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Minimally invasive coronary artery bypass grafting

  • Review Article
  • Published:
Indian Journal of Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

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.

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References

  1. Patel MR, Dehmer GJ, Hirshfeld JW, et al. ACCF/SCAI/STS/AATS/AHA/ASNC/HFSA/SCCT 2012 appropriate use criteria for coronary revascularization focused update: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, American Association for Thoracic Surgery, American Heart Association, American Society of Nuclear Cardiology, and the Society of Cardiovascular Computed Tomography. J Thorac Cardiovasc Surg. 2012;143:780-803.

  2. Tonino PA, De Bruyne B, Pijls NH, et al. Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med. 2009;360:213–24.

    Article  CAS  PubMed  Google Scholar 

  3. Wang JC, Normand SL, Mauri L, Kuntz RE. Coronary artery spatial distribution of acute myocardial infarction occlusions. Circulation. 2004;110:278–84.

    Article  PubMed  Google Scholar 

  4. Kolodgie FD, Burke AP, Farb A, et al. The thin-cap fibroatheroma: a type of vulnerable plaque: the major precursor lesion to acute coronary syndromes. Curr Opin Cardiol. 2001;16:285–92.

    Article  CAS  PubMed  Google Scholar 

  5. Loop FD, Lytle BW, Cosgrove DM, et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med. 1986;314:1–6.

    Article  CAS  PubMed  Google Scholar 

  6. Barner HB, Barnett MG. Fifteen- to twenty-one-year angiographic assessment of internal thoracic artery as a bypass conduit. Ann Thorac Surg. 1994;57:1526–8.

    Article  CAS  PubMed  Google Scholar 

  7. Yun KL, Wu Y, Aharonian V, et al. Randomized trial of endoscopic versus open vein harvest for coronary artery bypass grafting: six-month patency rates. J Thorac Cardiovasc Surg. 2005;129:496–503.

    Article  PubMed  Google Scholar 

  8. Taggart DP, D'Amico R, Altman DG. Effect of arterial revascularisation on survival: a systematic review of studies comparing bilateral and single internal mammary arteries. Lancet. 2001;358:870–5.

    Article  CAS  PubMed  Google Scholar 

  9. Aldea GS, Bakaeen FG, Pal J, et al. The Society of Thoracic Surgeons clinical practice guidelines on arterial conduits for coronary artery bypass grafting. Ann Thorac Surg. 2016;101:801–9.

    Article  PubMed  Google Scholar 

  10. Taggart DP, Altman DG, Gray AM, et al. Randomized trial of bilateral versus single internal-thoracic-artery grafts. N Engl J Med. 2016;375:2540–9.

    Article  PubMed  Google Scholar 

  11. Mohr FW, Morice MC, Kappetein AP, et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet. 2013;381:629–38.

    Article  PubMed  Google Scholar 

  12. Park SJ, Ahn JM, Kim YH, et al. Trial of everolimus-eluting stents or bypass surgery for coronary disease. N Engl J Med. 2015;372:1204–12.

    Article  CAS  Google Scholar 

  13. Farkouh ME, Domanski M, Sleeper LA, et al. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med. 2012;367:2375–84.

    Article  CAS  PubMed  Google Scholar 

  14. Magnuson EA, Farkouh ME, Fuster V, et al. Cost-effectiveness of percutaneous coronary intervention with drug eluting stents versus bypass surgery for patients with diabetes mellitus and multivessel coronary artery disease: results from the FREEDOM trial. Circulation. 2013;127:820–31.

    Article  PubMed  Google Scholar 

  15. Stone GW, Sabik JF, Serruys PW, et al. Everolimus-eluting stents or bypass surgery for left main coronary artery disease. N Engl J Med. 2016;375:2223–35.

    Article  CAS  Google Scholar 

  16. Makikallio T, Holm NR, Lindsay M, et al. Percutaneous coronary angioplasty versus coronary artery bypass grafting in treatment of unprotected left main stenosis (NOBLE): a prospective, randomised, open-label, non-inferiority trial. Lancet. 2016;388:2743–52.

