Clinical outcomes of left main coronary artery disease patients undergoing three different revascularization approaches

Robotic applications for intracardiac and endovascular procedures

The large incisions and long recovery periods that accompany traditional cardiac surgery procedures along with the constant patient demand for minimally invasive procedures have motivated cardiac surgeons to implement the robotic technologies in their armamentarium. The robotic systems have been utilized successfully in various cardiac procedures including atrial septal defect repair, left atrial myxoma resection, MAZE procedure and left ventricular lead placement, yet coronary artery bypass and mitral valve repair still comprise the vast majority of them. This review analyzes the development of the robot-assisted cardiac surgery in recent years, its outcomes, advantages, disadvantages, its patient selection criteria as well as its economic feasibility. Robotic endovascular surgery, albeit its limited applications, is presently considered an attractive alternative to conventional endovascular approaches. The increased flexibility and precision along with the wider range of accessible anatomy provided by the endovascular robotic systems, have increased the pool of patients that can be offered minimally invasive treatment options and have helped to overcome many limitations of the traditional endovascular procedures. With this review we aimed to summarize the applications of the commercially available endovascular robotic devices, as well as the limitations and the future perspectives in the field of endovascular robotic surgery.

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.

Safety and efficacy of percutaneous coronary intervention versus coronary artery bypass graft in patients with STEMI and unprotected left main stem disease: A systematic review & meta-analysis

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The advent of percutaneous coronary intervention (PCI) has caused much debate about the optimal revascularization method for LMCAD.

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Several studies have previously been conducted comparing PCI versus CABG for LMCAD, however most of these have only taken into account randomized controlled trials (RCTs), while ignoring observational studies.

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This study takes data from both RCTs and observational studies to obtain a better comparison of the two revascularization techniques.

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It is the first meta-analysis to report data for various adverse outcomes after 10 years of follow-up.

Introduction

Owing to its large area of supply, left main coronary artery disease (LMCAD) has the highest mortality rate among coronary artery lesions, resulting in debate about its optimal revascularization technique. This meta-analysis compares percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for the treatment of LMCAD.

Method

MEDLINE, TRIP, and Cochrane Central databases were queried from their inception until 25 April 2021, to determine MACCE (major adverse cardiac and cardiovascular events), all-cause mortality, repeat revascularization, myocardial infarction (MI) and stroke rates post-revascularization for different follow-ups. 7 RCTs and 50 observational studies having 56,701 patients were included. A random-effects model was used with effect sizes calculated as odds ratios (odds ratio, OR).

Results

In the short term (1 year), PCI had significantly higher repeat revascularizations (OR = 3.58, 95% CI 2.47–5.20; p < 0.00001), but lower strokes (OR = 0.55, 95% CI 0.38–0.81; p = 0.002). In the intermediate term (2–5 years), PCI had significantly higher rates of repeat revascularizations (OR = 3.47, 95% CI 2.72–4.44; p < 0.00001) and MI (OR = 1.39, 95% CI 1.17–1.64; p = 0.0002), but significantly lower strokes (OR = 0.54, 95% CI 0.42–0.70; p < 0.0001). PCI also had significantly higher repeat revascularizations (OR = 2.58, 95% CI 1.89–3.52; p < 0.00001) in the long term (≥5 years), while in the very long term (≥10 years), PCI had significantly lower all-cause mortalities (OR = 0.77, 95% CI 0.61–0.96; p = 0.02).

Conclusion

PCI was safer than CABG for patients with stroke for most follow-ups, while CABG was associated with lower repeat revascularizations. However, further research is required to determine PCI’s safety over CABG for reducing post-surgery MI.

