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Mid-Term Follow-up of Minimally Invasive Multivessel Coronary Artery Bypass Grafting: Is the Early Learning Phase Detrimental?

Rodriguez, Maria Lorena MD; Lapierre, Harry R. MD; Sohmer, Benjamin MD; Glineur, David MD, PhD; Ruel, Marc MD

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: March/April 2017 - Volume 12 - Issue 2 - p 116–120
doi: 10.1097/IMI.0000000000000353
Original Articles

Objective Minimally invasive coronary artery bypass grafting (MICS CABG) through a small left thoracotomy is a novel technique for surgical coronary revascularization, which is increasingly being adopted around the world. This study aimed to describe the characteristics and mid-term outcomes of a series of MICS CABG to identify areas for improvement.

Methods A prospective longitudinal study was performed on the 306 MICS CABG patients operated on by a single surgeon from 2005 to 2015. Minimally invasive coronary artery bypass grafting used a small left thoracotomy to enable coronary revascularization with a similar configuration to an open sternotomy technique, with left internal thoracic artery harvesting, and hand-sewn proximal radial/saphenous and distal anastomoses, under direct visualization. We compared patients who were operated on during the first and second halves of the series to ascertain the impact of a learning curve on outcomes.

Results The mean ± SD age was 62 ± 9 years, 87% were male, and 23% had three-vessel disease. Off-pump coronary artery bypass was performed in 80%, and the median number of grafts was 2 (range 1–4). Sternotomy conversion occurred in 3.3%, reoperation for bleeding in 2%, and unplanned, emergency CPB conversion in 1%. Superficial thoracotomy infection, atrial fibrillation, and left-sided pleural effusion requiring drainage were encountered in 2%, 4%, and 4%, respectively. There were no perioperative stroke, myocardial infarction, or death. At a mean ± SD follow-up of 2.8 ± 2.5 years, 97.4% of patients were free from major adverse cardiac and cerebrovascular events. Between the first and latter half of the series, there was a decrease in the rate of conversion to sternotomy (5.2%–1.3%, P = 0.05) and in the mid-term need for repeat revascularization (11% vs 2.6%, P = 0.03). Overall repeat revascularization rate was 2.5% per year. The intensive care unit and hospital lengths of stay (1.6 ± 1.5 vs 1.4 ± 0.9, P = 0.2, and 6.1 ± 2.6 vs 5.6 ± 1.8, P = 0.4) were not statistically different.

Conclusions Minimally invasive coronary artery bypass grafting can be safely initiated as a minimally invasive, multivessel alternative to open surgical coronary revascularization, with excellent mid-term results. Learning phase effects were not observed with regard to overall procedural safety, but rather in terms of improved freedom from conversion to sternotomy and from repeat revascularization.

From the University of Ottawa Heart Institute, Ottawa, ON Canada.

Accepted for publication December 31, 2016.

Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, June 15–18, 2016, Montreal, Quebec, Canada.

Disclosures: Marc Ruel, MD, is a proctor for Medtronic, Inc, Minneapolis, MN USA. Maria Lorena Rodriguez, MD, Harry R. Lapierre, MD, Benjamin Sohmer, MD, and David Glineur, MD, PhD, declare no conflicts of interest.

Address correspondence and reprint requests to Maria Lorena Rodriguez, MD, University of Ottawa Heart Institute, 40 Ruskin St, Suite 3402, Ottawa, ON Canada K1Y 4W7. E-mail:

©2017 by the International Society for Minimally Invasive Cardiothoracic Surgery