Technical adjuncts in beating heart surgery comparison of MIDCAB to off-pump sternotomy: a meta-analysis.

OBJECTIVES: The technical aspects of minimal invasive surgery are discussed, together with a comparison of off-pump MIDCAB with off-pump sternotomy, with special respect to outcomes of death, infarct and anastomoses. METHODS: Technical aspects of beating heart surgery are described under the headings: Trauma; Access; Stabilisation; Ischaemia; Haemostasis; Suturing; and Circulatory support. Data from papers and meetings on minimal invasive surgery were collated to September 1998 and correlated with the unit of origin. Percentage figures were back calculated to provide an actual number from which a new data base was obtained relevant to the reporting incidence. For statistical analysis a Chi squared test with Yates correction was used. RESULTS: Sixty-three centres reported 3304 cases of MIDCAB surgery (M) and 21 centres reported over 3060 cases of off-pump surgery through a sternotomy (S). There was no difference in early or late death rates between the two groups (1.6% M:2.2% S). There was a higher infarct rate with MIDCAB (2.9% M: 1.45% S; P < 0.03). The occlusion and stenosis rates for MIDCAB were 3.9 and 6.6% whilst for sternotomy off-pump they were 4.9 and 1.4%. The stenosis difference was significant at the P < 0.001 level. A combined occlusion and stenosis rate showed a higher incidence with MIDCAB (10.5%), than sternotomy 6.4% (P < 0.08). Four major series showed comparative data before and after stabiliser usage in MIDCABs. The stenosis rate was significantly reduced with stabilisation from 9.6 to 3.7% (P < 0.002) as was the combined occlusion and stenosis rate from 16 to 5.0% (P < 0.0001). In the total series there was no significant difference in length of stay (4.6 days), incidence of atrial fibrillation (9%), or between conversion to sternotomy(MIDCAB group) or to bypass (sternotomy group) (5%) between the two groups (M and S). Grafting the right coronary artery by MIDCAB produced worse results than for the left anterior descending artery (LAD). CONCLUSIONS: There is an important failure rate with beating heart surgery; stabilisers reduce this risk and are essential tools in both MIDCAB and beating heart surgery and encourages the further use of minimally invasive approaches.