Classical or minimaly invasive coronary revascularization surgery? What's the difference?

Öz

ABSTRACT Background The aim of coronary bypass surgery is complete revascularization. As a current method that provides this and minimizes patient choice, we aimed to report the classic CABG (Coronary Artery Bypass Graft surgery) series performed by the same team during the same period with the TCRAT ( Total Coronary Revascularization via Small Left Anterior Thoracotomy) method by comparing it with in-hospital and 30-day results. Methods This study included 250 patients with multivascular lesions who underwent total coronary revascularization with the TCRAT method between January 2020 and January 2024, and 250 patients who underwent conventional CABG by the same team during the same period. All patients underwent surgery using standard surgical instruments, and all underwent two or more distal anastomoses. Results In the operative data, CPB(Cardio Pulmonary Bypass) time was 68.3±15.7 minutes and cross-clamp time was 34±10.6 minutes in the CABG group, while in the TCRAT group, CPB time was 102.8±23.3 minutes and cross-clamp time was 63.7±23.3 minutes. (p<0.001). The postoperative blood transfusion requirement during the intensive care period was 2±0.6 units in the CABG group and 0.8±0.4 units in the TCRAT group (p<0.001). The extubation time for patients in the intensive care unit was 11±1.6 hours in the CABG group and 6.5±1 hours in the TCRAT group (p=0.001). New postoperative AF development was observed in 45 (18%) patients in the CABG group, compared to 22 (8.8%) in the TCRAT group (p=0.003). The revision rate, including suture and debridement, was limited to 75 (30%) patients in the CABG group and 5 (2%) in the TCRAT group (p<0.001). Conclusion When the likelihood of delayed wound and bone healing and return to daily life increases with conventional CABG, the TCRAT technique can be considered as an alternative surgical method.

Anahtar Kelimeler

• minimally invasive cardiac surgery
• coronary artery bypass grafting
• revascularization
• left anterior thoracotomy

Klasik veya minimal invaziv koroner revaskülarizasyon cerrahisi? Farkı nedir?

Öz

ÖZET Arka plan Koroner bypass cerrahisinin amacı tam revaskülarizasyondur. Bunu sağlayan ve hasta seçimini en aza indiren güncel bir yöntem olarak, aynı ekip tarafından aynı dönemde yapılan klasik CABG (Koroner Arter Bypass Greft cerrahisi) serisini TCRAT (Küçük Sol Anterior Torakotomi ile Total Koroner Revaskülarizasyon) yöntemi ile hastane içi ve 30-günlük sonuçları açısından karşılaştırmayı amaçladık. Yöntemler Bu çalışma Ocak 2020 ile Ocak 2024 arasında TCRAT yöntemiyle total koroner revaskülarizasyon yapılan 250 multivasküler lezyonlu hasta ile aynı dönemde aynı ekip tarafından klasik CABG yapılan 250 hastayı kapsamaktadır. Tüm hastalar standart cerrahi aletler kullanılarak ameliyat edildi ve hepsinde iki veya daha fazla distal anastomoz yapıldı. Sonuçlar Operatif verilerde CPB (Kardiyopulmoner Bypass) süresi 68.3±15.7 dakika, kros klemp süresi CABG grubunda 34±10.6 dakika, TCRAT grubunda ise CPB süresi 102.8±23.3 dakika ve kros klemp süresi 63.7±23.3 dakika idi. (p<0.001). Yoğun bakım döneminde ameliyat sonrası kan transfüzyonu gereksinimi KABG grubunda 2±0.6 ünite, TCRAT grubunda 0.8±0.4 ünite idi (p<0.001). Yoğun bakım ünitesindeki hastaların ekstübasyon süresi KABG grubunda 11±1.6 saat, TCRAT grubunda 6.5±1 saatti (p=0.001). CABG grubunda 45 (%18) hastada, TCRAT grubunda ise 22 (%8.8) hastada yeni postoperatif AF gelişimi gözlendi (p=0.003). Dikiş ve debridman dahil revizyon oranı CABG grubunda 75 (%30) hasta ile sınırlı iken TCRAT grubunda 5 (%2) hastada görüldü (p<0.001). Sonuç Konvansiyonel CABG ile yara ve kemik iyileşmesinin gecikmesi ve günlük hayata dönüşün uzaması olasılığı arttığında TCRAT tekniği düşünülebilir.

Anahtar Kelimeler

• minimal invazif kardiyak cerrahi
• koroner arter baypas greft
• revaskülarizasyon
• sol anterior torakotomi

