Zhi Xian OngI; Duoduo WuI; Jai Ajitchandra SuleI; Guohao ChangI; Faizus SazzadI; Haidong LuoI; Peggy HuI; Theo KofidisI
DOI: 10.21470/1678-9741-2022-0421
ABSTRACT
Introduction: Minimally invasive coronary artery bypass grafting (MICS CABG) offers a new paradigm in coronary revascularization. This study aims to compare the outcomes of MICS CABG with those of conventional median sternotomy CABG (MS CABG) within a growing minimally invasive cardiac surgical program in Singapore.CABG = Coronary artery bypass grafting
COPD = Chronic obstructive pulmonary disease
CPB = Cardiopulmonary bypass
EuroSCORE = European System for Cardiac Operative Risk Evaluation
IABP = Intra-aortic balloon pump
IQR = Interquartile range
LAD = Left anterior descending artery
LIMA = Left internal mammary artery
CABG = Coronary artery bypass grafting
MICS = Minimally invasive cardiac surgery
MICS CABG = Minimally- invasive coronary artery bypass grafting
MIDCAB = Minimally invasive direct coronary artery bypass
MS = Median sternotomy
NYHA = New York Heart Association
PCI = Percutaneous coronary intervention
SD = Standard deviation
INTRODUCTION
The conventional approach to coronary artery bypass grafting (CABG) via median sternotomy (MS) is invasive and often entails a prolonged recovery period lasting > 6 weeks to return to premorbid status. The current alternative of minimally invasive CABG (MICS CABG) has expanded from single vessel to multivessel coronary artery disease over the past decade[1,2]. MICS CABG presents a less invasive approach compared to MS CABG, yielding smaller incisions, reduced tissue trauma, and potentially expedited recovery periods for patients. Moreover, the smaller incisions characteristic of MICS CABG typically yield superior cosmetic results compared to the larger incisions necessitated by MS CABG, consequently enhancing patient satisfaction. Additionally, individuals undergoing MICS CABG may encounter shorter hospital stays and faster recovery times relative to counterparts undergoing conventional CABG, facilitating earlier resumption of daily activities[3,4,5].
On the other hand, performing MICS CABG requires specialized skills due to the challenges of operating through smaller incisions. Surgeons must be proficient in advanced techniques, as MICS CABG has a steeper learning curve compared to traditional CABG. The limited visibility and maneuverability associated with MICS CABG may make complex procedures more challenging. Additionally, MICS CABG procedures may take longer and carry a risk of conversion to open surgery, which can increase complications and recovery time[6,7,8,9].
Nevertheless, the advantages and disadvantages of MICS CABG have been limitedly compared to MS CABG in the past using propensity matching cohorts. Furthermore, there have been no evaluations of a multiracial Asian cohort to explicitly assess this comparison. The National University Heart Centre, Singapore, has established a comprehensive MICS CABG program, which includes multivessel coronary revascularization. This study aims to report early outcomes of MICS CABG and compare that to conventional MS CABG performed within a growing MICS CABG program at a centre with a moderate caseload.
METHODS
One hundred and twelve patients underwent MICS CABG between January 2009 and June 2020 at the National University Heart Centre, Singapore. This study was approved by the local ethics review board (#2020/00547), and requirement for individual patient consent was waived. Propensity-score matching was carried out using a 0.1 caliper with 3,614 patients within the institution’s database who underwent conventional MS CABG between January 2009 and December 2018 (Table 1).
