Minimally invasive off-pump bypass grafting-positioning the right posterior descending coronary artery.

Minimally invasive coronary surgery offers benefits to the patient. Besides the anterior wall, the lateral and inferior walls can be reached through a small thoracotomy with off-pump techniques. Thoracoscopic coronary identification can be very useful in these multivessel procedures. Positioning the heart without cardiopulmonary bypass can be challenging. We describe our technique for off-pump positioning and for grafting the right posterior descending coronary artery.

Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass: Impact of Chest Wall Dimensions in Single and Multivessel Bypass.

OBJECTIVE: There can be anatomical constraints on patient selection for minimally invasive surgery. For example, robot-assisted coronary artery bypass was reported to be more challenging when patients had a cardiothoracic ratio >50% and a sternum-vertebra anteroposterior and transverse diameter ratio <0.45. We sought to examine the impact of chest wall anatomic parameters on surgical outcomes in our totally endoscopic coronary artery bypass (TECAB) procedures. METHODS: We retrospectively reviewed patients who underwent robotic TECAB, all of whom had a preoperative chest radiograph at our institution from July 2017 to October 2021. The cohort was divided into 2 groups, which were patients undergoing single-vessel grafting using the left internal thoracic artery (ITA; group 1) and patients undergoing multivessel grafting with bilateral ITA grafts (group 2). We measured several anatomical parameters from the preoperative chest radiograph. RESULTS: A total of 352 patients undergoing TECAB were retrospectively analyzed. After exclusions, 193 were included in this study. In group 1 (n = 91), no parameters correlated with operative time. In group 2 (n = 102), a significant negative correlation was observed between operative time and the sternum-vertebrae anteroposterior diameter (rs = -0.228, P = 0.022) and lung anteroposterior diameter (rs = -0.246, P = 0.013). To confirm these results in group 2, a propensity-matched analysis was performed and showed a statistically significant difference in surgical time based on chest anteroposterior diameters. CONCLUSIONS: In single-vessel robotic TECAB, chest wall anatomic dimensions measured on chest radiograph did not affect operative time. In multivessel cases with bilateral ITA grafts, larger anteroposterior diameter correlated with shorter operative times.

Off-pump minimally invasive coronary artery bypass grafting in patients with left ventricular dysfunction: the lampang experience.

Introduction: The minimally invasive cardiac surgery off-pump coronary artery bypass (MICSOPCAB) is technically difficult; therefore, previous studies have indicated that MICSOPCAB should be contraindicated in patients with impaired left ventricular (LV) function. In this study, we investigated the feasibility of MICSOPCAB in patients with impaired LV function. Methods: The 226 patients underwent MICSOPCAB between August 2017 and September 2022. Our study defined impaired LV function as ejection fraction (EF) in echocardiography 40% or less. The patients were divided into Low EF group (n = 39) and Normal EF group (n = 187). Results: The Low EF group was in a more critical preoperative condition than Normal EF group (41.0% in the Low EF group vs. 14.4% in the Normal EF group; p < 0.001). For preoperative transthoracic echocardiography, LV end-diastolic diameter (5.5 ± 0.9 cm in the Low EF group vs. 5.0 ± 0.8 cm in the Normal EF group; p < 0.001) and LV end-systolic diameter (4.4 ± 1.0 cm in the Low EF group vs. 3.4 ± 1.0 cm in the Normal EF group; p < 0.001) were significantly larger in the Low EF group. No differences were found in the operative time (180 [160-240] min in the Low EF group vs. 205 [165-253] min in the Normal EF group; p = 0.231) and the median number of distal anastomoses (2 [1-2] in the Low EF group vs. 2 [1-3] in the Normal EF group; p = 0.073). Intensive care unit stay was longer in the Low EF group than in the Normal EF group (2 [1-2] in the Low EF group vs. 1 [1-2] in the Normal EF group; p = 0.010). Perioperative transfusion was more common in the Low EF group than in the Normal EF group (69.7% vs. 49.2%; p = 0.023). There were no differences in major complications, hospital stay, and 30-day mortality. The Kaplan-Meier curve showed no significant difference in postoperative major adverse cardiac or cerebrovascular events rates between the two groups (p = 0.185). Conclusion: In this study, MICSOPCAB can be performed in patients with low EF having short- and mid-term outcomes similar to patients with normal EF. Therefore, low EF should not be contraindicated in MICSOPCAB.

Thoracoscopic (non-robotic) harvesting of bilateral internal mammary artery grafts.

