Step-by-step technique of robotic-assisted minimally invasive direct coronary artery bypass.

Coronary artery bypass grafting (CABG) is the treatment of choice for coronary artery disease. The traditional method of performing CABG via a full sternotomy has its drawbacks, including increased postoperative morbidity, a higher incidence of complications, and extended hospitalizations. Although minimally invasive and robotic-assisted technology offer promising alternatives, they have not gained wide acceptance, largely because of the limited amount of literature supporting hybrid and robotic-assisted CABG. Since 2005, Lankenau Heart Institute's cardiothoracic surgical team has been developing and refining for selected patients a method for coronary revascularization that involves robotic harvesting of the left internal mammary artery (LIMA) and beating heart surgery through a limited minithoracotomy. This technique precisely places the robotic endoscopic port over the target site of the left anterior descending (LAD) artery. The LIMA is harvested using the enhanced visualization and precision of the robotic platform. The robotic instruments are then removed, and the endoscopic port site is slightly enlarged to become the minithoracotomy, allowing for LIMA-to-LAD anastomosis. The other two robotic ports are used for drains, eliminating the need for additional incisions. The method has been used in over 2,850 patients. The method has been used in over 2,850 patients. This article describes in detail our standardized technique for robotic-assisted minimally invasive direct coronary artery bypass (R-MIDCAB).

Ten-year outcomes of hybrid coronary revascularization at a single center.

Background: Hybrid coronary revascularization (HCR) is a well-established technique for treating multi-vessel coronary disease. There remains a paucity of discussion assessing the efficacy of HCR with respect to the timing of the surgical component relative to that of the percutaneous coronary intervention (PCI). Methods: A retrospective review was undertaken of our prospectively collected database from January 2009 to December 2019. Of 395 HCR patients analyzed, we examined the outcomes of 109 pairs of propensity-matched patients who either underwent robotic-assisted minimally-invasive direct coronary artery bypass (MIDCAB) first, or who had PCI prior to surgery. Results: Thirty-day mortality was 0.25% (1 death) for the entire cohort. Mid-term survival for the total 'MIDCAB-first' group was 94.1% (17 deaths), not significantly different to that for the 'PCI-first' cohort (8 deaths, 92.7%), and this was also statistically comparable after propensity matching. Perioperative morbidity was not different between patient groups. Freedom from major adverse cardiac and cerebrovascular events (MACCE) and the incidence of repeat revascularization was similar between the two groups at up to 11-year follow-up. Elevated serum creatinine independently predicted increased MACCE for all patients, irrespective of the sequence of HCR revascularization employed. Conclusions: In appropriately selected patients with multi-vessel coronary disease, HCR is associated with excellent short and longer-term results, irrespective of whether the MIDCAB or PCI procedure is performed first.

How to advance from minimally invasive coronary artery bypass grafting to totally endoscopic coronary bypass grafting: challenges in Europe versus United States of America.

Robotic coronary and intra-cardiac surgery has been available for more than 25 years. In this period, multiple studies have demonstrated the beneficial effects of robotic surgery over conventional open surgery. Throughout the years, technical developments have enabled us to perform totally endoscopic coronary artery bypass (TECAB) grafting. But these techniques remained in the hands of a small group of pioneers because of a lack of structured training programs and the absence of long-term results at that time. Currently, a renewed interest and a wide dispersion of robotic platforms, thanks to use of robotics in other disciplines, has led to an exponential increase in robotic cardiac centers both in Europe and USA. Nonetheless, this increase was slowed down in Europe as a result of the uncertainty introduced by the implementation of a revised regulatory framework for medical devices [Regulation 2017/745, 'Medical Device Regulation' ('MDR')]. The MDR was introduced with the goal of increasing patient safety and supporting innovation. Implementing the MDR has proven to be exceptionally challenging and risks to the supply of essential devices have been identified. Changes to both regulatory and market dynamics led to a circumstance where the only available robotic platform for cardiac surgery decided to cease marketing of essential accessories for conducting surgery. This resulted in the disappearance of dedicated tools such as the Endowrist stabilizer, essential for TECAB, and the atrial retractor which is essential for intra-cardiac surgery. In the mean-time, further clinical evidence was published demonstrating the superiority of robotic cardiac surgery over other minimally invasive approaches. This has demonstrated the need to better define the clinical evidence requirements for regulatory purposes to ensure that dedicated tools for evidence-based interventions in robotic coronary surgery remain available such that TECAB can continue in Europe.