Variables | Unmatched | Matched | ||||
---|---|---|---|---|---|---|
MICS CABG (N=112) | MS CABG (N=3614) | Standard Mean Difference (%) | MICS CABG (N=111) | MS CABG (N=111) | Standard Mean Difference (%) | |
Age, years, mean | 59.9 | 61.3 | -15.2 | 59.8 | 59.4 | < 10 |
Male (%) | 88.4 | 83.2 | -16.2 | 88.3 | 88.3 | 0 |
Diabetes (%) | 41.1 | 54. | -27 | 41.4 | 47.8 | -12.8 |
Cerebrovascular disease (%) | 10.7 | 11.0 | 0.96 | 10.8 | 10.8 | 0 |
Peripheral vascular disease (%) | 2.7 | 8.6 | -36.9 | 2.7 | 0.9 | -11.1 |
Ejection fraction category (%) | ||||||
Good (ò 50%) | 77.7 | 58.7 | 45.6 | 78.4 | 79.3 | < 10 |
Fair (30-49%) | 17.9 | 31.0 | -34.4 | 18.0 | 17.1 | < 10 |
Poor (< 30%) | 3.6 | 10.2 | -35.9 | 3.6 | 3.6 | 0 |
Operative urgency (%) | ||||||
Elective | 88.3 | 92.7 | 28.4 | 88.3 | 82.9 | < 10 |
Urgent | 11.7 | 7.3 | -28.4 | 11.7 | 17.1 | < 10 |
EuroSCORE II, mean (SD) | 1.32 | 2.95 | 56.4 | 1.31 | 1.28 | < 10 |
Minimally invasive direct coronary artery bypass (MIDCAB) patients were matched to single/double vessel MS CABG patients (Group 1) due to scarcity of single vessel MS CABG performed. Multivessel MICS CABG patients were propensity matched graft-for-graft to MS CABG patients (Group 2). Baseline characteristics, intraoperative data, and 30-day postoperative outcomes were compared between MICS and MS CABG groups.
Primary and Secondary Outcomes
The primary outcome of this study was postoperative length of stay. Secondary outcomes included operative times, 30-day mortality, and postoperative complications including reopening for bleeding, new onset atrial fibrillation, and neurological, renal, pulmonary, and infectious complications. Stroke was defined as a permanent neurological deficit associated with an ischaemic infarct or intracranial haemorrhage on radiological imaging. Prolonged ventilation was defined as requiring > 24 hours of ventilation. Renal impairment was defined as a rise in creatinine above the upper limit of baseline. Surgical site infection was defined as sternal infections for MS CABG and thoracotomy/cannulation site infections for MICS CABG. Non-surgical infections comprised urinary tract infection or septicaemia.
Statistical Analysis
All statistical analyses were performed using R Studio (RStudio Team 2015, Boston, Massachusetts, United States of America) software. Categorical data were represented as frequencies and percentages. Continuous data were tested for normality via Shapiro-Wilk’s method. Normally distributed continuous variables were expressed as mean (standard deviation). Propensity scores between the MICS CABG and database patients were estimated using logistic regression with 1:1 matching. MS CABG patients with poor matching propensity scores were excluded from the analysis. For non-matched cohorts, categorical variables were compared using the Chi-square test while continuous variables were analysed using the Student’s t-test or Mann-Whitney U test where appropriate. For propensity-score matched pairs, categorical variables were compared using McNemar’s test, and continuous variables were compared using Wilcoxon’s paired signed-rank test.
Surgical Technique
Most patients in the MS group underwent conventional on-pump CABG with individual aorto-coronary anastomosis performed via side-clamping of the aorta. Few patients in the MS group underwent off-pump or on-pump beating CABG. MICS CABG patients underwent either MIDCAB or multivessel grafting via left anterior mini-thoracotomy. The left internal mammary artery (LIMA) was taken down in situ in a pedicled fashion under direct vision through left anterior mini-thoracotomy using a combination of electrocautery and ultrasonic dissection (Harmonic Synergy®). The Rultract® retractor system (Rultract, Ohio, United States of America) coupled with the Thoratrak™ MICS CABG retractor (Medtronic, Minnesota, United States of America) was used for intercostal retraction and elevation of the left hemithorax to provide adequate exposure. MIDCAB was indicated in patients who had single-vessel left anterior descending artery (LAD) stenosis.
