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Minimally invasive coronary artery bypass grafting

  • Michael Owen Kayatta
  • Michael Emanuel Halkos
  • Pradeep NarayanEmail author
Review Article

Abstract

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.

Keywords

Myocardial revascularization Mini-thoracotomy Coronary artery bypass grafting 

Introduction

Coronary artery bypass grafting (CABG) has served as the standard of care for treating coronary artery disease for decades. A full sternotomy with cardiopulmonary bypass (CPB) still serves as the predominant approach today. Percutaneous coronary intervention (PCI) has evolved as a competing technology. In pursuit of maximizing patient outcomes and serving patients’ preferences for less invasive options, MICS-CABG has been developed. In this review, we will discuss patient selection, technical aspects, perioperative and long-term outcomes, as well as the importance of minimally invasive revascularization to the Indian subcontinent.

Comparing CABG and PCI

CABG was developed more than half a century ago. Over this time, there have been many advances in medical management of heart disease, significant evolution of percutaneous options for coronary artery disease (CAD), and vast improvements in peri- and postoperative care. However, the fundamental procedure of coronary bypass has changed less dramatically. Perhaps the greatest advance in CABG was the use of the pedicled internal thoracic artery (IMA) to bypass the left anterior descending artery (LAD), a development which occurred decades ago. Despite undergoing relatively little change, CABG remains the gold standard for myocardial revascularization. It is supported by society guidelines, especially for patients with a high complexity of disease [1].

Rationale for CABG over PCI

CABG is a procedure that treats the entire coronary vessel. In contrast, PCI is lesion specific, not addressing any further development stenosis or acute occlusions in the coronary system. In fact, treating lesions that are not clinically significant with PCI increases myocardial infarction (MI) and mortality [2]. Since most ST-elevation myocardial infarctions occur within the first 50 mm of the coronary vessels [3], and CABG bypasses the first 2/3rd of these vessels, any subsequent lesions in this territory will be clinically silent. In fact, a Left Internal Mammary Artery (LIMA) to left anterior descending artery anastomosis alone bypasses 50% of future threatening lesions, and three-vessel bypass treats nearly 90% of future threatening lesions [4]. As PCI has evolved, the rate of in-stent stenosis and thrombosis has gradually declined, but even with a rate of zero, the fundamental issue of treating future lesions is not addressed.

The LIMA is remarkably free of atherosclerosis, and when anastomosed to the LAD, patency rates are excellent at more than 95% at 10 years [5], which improves the survival of CABG over the use of vein conduit to bypass the LAD. Further, there is little to no evidence of narrowing or occlusion of the LIMA-to-LAD anastomosis even after 15–20 years [6]; if the anastomosis is technically successful, it is likely to stay open for at least 20 years.

Compared to the LIMA, vein grafts have been shown to have significantly inferior patency, with up to 25% of vein grafts failing within the first year [7]. For this reason, the use of arterial conduits beyond the LIMA has been shown in non-randomized studies to improve survival after CABG [8]. The Society for Thoracic Surgeons recommends the use of multiple arterial conduits in CABG when possible; however, currently, only about 5% of CABG operations in the USA are performed with more than one arterial graft [9]. One major reason for the low uptake is the reported increased risk of sternal wound complications with bilateral IMAs, which was found to be significantly higher in an interim analysis of the randomized ART trial. This trial also showed no decrease in major adverse cardiovascular and cerebral events (MACCE) at 5 years; 10-year data is upcoming [10]. Nonetheless, because current metrics for reimbursement hinge on successful short-term outcomes, the short-term risks, particularly with sternal complications, associated with multi-arterial grafting have prevented the more widespread adoption of this strategy.