Clinical outcomes of multivessel coronary artery disease patients revascularized by robot-assisted vs conventional standard coronary artery bypass graft surgeries in real-world practice

The treatment of patients with multivessel coronary artery disease (MVD) by coronary stenting (PCI) and the "gold standard" conventional coronary-artery bypass grafting (C-CABG) has been well explored in the literature. However, the clinical outcomes of robot-assisted CABG (R-CABG) vs C-CABG in MVD patients in real-world practice were unknown. We aimed to study the clinical outcomes of MVD patients who underwent R-CABG (robotic MIDCAB) and C-CABG at our institution between January 2005 and December 2013.A total of 516 MVD patients received CABG were recruited into this study. Among them, 281 patients received R-CABG and 235 patients underwent C-CABG. Patients in the R-CABG group were younger, and had fewer vessels with coronary artery disease (CAD), lower prevalence of chronic renal disease (CKD), higher left ventricular ejection fraction (LVEF), as well as lower Euro scores. The in-hospital and long-term mortalities were lower in the R-CABG group, but the incidences of target lesion revascularization (TLR), target vessel revascularization (TVR), myocardial infarction (MI), and stroke were not significantly different between the two groups. The long-term mortality was related to age, lower LVEF, and CKD, but not residual SYNTAX score, or completeness of revascularization. The revascularization modality (R-CABG vs C-CABG) was a borderline significantly independent predictor of long-term mortality (OR 1.76 [0.99-3.14], P = .055).Our study concluded that R-CABG, in comparison with C-CABG, for MVD carried out in younger patients involved fewer clinical complexities was associated with lower in-hospital and long-term mortalities in real-world practice. However, the long-term rates of TLR, TVR, MI, and stroke were similar. The long-term mortality was correlated with age, lower LVEF, and CKD, where R-CABG remained a borderline significant predictor after correcting for confounding factors. R-CABG could be an effective alternative to C-CABG for MVD patients with fewer clinical complexities in real-world practice.

Intensive care outcome of left main stem disease surgery: A single center three years’ experience

BACKGROUND

Left main coronary artery (LMCA) supplies more than 80% of the left ventricle, and significant disease of this artery carries a high mortality unless intervened surgically. However, the influence of coronary artery bypass grafting (CABG) surgery on patients with LMCA disease on morbidity intensive care unit (ICU) outcomes needs to be explored. However, the impact of CABG surgery on the morbidity of the ICU population with LMCA disease is worth exploring.

AIM

To determine whether LMCA disease is a definitive risk factor of prolonged ICU stay as a primary outcome and early morbidity within the ICU stay as secondary outcome.

METHODS

Retrospective descriptive study with purposive sampling analyzing 399 patients who underwent isolated urgent or elective CABG. Patients were divided into 2 groups; those with LMCA disease as group 1 (75 patients) and those without LMCA disease as group 2 (324 patients). We correlated ICU outcome parameters including ICU length of stay, post-operative atrial fibrillation, acute kidney injury, re-exploration, perioperative myocardial infarction, post-operative bleeding in both groups.

RESULTS

Patients with LMCA disease had a significantly higher prevalence of diabetes (43.3% vs 29%, P = 0.001). However, we did not find a statistically significant difference with regards to ICU stay, or other morbidity and mortality outcome measures.

CONCLUSION

Post-operative performance of Patients with LMCA disease who underwent CABG were comparable to those without LMCA involvement. Diabetes was more prevalent in patients with LMCA disease. These findings may help in guiding decision making for future practice and stratifying the patients’ care.

Robot-assisted coronary artery bypass surgery: a systematic review and meta-analysis of comparative studies

BACKGROUND

Robot-assisted coronary bypass (RCAB) surgery has been proposed as an alternative to conventional coronary artery bypass grafting (C-CABG) for managing coronary heart disease, but the evidence on its performance compared to other existing treatments is unclear. The aim of this study was to assess, through a systematic review of comparative studies, the safety and clinical effectiveness of RCAB compared to C-CABG and other minimally invasive approaches for the treatment of coronary heart disease.

METHODS

We conducted a systematic review of primary studies in the English-language literature comparing RCAB to existing treatment options (C-CABG, minimally invasive direct coronary artery bypass [MIDCAB] and port-access coronary artery bypass [PA-CAB]) following Cochrane Collaboration guidelines. Meta-analyses were performed where appropriate.

