MIDCAB and OPCAB Results for Isolated Left Anterior Descending Disease: A Comparative Analysis

Aim: to compare the safety and efficacy of minimally invasive direct coronary artery bypass grafting (MIDCAB) versus off-pump coronary artery bypass grafting (OPCAB) for revascularization in patients with isolated left anterior descending artery (LAD) disease.

Materials and methods: fifty-three patients were assigned to the MIDCAB group and 54 patients undergoing left anterior descending (LAD) coronary artery bypass grafting were assigned to the OPCAB group. Patient recruitment occurred between 2019 and 2022. Exclusion criteria included: (1) concomitant surgical treatment of coronary artery disease, (2) brachiocephalic artery disease, (3) myocardial pathology, (4) valvular heart disease, and (5) urgent or redo surgical interventions.

Results: the mean operative time was comparable between groups (189.9±77 min for MIDCAB vs. 174.9±54.5 min for OPCAB, p=0.247). OPCAB demonstrated: significantly greater intraoperative blood loss (348.6±63.7 mL vs. 143.3±34.5 mL, p <0.001); longer postoperative ventilation (6.5±2.46 vs. 5.4±3.1 hours, p=0.044); extended ICU stay (1.27±0.8 vs. 1.03±0.3 days, p=0.043); prolonged hospitalization (12.7±5.5 vs. 8.3±2.4 days, p <0.001). Transfusion requirements were higher in OPCAB (22.2% vs. 5.7%, p=0.024). Perioperative complications showed a nonsignificant trend favoring MIDCAB (7.4% vs. 20.4%, p=0.093). No in-hospital mortality occurred in either group. At 4-year follow-up survival rates were comparable (96.8% MIDCAB vs. 92.8% OPCAB, p=0.673). Freedom from adverse cardiac events was similar (91.2% vs. 91.9%, p=0.421).

Conclusion: MIDCAB represents a safe and effective surgical approach for coronary artery disease treatment, demonstrating optimal clinical outcomes and enhanced quality of life. These findings support its consideration as a preferred treatment strategy in routine clinical practice.

1. Ancygina L.N., Kordatov P. N. Principles of rehabilitation of patients with coronary heart disease after surgical myocardial revascularization. Fizicheskaja i reabilitacionnaja medicina, medicinskaja reabilitacija. 2020;2:190-199 DOI: 10.36425/rehab34111 [In Russ]

2. Loop F.D., Lytle B.W., Cosgrove D.M. et al. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med. 1986; 314(1): 1-6. DOI: 10.1056/NEJM198601023140101

3. Toutouzas K., Patsa C., Vaina S. et al. A preliminary experience report: Drug-eluting stents versus coronary artery bypass surgery in patients with a single lesion in the proximal left anterior descending artery suffering from diabetes mellitus and chronic stable angina. Hellenic J Cardiol. 2008; 49(2): 65-71.

4. Kolesov V. I. The first experience in the treatment of angina pectoris by the imposition of corono-systemic vascular fistulas. Kardiologija. 1967;4: 20-25. [In Russ].

5. Olearchyk A.S., Kolesov V. I. A pioneer of coronary revascularization by internal mammary- coronary artery grafting. J Thorac Cardiovasc Surg. 1988; 96(1): 13-18.

6. Raja S.G., Garg S., Rochon M. et al. Short-term clinical outcomes and long-term survival of minimally invasive direct coronary artery bypass grafting. Ann Cardiothorac Surg. 2018; 7(5): 621- 627. DOI: 10.21037/acs.2018.06.14

7. Dieberg G., Smart N.A., King N. Minimally invasive cardiacsurgery: A systematic review and meta- analysis. Int J Cardiol. 2016; 223: 554-560. DOI: 10.1016/j.ijcard.2016.08.227

8. Lapierre H., Chan V., Sohmer B. et al. Minimally invasivecoronary artery bypass grafting via a small thoracotomy versus off-pump: a case-matched study. Eur J Cardiothorac Surg. 2011; 40(4): 804-810. DOI: 10.1016/j.ejcts.2011.01.066

9. Birla R., Patel P., Aresu G., Asimakopoulos G. Minimallyinvasive direct coronary artery bypass versus off- pump coronary surgery through sternotomy. Ann R Coll Surg Engl. 2013; 95(7): 481-485. DOI: 10.1308/003588413X13629960047119

10. Detter C., Reichenspurner H., Boehm D.H. et al. Minimally invasive direct coronary artery bypass grafting (MIDCAB) and off-pump coronary artery bypass grafting (OPCAB): two techniques for beating heart surgery. Heart Surg Forum. 2002; 5(2): 157-162.