Minimally invasive coronary surgery offers benefits to the patient. Harvesting the internal mammary artery remains a challenging part of this procedure. We describe our technique for thoracoscopic harvesting of the left and right mammary arteries using routine endoscopic instruments. This is a non-robotic technique that might facilitate a more widespread growth of minimally invasive coronary surgery.

Minimally invasive multivessel coronary grafting using a robotic totally endoscopic approach.

Totally endoscopic multi-vessel coronary artery bypass grafting is an advanced surgical technique that offers the least-invasive alternative to traditional sternotomy bypass surgery. Although robotic-assisted minimally invasive left internal thoracic artery to left anterior descending artery bypass has been adopted widely, the application of a robotic totally endoscopic approach for multi-vessel bypass still remains limited. This case report demonstrates the surgical technique of robotic totally endoscopic multi-vessel coronary artery bypass using bilateral internal thoracic artery grafts.

Left Internal Mammary Artery Operative Topography for MIDCAB and TECAB Procedures.

OBJECTIVE: The left internal mammary artery (LIMA) is a common arterial graft in minimally invasive coronary surgery (MICS), such as minimally invasive coronary artery bypass grafting (MIDCAB) or totally endoscopic coronary artery bypass (TECAB). The aim of this study was to perform an analysis of the LIMA operative topography during MICS. METHODS: A total of 104 computed tomography angiographies were analyzed retrospectively using 3-dimensional reconstruction and visualization software. Measurements were developed in relation to the anatomical midpoint of the sternal body (SBMP). Parameters were evaluated as lengths, distances, diagonals, or categorical descriptions. RESULTS: A total of 208 internal mammary arteries of each side were analyzed with the following results: (1) LIMA width = 2.7 mm, (2) SBMP-LIMA bifurcation length = 6.2 cm, (3) SBMP-LIMA distance = 3.2 ± 0.5 cm, (4) xiphoid midpoint-LIMA distance = 3.5 ± 0.7 cm, (5) sternal line-LIMA distance = 1.7 ± 0.3 cm, (6) xiphoid end projection-LIMA bifurcation length = 2.2 ± 1.0 cm, (7) midsternal line-LIMA bifurcation distance = 3.3 ± 0.8 cm, (8) xiphoid end-LIMA bifurcation diagonal = 4.1 ± 0.9 cm, (9) LIMA-left coronary artery distance = 7.0 ± 1.4 cm at the proximal and 7.1 ± 1.3 cm at the distal segment, and (10) LIMA-left anterior descending artery distance = 5.5 ± 1.1 cm at proximal, 4.3 cm at middle, and 4.2 ± 1.5 cm at distal segment. The extent of LIMA bifurcation ranged from the level of 5 (1%) to 7 (6%) rib cartilages. CONCLUSIONS: Based on the detailed surgical anatomy of LIMA, it was concluded that the fourth intercostal space should be considered as an appropriate approach for MIDCAB or TECAB in the studied region.

Virtual Reality Simulation for Minimally Invasive Coronary Artery Bypass Grafting With Aortic No-Touch Total Arterial Grafting Technique.

OBJECTIVE: Virtual reality can be applied preoperatively by surgeons to gain precise insights into a patient's anatomy for planning minimally invasive coronary artery bypass grafting (CABG) with in situ arterial grafts. This study aimed to examine virtual reality simulation for minimally invasive CABG with in situ arterial grafts. METHODS: Preoperative stereolithographic files in 35 in situ arterial grafts were converted using 320-slice computed tomography and workstation. The accurate length and direction of each graft were confirmed through virtual reality glasses. The simulation of graft designs was performed by using an immersive virtual reality platform. RESULTS: The mean harvested lengths of in situ left internal thoracic artery (n = 17), right internal thoracic artery (n = 12), and gastroepiploic artery (n = 6) grafts predicted by virtual reality simulation were 21.4 ± 3.4 cm, 21.2 ± 3.6 cm, and 22.8 ± 4.8 cm. The required lengths of these grafts predicted by virtual reality simulation were 15.8 ± 2.3 cm, 16.4 ± 2.1 cm, and 14.5 ± 4.4 cm. Minimally invasive CABG using virtual reality simulation was completed in 17 patients, of whom 16 patients underwent aortic no-touch total arterial CABG. The surgical strategy was adjusted in 11.8% of the cases due to the 3-dimensional virtual reality-based anatomy evaluation. The early mortality and morbidity were 0%, and the patency of the graft was 100%. The median time to return to full physical activity was 7.1 days. CONCLUSIONS: This study demonstrated the successful development and clinical application of the first dedicated virtual reality platform for planning aortic no-touch total arterial minimally invasive CABG. Virtual reality simulation can allow the accurate preoperative understanding of anatomy and appropriate planning of the graft design with acceptable postoperative outcomes.