Clinical trials

Numerous large, well-conducted clinical trials have been completed that demonstrate the superiority of CABG over PCI. The SYNTAX trial compared patients with three-vessel disease and left main disease to PCI with a 2nd generation drug-eluting stent. This study found that PCI did not meet criteria for non-inferiority. There was a 58% relative excess mortality in patients with three-vessel disease at 5 years [11]. The BEST trial also compared CABG to PCI in patients with multivessel disease and again found that MACCE was higher with PCI than CABG [12]. The FREEDOM trial, which specifically addressed patients with multivessel disease and diabetes also showed a 50% relative excess mortality with PCI at 5 years [13]. These patients were overall relatively healthy with an average hemoglobin A1C of 7.8% and EF of 66%. One third had SYNTAX scores < 22. A cost-effectiveness analysis of this trial demonstrated that though CABG was more expensive, it cost just $8132 per quality-adjusted life year, a hugely cost-effective treatment [14]. The superiority of CABG is somewhat less clear in patients with left main disease. Patients with left main disease and low to intermediate SYNTAX scores were evaluated in two recent trials, the EXCEL trial [15] and the NOBLE trial [16]. While EXCEL showed non-inferiority with PCI at 3 years, the NOBLE trial demonstrated superiority with CABG at 5 years. Differing definitions of postoperative complications may partly explain the differing results of these two similar trails, but they both show that CABG remains an excellent treatment for left main disease which may be superior to PCI.

Perceptions and priorities

Given the robust data supporting CABG, it would seem surprising that there has been little to no growth in CABG over the last decade, while the number of patients receiving PCI currently stands at three times that of CABG and continues to grow [17]. Two important factors contribute to this: perceptions of heart surgery compared to PCI and patients’ short- and long-term preferences.

Among patients undergoing elective PCI, up to 90% believe that the procedure will reduce their risk of a heart attack, and 80% feel that it will reduce their risk of death [18]. In fact, just 1% of patients identify relief of angina as the only benefit of PCI. Referring cardiologists as well as interventional cardiologists were much more likely to identify angina relief as the primary benefit of elective PCI. Given the difference in invasiveness of the two procedures, patients are far more likely to prefer PCI over CABG given these perceptions. Interestingly, in a hypothetical scenario, patients were far more likely to prefer PCI over CABG even when specifically told the long-term risk of death was double with PCI. Physicians were much more likely to recommend CABG in this same scenario [19].

PCI has better quality of life scores than CABG for the first month, but they are no different by 6 months, after which they are otherwise similar but with less angina in CABG patients [20]. Thus, patients who place great importance on early recovery rightly choose PCI over traditional CABG. Beyond patient preferences, there is also considerable evidence that cardiologists are more likely to recommend PCI over CABG in equivocal settings. Among patients for whom both CABG and PCI are indicated, almost all are recommended for PCI. Furthermore, this recommendation is more accentuated in hospitals with PCI capability; there is clearly a self-referral bias [21].

Rationale for minimally invasive CABG

Patients will always prefer minimally invasive therapies, and cardiac surgery remains a surgery rightfully labeled as maximally invasive. Reducing the invasiveness of CABG can not only improve patient and provider perceptions but may also be able to improve patient outcomes.

Off-pump CABG (OPCAB), a component commonly used in MICS-CABG, was designed to reduce the invasiveness of CABG by removing the complications of CPB altogether. CPB has been shown to increase the inflammatory response [22], and its use during CABG may increase blood transfusions, stroke, neurocognitive outcomes, atrial fibrillation, and acute kidney injury relative to OPCAB [23]. By eliminating aortic manipulation from aortic cannulation, cross-clamping, and proximal anastomoses, stroke may be reduced by as much as 50% [24]. However, there are some concerns about incomplete revascularization and graft patency when OPCAB is used which may contribute to inferior long-term outcomes [25].

In addition to avoidance of CPB and aortic manipulation that is commonly, though not always, used in MICS-CABG, additional benefits relate to the approach to the heart. By avoiding a sternotomy, dreaded sternal wound infections and mediastinitis can be avoided. Additionally, as there is no bone to heal with a mini-thoracotomy, no sternal precautions are required after surgery; patients can return quickly to their baseline activity level without fear of sternal separation or infection. Because of the less invasive incision, patients can be extubated more rapidly (often in the operating room), and postoperative complications like respiratory failure can be minimized. As part of fast track recovery, patients may be mobilized more rapidly, transferred to the floor quicker, and discharged from the hospital earlier. While pain may be slightly higher during the first 24 h with MICS-CABG, pain is then improved and faster return to baseline physical function is possible with significantly improved pain after discharge [26]. Finally, there is improved cosmesis with the incision. Table 1 summarizes the potential benefits of MICS-CABG.
Table 1

