Outcomes of Bilateral Internal Thoracic Arteries in Minimally Invasive Coronary Artery Bypass Grafting With Analogy to the SYNTAX Trial

Abstract

Objectives

Minimally invasive CABG is making positive strides in the evolution of coronary artery bypass surgery. We carried out a retrospective study of the efficacy and outcomes of the usage of bilateral internal thoracic arteries in MICS CABG patients over a 6 year period using primary (MACCE) and secondary outcome measures and also carried out a subgroup analysis of patients with diabetes and methodology of revascularization, and with analogy to the SYNTAX trial of the relative risk.

Methods

Nine hundred and forty patients underwent multivessel MICS CABG via a left mini-thoracotomy from August 2011 to September 2017 and complete revascularization was done using the left internal thoracic artery–right internal thoracic artery Y (LITA–RITA Y) composite conduit. Efficacy and outcomes were evaluated by primary (MACCE) and secondary outcome measures including total length of stay, return to full physical activity, and quality of life. Propensity score matched analyses were carried out in diabetics, in the methodology of revascularization (MICS OPCABG vs. MICS ONCABG), and by comparison to the SYNTAX trial for relative risk. Mean follow-up was 2.9 years (maximum was 5.6 years).

Results

Out of the 940 patients, 843 (89.6%) were diabetic and 97 (10.4%) were nondiabetic. Average grafts were 3.2. There were 9 mortalities (0.9%). The average ICU and hospital stay was 40 ± 12 hours and 3.1 days. Ten patients (1.06%) required reintervention by angioplasty. A total of 99.3% patients were free from major adverse cardiac and cerebrovascular events (MACCE) at follow-up. Mean follow-up was 33 months and 846 (90%) of the patients were followed up. Based on propensity score–matched groups, patients who had their surgery done by MICS ONCABG (beating heart technique) had greater mean number of grafts and hospital length of stay and had significantly longer ICU stay, extubation in OR and blood loss in comparison to patients who had their CABG done by the MICS OPCABG technique. The new technique has shown favorable risk reduction in comparison to both the arms of the SYNTAX trial.

Conclusions

The safety, efficacy and outcomes of minimally invasive CABG evaluated by primary (MACCE) and secondary outcomes and quality-of-life measures have been good in this study, especially in diabetics, and have shown results better than conventional CABG. The learning curve can be safely negotiated by using peripheral cardiopulmonary bypass assistance and comparison with the SYNTAX trial has shown a relative reduction in all-cause risk.

Keywords

MICS CABG internal thoracic arteries SYNTAX

Get full access to this article

View all access options for this article.

References

McGinn

JT.

Usman

Lapierre

et al. Minimally invasive coronary artery bypass grafting: dual-center experience in 450 consecutive patients. Circulation 2009; 120(11 Suppl): S78–S84.doi:10.1161/CIRCULATIONAHA.108.840041

Lapierre

Chan

Sohmer

et al. 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.doi:10.1016/j.ejcts.2011.01.066

Nambiar

Mittal

. Minimally invasive coronary bypass using internal thoracic arteries via a left minithoracotomy: “the Nambiar Technique”. Innovations 2013; 8: 420–426.doi:10.1097/imi.0000000000000035

Nambiar

Kumar

Mittal

et al. Minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries: will this be the future? J Thorac Cardiovasc Surg 2018; 155: 190–197.doi:10.1016/j.jtcvs.2017.07.088

Barsoum

Azab

Shariff

et al. Long-term mortality following minimally invasive coronary artery bypass surgery in diabetics. Circulation 2016; 134: A15277.

Lytle

BW.

Blackstone

EH.

Sabik

et al. The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years. Ann Thorac Surg 2004; 78: 2005–2014.doi:10.1016/j.athoracsur.2004.05.070

Taggart

. Bilateral internal mammary artery grafting: are BIMA better? Heart 2002; 88: 7–9.doi:10.1136/heart.88.1.7

LaPar

DJ.

Crosby

IK.

Rich

et al. Bilateral internal mammary artery use for coronary artery bypass grafting remains underutilized: a propensity-matched multi-institution analysis. Ann Thorac Surg 2015; 100: 8–15.doi:10.1016/j.athoracsur.2015.02.088

Lytle

. Bilateral internal thoracic artery grafting. Ann Cardiothorac Surg 2013; 2: 485–492.doi:10.3978/j.issn.2225-319X.2013.07.04

10.

Gatti

. Sternal wound management after bilateral internal thoracic artery grafting: a significant detail. Ann Transl Med 2017; 5: 262.doi:10.21037/atm.2017.03.84

11.

Rodriguez

Ruel

. Minimally invasive multivessel coronary surgery and hybrid coronary revascularization: can we routinely achieve less invasive coronary surgery? Methodist Debakey Cardiovasc J 2016; 12: 14–19.doi:10.14797/mdcj-12-1-14

12.

Coriat

Beaussier

. Fast-tracking after coronary artery bypass graft surgery. Anesth Analg 2001; 92: 1081–1083.doi:10.1097/00000539-200105000-00001

13.

Duan

Wang

et al. Risk factors for ventilator dependency following coronary artery bypass grafting. Int J Med Sci 2012; 9: 306–310.doi:10.7150/ijms.4340

14.

Lomivorotov

VV.

Efremov

SM.

Kirov

et al. Low-cardiac-output syndrome after cardiac surgery. J Cardiothorac Vasc Anesth 2017; 31: 291–308.doi:10.1053/j.jvca.2016.05.029

15.

Mostafa

El-Haddad

MA.

Shenoy

et al. Atrial fibrillation post cardiac bypass surgery. Avicenna J Med 2012; 2: 65–70.doi:10.4103/2231-0770.102280

16.

Herman

CR.

Buth

KJ.

Légaré

J-F

et al. Development of a predictive model for major adverse cardiac events in a coronary artery bypass and valve population. J Cardiothorac Surg 2013; 8: 177.doi:10.1186/1749-8090-8-177

17.

Lin

H-C.

Xirasagar

Tsao

N-W

et al. Volume-outcome relationships in coronary artery bypass graft surgery patients: 5-year major cardiovascular event outcomes. J Thorac Cardiovasc Surg 2008; 135: 923–930.doi:10.1016/j.jtcvs.2007.10.005

18.

Whang

Bigger

. Diabetes and outcomes of coronary artery bypass graft surgery in patients with severe left ventricular dysfunction: results from the CABG Patch Trial database. J Am Coll Cardiol 2000; 36: 1166–1172.doi:10.1016/S0735-1097(00)00823-8

19.

Liu

Wang

Ren

et al. A propensity score analysis on the effect of on-pump versus off-pump coronary artery bypass grafting for patients with coronary artery disease. J Thorac Dis 2014; 6: 838–844.doi:10.3978/j.issn.2072-1439.2014.05.08

20.

Reichenspurner

Boehm

DH.

Welz

et al. Minimally invasive coronary artery bypass grafting: port-access approach versus off-pump techniques. Ann Thorac Surg 1998; 66: 1036–1040.doi:10.1016/S0003-4975(98)00706-1

21.

Serruys

PW.

Morice

M-C.

Kappetein

et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med 2009; 360: 961–972.doi:10.1056/NEJMoa0804626

22.

Mohr

FW.

Morice

M-C.

Kappetein

et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 2013; 381: 629–638.doi:10.1016/S0140-6736(13)60141-5