11. Greenspun H.G., Adourian U.A., Fonger J.D., Fan J.S. Minimally invasive direct coronary artery bypass (MIDCAB): surgical techniques and anesthetic considerations. J Cardiothorac Vasc Anesth. 1996; 10(4): 507-509. DOI: 10.1016/s10530770(05)80013-8

12. Zhbanov I.V., Kiladze I.Z., Uriuzhnikov V.V., ShabalkinB.V. Minimally invasive coronary artery bypass surgery. Kardiologiya i Serdechno-Sosudistaya Khirurgiya. 2019; 12(5): 377385 DOI: 10.17116/kardio201912051377 [In Russ].

13. Calafiore A.M., Giammarco G.D., Teodori G. et al. Leftanterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg. 1996;61(6):1658-1665. DOI: 10.1016/0003-4975(96)00187-7

14. Subramanian V.A. Less invasive arterial CABG on a beating heart. Ann Thorac Surg. 1997; 63(6 Suppl): S68-S71. DOI: 10.1016/s0003-4975(97)00417-7

15. Garg S., Raja S. Minimally invasive direct coronaryartery bypass (MIDCAB) grafting. Medical Journal. 2020; 5. DOI: 10.21037/amj.2020.03.05

16. Holzhey D.M., Jacobs S., Mochalski M. et al. Seven- yearfollow-up after minimally invasive direct coronary artery bypass: experience with more than 1300 patients. Ann Thorac Surg. 2007; 83(1):108-114. DOI: 10.1016/j.athoracsur.2006.08.029

17. Xu Y., Li Y., Bao W., Qiu S. MIDCAB versus off- pumpCABG: Comparative study. Hellenic J Cardiol. 2020;61(2):120124. DOI: 10.1016/j.hjc.2018.12.004

18. Deppe A.C., Liakopoulos O.J., Kuhn E.W. et al. Minimallyinvasive direct coronary bypass grafting versus percutaneous coronary intervention for single- vessel disease: a meta-analysis of 2885 patients. Eur J Cardiothorac Surg. 2015; 47(3): 397406. DOI: 10.1093/ejcts/ezu285

19. Martins E.B., Hueb W., Brown D.L. et al. Surgical and percutaneous revascularization outcomes based on SYNTAX I, II, and residual scores: a long-term follow-up study. J Cardiothorac Surg. 2021; 16(1): 248. DOI: 10.1186/s13019-021-01616-6

20. Casula R., Khoshbin E., Athanasiou T. The midterm outcome and MACE of robotically enhanced grafting of left anterior descending artery with left internal mammary artery. J Cardiothorac Surg. 2014;9:19. DOI: 10.1186/1749-8090-9-19

21. Etienne P.Y., D’hoore W., Papadatos S. et al. Five- year follow-up of drug-eluting stents implantation vs minimally invasive direct coronary artery bypass for left anterior descending artery disease: a propensity score analysis. Eur J Cardiothorac Surg. 2013; 44(5): 884- 890. DOI: 10.1093/ejcts/ezt137

22. Halkos M.E., Liberman H.A., Devireddy C. et al. Earlyclinical and angiographic outcomes after robotic- assisted coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2014;147(1): 179-185. DOI: 10.1016/j.jtcvs.2013.09.010

23. Palmerini T., Biondi-Zoccai G., Riva D.D. et al. Risk ofstroke with percutaneous coronary intervention compared with on-pump and off-pump coronary artery bypass graft surgery: Evidence from a comprehensive network meta-analysis. Am Heart J. 2013; 165(6):910- 917.e14. DOI: 10.1016/j.ahj.2013.03.011

24. Stanbridge R.D., Hadjinikolaou L.K. Technical adjunctsin beating heart surgery comparison of MIDCAB to off-pump sternotomy: a meta-analysis. Eur J Cardiothorac Surg. 1999; 16 Suppl 2: S24-S33.

25. 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(5): 341-344.