 6 experienced centers in China. MATERIAL AND METHODS From September 2014 to July 2016, 1241 patients with cardiac conditions who underwent MICS procedures were randomly enrolled in 6 centers in China, and those patients were randomly selected for inclusion in this study. The MICS procedures were defined as any cardiac surgery performed through a less invasive incision, rather than a complete median sternotomy, mainly including mini-incision surgery (400, 32.2%), video-assisted approach (265, 21.3%), completely thoracoscopic approach without robotic assistance (504, 40.6%), and robotic procedure (55, 4.4%). RESULTS The 5 most common in-hospital complications were respiratory failure (28, 2.3%), reoperation for all reasons (19, 1.5%), renal failure (11, 0.9%), heart failure (9, 0.7%), and stroke (6, 0.5%). The multivariate logistic regression analysis results showed that cardiopulmonary bypass (CPB) time (P=0.033), aortic cross-clamp time (P=0.003), cannulation approach (P=0.010), and left ventricular ejection fraction (LVEF) (P=0.003) at baseline were all significant risk factors of any in-hospital complication of MICS procedures. CONCLUSIONS From our experience, minimally invasive cardiac approaches are safe and reproducible, with acceptable CPB and aortic cross-clamp time duration and low mortality.

Robotic-enhanced coronary surgery in octogenarians

Objectives

Robotic-enhanced minimally invasive direct coronary artery bypass grafting surgery (RE-MIDCAB) is based on the use of a robotic console and instrumentation for the dissection of the left internal thoracic artery (LITA). The LITA to left anterior descending (LAD) artery anastomosis is subsequently constructed through a mini thoracotomy. The purpose of this study is to present our experience of RE-MIDCAB outcomes in elderly patients.

Methods

From 2002 until 2015, 44 octogenarians (the mean age of 82.9 years) underwent RE-MIDCAB. The mean logistic EuroSCORE was 9.2. The majority of the patients were male with a medical history of hypertension, dyslipidaemia and previous coronary interventions. Of these patients 25% underwent RE-MIDCAB combined with percutaneous coronary intervention (PCI) for the treatment of multi-vessel disease (hybrid revascularization).

Results

All RE-MIDCABs and combined 'hybrid' PCI procedures were successfully completed. The mean intensive care unit (ICU) and hospital stay were 1.6 days and 10.9 days, respectively. There was 1 in-hospital mortality (2.3%). After an average follow-up period of 29.2 months, 5 patients required repeat revascularization procedures (9.1%). Mortality on follow-up was estimated at 25.6%.

Conclusions

Our report suggests that considering the age and frailty of the octogenarian population, RE-MIDCAB is a feasible and safe procedure which is associated with acceptable mid-term results.

Cardiac surgery 2015 reviewed

For the year 2015, almost 19,000 published references can be found in PubMed when entering the search term "cardiac surgery". The last year has been again characterized by lively discussions in the fields where classic cardiac surgery and modern interventional techniques overlap. Lacking evidence in the field of coronary revascularization with either percutaneous coronary intervention or bypass surgery has been added. As in the years before, CABG remains the gold standard for the revascularization of complex stable triple-vessel disease. Plenty of new information has been presented comparing the conventional to transcatheter aortic valve implantation (TAVI) demonstrating similar short- and mid-term outcomes at high and low risk, but even a survival advantage with transfemoral TAVI at intermediate risk. In addition, there were many relevant and interesting other contributions from the purely operative arena. This review article will summarize the most pertinent publications in the fields of coronary revascularization, surgical treatment of valve disease, heart failure (i.e., transplantation and ventricular assist devices), and aortic surgery. While the article does not have the expectation of being complete and cannot be free of individual interpretation, it provides a condensed summary that is intended to give the reader "solid ground" for up-to-date decision-making in cardiac surgery.

Short- and long-term follow-up after minimally invasive direct coronary artery bypass in octogenarians

OBJECTIVES

Demographic changes lead to a rising incidence of octogenarians undergoing surgical revascularization of coronary artery disease. Minimally invasive direct coronary artery bypass (MIDCAB) represents a surgical treatment with reduced trauma and without the use of cardiopulmonary bypass. The aim of this study was to evaluate short- and long-term outcomes after MIDCAB in octogenarians.

METHODS

Between 1998 and 2012, 1060 patients underwent MIDCAB at our department. Among them, 72 patients (6.8%) were older than 80 years at the time of operation. Incidence of major adverse cardiac and cerebrovascular events (MACCEs) was compared between octogenarians [median age 82 (81; 85) years, 63.9% male] and younger MIDCAB patients [median age 64 (56; 70) years, 70.7% male] after 30 days and during follow-up. The impact of demographics and preoperative comorbidities on mortality during follow-up was analysed.

RESULTS

At baseline, the elderly group presented with a statistically significant higher logistic EuroSCORE I (9.2 vs 2.2%, P < 0.001). Within 30 days, octogenarians showed a mortality rate of 5.6% (younger patients 0.8%, P = 0.006) and an MACCE rate of 5.6% (younger patients 1.3%, P = 0.024). The median follow-up time of 30-day survivors was 5.5 (2.9; 7.6) years and follow-up completeness reached 96.9%. In the elderly group, 1-, 3- and 5-year survival rates were 89, 78 and 63% in comparison with 97, 94 and 90% in the younger group (P < 0.001), respectively. The estimated median survival time in octogenarians was 6.7 (CI 4.854; 8.629) years. Logistic regression showed preoperative renal impairment, peripheral arterial occlusive disease and pulmonary hypertension to have a stronger impact on mortality during follow-up than age above 80 years.

CONCLUSIONS

MIDCAB represents a safe treatment option in octogenarians and is associated with a good perioperative outcome and satisfying long-term results in octogenarians.

Developments in surgical revascularization to achieve improved morbidity and mortality

Coronary artery bypass graft surgery remains the main treatment modality for multivessel coronary artery disease and has consistently been demonstrated to have significantly lower rates of major adverse cardiac and cerebrovascular events in comparison to percutaneous coronary intervention. In this article we will explore the advances over time and the recent refinements in the techniques of surgical revascularization and how these contribute to the superior outcome profile associated with coronary artery bypass graft surgery. These include the current outcome status of coronary artery bypass grafting; the major landmark trials, registries and meta-analyses comparing coronary artery bypass grafting and percutaneous coronary intervention; the developments in coronary artery disease lesion classification; the techniques for the physiological assessment of coronary artery lesions; bypass grafting using arterial conduits; the role of off-pump coronary artery surgery; the outcomes of reoperative surgery; hybrid techniques for coronary revascularization; minimally invasive coronary artery surgery and finally robotic surgery.