Cost Analysis of Robot-Assisted Versus On-Pump and Off-Pump Coronary Artery Bypass Grafting: A Single-Center Surgical and 30-Day Outcomes Comparison.

OBJECTIVE: Throughout Europe, the interest in implementing robot-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) has been growing. However, concerns about additional costs have emerged concurrently. In this analysis, we aim to provide a comparison of the cumulative perioperative costs of RA-MIDCAB, on-pump coronary artery bypass grafting (CABG), and off-pump CABG (OPCAB). METHODS: We conducted a propensity score-matched analysis comparing patients undergoing RA-MIDCAB with those undergoing CABG or OPCAB at our institution from January 2016 to December 2021. After matching, we analyzed the combined intraoperative surgical costs and 30-day postoperative costs. We first compared RA-MIDCAB costs to CABG and then to OPCAB separately. Violin plots illustrated the cost distribution among individual patients. Total cost uncertainty was estimated using 1,000 bootstrapping iterations. RESULTS: Seventy-nine RA-MIDCAB patients were matched to 158 CABG patients, and 80 RA-MIDCAB patients were matched to 149 OPCAB patients. Considering both surgical and clinical outcomes, RA-MIDCAB yielded an average cost of €17,121 per patient (€16,781 to €33,294), CABG was €16,571 per patient (€16,664 to €41,860), and OPCAB was €15,463 per patient (€10,895 to €57,867). After bootstrap iterations, RA-MIDCAB was found to be €472 (2.8%) and €1,599 (10.3%) more expensive per patient than CABG and OPCAB, respectively. CONCLUSIONS: In The Netherlands, the adoption of RA-MIDCAB did not show a significant economic impact on hospital resources. The additional robotic costs for the surgery were almost entirely offset by the cost savings during the postoperative hospital stay. However, these comparisons may differ when considering hybrid coronary revascularization with its additional percutaneous coronary intervention costs.

Is minimally invasive multi-vessel off-pump coronary surgery as safe and effective as MIDCAB?

Introduction: The safety and efficacy of minimally invasive direct coronary artery bypass (MIDCAB) surgery has been confirmed in numerous reports. However, minimally invasive multi-vessel off-pump coronary artery bypass grafting (MICS CABG) has lower uptake and has not yet gained widespread adoption. The study aimed to investigate the non-inferiority of MICS CABG to MIDCAB in long-term follow-up for several clinical outcomes, including angina pectoris, major adverse cardiac and cerebrovascular events (MACCE) and overall survival. Methods: This is an observational, retrospective, single center study of 1,149 patients who underwent either MIDCAB (n = 626) or MICS CABG (n = 523) at our institution between 2007 and 2018. The left internal thoracic artery and portions of the radial artery and saphenous vein were used for the patients' single-, double-, or triple-vessel revascularization procedures. We used gradient boosted propensity-score estimation to account for possible interactions between variables. After propensity-score adjustment, the two groups were similar in terms of preoperative demographics and risk profile. Long-term follow-up (mean 5.87, median 5.6 years) was available for 1,089 patients (94.8%). Results: A total of 626, 454 and 69 patients underwent single, double and triple coronary revascularization, respectively. The long-term outcomes of freedom from angina pectoris, acute myocardial infarction, and revascularization rate were similar between the two groups. During follow-up, there were 123 deaths in the MIDCAB group and 96 in the MICS CABG group. The 1-, 3-, 5-, and 10-year survival rates were 97%, 92%, 85%, and 69% for the MIDCAB group and 97%, 93%, 89%, and 74% for the MICS CABG group, respectively. The hazard ratio of overall survival for patients with two or more bypass grafts compared to those with one bypass graft was 1.190 (p-value = 0.234, 95% CI: 0.893-1.586). This indicates that there was no significant difference in survival between the two groups. Furthermore, if we consider a hazard ratio of 1.2 to be clinically non-relevant, surgery with two or more grafts was significantly non-inferior to surgery with just one graft (p-value = 0.0057). Conclusion: In experienced hands, MICS CABG is a safe and effective procedure. Survival and durability are comparable with MIDCAB.

The impact of incomplete revascularization on survival in minimal invasive off-pump coronary artery surgery: a propensity score analysis of 1,149 cases.