MIDCAB surgeries were predominantly performed off-pump, grafting the LIMA to the LAD with the LAD target stabilised using an Octopus™ Nuvo or Octopus™ Evolution stabiliser (Medtronic, Minnesota, United States of America). Multivessel MICS CABG surgeries were per formed either on an arrested heart or on a beating heart with peripheral cardiopulmonary bypass (CPB) support. If the heart was arrested, a Chitwood® cross-clamp (Scanlan International, Inc, Minnesota, United States of America) was inserted via a left axillary stab incision, and antegrade cardioplegia was administered using a Miar™ cannula (Medtronic, Minnesota, United States of America). For multivessel MICS CABG performed on a beating heart, coronary targets were stabilised using an Octopus™ Nuvo stabiliser with or without a Starfish™ heart positioner (Medtronic, Minnesota, United States of America).
CPB was performed using standard aortic and two-stage right atrial cannulation for MS CABG cases, while femoral arterial and venous cannulations were used in on-pump MICS CABG cases. In all multivessel CABG cases, CABG was performed first with the right coronary artery target, followed by obtuse marginal, ramus, or diagonal, where applicable, and lastly, the LAD. LIMA was the default conduit to graft the LAD, while saphenous vein or left radial artery grafts were used for the remaining targets. All distal anastomoses were performed conventionally under direct vision with continuous 7-0 polypropylene sutures.
RESULTS
There were 111 propensity-matched pairs. Baseline characteristics are summarised in Supplementary Table 1. Patient demographics within the propensity-matched groups were comparable. Institutional caseload for MICS CABG and CPB times are demonstrated in Figures 1A and 1B. Distribution of the grafts in MICS CABG are also shown in Figure 2.
Variables | Overall | Single/Double Graft(s) (Group 1) | Multivessel (Group 2) | ||||||
---|---|---|---|---|---|---|---|---|---|
MICS CABG (N=111) | MS CABG (N=111) | P-value | MIDCABa (N=64) | MS CABG (N=64) | P-value | MICS CABG (N=46) | MS CABG (N=46) | P-value | |
Age, years, mean (SD) | 59.8 (9.7) | 59.4 (7.7) | 0.737 | 58.3 (9.8) | 57.7 (7.9) | 0.737 | 60.9 (9.4) | 61 (8.0) | 0.953 |
Male (%) | 98 (88.3) | 98 (88.3) | 1.00 | 55 (85.9) | 54 (84.4) | 1.00 | 43 (93.5) | 43 (93.5) | 1.00 |
Race (%) | 0.990 | 0.540 | 0.435 | ||||||
Chinese | 76 (67.6) | 76 (68.5) | 41 (64.1) | 37 (57.8) | 34 (73.9) | 27 (58.7) | |||
Indian | 13 (11.7) | 13 (11.7) | 8 (12.5) | 12 (18.8) | 4 (8.7) | 6 (13) | |||
Malay | 18 (16.2) | 18 (16.2) | 12 (18.8) | 14 (21.9) | 7 (15.2) | 10 (21.7) | |||
Others | 4 (3.6) | 5 (4.5) | 3 (4.7) | 1 (1.6) | 1 (2.2) | 3 (6.5) | |||
