Technical Aspects of Minimally Invasive Direct Coronary Artery Bypass Surgery: Single-Center Experience

Objectives: To report single-center experience with different technical approaches in minimally invasive direct coronary artery bypass (MIDCAB) surgery.

Methods: From 2010 to July 2018, 90 patients (93.3% males, age 59.5 ± 10.4 years, log EuroSCORE I 2.15%) underwent MIDCAB grafting procedures. Periprocedural, 30-day and 1-year follow-up data were prospectively computed into a dedicated database and retrospectively analyzed.

Results: In 96.7% (87/90) patients, MIDCAB surgery was successfully performed for left internal mammary artery (LIMA) to left anterior descending (LAD) grafting via left anterior minithoracotomy. Elective conversion to sternotomy was necessary in 2.2% (2/90). One case had to be aborted due to massive calcification of the LAD. In 59.8% (52/87), conventional MIDCAB surgery (convMIDCAB) was performed. LIMA take down was supported by the use of the da Vinci robotic system (dvMIDCAB) in 29.9% (26/87) and 11.5% (10/87) of patients underwent 3D endoscope-enhanced thoracoscopic procedures (3dMIDCAB) for this matter. Mean operation time was 187.0 ± 47.1 versus 249.2 ± 22.7 versus 209.4 ± 33.9 minutes (convMIDCAB vs. 3dMIDCAB vs. dvMIDCAB). Immediate postoperative extubation in the operating room was performed in 77.0% (67/87), all remaining patients were extubated on the day of surgery in the intensive care unit (ICU). Surgical revision for bleeding was necessary in 3.4% (3/87). ICU and overall postoperative hospital stay were 1.8 ± 1.1 and 6.8 ± 5.0 days. A hybrid approach with sequential percutaneous coronary intervention (PCI) was planned in 21.1% (19/90) of cases. Mean follow-up was 947.4 ± 721.1 days. No myocardial infarction or stroke occurred until 30 days of follow-up. Mortality at 30 days was 0%. One-year follow-up was complete in 76.8% (63/82) of cases. MACCE-free survival was 82.5% (52/63), repeat revascularization of LAD was necessary in 4.8% (3/63), 3.2% (2/63) suffered a non-LAD-related myocardial infarction, and 1 patient had a stroke. Mortality at 1 year was 1.6% (1/63). The cause of death was noncardiac related. After 1-year follow-up, no major adverse events or cardiac-related deaths occurred in any patient.

Conclusion: All three different technical approaches of MIDCAB surgery yielded excellent clinical outcomes for stand-alone LAD revascularization or hybrid procedures with sequential non-LAD PCI at a mean follow-up of over 2 years (947.4 ± 721.1 days).

No conflict of interest has been declared by the author(s).