Coronary artery bypass grafting and mitral valve replacement via a left anterior minithoracotomy.

We present a technique for multivessel minimally invasive coronary revascularization combined with mitral valve replacement through a left anterior minithoracotomy. This newly developed technique is unique because it allows us to intervene and repair or replacement the mitral valve with a conventional surgical technique through a limited left anterior approach. The minimally invasive approaches for combined cardiac surgical procedures are being increasingly investigated and are of special interest to cardiac surgeons.

Robotic-assisted MIDCAB procedure through a minithoracotomy: Step-by-step instructions.

Minimally invasive cardiac surgery has evolved in recent years. Complex minimally invasive surgical techniques can further reduce the morbidity associated with surgical coronary bypass grafting. Robotic-assisted minimally invasive direct coronary artery bypass grafting is an effective and safe procedure in all risk groups. More experience with this procedure over the coming years should lead to the implementation of guidelines and the incorporation in heart-team decisions of schemes for individual patient care. We present a young male patient with familial hypercholesterolemia and chronic total occlusion of the left anterior descending artery (LAD) treated in January 2021 with a robotic-assisted minimally invasive direct coronary artery bypass graft through a minithoracotomy. The procedure was. The patient showed a fast recovery from the uncomplicated procedure and was discharged from the hospital after 3 days. We prepared this case report to facilitate training for this complex technical procedure. Robotic-assisted MIDCAB through a minithoracotomy is a technically demanding but safe minimally invasive alternative to coronary artery bypass grafting in patients with severe coronary lesions not suitable for percutaneous coronary intervention. In a hybrid coronary revascularization strategy, this technique minimizes surgical risk and optimizes long-term outcomes with high patency of surgical grafts.

Minimally invasive coronary artery bypass grafting with ultrasonically skeletonized internal thoracic artery.

Objective: This study aimed to examine the feasibility and safety of minimally invasive cardiac surgery coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery in the authors' initial experience. Methods: From February 2012 to May 2021, 247 consecutive patients who underwent minimally invasive coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery were reviewed retrospectively. Internal thoracic arteries were harvested in a full skeletonized fashion using an ultrasonic scalpel via left minithoracotomy. Bilateral internal thoracic arteries were used in 108 patients, and the internal thoracic arteries as in situ grafts were used in 393 anastomoses. Total arterial revascularization was performed in 126 patients, and 142 patients underwent aortic nontouch minimally invasive coronary artery bypass grafting. Results: The patients' mean (range) age was 65.9 ± 11.5 (30-90) years. The mean (range) number of anastomoses performed was 2.6 ± 1.1 (1-6). Forty-six patients (18.6%) had 4 grafts, 94 patients (38.1%) had 3 grafts, and 60 patients (24.3%) had 2 grafts. Minimally invasive coronary artery bypass grafting was completed without conversion to sternotomy in all patients. Cardiopulmonary bypass was performed in 3 patients (1.2%), reinterventions due to bleeding were performed in 7 patients (2.8%), and chest wound infections were observed in 5 patients (2.0%). There was 1 (0.4%) mortality. Conclusions: Minimally invasive coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery is feasible and has shown good perioperative outcomes. This approach has the potential for further optimization with revascularization strategies.

Comparing patient outcomes following minimally invasive coronary artery bypass grafting surgery vs. coronary artery bypass grafting: a single-center retrospective cohort study.

Background: This present research was designed for comparing coronary artery disease (CAD) patient outcomes following minimally invasive coronary artery bypass grafting surgery (MICS) or coronary artery bypass grafting (CABG). Methods: From 2014-2017, 679 CAD patients underwent MICS (n=281) or CABG (n=398) and were evaluated for the present study. Patient data were analyzed using 1:1 propensity score-matched assessment and a multivariate Cox proportional hazards regression model, and primary study achievements comprised major adverse cardiac and cerebrovascular events (MACCEs), myocardial infarction (MI), cardiac death, heart failure (HF), revascularization, and stroke. The median follow-up period was 2.68 years. Results: CABG patients exhibited a trend towards higher cumulative overall rates of MACCEs at 2 years (CABG: 6.2% vs. MICS: 3.8%) and 4 years (CABG: 9.3% vs. MICS: 7.6%) [adjusted hazard ratio (HR): 1.33; 95% confidence interval (CI): 0.33-5.39 for CABG vs. MICS; P=0.687], although this difference was not significant. No significant differences in 2- or 4-year cardiac death rates were observed between groups (CABG: 3.5%, 5.6% vs. MICS 2.8%, 2.8%; adjusted HR: 0.23; 95% CI: 0.03-1.81 for CABG vs. MICS; P=0.160). Further, there existed no discrepancies in rates of MI (P=1.000), HF (adjusted HR: 4.76; 95% CI: 0.01-6.40 for CABG vs. MICS; P=0.996), stroke (adjusted HR: 9.58; 95% CI: 0.11-25.24 for CABG vs. MICS; P=0.320), or repeated revascularization (adjusted HR: 1.71; 95% CI: 0.01-7.21 for CABG vs. MICS; P=0.631) when comparing these patient groups. In a multivariable Cox proportional hazards regression analysis, patients that were male (adjusted HR: 5.28; 95% CI: 1.48-18.83; P=0.010) and cases with a history of previous MI epsiodes (adjusted HR: 3.20; 95% CI: 1.09-9.37; P=0.034) were found to be at a higher risk of MACCEs. Conclusions: Follow-up data indicated that the MICS and CABG treatments could achieve similar outcomes.