Potential benefits of MICS-CABG

1. Avoid CPB

2. Reduce stroke

3. Decrease blood transfusion

4. Decrease postoperative complications

5. Improve length of stay, recovery time, and return to baseline activity level

6. Combat negative perceptions of heart surgery

7. Improved cosmesis

Surgical techniques

A feature of all MICS-CABG approaches is the avoidance of a sternotomy. The most common approach is minimally invasive direct coronary artery bypass (MIDCAB) via an anterior thoracotomy, as previously described [27]. For this technique, a transverse incision in made anteriorly in the 4th or 5th intercostal space. The left lung is typically deflated via the use of a double-lumen endotracheal tube or bronchial blocker. With the use of a specialized retractor, the cranial ribs are elevated to visualize the LIMA, which is then harvested under direct visualization. Next, a standard retractor is placed, the pericardium is opened, and the LAD identified. A stabilizer is introduced into the chest, typically via a separate incision which will become the chest tube site. Under direct visualization using traditional techniques, the LIMA is anastomosed to the LAD with a running polypropylene suture. This is most often done off-pump, but cardiopulmonary bypass assistance is sometimes necessary which can be performed peripherally via the femoral artery and vein. Endoscopic assistance for LIMA harvest has also been described, but has fallen out of favor since the introduction of robotics.

An alternative to this anterior thoracotomy approach is to perform an inferior partial sternotomy, as previously described [28]. After making the partial sternotomy, the LIMA is dissected under direct visualization. Thoracoscopic harvest of the LIMA is also possible, but again has fallen out of favor since the development of robotic techniques at the turn of the century.

In some centers, multivessel bypass is performed with minimally invasive techniques, as popularized by McGinn et al. [29]. Aortocoronary anastomoses are performed for vein proximals as with traditional CABG. To expose the heart for anastomoses, two positioners are used. A retractor is placed via a subxiphoid incision which is used to lift and move the apex of the heart, as with OPCAB. A second positioner is introduced through the mini-thoracotomy incision which stabilizes the distal target. Figure 1 demonstrates the exposure for multivessel grafting via an anterior thoracotomy.
Fig. 1

Multivessel grafting via an anterior thoracotomy (with permission from Medtronic © 2017)

Patient selection

Identifying the best patients for MICS-CABG is somewhat challenging. On one hand, healthy patients with low BMIs seem ideal, but older patients with multiple comorbidities may benefit the most from a minimally invasive approach. Early in a surgeon’s experience, however, there are several factors that should be avoided. Patients with obesity can greatly hamper visualization, for example. Emergencies are generally not appropriate for a minimally invasive approach, and patients with significant peripheral vascular disease should be approached with caution since peripheral cardiopulmonary bypass is often the first bail out. A diffusely diseased, calcified, or intramyocardial LAD may not be appropriate as finding an anastomotic site can be challenging with limited exposure. The presence of chest deformities, previous chest surgery, and presence of pericardial adhesions are all relative contraindications to minimally invasive approaches. Finally, as there are relatively few patients with isolated LAD disease, a multidisciplinary approach to patients with multivessel disease should be taken, as hybrid coronary revascularization requires assessment by both a surgeon and interventional cardiologist.

Results with MICS-CABG

Critical to the success of MICS-CABG is maintaining the excellent results of traditional CABG. Ideally, short-term outcomes should be improved without compromising long-term outcomes. Perioperative outcomes of recent series are reported in Table 2.
Table 2

Perioperative results with MICS-CABG

Series

Patients

Mortality

Stroke

MI

AF

Wound Infection

Revision for bleeding

Conversion

LIMA patency

Blood transfusion

Ventilatory time

Hospital LOS

Hu et al. 2011 [28]

104

0%

0

0

11.5%

0%

3.8%

1%

99%

28.8%

11.6

8.2

Repossini et al. 2013 [30]