Kaynakça

1. Doenst T, Diab M, Sponholz C, Bauer M, Färber G. The opportunities and limitations of minimally invasive cardiac surgery. Dtsch Arztebl Int. 2017;114(46):777-784. Crossref
2. 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; Synergy between PCI with Taxus and Cardiac Surgery (SYNTAX) Investigators. Quality of life after PCI with drug-eluting stents or coronary-artery bypass surgery. N Engl J Med. 2011;364(11):1016-1026. Crossref
3. Järvinen O, Saarinen T, Julkunen J, Huhtala H, Tarkka MR. Changes in health-related quality of life and functional capacity following coronary artery bypass graft surgery. Eur J Cardiothorac Surg. 2003;24(5):750-756. Crossref
4. Babliak O, Demianenko V, Melnyk Y, Revenko K, Pidgayna L, Stohov O. Complete Coronary Revascularization via Left Anterior Thoracotomy. Innovations (Phila). 2019;14(4):330-341. Crossref
5. Calafiore AM, Di Giammarco G, Teodori G, Bosco G, D'Annunzio E, Barsotti A, Maddestra N, Paloscia L, Vitolla G, Sciarra A, Fino C, Contini M. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg. 1996;61(6):1658-1665. Crossref
6. Neumann FJ, Sousa-Uva M, Ahlsson A, Alfonso F, Banning AP, Benedetto U, Byrne RA, Collet JP, Falk V, Head SJ, Jüni P, Kastrati A, Koller A, Kristensen SD, Niebauer J, Richter DJ, Seferovic PM, Sibbing D, Stefanini GG, Taggart DP, Windecker S; ESC Scientific Document Group. 2018 ESC/EACTS Guidelines on myocardial revascularization. Eur Heart J. 2019;40(2):87-165. Crossref
7. Kofler M, Schachner T, Reinstadler SJ, Stastny L, Dumfarth J, Wiedemann D, Feuchtner G, Friedrich G, Bonatti J, Bonaros N. Comparative analysis of perioperative and mid-term results of TECAB and MIDCAB for revascularization of anterior wall. Innovations (Phila). 2017;12(3):207-213. Crossref
8. Bonatti J, Wallner S, Crailsheim I, Grabenwöger M, Winkler B. Minimally invasive and robotic coronary artery bypass grafting - A 25-year review. J Thorac Dis. 2021;13(3):1923-1944. Crossref

9. McGinn JT, 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(11 Suppl):S78-S84. Crossref
10. Chikwe J, Lee T, Itagaki S, Adams DH, Egorova NN. Long-term outcomes after off-pump versus on-pump coronary artery bypass grafting by experienced surgeons. J Am Coll Cardiol. 2018;72(13):1478-1486. Crossref
11. Diegeler A, Matin M, Falk V, Binner C, Walther T, Autschbach R, Mohr FW. Indication and patient selection in minimally invasive and “off-pump” coronary artery bypass grafting. Eur J Cardiothorac Surg. 1999;16(Suppl 1):S4-S7. Crossref
12. Czerny M, Baumer H, Kilo J, Lassnigg A, Hamwi A, Vukovich T, Wolner E, Grimm M. Inflammatory response and myocardial injury following coronary artery bypass grafting with or without cardiopulmonary bypass. Eur J Cardiothorac Surg. 2000;17(6):737-742. Crossref
13. Mao H, Katz N, Ariyanon W, Blanca-Martos L, Adýbelli Z, Giuliani A, Danesi TH, Kim JC, Nayak A, Neri M, Virzi GM, Brocca A, Scalzotto E, Salvador L, Ronco C. Cardiac surgery-associated acute kidney injury. Cardiorenal Med. 2013;3(3):178-199. Crossref
14. Ling Y, Bao L, Yang W, Chen Y, Gao Q. Minimally invasive direct coronary artery bypass grafting with an improved rib spreader and a new-shaped cardiac stabilizer: Results of 200 consecutive cases in a single institution. BMC Cardiovasc Disord. 2016;16:1. Crossref
15. Rufa MI, Ursulescu A, Aktuerk D, Nagib R, Albert M, Göbel N, Shavahatli T, Franke UF. Minimally invasive strategies of surgical coronary artery revascularization for the aging population. J Cardiovasc Surg (Torino). 2023;64(5):534-540. Crossref
16. Kawashima H, Serruys PW, Hara H, Ono M, Gao C, Wang R, Garg S, Sharif F, de Winter RJ, Mack MJ, Holmes DR, Morice MC, Kappetein AP, Thuijs DJFM, Milojevic M, Noack T, Mohr FW, Davierwala PM, Onuma Y. 10-Year All-Cause Mortality Following Percutaneous or Surgical Revascularization in Patients With Heavy Calcification. JACC Cardiovasc Interv. 2022;15(2):193-204. Crossref
17. Guo MH, Wells GA, Glineur D, Fortier J, Davierwala PM, Kikuchi K, Lemma MG, Mishra YK, McGinn J, Ramchandani M, Rabindra P, Nambala S, Chiu KM, Kiaii B, Gibson S, Ruel M. Minimally Invasive coronary surgery compared to STernotomy coronary artery bypass grafting: The MIST trial. Contemp Clin Trials. 2019;78:140-145. Crossref
18. Birla R, Patel P, Aresu G, Asimakopoulos G. Minimally invasive direct coronary artery bypass versus off-pump coronary surgery through sternotomy. Ann R Coll Surg Engl. 2013;95(7):481-485. Crossref
19. 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(4):804-810. Crossref
20. D'Agostino RS, Jacobs JP, Badhwar V, Fernandez FG, Paone G, Wormuth DW, Shahian DM. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2019 Update on Outcomes and Quality. Ann Thorac Surg. 2019;107(1):24-32. Crossref
21. Manuel L, Fong LS, Betts K, Bassin L, Wolfenden H. LIMA to LAD grafting returns patient survival to age-matched population: 20-year outcomes of MIDCAB surgery. Interact Cardiovasc Thorac Surg. 2022;35(4):ivac243. Crossref