34. Total Arterial Minimally Invasive Coronary Artery Bypass Surgery with Bilateral Internal Thoracic Arteries Provides Excellent Early Outcomes and Angiographic Patency
Piroze Minoo Davierwala, Alexander Verevkin, Sophia Sgouropoulou, Elham Hasheminejad, *Michael A. Borger
Heart Center Leipzig, Leipzig, Germany
Invited Discussant: *Michael P. Fischbein
Objective: Multivessel minimally invasive coronary artery bypass grafting (MICS-CABG) through a left mini-thoracotomy has recently emerged as an alternative to conventional CABG. However, it is most commonly performed with the left internal thoracic artery (ITA) and saphenous venous grafts. We developed a MICS-CABG technique that involves total arterial multi-vessel off-pump revascularization with bilateral ITAs (BITA) through a left anterior mini-thoracotomy. The present study analyzes the early postoperative outcomes and angiographic patency of grafts associated with this technique.
Methods: A total of 72 consecutive patients undergoing total arterial MICS-CABG with BITAs were included in this study. BITAs were harvested under direct vision (without the use of a thoracoscope/robot-assist) through a 6-8 cm left anterolateral thoracotomy and were utilized in a composite Y-graft or in situ configuration. Multi-vessel grafting was performed off-pump with the help of a heart positioner and stabilizer. No patient underwent manipulation of the ascending aorta. Coronary angiography was prospectively planned in the first 55 patients as a measure of quality control. Amongst these, 4 patients did not undergo early angiography -- 2 due to refusal and 2 because of renal insufficiency -- and another 2 patients underwent computed tomographic scans of the coronary arteries and grafts instead of angiography.
Results: The mean age of patients was 65.8±7.6 years and 65 (90.3%) were male. The mean body mass index was 26.7±2.6. The mean ejection fraction was 58.7%±6.0% and 27 patients (37.5%) had left main disease. The operations were performed off-pump in all patients. There were no intraoperative conversions to cardiopulmonary bypass or sternotomy. A total of 174 distal anastomoses were performed. The mean number of grafts was 2.4±0.5 with 43 patients undergoing double, 28 undergoing triple and 1 undergoing quadruple bypass. There was no in-hospital mortality and 4 patients underwent re-exploration for bleeding. No patient developed superficial or deep chest wound infections, but 9 patients developed respiratory insufficiency early postoperatively. Predischarge coronary angiography revealed one occluded and one spastic left ITA, one torqued right ITA and one 70% stenosed anastomosis resulting in an overall patency rate of 94.5%. Bypass revision was performed in 2 patients and percutaneous intervention in 1.
Conclusions: MICS-CABG utilizing total arterial revascularization with BITA is a feasible and safe operation that is associated with excellent short-term outcomes and early anastomotic patency. Future studies should focus on improving the generalizability and reproducibility of this technique.