Smokers (%) | 26 (23.4) | 26 (23.4) | 1.00 | 16 (25) | 19 (30.2) | 0.556 | 26 (56.5) | 25 (54.3) | 1.00 |
Diabetes (%) | 46 (41.1) | 53 (47.7) | 0.418 | 27 (42.2) | 25 (39.1) | 0.857 | 19 (41.3) | 13 (28.3) | 0.274 |
Hypertension (%) | 82 (73.9) | 89 (80.2) | 0.338 | 47 (73.4) | 50 (78.1) | 0.680 | 36 (78.3) | 41 (89.1) | 0.259 |
Hyperlipidaemia (%) | 91 (82) | 103 (92.8) | 0.025 | 55 (85.9) | 55 (85.9) | 1.00 | 33 (71.7) | 38 (82.6) | 0.321 |
Renal disease (%) | 9 (8.1) | 3 (2.7) | 0.135 | 8 (12.5) | 2 (3.1) | 0.096 | 1 (2.2) | 3 (6.5) | 0.617 |
COPD (%) | 3 (2.7) | 1 (0.9) | 0.175 | 1 (1.6) | 0 | 0.603 | 0 | 1 (2.2) | 1.00 |
Cerebrovascular disease (%) | 12 (10.8) | 12 (10.8) | 1.00 | 8 (12.5) | 9 (14.1) | 1.00 | 2 (4.3) | 1 (2.2) | 1.00 |
Previous PCI (%) | 37 (33.3) | 23 (20.7) | 0.049 | 20 (31.1) | 16 (25) | 0.556 | 17 (37) | 11 (23.9) | 0.257 |
Peripheral vascular disease (%) | 3 (2.7) | 1 (0.9) | 0.622 | 1 (1.6%) | 0 | 1.00 | 1 (2.2) | 1 (2.2) | 1.00 |
Ejection fraction, mean (SD) | 54.9 (11) | 55.3 (12) | 0.778 | 55.4 (11.9) | 53.2 (12.6) | 0.303 | 53.7 (10.3) | 53.7 (10.9) | 0.998 |
Ejection fraction category (%) | 0.984 | 0.893 | 0.550 | ||||||
Good (ò 50%) | 87 (78.4) | 88 (79.3) | 50 (78.1) | 48 (75) | 35 (76.1) | 34 (73.9) | |||
Fair (30-49%) | 20 (18) | 19 (17.1) | 11 (17.2) | 12 (18.8) | 10 (21.7) | 12 (26.1) | |||
Poor (< 30%) | 4 (3.6) | 4 (3.6) | 3 (4.7) | 4 (6.3) | 1 (2.2) | 0 | |||
Preoperative IABP (%) | 0 | 3 (2.7) | 0.247 | 0 | 4 (6.3) | 0.119 | 0 | 4 (8.7) | 0.117 |
Preoperative NYHA II and above (%) | 52 (46.8) | 43 (38.7) | 0.278 | 29 (45.3) | 21 (32.8) | 0.205 | 22 (47.8) | 18 (39.1) | 0.528 |
EuroSCORE II, mean (SD) | 1.31 (1.28) | 1.28 (1.16) | 0.850 | 1.31 (1.49) | 1.38 (1.43) | 0.786 | 1.29 (0.92) | 1.37 (0.95) | 0.687 |
CABG=coronary artery bypass grafting; COPD=chronic obstructive pulmonary disease; EuroSCORE=European System for Cardiac Operative Risk Evaluation; IABP=intra-aortic balloon pump; MICS CABG=minimally invasive CABG; MIDCAB=minimally invasive direct coronary artery bypass; MS=median sternotomy; NYHA=New York Heart Association; PCI=percutaneous coronary intervention; SD=standard deviation
a MIDCAB patients were matched to MS patients with single or double vessel CABG with via propensity score matching
Intraoperative Details
Procedural details of matched pairs are shown in Table 2. Most MIDCAB patients underwent off-pump and on-pump beating heart surgery (P<0.001). In Group 2, on-pump beating procedures were more common among MICS CABG patients (P<0.001). CPB time (P=0.005) and procedure durations (P<0.001) were significantly longer in MICS CABG patients.