Background: Minimally invasive concepts are increasingly influential in modern cardiac surgery. This study aimed to evaluate the effect of completeness of revascularization on clinical outcomes and overall survival in minimally invasive, thoracoscopic coronary artery bypass grafting (CABG) surgery. Methods: We retrospectively evaluated a consecutive series of 1,149 patients who underwent minimally invasive off-pump CABG with single, double, or triple-vessel revascularization between 2007 and 2018. Of these patients, 185 (16.1%) had incomplete revascularization (IR) (group I), and 964 (83.9%) had complete revascularization (CR) (group C). We used gradient boosted propensity score estimation to account for possible confounding variables. Results: Median age was 69 years, interquartile range (IQR) 60-76 years, and median EuroSCORE II was 4, IQR 2-7. Of the 1,149 patients, 495 patients suffered from two vessel disease (VD) and 353 presented with three VD. Long-term median follow-up 5.58 (3.27-8.48) years was available for 1,089 patients (94.8%). The incidence of recurrent or persisting angina, myocardial infarction, redo-bypass surgery, and stroke during follow-up did not differ significantly between groups. During follow-up, there were 47 deaths in group I and 172 deaths in group C. The 1-, 3-, 5-, 8-, and 10-year unadjusted survival rates were 94%, 84%, 75%, 62%, and 51% for group I, and 97%, 94%, 88%, 77%, and 72% for group C, respectively (long-rank test P<0.001), favouring CR. Following risk adjustment the long-rank test P value for survival was 0.23. Conclusions: In minimally invasive coronary surgery, IR resulted in decreased long-term survival, but did not achieve statistical significance after risk adjustment. However, IR should only be used in carefully selected cases.

Robotic-assisted coronary artery bypass grafting: how I teach it.

The first robotic cardiac operation was performed more than two decades ago. This paper describes the distinct steps and components necessary for teaching robotic-assisted minimally invasive direct coronary artery bypass (R-MIDCAB). It also provides a general overview of the surgical robotic setup and ways to troubleshoot potential complications. The focus of robotic training is not only on the surgeon but includes an entire dedicated cardiac team and administrative institutional support. This team approach ensures that R-MIDCAB can be performed safely and reproducibly. Meticulous planning, incremental learning, and teamwork are the main factors leading to program success and optimal patient outcomes. Robotic-assisted internal mammary artery (IMA) harvesting and coronary revascularization via a small, anterior mini-thoracotomy has provided an alternative to sternotomy in selected patients with coronary artery disease (CAD). Benefits include less postoperative atrial fibrillation, fewer blood transfusion, less time in the operating room (OR), less ventilatory support, fewer strokes, decreased intensive care unit stay and shortened postoperative length of stay all of which manifests as a decrease in institutional resource utilization. Recent data show that R-MIDCAB and hybrid coronary revascularization provides good long-term outcomes. In addition to patient satisfaction, there is an additional overall cost benefit to R-MIDCAB over traditional sternotomy coronary artery bypass grafting (CABG), secondary to decreased hospital length of stay. Robotically harvesting the IMA, operating on a beating heart, and performing anastomoses through a small incision all require advanced training and incremental learning. Increased experience generally leads to shortened surgical times and fewer complications.

Systematic review and meta-analysis of two decades of reported outcomes for robotic coronary artery bypass grafting.

Background: Despite the well-documented safety and feasibility of robotic coronary artery bypass grafting (CABG), widespread adoption of this approach remains limited by its steep learning curve, high procedural costs and paucity of data on longer-term efficacy. This current meta-analysis aims to provide a systematic overview of the outcomes of robot-assisted CABG, with a focus on long term graft patency and freedom from major adverse cardiac and cerebrovascular events (MACCE). Methods: A systematic literature search of three electronic databases was conducted for studies reporting outcomes of robotic-assisted CABG, and were grouped based on whether patients underwent robot-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB), totally endoscopic coronary artery bypass (TECAB) or were mixed. Perioperative and mid-to-long term results from included studies were pooled using meta-analysis of proportion or means in a random effects model. Results: In the quantitative analysis, thirty-nine eligible studies included 6,152 patients who underwent RA-MIDCAB, 1,729 patients who underwent TECAB and 21,642 patients who underwent either form of robot-assisted CABG. A high level of heterogeneity was observed amongst baseline characteristics. Perioperative mortality and complication rates were low. Conversion rate to full sternotomy overall was less than 3.2% [95% confidence interval (CI): 2.1-5.2%, I2=39%]. At a mean follow-up duration of 5.2 years, overall graft patency was 96% for both RA-MIDCAB and TECAB, and freedom from major adverse cardiac events (MACE) or MACCE was 83.2% (95% CI: 72.0-90.4%; I2=90%) for RA-MIDCAB and 91.6% (95% CI: 86.6-94.9%; I2=76%) for TECAB. Conclusions: Robot-assisted CABG is observed to have acceptable perioperative and mid-to-long term outcomes with promising overall graft patency.