Minimally invasive direct coronary artery bypass to the left anterior descending artery using right gastroepiploic artery graft for a redo case with poor conduits.

A 64-year-old Thai woman underwent coronary artery bypass grafting (CABG) using saphenous vein grafts (SVG) for completely occluded left anterior descending artery (LAD) and mitral valve replacement with mechanical valve about a year ago. She presented with unstable angina. Three-dimensional computed tomography angiography (3DCTA) showed occlusion of all the grafts. The left subclavian artery had 99% stenosis. The patient underwent redo CABG via a minimally invasive direct approach. The chest was entered through the left fifth intercostal space. The right gastroepiploic artery (RGEA) and a small length of SVG were harvested. The RGEA was extended using the SVG with an end-to-end anastomosis and used to graft the LAD without cardiopulmonary bypass. The patient's postoperative course was uneventful. Postoperative 3DCTA revealed patent RGEA-SVG graft. Minimally invasive direct coronary artery bypass to LAD with RGEA is a useful alternative approach for redo CABG in patients with not much choice of conduits.

Minimally Invasive Multiple Coronary Artery Bypass Grafting with Composite Graft Using in situ Right Gastroepiploic and Radial Arteries.

Minimally invasive surgery/coronary artery bypass grafting (MICS CABG) via left thoracotomy and multiple CABG is a reported alternative to the standard sternotomy approach. However, harvesting the right internal thoracic artery (RITA) under direct vision requires high surgical skill. We describe MICS CABG with the left internal thoracic artery (LITA) and a composite graft using the in situ right gastroepiploic artery (GEA) and radial artery (RA) to achieve complete coronary revascularization. No complications occurred, and postoperative computed tomography showed patency of all grafts. Our experience suggests that this composite graft can be used safely and effectively in MICS CABG for complete arterial revascularization without difficulty.

Multivessel Arterial Revascularization via Left Anterior Thoracotomy.

To present the technique and to evaluate the outcomes of the multivessel minimally invasive coronary revascularization through the left anterior thoracotomy. From July 2017 to March 2019 in 229 consecutive patients with isolated multivessel coronary artery disease we performed complete coronary revascularization through the left anterior minithoracotomy (6-8 cm skin incision). In 47 of them we performed multiarterial revascularization using left internal mammary artery and T-shunt with left radial artery or right internal mammary artery. Cardiopulmonary bypass (CPB), Chitwood clamp and blood cardioplegia were used in all patients. Heart strings, encircling tapes and Chitwood clamp were used to reduce the distance from skin to coronary targets. Usual coronary instruments were used. The perioperative outcomes of multiarterial graft strategy group were compared with uniarterial graft strategy group. There were no mortality, no perioperative myocardial infarcts, and no conversion to sternotomy with either graft strategy groups. The mean number of distal anastomoses, CPB time, and total hospital stay were not different between the groups. Aortic cross-clamp time ((83.8 ± 17.4 (45;121) vs 67.8 ± 17.4 (35;146), P < 0.0001) and total operation time (283.5 ± 45 (205;495) vs 254.3 ± 48.6 (175;590), P = 0.0003) were longer in patients with multiarterial revascularization compared to uniarterial revascularization using left internal mammary artery and veins. Multivessel coronary bypass grafting using CPB and cardioplegia can be routinely performed minimally invasively through the left anterior thoracotomy. In selected patients multiarterial revascularization could be done with excellent procedural outcomes.

Complete Coronary Revascularization via Left Anterior Thoracotomy.