Variables | Overall | Non-multivessel (Group 1) | Multivessel (Group 2) | ||||||
---|---|---|---|---|---|---|---|---|---|
MICS CABG (N=111) | MS CABG (N=111) | P-value | MIDCABa (N=64) | MS CABG (single/ double) (N=64) | P-value | MICS CABG (N=46) | MS CABG (N=46) | P-value | |
Operative urgency (%) | 0.339 | 1.00 | 1.00 | ||||||
Elective | 98 (88.3) | 92 (82.9) | 64 (100) | 64 (100) | 39 (84.8) | 39 (84.8) | |||
Urgent | 13 (11.7) | 19 (17.1) | 0 | 0 | 7 (15.2) | 7 (15.2) | |||
CABG category (%) | < 0.001 | < 0.001 | < 0.001 | ||||||
Off-pump | 56 (50.5) | 2 (1.8) | 54 (84.4) | 7 (10.9) | 1 (2.2) | 3 (6.5) | |||
On-pump beating | 33 (29.7) | 2 (1.8) | 8 (12.5) | 3 (4.7) | 26 (56.5) | 1 (2.2) | |||
Cardioplegic arrest | 22 (19.8) | 107 (96.4) | 2 (3.1) | 54 (84.4) | 19 (41.3) | 42 (91.3) | |||
Cardiopulmonary bypass duration, mean (SD) | 131.2 (42.7) | 136.3 (46.1) | 0.62 | - | - | - | 145.5 (70.6) | 104.3 (48.4) | 0.005 |
Aortic cross-clamping duration, mean (SD) | 64.7 (13.1) | 80.5 (23.7) | 0.037 | - | - | - | 59.1 (15.7) | 52.9 (20) | 0.434 |
Length of procedure, mean (SD) | 286.3 (85.1) | 272.8 (69.6) | 0.24 | 234.3 (57.5) | 239 (49.2) | 0.62 | 359.7 (63.1) | 233.5 (36.3) | < 0.001 |
CABG=coronary artery bypass grafting; MICS CABG=minimally invasive CABG; MIDCAB=minimally invasive direct coronary artery bypass; MS=median sternotomy; SD=standard deviation
a MIDCAB patients were matched to MS patients with single or double vessel CABG with propensity score matching.
Postoperative Outcomes
Thirty-day mortality rates and perioperative complications were comparable between MICS and MS CABG patients (Table 3). Overall, postoperative length of stay was generally shorter amongst MICS CABG patients. Rates of reoperation and neurological complications were generally low in all patients.
Variables | Overall | Non-multivessel (Group 1) | Multivessel (Group 2) | ||||||
---|---|---|---|---|---|---|---|---|---|
MICS CABG (N=111) | MS CABG (N=111) | P-value | MIDCABa (N=64) | MS CABG (N=64) | P-value | MICS CABG (N=46) | MS CABG (N=46) | P-value | |
Postoperative length of stay, median (IQR) | 6 (2) | 7 (3) | < 0.001 | 5 (2) | 7 (5) | < 0.001 | 6 (5.7) | 7 (2.25) | 0.288 |
Conversion to median sternotomy (%) | 7 (6.3) | - | - | 2 (3.1) | - | - | 5 (10.9) | - | - |
Reopening (%) | 5 (4.5) | 4 (3.6) | 1.00 | 2 (3.1) | 4 (6.3) | 0.687 | 3 (6.8) | 2 (4.7) | 1.00 |
Permanent pacemaker (%) | 0 | 0 | - | 0 | 1 (1.6) | - | 0 | 1 (2.2) | - |
New-onset atrial fibrillation (%) | 12 (10.8) | 15 (13.5) | 0.701 | 5 (7.8) | 8 (12.5) | 0.549 | 7 (15.2) | 6 (13) | 1.00 |
Postoperative IABP (%) | 2 (1.8) | 0 | - | 1 (1.6) | 0 | - | 1 (2.2) | 0 | - |
Neurological complicationsb (%) | 1 (0.9) | 4 (3.6) | 0.375 | 0 | 2 (3.1) | - | 1 (2.2) | 2 (4.7) | 1.00 |
Surgical site infections (%) | 2 (1.8) | 4 (3.6) | 0.687 | 1 (1.6) | 1 (1.6) | 1.00 | 1 (2.2%) | 0 | - |
Non-surgical site infectionsc (%) | 3 (2.7) | 2 (1.8) | 1.00 | 1 (1.6) | 2 (3.1) | 1.00 | 1 (2.2) | 1 (2.2) | 1.00 |
Prolonged ventilationd (%) | 3 (2.7) | 3 (2.7) | 1.00 | 0 | 3 (4.7) | - | 3 (6.8) | 1 (2.2) | 0.625 |
Pneumonia (%) | 4 (3.6) | 2 (1.8) | 0.687 | 1 (1.6) | 3 (4.7) | 0.50 | 3 (6.8) | 1 (2.2) | 0.625 |
Pleural effusion requiring drainage (%) | 0 | 0 | - | 0 | 1 (1.6) | - | 0 | 0 | - |
Acute renal injury (%) | 2 (1.8) | 2 (1.8) | 1.00 | 1 (1.6) | 5 (7.8) | 0.125 | 1 (2.2) | 1 (2.2) | 1.00 |
30-day mortality (%) | 0 | 0 | 1.00 | 0 | 1 (1.6) | - | 0 | 1 (2.2) | - |
DISCUSSION