    Article  PubMed  Google Scholar 

  17. Epstein AJ, Polsky D, Yang F, Yang L, Groeneveld PW. Coronary revascularization trends in the United States, 2001-2008. JAMA. 2011;305:1769–76.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Rothberg MB, Sivalingam SK, Ashraf J, et al. Patients' and cardiologists' perceptions of the benefits of percutaneous coronary intervention for stable coronary disease. Ann Intern Med. 2010;153:307–13.

    Article  PubMed  Google Scholar 

  19. Kipp R, Lehman J, Israel J, Edwards N, Becker T, Raval AN. Patient preferences for coronary artery bypass graft surgery or percutaneous intervention in multivessel coronary artery disease. Catheter Cardiovasc Interv. 2013;82:212–8.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Cohen DJ, Van Hout B, Serruys PW, et al. Quality of life after PCI with drug-eluting stents or coronary-artery bypass surgery. N Engl J Med. 2011;364:1016–26.

    Article  CAS  PubMed  Google Scholar 

  21. Hannan EL, Racz MJ, Gold J, et al. Adherence of catheterization laboratory cardiologists to American College of Cardiology/American Heart Association guidelines for percutaneous coronary interventions and coronary artery bypass graft surgery: what happens in actual practice? Circulation. 2010;121:267–75.

    Article  PubMed  Google Scholar 

  22. Czerny M, Baumer H, Kilo J, et al. Inflammatory response and myocardial injury following coronary artery bypass grafting with or without cardiopulmonary bypass. Eur J Cardiothorac Surg. 2000;17:737–42.

    Article  CAS  PubMed  Google Scholar 

  23. Sellke FW, Chu LM, Cohn WE. Current state of surgical myocardial revascularization. Circ J .2010;74:1031-1037.

  24. Misfeld M, Brereton RJ, Sweetman EA, Doig GS. Neurologic complications after off-pump coronary artery bypass grafting with and without aortic manipulation: meta-analysis of 11,398 cases from 8 studies. J Thorac Cardiovasc Surg. 2011;142:e11–7.

    Article  PubMed  Google Scholar 

  25. Shroyer AL, Hattler B, Wagner TH, et al. Five-year outcomes after on-pump and off-pump coronary-artery bypass. N Engl J Med. 2017;377:623–32.

    Article  PubMed  Google Scholar 

  26. Diegeler A, Walther T, Metz S, et al. Comparison of MIDCAP versus conventional CABG surgery regarding pain and quality of life. Heart Surg Forum. 1999;2:290–5.

    CAS  PubMed  Google Scholar 

  27. Subramanian VA. MIDCAB approach for single vessel coronary artery bypass graft. OperTechCardiac Thorac Surg. 1998;3:2–15.

    Google Scholar 

  28. Hu S, Li Q, Gao P, et al. Simultaneous hybrid revascularization versus off-pump coronary artery bypass for multivessel coronary artery disease. Ann Thorac Surg. 2011;91:432–8.

    Article  PubMed  Google Scholar 

  29. McGinn JT Jr, Usman S, Lapierre H, Pothula VR, Mesana TG, Ruel M. Minimally invasive coronary artery bypass grafting: dual-center experience in 450 consecutive patients. Circulation. 2009;120:S78–84.

    Article  PubMed  Google Scholar 

  30. Repossini A, Tespili M, Saino A, et al. Hybrid revascularization in multivessel coronary artery disease. Eur J Cardiothorac Surg. 2013;44:288–93.

    Article  PubMed  Google Scholar 

  31. Gasior M, Zembala MO, Tajstra M, et al. Hybrid revascularization for multivessel coronary artery disease. JACC Cardiovasc Interv. 2014;7:1277–83.