Robot-Assisted MIDCAB Using Bilateral Internal Thoracic Artery: A Propensity Score-Matched Study With OPCAB Patients.

OBJECTIVE: Robot-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) is an attractive strategy for coronary revascularization. Growing evidence supports the use of total arterial grafting in coronary surgery. We evaluated total arterial left-sided coronary revascularization with bilateral internal thoracic artery (BITA) using RA-MIDCAB and compared it with a propensity score-matched (PSM) off-pump CAB (OPCAB) surgery population. METHODS: We retrospectively included all isolated OPCAB and RA-MIDCAB surgery using BITA without saphenous vein graft from January 1, 2015, to October 31, 2022. We analyzed all our RA-MIDCAB patients and performed PSM to compare them with our OPCAB population. Primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE) and mortality. Secondary outcomes were surgical parameters, length of hospital stay, and learning curve. RESULTS: We included 601 OPCAB and 77 RA-MIDCAB procedures, which resulted in 2 cohorts of 54 patients after PSM. Mortality and MACCE survival analysis showed no significant difference. There was less blood transfusion in the RA-MIDCAB (16.7%) compared with the OPCAB group (38.9%; P = 0.02). We observed fewer intensive care unit (ICU) admissions (24.1% vs 96.6%), shorter ICU stay (0.78 ± 1.7 vs 1.91 ± 1.01 days), and shorter hospital stay (6.78 ± 2.4 vs 8.01 ± 2.5 days) in the RA-MIDCAB versus OPCAB group (P < 0.01). Surgery time decreased from 400.0 ± 70.8 to 325.0 ± 38.0 min with more experience in RA-MIDCAB BITA harvesting (P < 0.01). CONCLUSIONS: This is a first publication of 77 consecutive RA-MIDCAB BITA harvesting for left coronary artery system revascularization. This technique is safe in terms of MACCE and mortality. Additional advantages are shorter length of hospital stay, fewer ICU admissions, and less blood transfusion.

Minimally Invasive Direct Coronary Artery Bypass Grafting: Sixteen Years of Single-Center Experience.

Background: Coronary artery disease is a major cause of death globally. Minimally invasive direct coronary artery bypass (MIDCAB), using a small left anterior thoracotomy, aims to provide a less invasive alternative to traditional procedures, potentially improving patient outcomes with reduced recovery times. Methods: This retrospective, non-randomized study analyzed 310 patients who underwent MIDCAB between July 1999 and April 2022. Data were collected on demographics, clinical characteristics, operative and postoperative outcomes, and follow-up mortality and morbidity. Statistical analysis was conducted using IBM SPSS, with survival curves generated via the Kaplan-Meier method. Results: The cohort had a mean age of 63.3 ± 10.9 years, with 30.6% females. The majority of surgeries were elective (76.1%), with an average operating time of 129.7 ± 35.3 min. The median rate of intraoperative blood transfusions was 0.0 (CI 0.0-2.0) Units. The mean in-hospital stay was 8.7 ± 5.5 days, and the median ICU stay was just one day. Early postoperative complications were minimal, with a 0.64% in-hospital mortality rate. The 6-month and 1-year mortalities were 0.97%, with a 10-year survival rate of 94.3%. There were two cases of perioperative myocardial infarction and no instances of stroke or new onset dialysis. Conclusions: The MIDCAB approach demonstrates significant benefits in terms of patient recovery and long-term outcomes, offering a viable and effective alternative for patients suitable for less invasive procedures. Our results suggest that MIDCAB is a safe option with favorable survival rates, justifying its consideration in high-volume centers focused on minimally invasive techniques.

Hybrid total arterial minimally invasive off-pump coronary revascularization and percutaneous coronary intervention strategy for multivessel coronary artery disease: a cohort study with a median 11-year follow-up.

