Can Minimally Invasive Coronary Artery Bypass Grafting be Initiated and Practiced Safely?

Abstract

<jats:sec><jats:title>Objective</jats:title><jats:p> We examined the effects of learning curve on clinical outcomes and operative time in minimally invasive coronary artery bypass grafting (MICS CABG). </jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p> We studied 210 consecutive MICS CABG cases performed by the same surgeon, composed of 3 cardiopulmonary bypass (CPB)–assisted single-vessel small thoracotomy (SVST), 87 off-pump SVST, 51 CPB-assisted multivessel small thoracotomy (MVST), and 69 off-pump MVST. For each MICS CABG technique, the frequency of early clinical events (mortality, reopening, stroke, myocardial infarction, and revascularization) was compared between the first 25 cases and the remainder. Logarithmic curve regression analysis and a cumulative summation technique were performed to assess the correlation between operative time and the performed number of each technique. </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> There was no mortality, and there were 10 conversions to standard sternotomy, all of which were intended as off-pump MVST ( P &lt; 0.001, vs other procedures). Experience was otherwise not associated with perioperative outcome. However, experience numbers correlated with operative time in off-pump SVST and off-pump MVST (122 ± 30 minutes, R<jats:sup>2</jats:sup> = 0.18, P &lt; 0.001, and 241 ± 80 minutes, R<jats:sup>2</jats:sup> = 0.38, P &lt; 0.001, respectively) but not in CPB-assisted MVST (258 ± 44 minutes, R<jats:sup>2</jats:sup> = 0.004, P = 0.7). No complications occurred as a result of CPB assistance. </jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p> Minimally invasive coronary artery bypass grafting can be safely initiated, with a very low perioperative risk. Pump assistance is a good strategy to alleviate some of the learning curve and avoid conversions to sternotomy when initiating a multivessel MICS CABG program. 2009:83–94. </jats:p></jats:sec>

Minimally Invasive Multivessel Coronary Surgery and Hybrid Coronary Revascularization: Can We Routinely Achieve Less Invasive Coronary Surgery?

“…1 Other advantages include a decreased need for blood transfusion, lower surgical site infection rates, and earlier return to full physical function. 1,3,4 Associated complications include sternotomy conversion and development of left-sided pleural effusion. 1,3,5 Postoperative pain can be an issue during the initial hours, but it is transient, controllable, and significantly reduced by the third postoperative day; it is also associated with an overall improved postoperative pain picture with improved pulmonary functions.…”

“…1,3,4 Associated complications include sternotomy conversion and development of left-sided pleural effusion. 1,3,5 Postoperative pain can be an issue during the initial hours, but it is transient, controllable, and significantly reduced by the third postoperative day; it is also associated with an overall improved postoperative pain picture with improved pulmonary functions. 6,7 Notably, unlike sternotomy patients, MICS-CABG patients have no physical restriction postoperatively, which leads to improved independence.…”

Influence of experience and the surgical learning curve on long-term patient outcomes in cardiac surgery

“…A similar phenomenon may occur with CABG as it is supplanted by improved interventional techniques and used on increasingly complex patients. Also implied by our data is that learning curves are more likely to exist when new technologies such as robotics or new procedures such as transaortic/transapical aortic valves, 18,19 minimally invasive CABG, 20,21 or minimally invasive mitral valve surgery 5 are introduced into a surgeon's repertoire.…”

Evolution of Minimally Invasive Coronary Artery Bypass Grafting

“…Later cases had proximal anastomoses performed on the ascending aorta. 1,2,4,5 Chest wall bupivacaine pumps were used to reduce postoperative pain.…”