166

1.2%

0

21.7%

0%

2.4%

100%

26.5%

6.6

6.5

Gasior et al. 2014 [31]

98

0%

0%

5.1

6.1%

97.8

19.4

8.8

Modrau et al. 2015 [32]

100

0%

1%

2%

3%

6%

0%

95%

9%

8

Holzhey et al. 2012 [33]

1768

0.8%

0.4%

0.5%

8.2%

1.5%

0.2%

1.75%

96.8%

McGinn et al. 2009 [29]

450

1.3%

0.4%

1.1%

24.4%

0.9%

2.2%

3.8%

21.3%

5.9

These series demonstrate that in skilled hands, MICS-CABG can be performed with low mortality and excellent perioperative outcomes [34]. There were very few strokes, consistent with the lack of aortic manipulation. Postoperative complications like atrial fibrillation and blood transfusion were either similar to historical norms with CABG or better. There were very few wound infections, and importantly, these were typically minor skin infections, managed much differently from the deep sternal wound infections seen with full sternotomy. Rates of LIMA-to-LAD patency were excellent, and there were few conversions to sternotomy. Quality of life is excellent after recovery from MIDCAB, similar to age-matched patients [35], and better than after conventional CABG [26]. Mid-term outcomes with MICS-CABG have also been encouraging, as summarized in Table 3. These data demonstrate that rates of MACCE, both short- and mid-term, are excellent, and are consistent with other series [37]. Target vessel revascularization is very low, consistent with excellent LIMA-to-LAD patency.
Table 3

Mid-term results with MICS-CABG

Series

1 year MACCE

5 year MACCE

10 year MACCE

1 year TVR

5 year TVR

Hu et al. 2011 [28]

1%

1%

Repossini et al. 2013 [30]

6.9%

17%

4.8%

7.2%

Gasior et al. 2014 [31]

10.2%

Modrau et al. 2015 [36]

20%

7%

Holzhey et al. 2012 [33]

14.5%

29.1%

MICS-CABG vs PCI

As discussed above, PCI is a common alternative to CABG. Referral for MICS-CABG is often based on a desire for decreased invasiveness, so these two approaches have been rigorously compared. A non-matched study comparing PCI to MIDCAB found repeat revascularization of the LAD in 24% of PCI patients and 0% of MIDCAB patients at 3.4 years [37]. While MIDCAB was initially more expensive than PCI, the need for less revascularization negated the initial cost savings with PCI. Several randomized studies have also been completed comparing PCI to MIDCAB. In one, 7-year follow-up showed similar rates of death in MI, but greatly increased revascularization in the PCI group (20 vs 1.5%) [38]. Another randomized trial also found significantly higher rates of target vessel revascularization (TVR) at 5 years (32 vs 10%) with PCI [39]. Additionally, symptoms were improved more in the MIDCAB arm.

Several meta-analyses have been performed comparing MIDCAB and PCI [40, 41]. These all showed no differences in death or MI, but all showed significantly higher rates of TVR with PCI. Initial hospitalization was 3 days longer with CABG. Of note, most of the trials in these meta-analyses used bare-metal stents. A subsequent meta-analysis performed in 2015, however, found that even with drug-eluting stents, there was a similar increase in rates of TVR with PCI [42].

Competing with other CABG approaches

Minimally invasive approaches to CABG not only compete with PCI but also among each other and traditional CABG. A case-matched study of multivessel MICS-CABG and OPCAB patients found lower complication rates, shorter length of stay, and much more rapid return to full physical activity with MICS-CABG (12 days vs > 5 weeks) [43]. A similar study also found a shorter length of stay with MICS-CABG. Extubation in the OR was much more common (70 vs 12.7%), and this was associated with further reduction in length of stay. Of note, there were less grafts performed with MICS-CABG than OPCAB (2.1 vs 3.2) [44]. Some concern with graft patency does exist despite the excellent results highlighted above. In a non-matched comparison of MIDCAB to OPCAB, one center found that there was a shorter length of surgery and vessel occlusion time with OPCAB. More concerning, they found a higher rate of stenosis and occluded vessels with MIDCAB with a further need for reintervention at 5 years [45].

