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Rufa MI, Ursulescu A, Aktuerk D, Nagib R, Albert M, Göbel N, Shavahatli T, Franke UF. Minimally invasive strategies of surgical coronary artery revascularization for the aging population. THE JOURNAL OF CARDIOVASCULAR SURGERY 2023; 64:534-540. [PMID: 37255493 DOI: 10.23736/s0021-9509.23.12621-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND The increasing prevalence of elderly or frail patients with severe coronary disease, who are not suitable for interventional coronary revascularization, necessitates the exploration of alternative treatment options. A less invasive approach, such as minimally-invasive off-pump coronary-artery-bypass (MICS-CABG) grafting through mini-thoracotomy, which avoids both extracorporeal circulation and sternotomy, may be more appropriate for this patient population. This study, a retrospective, monocentric analysis, aimed to evaluate the long-term outcomes of these patients. METHODS The study included 172 patients aged 80 years or older, who underwent MICS-CABG between 2007 and 2018. The patients underwent single, double, or triple-vessel revascularization using the left internal thoracic artery, and in some cases, the radial artery or saphenous vein. Follow-up, mean duration of 50.4±30.8 months, was available for 163 patients (94.7%). RESULTS The mean age of the patients was 83.2±3.0 years, 77.3% of them were male. The EuroSCORE I additive was 11.0±12.1. There were no conversions to sternotomy or cardiopulmonary-bypass. The postoperative 30-day mortality rate was 2.9%, with 5 deaths. The in-hospital rate of major adverse cardiac and cerebrovascular events was 4.7% (perioperative myocardial infarction 1.2%, perioperative stroke 2.3%, repeat revascularization 1.2%). Acute renal kidney injury, (stage 3 KDOQI or more), occurred in 5 patients (2.9%) and new-onset atrial fibrillation in 6 patients (3.5%). The 1-, 3-, 5- and 8-year actuarial survival rate of the 30-day survivors was 97%, 82%, 73%, and 42%, respectively. CONCLUSIONS MICS-CABG grafting is associated with excellent early and long-term outcomes in eligible octogenarians.
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Affiliation(s)
- Magdalena I Rufa
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany -
| | - Adrian Ursulescu
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | | | - Ragi Nagib
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Marc Albert
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Nora Göbel
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Tunjay Shavahatli
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
| | - Ulrich F Franke
- Department of Cardiovascular Surgery, Robert Bosch Hospital, Stuttgart, Germany
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Manuel L, Fong LS, Betts K, Bassin L, Wolfenden H. LIMA to LAD grafting returns patient survival to age-matched population: 20-year outcomes of MIDCAB surgery. Interact Cardiovasc Thorac Surg 2022; 35:6709348. [PMID: 36130278 PMCID: PMC9519092 DOI: 10.1093/icvts/ivac243] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Accepted: 09/20/2022] [Indexed: 11/14/2022] Open
Affiliation(s)
- Lucy Manuel
- Cardiothoracic Surgery Department, Royal North Shore Hospital , St Leonards, Australia
| | - Laura S Fong
- Cardiothoracic Surgery Department, Prince of Wales Hospital , Randwick, Australia
| | - Kim Betts
- School of Public Health, Curtin University , Perth, Australia
| | - Levi Bassin
- Cardiothoracic Surgery Department, Royal North Shore Hospital , St Leonards, Australia
- Cardiothoracic Surgery Department, Prince of Wales Hospital , Randwick, Australia
| | - Hugh Wolfenden
- Cardiothoracic Surgery Department, Prince of Wales Hospital , Randwick, Australia
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What does complete revascularization mean in 2021? - Definitions, implications, and biases. Curr Opin Cardiol 2021; 36:748-754. [PMID: 34483299 DOI: 10.1097/hco.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Coronary revascularization is known to be an excellent treatment for coronary artery disease. However, whether incomplete myocardial revascularization compromises long-term outcomes, as compared to complete revascularization (CR), remains contentious. Herein, we review the concept of and evidence on CR/incomplete revascularization (ICR) and discuss future perspectives. RECENT FINDINGS When possible, achieving CR in coronary artery bypass grafting is desirable; nonetheless, ICR is also a reasonable option to balance the therapeutic benefits against the risks. SUMMARY Although angiography-based assessment currently remains the standard of care, fractional flow reserve guidance may reduce the number of lesions requiring revascularization, which may be helpful for an appropriate surgical revascularization strategy. In particular, utilizing this approach may refine hybrid revascularization procedures, especially among high-risk patients.