Background: Hybrid coronary revascularization (HCR) is a treatment approach that combines the benefits of coronary artery bypass grafting (CABG) techniques such as minimally invasive direct coronary artery bypass (MIDCAB) or minimally invasive multivessel CABG (MICS-CABG) with percutaneous coronary intervention (PCI) for carefully selected patients with multivessel coronary artery disease (MV CAD). The extant body of research primarily concentrates on the comparison of outcomes between HCR and CABG or PCI. Furthermore, HCR is defined primarily as MIDCAB and PCI. Given the various criteria for HCR identified in the current body of literature, as well as several hybrid revascularization techniques, our primary goal was to analyse the characteristics and track the development of HCR patients operated on in our centre (Robert Bosch Hospital) over both short and long periods of time. Additionally, we sought to validate the practical challenges that arise during the implementation of an HCR methodology. Methods: This cohort study included 138 patients with MV CAD who had an HCR approach in conjunction with isolated total arterial off-pump MICS-CABG or MIDCAB between 2007 and 2018 at Robert Bosch Hospital in Stuttgart. Data on major adverse cardiac and cerebral events (MACCE), defined as all-cause mortality, myocardial infarction, repeat revascularization and stroke were gathered through a questionnaire. Long-term follow-up, with a mean duration of 8.7±0.3 years and a median duration of 11 years, was available for a significant majority of the patients (92.8%, n=128). Results: The average age was 69.6±11.2 years, with 79% being male. The mean European System for Cardiac Operative Risk Evaluation score I additive (EuroSCORE I) additive was 7.6±10.2 and the mean SYNergy between PCI with TAXUS and Cardiac Surgery (SYNTAX) Score I was 22.9±9.4. A total of 97 MIDCAB surgeries and 41 MICS-CABG procedures were performed without any instances of conversion to sternotomy or cardiopulmonary bypass (CPB). A total of 70 patients, or 50.7% of the sample, received the planned PCI treatment. This percentage was substantially lower in the subgroup with chronic CAD, with just 27, equivalent to 39.1%. The observed 30-day death rate was 2.1% (3/138). During follow-up, 3 myocardial infarctions, 18 PCI repeats, no CABG, and 4 strokes occurred. From 128 followed-up patients, 28 died (21.9%), 7 of which were heart deaths (5.5%). Total MACCE was 36.7%. The survival rates at 3 and 5 years were 92% and 85% respectively. Patients who didn't get the planned PCI had a mean survival rate of 6.8-9.1 years, while those with completed hybrid treatment had a higher mean survival rate of 8.4-10.2 years. Conclusions: In selected individuals with MVCAD, current evidence suggests that HCR is a safe and effective coronary artery revascularization approach. After coronary bypass surgery, the attention going forward needs to be devoted toward the organization of the PCI step in the treatment process.

Minimally Invasive Isolated and Hybrid Surgical Revascularization for Multivessel Coronary Disease: A Single-Center Long-Term Follow-Up.

INTRODUCTION: Some evidence suggests that surgical minimally invasive (MIDCAB) and hybrid coronary revascularization (HCR) are safe and potentially effective at short-term follow-up. Data on long-term outcomes are more limited and inconclusive. METHODS: Between February 2013 and December 2023, a total of 1997 patients underwent surgical coronary artery revascularization at our institution, of whom, 92 (4.7%) received left anterior mini-thoracotomy access (MIDCAB), either isolated (N = 78) or in combination with percutaneous coronary intervention (N = 14, HCR group). RESULTS: After a median follow-up of 75 months (range 3.1: 149 months), cardiac mortality was 0% while overall mortality was 3%, with one in-hospital mortality and two additional late deaths. Conversion to sternotomy happened in two patients (2.1%), and surgical re-explorations occurred in five patients (4.6%), of whom three for bleeding and two for graft failure. All patients received left internal mammary (LIMA) to left anterior descending artery (LAD) grafting (100%). In the HCR group, 10 patients (72%) showed percutaneous revascularization (PCI) after MIDCAB, showing PCI on a mean of 1.6 ± 0.6 vessels and implanting 2.1 ± 0.9 drug-eluting stents. CONCLUSIONS: MIDCAB, in isolation or in association with hybrid coronary revascularization, is associated with encouraging short- and long-term results in selected patients discussed within a dedicated heart-team.

Early and late outcomes after minimally invasive direct coronary artery bypass vs. full sternotomy off-pump coronary artery bypass grafting.

