Minimally Invasive Multivessel Coronary Artery Bypass Grafting: a Single Center's Experience of 600 Cases

Aim: To assess the safety and efficacy of multivessel minimally invasive coronary artery bypass grafting (MICS CABG) in the immediate and mid-term period.

Methods: A total of 611 patients with multivessel coronary artery disease who underwent MICS CABG in the period from 2011 to 2022 were recruited in a cohort study. All patients underwent complete myocardial revascularization via left mini-thoracotomy on the beating heart. The age of the patients was 58.9±8.1 years. 87 (14.2%) patients were women. Diabetes mellitus was detected in 129 (21.1%) patients, obesity – in 233 (38.1%). The EuroScore was 1.2±0.7 and the SyntaxScore was 26.7±8.9.

Results: The mean operation time was 261.7±93.5 minutes, the number of distal anastomoses was 2.5±0.7. 292 (47.8%) patients underwent mammary coronary artery bypass grafting, whereas 319 (52.2%) patients underwent coronary artery bypass surgery without touching the aorta. Cardiopulmonary bypass was initiated in 25 (4.1%) patients, of them 14 patients (2.3%) patients underwent emergency conversion. The median intraoperative blood loss was 250 (200; 300) mL, and the 24-hour blood loss after the intervention – 270 (150; 350) mL. Transfusion of blood and its components was performed in 56 (9.2%) patients. There were no cases of deep wound infection. Perioperative stroke was recorded in 2 (0.33%) patients, myocardial infarction – in 8 (1.3%) patients. The 30-day mortality was 0.49% (n=3). The postoperative in-hospital stay was 7 (7; 10) days, the median time up to return to full physical activity – 14 (9; 24) days. With the follow-up of 5.1 (3.2; 7.1) years, the 8-year cumulative survival rate was 91.4% and the freedom from major adverse cardiac and cerebrovascular events was 87.6%.

Conclusion: MICS CABG is a safe operation, associated with a low incidence of perioperative complications. MICS CABG can be applied to multi-vessel CAD patients saving the effectiveness during mid-term follow-up, comparable to traditional CABG. MICS CABG is a reproducible operation, but more demanding on surgical skills and requiring patient selection, especially at the beginning of the learning curve.

1. 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;40:804-810. https://doi.org/10.1016/j.ejcts.2011.01.066

2. Revishvili A.S., Popov V.A., Korostelev A.N., Plotnikov G.P., Malyshenko E.S., Anishchenko M.M. Predictors of new onset of atrial fibrillation after coronary artery bypass grafting surgery. Journal of Arrhythmology. 2018;(94):11-16. (In Russ.) https://doi.org/10.25760/VA-2018-94-11-16.

3. Ruel M, Une D, Bonatti J, McGinn JTJr. Minimally invasive coronary artery bypass grafting: is it time for the robot?. Curr Opin Cardiol. 2013;28(6):639-645. https://doi.org/10.1097/HCO.0b013e3283653fd1

4. Poston RS, Tran R, Collins M, Reynolds M, Connerney I, Reicher B, Zimrin D, Griffith BP, Barlett ST. Comparison of economic and patient outcomes with minimally invasive versus traditional off-pump coronary artery bypass grafting techniques // Ann Surg. 2008; 248:638-646. https://doi.org/10.1097/SLA.0b013e31818a15b5

5. Puskas JD, Williams WH, Mahoney EM, Huber PR, Block PC, Duke PG, Staples JR, Glas KE, Marshall JJ, Leimbach ME, McCall SA, Petersen RJ, Bailey DE, Weintraub WS, Guyton RA. Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial. JAMA. 2004; 21:291(15):1841-1849. https://doi.org/10.1001/jama.291.15.1841

6. Cohen DJ, Van Hout B, Serruys PW, Mohr FW, Macaya C, den Heijer P, Vrakking MM, Wang K, Mahoney EM, Audi S, Leadley K, Dawkins KD, Kappetein AP. Quality of life after PCI with drug-eluting stents or coronary-artery bypass surgery. N Engl J Med;364(11):1016-1026. https://doi.org/10.1056/NEJMoa1001508

7. Serruys PW, Morice MC, Kappetein AP, Colombo A, Holmes DR, Mack MJ, Stahle E, Feldman TE, van den Brand M, Bass EJ, Dyck NV, Leadley K, Dawkins KD, Mohr FW. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009;360(10):961-972. https://doi.org/10.1056/NEJMoa0804626

8. Shennib H. Evolving strategies in minimally invasive coronary artery surgery. Int J Cardiol. 1997;62(1):81-88.

9. Calafiore AM, De Giammarco G, Teodori G, Bosco G, D'Annunzio E, Barsotti A, Maddestra N, Paloscia L, Sciarra A, Contini M. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg. 1996;61(6):1658-1663. https://doi.org/10.1016/0003-4975(96)00187-7

10. Ziankou AA, Ostrovsky YP, Laiko MG, Vykhrystsenka KS, Chuyashou VA, Zhyhalkovich AS. Hospital and mid-term results of prospective randomized controlled trial MICSREVS - Minimally Invasive Cardiac Surgery REVascularization Strategy. 30th EACTS Annual Meeting, Barcelona, Spain, 1-5 October 2016. Available at: http://medialibrary.eacts.cyim.com/mediatheque/media.aspx?mediaId=18441&channel=10233. (accessed 20.11.2016)

11. Lemma M, Atanasiou T, Contino M. Minimally invasive cardiac surgery-coronary artery bypass graft. Multimed Man Cardio-Thoracic Surg. Available at: http://mmcts.oxfordjournals.org/content/2013/mmt007.full (accessed 02.11.2017)

12. McGinn JTJr, 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(11Suppl):78-84. https://doi.org/10.1161/CIRCULATIONAHA.108.840041

13. Nambiar P, Mittal C. Minimally Invasive Coronary Bypass Using Internal Thoracic Arteries via a Left Minithoracotomy ‘‘The Nambiar Technique’’. Innovations (Phila) 2013;8(6):420-426. https://doi.org/10.1097/IMI.0000000000000035

14. McGinn JrJT, Shariff MA, Nabagiez JP, Carluchi R, Sadel S, Sharma R, et al. Minimally Invasive CABG is Safe and Reproducible: Report on the First Thousand Cases. Proceedings of the 14th ISMICS Annual scientific meeting; 2014 May 28-31; Boston, USA: Innovations; 2014. p.158.

15. Barsoum EA, Azab B, Shah N, Patel N, Shariff MA, Lafferty J, Nabagiez JP, McGinn JrJT. Long-term mortality in minimally invasive compared with sternotomy coronary artery bypass surgery in the geriatric population (75 years and older patients). Eur J Cardiothorac Surg. 2015;47(5):862-867. https://doi.org/10.1093/ejcts/ezu267

16. Une D, Lapierre H, Sohmer B, Rai V, Ruel M. Can minimally invasive coronary artery bypass grafting be initiated and practiced safely?: a learning curve analysis. Innovations (Phila). 2013; 8(6):403–409. https://doi.org/10.1097/IMI.0000000000000019

17. Novikov M.A., Popov V.A., Malyshenko E.S., Revishvili A.Sh. Results of minimally invasive endoscopic-assisted coronary bypass grafting in the ENPILA randomized trial. Eurasian Cardiology Journal. 2019;(2S):352.