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Hoffmann G, Friedrich C, Huenges K, Petzina R, Vogt AM, Cremer J, Grothusen C. Minimally Invasive Direct Coronary Artery Bypass in High-Risk Patients with Multivessel Disease. Thorac Cardiovasc Surg 2021; 69:607-613. [PMID: 34044462 DOI: 10.1055/s-0041-1723845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND High-risk patients with multivessel disease (MVD) including a complex stenosis of the left anterior descending coronary may not be ideal candidates for guideline compliant therapy by coronary artery bypass grafting (CABG) regarding invasiveness and perioperative complications. However, they may benefit from minimally invasive direct coronary artery bypass (MIDCAB) grafting and hybrid revascularization (HCR). METHODS A logistic European system for cardiac operative risk evaluation score (logES) >10% defined high risk. In high-risk patients with MVD undergoing MIDCAB or HCR, the incidence of major adverse cardiac and cerebrovascular events (MACCEs) after 30 days and during midterm follow-up was evaluated. RESULTS Out of 1,250 patients undergoing MIDCAB at our institution between 1998 and 2015, 78 patients (logES: 18.5%; age, 76.7 ± 8.6 years) met the inclusion criteria. During the first 30 days, mortality and rate of MACCE were 9.0%; early mortality was two-fold overestimated by logES. Complete revascularization as scheduled was finally achieved in 64 patients (82.1%). Median follow-up time reached 3.4 (1.2-6.5) years with a median survival time of 4.7 years. Survival after 1, 3, and 5 years was 77, 62, and 48%. CONCLUSION In high-risk patients with MVD, MIDCAB is associated with acceptable early outcome which is better than predicted by logES. Taking the high-risk profile into consideration, midterm follow-up showed satisfying results, although scheduled HCR was not realized in a relevant proportion. In selected cases of MVD, MIDCAB presents an acceptable alternative for high-risk patients.
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Affiliation(s)
- Grischa Hoffmann
- Department of Cardiac and Vascular Surgery, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Christine Friedrich
- Department of Cardiac and Vascular Surgery, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Katharina Huenges
- Department of Cardiac and Vascular Surgery, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Rainer Petzina
- Department for Quality and Risk Management and Patient Safety, Universitatsklinikum Schleswig-Holstein Campus Kiel, Kiel, Germany
| | - Astrid-Mareike Vogt
- Department of Obstetrics and Gynecology, Stadtisches Krankenhaus Kiel, Kiel, Schleswig-Holstein, Germany
| | - Joachim Cremer
- Department of Cardiac and Vascular Surgery, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
| | - Christina Grothusen
- Department of Cardiac and Vascular Surgery, University Hospital Schleswig-Holstein-Campus Kiel, Kiel, Germany
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Hoffmann G, Friedrich C, Barrabas M, Petzina R, Haneya A, Panholzer B, Berndt R, Cremer J. Short- and long-term follow-up after minimally invasive direct coronary artery bypass in octogenarians. Interact Cardiovasc Thorac Surg 2016; 23:377-82. [PMID: 27209534 DOI: 10.1093/icvts/ivw149] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 04/09/2016] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Grischa Hoffmann
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Christine Friedrich
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Moritz Barrabas
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Rainer Petzina
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Assad Haneya
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Bernd Panholzer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Rouven Berndt
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Jochen Cremer
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Kiel, Germany
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Cohn WE, Frazier OH, Mallidi HR, Cooley DA. Surgical Treatment of Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Early and mid-term results of minimally invasive coronary artery bypass grafting. Indian Heart J 2014; 66:193-6. [PMID: 24814114 DOI: 10.1016/j.ihj.2014.02.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Revised: 12/01/2013] [Accepted: 02/05/2014] [Indexed: 10/25/2022] Open
Abstract
INTRODUCTION Minimally invasive coronary artery bypass grafting (MICABG) is a less invasive method of performing surgical revascularization. This technique coupled with use of off pump technique of surgical revascularization makes it truly less invasive. This method is highly effective even in high-risk patients. Results of this procedure are comparable to standard off pump technique and are better than percutaneous coronary intervention utilizing drug-eluting stent. We present an early and mid-term result of the use of this technique. METHOD We enrolled 33 patients for analysis operated between 2008 and 2012. Operation was performed utilizing off-pump technique of coronary artery bypass grafting through a minimal invasive incision. Left internal mammary artery graft was done for single vessel disease and radial artery was utilized for other grafts if required. Median follow up of 2.5 years (6 months-4 years) is available. RESULTS Median age was 58.5 years (41-77) and all were male. Single vessel disease was present in 7, double vessel in 14 and triple vessel disease in 12 patients. All the patients had normal left ventricular size and function. There was no operative and 30-day mortality. Conversion to median sternotomy to complete the operation was done in 6.6% (2 out of 33 patients). One patient had acute myocardial infarction and there were no deaths during follow up. CONCLUSION MICABG is a safe and effective method of revascularization in low risk candidates for coronary artery bypass grafting.