Objectives: Minimally-invasive direct coronary artery bypass (MIDCAB) is a less-invasive alternative to full sternotomy off-pump coronary artery bypass (FS-OPCAB) revascularization of the left anterior descending artery (LAD). Some studies suggested that MIDCAB is associated with a greater risk of graft occlusion and repeat revascularization than FS-OPCAB LIMA-to-LAD grafting. Data comparing MIDCAB to FS-OPCAB with regard to long-term follow-up is scarce. We compared short- and long-term results of MIDCAB vs. FS-OPCAB revascularization over a maximum follow-up period of 10 years. Patients and methods: From December 2009 to June 2020, 388 elective patients were included in our retrospective study. 229 underwent MIDCAB, and 159 underwent FS-OPCAB LIMA-to-LAD grafting. Inverse probability of treatment weighting (IPTW) was used to adjust for selection bias and to estimate treatment effects on short- and long-term outcomes. IPTW-adjusted Kaplan-Meier estimates by study group were calculated for all-cause mortality, stroke, the risk of repeat revascularization and myocardial infarction up to a maximum follow-up of 10 years. Results: MIDCAB patients had less rethoracotomies (n = 13/3.6% vs. n = 30/8.0%, p = 0.012), fewer transfusions (0.93 units ± 1.83 vs. 1.61 units ± 2.52, p < 0.001), shorter mechanical ventilation time (7.6 ± 4.7 h vs. 12.1 ± 26.4 h, p = 0.005), and needed less hemofiltration (n = 0/0% vs. n = 8/2.4%, p = 0.004). Thirty-day mortality did not differ significantly between the two groups (n = 0/0% vs. n = 3/0.8%, p = 0.25). Long-term outcomes did not differ significantly between study groups. In the FS-OPCAB group, the probability of survival at 1, 5, and 10 years was 98.4%, 87.8%, and 71.7%, respectively. In the MIDCAB group, the corresponding values were 98.4%, 87.7%, and 68.7%, respectively (RR1.24, CI0.87-1.86, p = 0.7). In the FS group, the freedom from stroke at 1, 5, and 10 years was 97.0%, 93.0%, and 93.0%, respectively. In the MIDCAB group, the corresponding values were 98.5%, 96.9%, and 94.3%, respectively (RR0.52, CI0.25-1.09, p = 0.06). Freedom from repeat revascularization at 1, 5, and 10 years in the FS-OPCAB group was 92.2%, 84.7%, and 79.5%, respectively. In the MIDCAB group, the corresponding values were 94.8%, 90.2%, and 81.7%, respectively (RR0.73, CI0.47-1.16, p = 0.22). Conclusion: MIDCAB is a safe and efficacious technique and offers comparable long-term results regarding mortality, stroke, repeat revascularization, and freedom from myocardial infarction when compared to FS-OPCAB.

Thirteen Years of Impactful, Minimally Invasive Coronary Surgery: Short- and Long-Term Results for Single and Multi-Vessel Disease.

OBJECTIVES: Minimally invasive coronary surgery (MICS) via lateral thoracotomy is a less invasive alternative to the traditional median full sternotomy approach for coronary surgery. This study investigates its effectiveness for short- and long-term revascularization in cases of single and multi-vessel diseases. METHODS: A thorough examination was performed on the databases of two cardiac surgery programs, focusing on patients who underwent minimally invasive coronary bypass grafting procedures between 2010 and 2023. The study involved patients who underwent either minimally invasive direct coronary artery bypass grafting (MIDCAB) for the revascularization of left anterior descending (LAD) artery stenosis or minimally invasive multi-vessel coronary artery bypass grafting (MICSCABG). Our assessment criteria included in-hospital mortality, long-term mortality, and freedom from reoperations due to failed aortocoronary bypass grafts post-surgery. Additionally, we evaluated significant in-hospital complications as secondary endpoints. RESULTS: A total of 315 consecutive patients were identified between 2010 and 2023 (MIDCAB 271 vs. MICSCABG 44). Conversion to median sternotomy (MS) occurred in eight patients (2.5%). The 30-day all-cause mortality was 1.3% (n = 4). Postoperative AF was the most common complication postoperatively (n = 26, 8.5%). Five patients were reoperated for bleeding (1.6%), and myocardial infarction (MI) happened in four patients (1.3%). The mean follow-up time was six years (±4 years). All-cause mortality was 10.3% (n = 30), with only five (1.7%) patients having a confirmed cardiac cause. The reoperation rate due to graft failure or the progression of aortocoronary disease was 1.4% (n = 4). CONCLUSIONS: Despite the complexity of the MICS approach, the results of our study support the safety and effectiveness of this procedure with low rates of mortality, morbidity, and conversion for both single and multi-vessel bypass surgeries. These results underscore further the necessity to implement such programs to benefit patients.