OBJECTIVE: Our aim was to develop the minimally invasive coronary artery bypass grafting (CABG) technique, which is equally effective and safe compared with conventional coronary grafting technique, is reproducible, and can be applied in the vast majority of patients with isolated coronary artery disease. METHODS: From July 2017 to November 2018 a total of 170 nonselected consecutive patients underwent minimally invasive on-pump multivessel CABG through the left anterior minithoracotomy in the fourth intercostal space using a Chitwood clamp and blood cardioplegia. We named this technique total coronary revascularization via left anterior thoracotomy. The mean number of grafts was 3.1 ± 0.7. Left internal mammary artery was used in 159 (93.5%) patients, right internal mammary artery in 4 (2.4%) patients, radial artery in 25 (14.7%) patients, and veins in 148 (87%) patients. RESULTS: We had no mortality, no postoperative myocardial infarcts, and no conversion to sternotomy. There were 2 postoperative strokes without residual neurological deficit and 2 revisions for postoperative bleeding. The total operation time was 258.8 ± 43.9 minutes, cardiopulmonary bypass time 135.8 ± 26.6 minutes, and aortic cross-clamp time 71.2 ± 19.4 minutes. The mean intensive care stay was 2.1 ± 0.56 days and mean total hospital stay 6.3 ± 1.3 days. CONCLUSIONS: Complete coronary revascularization could be routinely performed using the above-mentioned technique. No patient selection, based on number of grafts, quality and location of coronary vessels, left ventricle function, age, gender, or body mass index, is required.

Initiation and modification of minimally invasive coronary artery bypass grafting.

Minimally invasive coronary artery bypass grafting (MICS CABG) via a small left thoracotomy has been proposed as an alternative to standard coronary artery bypass grafting. However, this technique is still limited to skillful surgeons. Off-pump multi-vessel bypass grafting and the use of bilateral internal thoracic arteries are particularly challenging via a small thoracotomy, while they are widely performed via a full median sternotomy. The purpose of this review is to serve as a guide for the proper introduction of MICS CABG in the current era. We examine the advances, current techniques, outcomes and learning curves of MICS CABG and discuss the safe introduction.

Perioperative outcomes of off-pump minimally invasive coronary artery bypass grafting with bilateral internal thoracic arteries under direct vision†.

OBJECTIVES: We previously introduced techniques to harvest and use the right internal thoracic artery in minimally invasive coronary artery bypass grafting (CABG) via a single left thoracotomy for revascularization with bilateral internal thoracic arteries (BITA). We report our short-term outcomes of patients who underwent minimally invasive CABG using BITA and a single internal thoracic artery (SITA). METHODS: Consecutive patients who underwent minimally invasive CABG using BITA or SITA at a Japanese medical center between February 2012 and December 2015 were reviewed retrospectively. Preoperative, intraoperative and 30-day postoperative outcomes were analysed. Perioperative data for the SITA cohort is presented to provide a context in which the outcomes of the BITA cohort can be evaluated. RESULTS: A total of 25 and 37 patients underwent BITA and SITA revascularization, respectively. The mean duration of the operation was longer in the BITA group than in the SITA group (265 ± 104 vs 336 ± 73 min). There were no deaths in the BITA group and one death in the SITA group. There were no strokes in either cohort, and new haemodialysis was required in one patient in each group. All BITA grafts were harvested without major complications and were all patent on computed tomography angiograms 1 week following the operations. CONCLUSIONS: BITA can be safely harvested in a reproducible manner under direct vision via a small left thoracotomy. The potential advantages of minimally invasive CABG using BITA, although yet to be established, include a long-term survival benefit conferred by BITA grafts and elimination of the risk of sternal wound infection, in addition to the established advantages of minimally invasive coronary artery surgery. This approach has the potential for further optimization with hybrid revascularization strategies.

Off-pump minimally invasive coronary artery bypass grafting using the bilateral internal thoracic arteries and the right gastroepiproic artery.

We report our initial experience of an off-pump total arterial minimally invasive coronary arterial bypass grafting (MICS CABG) with the use of bilateral internal thoracic arteries (BITA) and the right gastroepiproic artery. A 47-year old male with renal dysfunction secondary to diabetes mellitus was admitted for heart failure due to severe triple-vessel disease. Off-pump MICS CABG with total arterial grafts was elected because the patient refused to undergo median sternotomy due to the strong desire to regain the baseline function promptly. Total arterial grafts were selected to maximize the potential long-term outcome. There were no postoperative complications except temporary dialysis. Postoperative coronary computed tomography revealed the patency of all grafts. Our experience suggests that BITA can be safely harvested under direct vision in MICS CABG. Total arterial graft revascularization with BITA via minimally invasive approach may offer the benefits of MICS CABG while providing the undetermined but potentially superior conduit longevity of arterial grafts.