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Girerd N, Magne J, Rabilloud M, Charbonneau E, Mohamadi S, Pibarot P, Voisine P, Baillot R, Doyle D, Dumont E, Dagenais F, Mathieu P. The Impact of Complete Revascularization on Long-Term Survival Is Strongly Dependent on Age. Ann Thorac Surg 2012; 94:1166-72. [DOI: 10.1016/j.athoracsur.2012.05.023] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 04/30/2012] [Accepted: 05/03/2012] [Indexed: 10/28/2022]
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Holzhey DM, Cornely JP, Rastan AJ, Davierwala P, Mohr FW. Review of a 13-year single-center experience with minimally invasive direct coronary artery bypass as the primary surgical treatment of coronary artery disease. Heart Surg Forum 2012; 15:E61-8. [PMID: 22543338 DOI: 10.1532/hsf98.20111141] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY In this study, we review our experience with 1768 minimally invasive direct coronary artery bypass (MIDCAB) operations. The focus is on long-term outcome with more than 10 years of follow-up. METHODS All patients undergoing standard MIDCAB between 1996 and 2009 were included. For all 1768 patients, pre-, intra-, and postoperative data could be completed. Long-term follow-up information about health status, major adverse cardiac and cerebrovascular events (MACCE), and freedom from angina was collected annually via questionnaire or personal contact. Five-year follow-up is available for 1313 patients, and 10-year-follow-up is available for 748 patients. A multivariate Cox regression analysis was performed to determine risk factors for long-term outcome. RESULTS Mean age was 63.4 ± 10.8 years, mean ejection fraction was 60.0% ± 14.2%, and perioperative mortality risk calculated by logistic EuroSCORE was 3.8 ± 6.2%. In 31 patients (1.75%) intraoperative conversion to sternotomy was necessary. Early postoperative mortality was 0.8% (15 patients); 0.4% (7 patients) had a perioperative stroke. Seven hundred twelve patients received routine postoperative angiogram, showing 95.5% early graft patency. Short-term target vessel reintervention was needed in 59 patients (3.3%) (11 percutaneous transluminal coronary angioplasty (PTCA)/stent, 48 re-operation). Kaplan-Meyer analysis revealed a 5-year survival rate of 88.3% (95% confidence interval [CI], 86.6% to 89.9%) and a 10-year-survival rate of 76.6% (95% CI, 73.5% to 78.7%). The freedom from MACCE and angina after 5 and 10 years was 85.3% (95% CI, 83.5% to 87.1%) and 70.9% (95% CI, 68.1% to 73.7%), respectively. CONCLUSIONS MIDCAB is a safe operation with low postoperative mortality and morbidity. With excellent short-term and long-term results, it is a very good alternative compared to both percutaneous coronary intervention (PCI) and conventional surgery.
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Affiliation(s)
- David M Holzhey
- Department of Cardiac Surgery, Heart Center, Leipzig, Germany.
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Hybrid myocardial revascularization - the cardiologist's view. COR ET VASA 2012. [DOI: 10.1016/j.crvasa.2012.05.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
Despite increasing competition from percutaneous interventions and other novel methods of non-surgical coronary revascularization, coronary artery bypass grafting (CABG) remains one of the most definitive and durable treatments for coronary artery disease, especially for those patients with extensive and diffuse disease. In recent years the CABG procedure itself has undergone innovation and evolution. This review article provides a brief historical perspective on the procedure, and examines the current state of modern variations including off-pump, limited-access, and robotic-assisted CABG.
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Affiliation(s)
- Frank W Sellke
- Department of Cardiothoracic Surgery, Alpert Medical School of Brown University, Providence, RI, USA.
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Changing Operative Characteristics of Patients Undergoing Operations for Coronary Artery Disease: Impact on Early Outcomes. Ann Thorac Surg 2008; 86:1424-30. [DOI: 10.1016/j.athoracsur.2008.07.050] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Revised: 07/16/2008] [Accepted: 07/17/2008] [Indexed: 11/22/2022]
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