Combining Minimally Invasive Direct Coronary Artery Bypass Grafting with Transapical Aortic Valve Implantation-The Next Level Heart Team Approach.

We present the results of a combined approach for transapical aortic valve replacement and minimally invasive coronary artery bypass grafting (taTAVI-MIDCAB) in patients with combined aortic stenosis and coronary artery disease. BACKGROUND: For patients presenting with aortic stenosis and coronary artery disease, a simultaneous procedure addressing both diseases is recommended to reduce operative risk. In high-risk patients with hostile femoral or coronary axis, taTAVI-MIDCAB can be an alternative minimally invasive approach, offering the benefits of left interior mammary artery to left anterior descending coronary artery (LIMA-LAD) grafting. METHODS: From 2014 to 2022, 10 patients underwent taTAVI-MIDCAB for combined coronary and severe aortic stenosis in the hybrid operation theater at our institution. We assessed perioperative outcomes and follow-up outcomes. RESULTS: The median age was 83 years (81 to 86). The procedure was successfully performed in all patients without conversion to sternotomy. The median length of hospital and intensive care unit stay was 9 days (7 to 16) and 2.5 days (1 to 5), respectively. The median flow over the coronary artery bypass was 31 (22 to 44) mL/min, with a pulsatility index (PI) of 2.4 (2.1 to 3.2). Mild paravalvular leak occurred in 2 patients (10%). There were no neurological events nor acute kidney injury. Pacemaker implantation was required in 1 patient (10%). CONCLUSIONS: Simultaneous surgical coronary revascularization and interventional valve implantation in the setting of a hostile femoral and coronary axis appears to be safe and beneficial.

Minimally invasive direct coronary artery bypass and percutaneous coronary intervention followed by transcatheter aortic valve implantation: A promising concept in high-risk octogenarians.

Objectives: In this article, we present our initial clinical experience with staged minimally invasive direct coronary bypass (MIDCAB), percutaneous coronary intervention (PCI), and transcatheter aortic valve implantation (TAVI) in high-risk octogenarians (Hybrid). Background: The use of percutaneous techniques for managing structural heart diseases, especially in elderly high-risk patients, has revolutionized the treatment of structural heart diseases. These procedures are present predominantly being offered as isolated interventions. The feasibility, clinical benefit, and outcomes of combining these techniques with MIDCAB have not been sufficiently explored and have subsequently been underreported in the contemporary literature. Methods: Four consecutive octogenarians with severe aortic stenosis (AS) and complex coronary artery disease (CAD) that were at high risk for conventional surgery with extracorporeal circulation (ECC) were discussed in our Multidisciplinary Heart Team (MDH). Our MDH consisted of an interventional cardiologist, cardiac surgeon, and cardiac anesthesiologist. A hybrid approach with the alternative strategy comprising of MIDCAB, PCI, and TAVI in a staged fashion was agreed on. All 4 patients had both PCI/stenting and MIDCAB prior to deployment of the TAVI-prosthesis. Results: From January 2019 to December 2020, 4 consecutive patients aged between 83 and 85 (3 male/1 female) years were scheduled for MIDCAB/PCI followed by percutaneous treatment of severe symptomatic AS. Intraoperatively, one patient was converted to full sternotomy, and surgery was performed by off-pump coronary artery bypass grafting. The overall procedural success rate was 100% in all 4 patients with resolution of their initial presenting cardiopulmonary symptoms. There were no severe complications associated with all hybrid procedures. There was no 30-day mortality in all patients. All patients were discharged home with a median hospital stay ranging between 9 and 25 days. All patients have since then been followed-up regularly. There was one noncardiac-related mortality at 6-months postsurgery. All other patients were well at 1-year follow-up with improved New York Heart Association Class II. Conclusions: In a selected group of elderly, high prohibitive risk patients with CAD and severe symptomatic AS, a staged approach with MIDCAB and PCI followed by TAVI can be safely performed with excellent outcomes. We advocate a MDH-based preliminary evaluation of this patient cohort in selecting suitable patients and appropriate timing of each stage of the hybrid procedure.