As robotics has grown over the last two decades, more surgeons have started using robotics to assist with LIMA harvest, and some also perform coronary anastomoses endoscopically. One comparison of total endoscopic robotic CABG to MIDCAB found that MIDCAB was more cost-effective and had improved 3-year angina-free survival (100 vs 85%). Conversion to MIDCAB (i.e., robotic-assisted CABG) was common [46]. Operative time may be longer with robotics [47], and costs are higher [48] given the increased fixed and marginal costs [48].

Reservations

There is currently a low adoption rate of MICS-CABG throughout the world, probably due to fear of added complexity. Adverse patient characteristics (obesity, tolerance of single lung ventilation) also likely play a role [49]. The learning curve for MICS-CABG approaches is typically between 50 and 100 cases [50, 51], and some surgeons still show unacceptable complication rates despite adequate training. Maintaining quality with these techniques also likely requires consistent volume, even after the learning curve [50]. Beyond concerns for anastomotic quality, operative complications such as arrhythmia or intolerance of positioning can be more difficult to handle with a limited operative field. While the series discussed previously in this review demonstrated excellent quality, these centers are centers of excellence, and their results may not be broadly applicable.

Future developments

The techniques used in MICS-CABG have existed for two decades, though continuous adjustments and new devices to make the operation safer and more broadly available continue to be developed. For example, a new retractor was recently designed to reduce pain from lifting the ribs. Coupled with an L-shaped retractor, better visualization with potentially less postoperative pain was possible [47]. As exposure is a critical component of MICS-CABG, new retractors and devices to improve exposure will make the technique simpler and more broadly applicable. As performing a coronary anastomosis via a small incision can be challenging, several commercial anastomotic devices have been developed, though their use has been limited to date. One such device did show similar patency to hand-sewn anastomosis at 2 years [52]. Further improvements in design could allow surgeons not comfortable with the exposure to start performing MICS-CABG. The use of endoscopic assistance or robotics to perform minimally invasive CABG is seen by some as the next step in the evolution of the approach. Unfortunately, these increase cost and may be unnecessary with proper training in MICS-CABG.

As MICS-CABG is not performed at most centers and training programs across the world, most surgeons have no experience or exposure to minimally invasive CABG. Better training programs and proctoring will need to be developed to train more surgeons. Achieving a critical mass of surgeons could lead to rapid expansion of the market.

The Indian perspective

MICS-CABG in India has been adopted by many surgeons across the country. Unfortunately, there are no national or regional databases that currently exist to track procedural volume. Rather, case volumes and outcomes are maintained by individual surgeons and some institutions. As a result, assessing nationwide results of MICS-CABG in India is extremely difficult. However, to get some idea on the MICS-CABG status in India, two different approaches were attempted. First, a literature search for reports of MICS-CABG was carried out on PubMed and attempts were made to gather information from presentations in major international cardiothoracic meetings. Second, a random survey of surgeons across the country was carried out for this review.

The bulk of the papers published on MICS-CABG from India has been from one group [53, 54, 55, 56, 57]. This group of surgeons has described their experience with different approaches for minimally invasive myocardial revascularization [54], adjuncts to MICS-CABG [55], robotically enhanced myocardial revascularization [56], and totally endoscopic coronary bypass [57] using the da Vinci system. In the early part of their experience, the group suggested that transmyocardial laser was a useful adjunct to minimally invasive CABG for achieving complete myocardial revascularization [55], and also concluded that compared to mini-thoracotomy, ministernotomy was a better approach with regards to postoperative pain and approach to the IMA [54]. However, the majority of MICS-CABG in India are performed through a left thoracotomy approach with satisfactory outcomes. This group initially only performed isolated LIMA-to-LAD anastomoses, but did also describe a bilateral thoracotomy for double vessel disease [53]. More recently, they describe treating double and triple vessel coronary artery disease through a mini-thoracotomy incision [58, 59]. Harvesting skeletonized bilateral IMAs through a 2-in long left mini-thoracotomy incision under direct vision without robotic or thoracoscopic assistance has been reported [59]. However, harvesting bilateral IMA with a thoracoscope or with robotic assistance remains limited to certain centers. The MICS-CABG approach is reported to be associated with significantly shorter intubation time, need for blood transfusion, and hospital stay [58, 59]. A hybrid approach for management of multivessel coronary artery disease has also been reported [60]. The use of robotics in MICS-CABG is comparatively rare in India, and while there are two or three centers with the facility, the bulk of these reports are once again from a single center. The mortality, morbidity, and conversion rates were extremely low in the study population. Total endoscopic CABG using the da Vinci system has also been reported in a small subset of patients both on beating and arrested hearts.