RESULTS

We reviewed 13 studies: 11 primary studies of RCAB (v. C-CABG in 7, v. MIDCAB in 3 and v. PA-CAB in 1) and 2 multicentre database studies (RCAB v. non-RCAB). The overall quality of the evidence was low. Most studies showed no significant benefit of RCAB over other treatments in a majority of outcome variables. Meta-analyses showed that RCAB had lower rates of pneumonia or wound infection than C-CABG, and shorter intensive care unit length of stay than C-CABG or MIDCAB. Individual studies showed that RCAB had some better outcomes than C-CABG (ventilation time, transfusion, postoperative pain, hospital length of stay) or MIDCAB (transfusion, postoperative pain, time to return to normal activities, physical functioning and hospital length of stay). The review of the database studies showed that RCAB was statistically superior to non-RCAB approaches in postoperative pain, renal failure, transfusion, reoperation for bleeding, stroke and hospital length of stay; however, the difference between the 2 groups in several of these outcomes was small.

CONCLUSION

Although the findings from this review of comparative studies of RCAB appear promising and suggest that RCAB may offer some benefits to patients, in the absence of randomized controlled trials, these results should be interpreted cautiously.

Postoperative complications associated with coronary artery bypass graft surgery and their therapeutic interventions

Coronary artery disease is one of the commonest surgery demanding cardiovascular diseases. Coronary artery bypass graft surgery is practiced all over the world for the treatment of coronary artery disease. Systemic trauma during the surgery is associated with a wide range of complications, some of which are fatal. Preoperative risk factors such as age, previous illness and obesity are common predictors of these adverse events. Advances in therapeutic medicine have allowed timely treatment of these adverse events and co-morbidities. This review summarizes some of the most occurring complications associated with coronary artery bypass graft and corresponding treatment options.

Clinical outcomes of patients with multivessel coronary artery disease treated with robot-assisted coronary artery bypass graft surgery versus one-stage percutaneous coronary intervention using drug-eluting stents

A number of studies have reported on treatment outcomes of coronary stenting (PCI) for multivessel coronary artery diseases (MVD), and compared them with the conventional coronary artery bypass grafting (CABG). However, the clinical outcomes of robot-assisted CABG (R-CABG) in comparison with PCI in MVD patients have not been investigated.We recruited retrospectively MVD patients receiving R-CABG and PCI with drug-eluting stents for all vessels in one stage between January 2005 and December 2013 at our institution with at least 3 years of outcomes were retrospectively recruited and analyzed.A total of 638 MVD patients were studied. Among them, 281 received R-CABG, and 357 received PCI. Similar complete revascularizations were achieved in both groups (R-CABG: 40.2%, PCI: 41.5%, P = .751). The residual stenosis was 4.1 ± 4.4 in the R-CABG group, and comparably 3.5 ± 3.7 in the PCI group (P = .077). Patients in the R-CABG group were younger, with more severe coronary artery disease (CAD) and had more background risk factors. The in-hospital and long-term mortalities as well as the incidence of TLR, myocardial infarction (MI), stroke were all similar between groups. But the incidence of TVR and any revascularization were lower in the R-CABG group. The long-term mortality was predicted by age, left ventricular ejection fraction, and chronic kidney disease, but not by the revascularization modality, completeness of revascularization, nor residual SYNTAX scores. The last 3 factors were not predictors of long-term TLR, TVR, MI, and stroke.The in-hospital and long-term survival rates of MVD were similar for both the R-CABG and PCI groups. But the R-CABG group had rates of TVR and any revascularization lower than PCI. Revascularization modality, completeness of revascularization, and residual SYNTAX scores were not predictors of in-hospital and long-term mortalities, MI, and stroke in real-world practice. R-CABG was associated with lower rates of TLR and TVR, and is likely a safe and effective treatment and an alternative choice of PCI for MVD patients who have low surgical risks.