    Article  PubMed  Google Scholar 

  32. Modrau IS, Nielsen PH, Botker HE, et al. Feasibility and early safety of hybrid coronary revascularisation combining off-pump coronary surgery through J-hemisternotomy with percutaneous coronary intervention. Euro Intervention. 2015;10:e1–6.

    PubMed  Google Scholar 

  33. Holzhey DM, Cornely JP, Rastan AJ, Davierwala P, Mohr FW. Review of a 13-year single-center experience with minimallyinvasive direct coronary artery bypass as the primary surgical treatment of coronary artery disease. Heart Surg Forum. 2012;15:E61–8.

    Article  PubMed  Google Scholar 

  34. Kettering K, Dapunt O, Baer FM. Minimally invasive direct coronary artery bypass grafting: a systematic review. J Cardiovasc Surg (Torino). 2004;45:255–64.

    CAS  Google Scholar 

  35. Al-Ruzzeh S, Mazrani W, Wray J, et al. The clinical outcome and quality of life following minimally invasive direct coronary artery bypass surgery. J Card Surg. 2004;19:12–6.

    Article  PubMed  Google Scholar 

  36. Modrau IS, Holm NR, Maeng M, et al. One-year clinical and angiographic results of hybrid coronary revascularization. J Thorac Cardiovasc Surg. 2015;150:1181–6.

    Article  PubMed  Google Scholar 

  37. Fraund S, Herrmann G, Witzke A, et al. Midterm follow-up after minimally invasive direct coronary artery bypass grafting versus percutaneous coronary intervention techniques. Ann Thorac Surg. 2005;79:1225–31.

    Article  PubMed  Google Scholar 

  38. Blazek S, Rossbach C, Borger MA, et al. Comparison of sirolimus-eluting stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery: 7-year follow-up of a randomized trial. JACC Cardiovasc Interv. 2015;8:30–8.

    Article  PubMed  Google Scholar 

  39. Thiele H, Oettel S, Jacobs S, et al. Comparison of bare-metal stenting with minimally invasive bypass surgery for stenosis of the left anterior descending coronary artery: a 5-year follow-up. Circulation. 2005;112:3445–50.

    Article  CAS  PubMed  Google Scholar 

  40. Jaffery Z, Kowalski M, Weaver WD, Khanal S. A meta-analysis of randomized control trials comparing minimally invasive direct coronary bypass grafting versus percutaneous coronary intervention for stenosis of the proximal left anterior descending artery. Eur J Cardiothorac Surg. 2007;31:691–7.

    Article  PubMed  Google Scholar 

  41. Aziz O, Rao C, Panesar SS, et al. Meta-analysis of minimally invasive internal thoracic artery bypass versus percutaneous revascularisation for isolated lesions of the left anterior descending artery. BMJ. 2007;334:617.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Deppe AC, Liakopoulos OJ, Kuhn EW, et al. Minimally invasive direct coronary bypass grafting versus percutaneous coronary intervention for single-vessel disease: a meta-analysis of 2885 patients. Eur J Cardiothorac Surg. 2015;47:397–406.

    Article  PubMed  Google Scholar 

  43. Lapierre H, Chan V, Sohmer B, Mesana TG, Ruel M. Minimally invasive coronary artery bypass grafting via a small thoracotomy versus off-pump: a case-matched study. Eur J Cardiothorac Surg. 2011;40:804–10.

    PubMed  Google Scholar 

  44. Rabindranauth P, Burns JG, Vessey TT, Mathiason MA, Kallies KJ, Paramesh V. Minimally invasive coronary artery bypass grafting is associated with improved clinical outcomes. Innovations. (Phila) 2014;9:421-426.

  45. Vicol C, Nollert G, Mair H, et al. Midterm results of beating heart surgery in 1-vessel disease: minimally invasive direct coronary artery bypass versus off-pump coronary artery bypass with full sternotomy. Heart Surg Forum. 2003;6:341–4.