For this review, we conducted a cross-sectional survey where 100 randomly selected cardiac surgeons were asked if they were involved in minimally invasive cardiac surgery. The questionnaire was very brief, and the idea was just to assess the involvement of surgeons in minimally invasive cardiac surgery. The response rate was 61%. Out of these 61 responders, 42 (69%) surgeons confirmed undertaking minimally invasive work. Minimally invasive workload reported had a median of 10% (interquartile range 5–20%). So the majority of minimally invasive surgeons carried out 5 to 20% of their cardiac procedures using minimally invasive techniques. However, the proportion of surgeons undertaking MICS-CABG was lower. Only 15 (37%) of those undertaking minimally invasive work reported to be currently engaged in MICS-CABG and only 3 of the surgeons surveyed reported to be currently involved in or had experience in robotically enhanced or total endoscopic myocardial revascularization. As part of the survey, the surgeons were also asked if in their experience they felt that MICS-CABG was associated with significantly lower morbidity. The majority of the surveyed surgeons (67%) engaged in MICS-CABG felt that MICS-CABG was associated with not only better cosmetic results but also led to lower morbidity. However, it was suggested that the need for complete revascularization overrides all other considerations.

A limitation of using publications to assess the workload in India is that due to a variety of reasons, the number of publications published annually is quite low in India. This is true for cardiac surgery in general and applies to MICS-CABG too. Therefore, the lack of publications does not equate to lack of volume. Also the survey was not very exhaustive as the main aim was to only gather information about the existing practice of minimally invasive cardiac surgery and MICS-CABG and it was felt that a very exhaustive survey may reduce the response rate. The other limitation was that it was not possible to reach out to all surgeons across India, and among those contacted the response rate was only 61%. Therefore, it is not improbable that the results obtained may not be an accurate reflection of existing cardiac surgical practice. Despite these limitations, in the absence of a dedicated database, this survey provides some light on the existing practice of minimally invasive cardiac surgery and MICS-CABG in India.

The future for MICS-CABG in India remains positive. The usage of OPCAB and bilateral IMA usage in India is already high. Considering the active involvement of private sector in healthcare in India, market forces demand and dictate procedures that set institutions apart. This coupled with the competition from cardiologists especially in single vessel and double vessel coronary artery disease will perhaps increase the volume of MICS-CABG in India. There is a need to not only disseminate the expertise to a larger number of surgeons already established in their careers but also to provide opportunities to surgeons in training through fellowships either in India or overseas at centers of excellence. At the same time, both surgeons and patients must be assured that the benefits of MICS-CABG are beyond cosmesis alone. It is prudent to conduct high quality, sufficiently powered studies to establish the safety and benefit of MICS-CABG in India.

Notes

Acknowledgements

We acknowledge the input of the surgeons participating in the questionnaire survey.

Compliance with ethical standards

There was no funding for this manuscript. Dr. Michael Halkos is a consultant for Medtronic but no funds were received by any of the authors for this review and as such, there are no conflicts of interest. The review details a technique, and no patient-specific details are mentioned and as a result, formal ethical approval was not required.

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Copyright information

© Indian Association of Cardiovascular-Thoracic Surgeons 2018

Authors and Affiliations

  1. 1.Division of Cardiothoracic SurgeryEmory University School of MedicineAtlantaUSA
  2. 2.Department of Cardiac SurgeryNH Rabindranath Tagore International Institute of Cardiac SciencesKolkataIndia

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