In our MICS CABG program, we report comparable perioperative outcomes in MICS CABG patients with a shorter postoperative length of stay. The longer procedural times for MICS CABG are consistent with other studies[10,11]. This is attributed to technical challenges associated with a much smaller access and a learning curve for MICS CABG. This observation of longer operative time did not translate to any clinical significance.
Previous studies showed that MICS CABG is associated with less postoperative complications, such as new onset atrial fibrillation and surgical site infections[12,13,14,15,16]. The Sternotomy Versus Thoracotomy (or STET) trial reported rates of postoperative arrhythmias and not just atrial fibrillation. It showed a higher incidence of arrhythmia among MS off-pump CABG patients than thoracotomy CABG patients[5,11]. This was comparable in this stringent propensity-matched study.
Single lung ventilation in the setting of MICS CABG did not increase risk of pulmonary complications. This is consistent with a previous review of five non-randomised control trials which demonstrated that postoperative lung function in patients with known respiratory problems is better with MICS CABG[17]. More recently, continuous full-lung ventilation during MICS CABG which improves postoperative lung function has been described[9,10]. More studies are warranted to determine its efficacy.
The shorter postoperative length of stay among MICS CABG patients was consistently reported in the literature[10,11]. This can be attributed to the shorter recovery needed with smaller incisions. Reduced surgical trauma and strict postoperative protocols in physiotherapy in our institution could be contributing factors. Despite this, it is important to note that discharge protocols from intensive care unit and from the hospital vary between centres.
Whilst conferring the benefits of MICS CABG, the reduced utility of conventional on-pump techniques may yield additional benefits associated with reduced systemic inflammatory response and reduced manipulation of the aorta[18,19]. The Randomized On/Off Bypass (or ROOBY) and CABG Off or On Pump Revascularization Study (or CORONARY) trials demonstrated similar outcomes between CABG performed off-pump versus on-pump[18,20]. In our institution, off-pump procedures are mainly reserved for MS CABG in patients who have a hostile aorta due to institutional practice.
CONCLUSION
This study demonstrates that MICS CABG is a safe and effective alternative to conventional MS CABG and is likely to enhance recovery. More prospective follow-up data is required to validate the findings of this study. Our moderate but increasing case volume may provide a better perspective on our performance in future studies.
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Authors’Roles & Responsibilities
ZXO = Substantial contributions to the analysis of data for the work; drafting the work; final approval of the version to be published
DW = Substantial contributions to the analysis of data for the work; drafting the work; final approval of the version to be published
JAS = Drafting the work or revising it critically; final approval of the version to be published
GC = Drafting the work or revising it critically; final approval of the version to be published
FS = Drafting the work or revising it critically; final approval of the version to be published
HL = Drafting the work or revising it critically; final approval of the version to be published
PH = Drafting the work and revising it; final approval of the version to be published
TK = Drafting the work or revising it critically; final approval of the version to be published
Article receive on Tuesday, November 15, 2022
Article accepted on Thursday, January 19, 2023