    PubMed  Google Scholar 

  46. Jegaden O, Wautot F, Sassard T, et al. Is there an optimal minimally invasive technique for left anterior descending coronary artery bypass? J Cardiothorac Surg. 2011;6:37.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Ling Y, Bao L, Yang W, Chen Y, Gao Q. Minimally invasive direct coronary artery bypass grafting with an improved rib spreader and a new-shaped cardiac stabilizer: results of 200 consecutive cases in a single institution. BMC Cardiovasc Disord. 2016;16:42.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  48. Iribarne A, Easterwood R, Chan EY, et al. The golden age of minimally invasive cardiothoracic surgery: current and future perspectives. Future Cardiol. 2011;7:333–46.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Head SJ, Borgermann J, Osnabrugge RL, et al. Coronary artery bypass grafting: Part 2--optimizing outcomes and future prospects. Eur Heart J. 2013;34:2873–86.

    Article  PubMed  Google Scholar 

  50. Holzhey DM, Jacobs S, Walther T, Mochalski M, Mohr FW, Falk V. Cumulative sum failure analysis for eight surgeons performing minimally invasive direct coronary artery bypass. J Thorac Cardiovasc Surg. 2007;134:663–9.

    Article  PubMed  Google Scholar 

  51. Rodriguez ML, Lapierre HR, Sohmer B, Glineur D, Ruel M. Mid-Term Follow-up of Minimally Invasive Multivessel Coronary Artery Bypass Grafting: Is the Early Learning Phase Detrimental? Innovations (Phila). 2017;12:116–20.

    Article  PubMed  Google Scholar 

  52. Cohn WE. Advances in surgical treatment of acute and chronic coronary artery disease. Tex Heart Inst.J 2010;37:328-330.

  53. Mishra Y, Mehta Y, Mittal S, et al. Mammary coronary artery anastomosis without cardiopulmonary bypass through minithoracotomy: one year clinical experience. Eur J Cardiothorac Surg. 1998;14:S31–7.

    Article  PubMed  Google Scholar 

  54. Trehan N, Mishra Y, Mehta Y, Jangid DR. Transmyocardial laser as an adjunct to minimally invasive CABG for complete myocardial revascularization. Ann Thorac Surg. 1998;66:1113–8.

    Article  CAS  PubMed  Google Scholar 

  55. Trehan N, Malhotra R, Mishra Y, Shrivastva S, Kohli V, Mehta Y. Comparison of ministernotomy with minithoracotomy regarding postoperative pain and internal mammary artery characteristics. Heart Surg Forum. 2000;3:300–6.

    CAS  PubMed  Google Scholar 

  56. Mishra YK, Wasir H, Sharma M, Sharma KK, Mehta Y, Trehan N. Robotically enhanced coronary artery bypass surgery. Indian Heart J. 2004;56:622–7.

    CAS  PubMed  Google Scholar 

  57. Mishra YK, Wasir H, Sharma KK, Mehta Y, Trehan N. Totally endoscopic coronary artery bypass surgery. Asian Cardiovasc Thorac Ann. 2006;14:447–51.

    Article  PubMed  Google Scholar 

  58. Pande S, Agarwal SK, Gupta D, et al. Early and mid-term results of minimally invasive coronary artery bypass grafting. Indian Heart J. 2014;66:193–6.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Nambiar P, Mittal C. Minimally invasive coronary bypass using internal thoracic arteries via a left minithoracotomy: "the Nambiar Technique". Innovations (Phila). 2013;8:420–6.

    Article  Google Scholar 

  60. Hiremath J, Sheth K. Hybrid procedure. J Assoc Physicians India. 2014;62:259–61.

    PubMed  Google Scholar 

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Acknowledgements

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

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Correspondence to Pradeep Narayan.

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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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Kayatta, M.O., Halkos, M.E. & Narayan, P. Minimally invasive coronary artery bypass grafting. Indian J Thorac Cardiovasc Surg 34 (Suppl 3), 302–309 (2018). https://doi.org/10.1007/s12055-017-0631-x

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