Predictors and Outcomes of Sternotomy Conversion and Cardiopulmonary Bypass Assistance in Minimally Invasive Coronary Artery Bypass Grafting

Abstract

<jats:sec><jats:title>Objective</jats:title><jats:p> This work's objective was to identify the determinants of conversion of minimally invasive coronary artery bypass grafting to sternotomy, with and without cardiopulmonary bypass assistance, and to compare clinical outcomes in patients who needed conversion. </jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p> This is a prospectively collected data on patients who underwent minimally invasive coronary bypass done by a single surgeon from February 2005 to September 2014. Statistical analyses were expressed as mean values ± standard deviation or proportions. </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> The total number of patients was 266, with an average age of 62 years. The median number of grafted territories was 2, higher in those with pump assistance (median, 3 grafts; P ≤ 0.01). Predictors for use of cardiopulmonary bypass included diabetes, 3-vessel disease, left circumflex involvement, and small target vessels (P &lt; 0.05). The rate for sternotomy conversion was 3.8%. Risk factors for conversion to sternotomy included smoking, preoperative bradycardia (&lt;50 beats per minute), low intraoperative ejection fraction, inability to tolerate one-lung ventilation, inadequate surgical exposure, and hemodynamic instability. Postoperative complications included superficial thoracotomy infection (3%), sternotomy infection (10%), new atrial fibrillation (3%), and need for blood transfusion (14%). Twelve patients (5%) developed left-sided pleural effusion that required drainage. There were no perioperative deaths, major adverse cardiac event, or stroke. </jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p> Minimally invasive coronary bypass grafting with conversion to sternotomy and use of cardiopulmonary bypass is safe. Conversions may be alleviated by an effort to optimize modifiable risk factors and the adequacy of surgical exposure. These data may help develop objective selection criteria to identify patients who are excellent candidates for the procedure. </jats:p></jats:sec>

Repeat Revascularization after Minimally Invasive Coronary Artery Bypass Grafting

“…Cardiopulmonary bypass assistance remains useful, especially for exposure due to heart enlargement, to provide hemodynamic stability, and in facilitating revascularization in diabetics with small targets. 12 Our eventual 2% per year RR rates are comparable with that reported for CABG through median sternotomy as well as through minimally invasive direct CABG, which mostly uses LITA-LAD through a small left thoracotomy. [19][20][21][22][23] More advanced procedures such as endoscopic atraumatic CABG have varying results, with some centers manifesting with excellent outcomes, and others show the expectedly higher RR rates associated with the increased complexity of the surgery.…”

“…[1][2][3][4]7 In general, the population is of a less-sick profile, being younger, nonobese, with less advanced comorbidities, with preserved ventricular function, and with most surgery performed on an elective basis. The presence of active smoking, preoperative bradycardia, and low intraoperative ejection fraction has been shown to predispose to sternotomy conversion 12 and may be considered as markers for poor candidacy for a MICS approach. In this study, to further illustrate the outcomes of the new technique, we focused on the mid-term rates of RR.…”

Mid-Term Follow-Up of Minimally Invasive Multivessel Coronary Artery Bypass Grafting

“…4 Cardiopulmonary bypass assistance is useful for exposure due to heart enlargement, to provide hemodynamic stability and to facilitate revascularization in diabetics with small targets. 11 Our results show lower rates of bleeding and sternotomy conversion compared with more complex procedures such as endoscopic CABG. 12,13 Ninety-seven percent of our patients were free from major adverse cardiac and cerebrovascular events including death, at the time of last follow-up.…”

Revascularización quirúrgica del miocardio por acceso mínimamente invasivo

“…La ventaja del acceso por minitoracotomía es que se evita la esternotomía media e infecciones del sitio operatorio, hay mejor manejo del dolor, especialmente el dolor crónico posoperatorio y también hay menor estadía en la unidad de cuidados posoperatorios, con alta pronta, como se ha demostrado en diferentes estudios de centros grandes (2,3). Se recomienda realizar la cirugía en pacientes diabéticos y pacientes con un índice de masa corporal < 30 kg/m2 con múltiples comorbilidades (4)(5)(6) . Por el contrario, está contraindicado emplear este abordaje en las emergencias, deformidades de la caja torácica como pectus excavatum, enfermedad pulmonar grave, una arteria DA intramiocárdica o calcificada, o ante enfermedad difusa y enfermedad arterial periférica, si se piensa usar CEC (7) .…”