Less invasive multivessel coronary artery bypass grafting: now is the time.

PURPOSE OF REVIEW: Less invasive multivessel coronary artery bypass grafting techniques have seen a progressive evolution over the last two decades. In their current state, they are easily reproduced and applicable to most patients requiring multivessel revascularization. The purpose of this review is to highlight their importance among a spectrum of evolving therapies and the accruing evidence in their favour. RECENT FINDINGS: The first large dual center experience with minimally invasive coronary artery bypass grafting (MICS CABG) demonstrated the feasibility of performing multivessel surgical revascularization without the need for sternotomy or cardiopulmonary bypass. Subsequent angiographic studies to assess graft patency showed excellent early results. Studies comparing MICS CABG to conventional CABG demonstrate faster recovery while reducing hospitalization and cost. SUMMARY: Multivessel less invasive coronary artery bypass grafting is basically limited to two procedures, MICS CABG and robotically assisted totally endoscopic CABG (TECAB). MICS CABG has evolved as a procedure that preserves the safety and efficacy of conventional CABG while avoiding the associated morbidity. It is reproducible, versatile and holds promise as the procedure of choice for multivessel coronary revascularization in the future. TECAB is likely the pinnacle of minimally invasive coronary surgery, the growth of which is hindered by widespread acceptance and industry involvement.

Anticoagulation Management in Patients with Valve Replacement.

Background: Prosthetic valve implantation requires postoperative prophylactic anticoagulation to preclude thrombotic events. The aim of this review is to assess the role of anticoagulation therapy in the management of valve replacement patients. Methodology: Literature from PubMed, Embase, Medline and Google Scholar were searched using the terms "valvular heart disease", "anticoagulant", "mechanical heart valve", "bioprosthesis", "bridging", "Vitamin K antagonist (VKA)", and "acenocoumarol". A committee comprising leading cardiothoracic surgeons from India was convened to review the literature and suggest key practice points. Results: Prosthetic valve implantation requires postoperative prophylactic anticoagulation to preclude thrombotic events. A paramount risk of thromboembolic events is observed during the first three months after surgery for both mechanical and bioprosthetic devices. The VKA therapy with individualized target international normalized ratio (INR) is recommended in patients after prosthetic valve replacement. Therapies for the management of prosthetic valve complications should be based on the type of complications. Special care is mandated in distinguished individuals and those with various co-morbidities. Conclusion: In patients with prosthetic valve replacement, anticoagulant therapy with VKA seems to be an effective option. The role for non-VKA oral anticoagulants in the setting of prosthetic valve replacement has yet to be established. Furthermore, whether the novel oral anticoagulants are safe and efficacious in patients after placement of a bioprosthetic valve remains unanswered.

Minimally invasive surgery in the treatment of triple vessel coronary artery disease with coexisting coronary artery fistula.

Coexistence of triple vessel coronary artery disease with coronary-pulmonary artery fistula is extremely rare. Minimally invasive cardiac surgery in the treatment of such coexisting disease is so far not reported. This case report emphasizes the feasibility of performing complete revascularization of the coronaries with coronary artery fistula ligation through a minimally invasive anterior thoracotomy, obviating full sternotomy.

Minimally Invasive coronary surgery compared to STernotomy coronary artery bypass grafting: The MIST trial.

RATIONALE: Minimally invasive cardiac surgery has emerged as a safe alternative to standard cardiac surgery. Minimally invasive coronary surgery (MICS CABG) was developed to allow adequate exposure and complete revascularization in CABG from a small thoracotomy incision without cardiopulmonary bypass. Multiple studies have reported significant shorter length of hospital stay and earlier postoperative physical recovery for MICS CABG patients when compared to sternotomy CABG patients. However, there have been no convincing clinical trials that demonstrate improvement in post-operative quality of life for patients who undergo MICS CABG. STUDY DESIGN: The Minimally Invasive Coronary Surgery compared to Sternotomy Coronary Artery Bypass Grafting (MIST) trial is a multi-centered, prospective randomized controlled trial that compares the quality of life and recovery in the early post-operative period between patients undergoing MICS CABG versus patients undergoing sternotomy CABG. Patients will be randomized either to the MICS CABG group or the sternotomy CABG group, and the target enrollment is 88 patients per group. The primary outcome is quality of life assessment performed by SF-36 questionnaire at 1 month. CONCLUSION: The MIST trial is the first prospective study that compares the quality of life between MICS CABG and sternotomy CABG patients. The results of this trial may enhance the procedural desirability of MICS CABG by patients and provide an incentive for surgeons and institutions to increase the availability of MICS CABG in suitable patients.

A lethal tension pneumothorax during minimally invasive coronary artery bypass surgery: Can transesophageal echocardiography pick it?

Minimally invasive cardiac surgery is establishing itself as the standard of care across the world. MICS CABG is currently performed in only a few centers. Hemodynamics disturbances are peculiar during MICS CABG due to space constraints. We report a 70-year-old man who underwent MICS CABG who developed tension pneumothorax during revascularization that was diagnosed in a novel way.

Selective lobar blockade in minimally invasive coronary artery bypass grafting: A technical advantage in patients with low respiratory reserve that precludes one-lung ventilation.

Minimally invasive cardiac surgery/coronary artery bypass grafting (MICS CABG) is performed through a small 2 inch left thoracotomy incision. Lung isolation is must during MICS CABG. Oxygenation with one-lung ventilation can be difficult, especially during supine position. We report a case of a 53-year-old male patient who underwent MICS CABG with the selective lobar blockade.

Off-pump LIMA-RIMA Y graft: a practical option in adult-type ALCAPA.

A 29-year-old female was diagnosed to have adult-type anomalous left coronary artery from pulmonary artery (ALCAPA). She underwent a two-coronary system repair using left internal mammary artery and right internal mammary artery Y (LIMA-RIMA Y) off-pump coronary artery bypass grafting and made an uneventful postoperative recovery. The usage of off-pump LIMA-RIMA Y graft can be a suitable option for adult ALCAPA with a potential for good long-term outcomes.