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ORIGINAL ARTICLE

Minimally Invasive Coronary Artery Bypass Grafting in a Low-Risk Asian Cohort: A Propensity-Score Matched Study

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.
Methods: Propensity matching produced 111 patient pairs who underwent MICS CABG or MS CABG between January 2009 and February 2020 at the National University Heart Centre, Singapore. Minimally invasive direct coronary artery bypass surgery patients were matched to single- or double-graft MS CABG patients (Group 1). Multivessel MICS CABG patients were matched to MS CABG patients with equal number of grafts (Group 2).
Results: Overall, MICS CABG patients experienced shorter postoperative length of stay (P<0.071). In Group 2, procedural duration (P<0.001) was longer among MICS CABG patients, but it did not translate to adverse postoperative events. Postoperative outcomes, including 30-day mortality, reopening for bleeding, new onset atrial fibrillation as well as neurological, pulmonary, renal, and infectious complications were comparable between MICS and MS CABG groups.
Conclusion: MICS CABG is a safe and effective approach for surgical revascularization of coronary artery disease and trends toward a reduction in hospital stay.

ABBREVIATIONS AND ACRONYMS

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).

Table 1 - Unmatched and matched groups.
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

CABG=coronary artery bypass grafting; EuroSCORE=European System for Cardiac Operative Risk Evaluation; MICS CABG=minimally invasive CABG; MS=median sternotomy; SD=standard deviation

Table 1 - Unmatched and matched groups.

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.

Supplementary Table 1 - Patient demographics.
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

Supplementary Table 1 - Patient demographics.

Fig. 1A - Minimally invasive coronary artery bypass grafting (MICS CABG) over years. MIDCAB=minimally invasive direct coronary artery bypass.

Fig. 1B - Mean cardiopulmonary bypass time over years in Group 2.

Fig. 2 - Distribution of cases over years by the number of grafts. MICS CABG=minimally invasive coronary artery bypass grafting; MIDCAB=minimally invasive direct coronary artery bypass.

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.

Table 2 - Procedure and intraoperative data.
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.

Table 2 - Procedure and intraoperative data.

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.

Table 3 - Postoperative outcomes of matched pairs.
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) -

CABG=coronary artery bypass grafting; IABP=intra-aortic balloon pump; IQR=interquartile range; MICS CABG=minimally invasive CABG; MIDCAB=minimally invasive direct coronary artery bypass; MS=median sternotomy

aMIDCAB patients were matched to MS patients with single or double vessel CABG with propensity score matching; bComprises permanent stroke, transient ischemic attack, delirium;cUrinary tract infection or sepsis; dProlonged ventilation defined as ventilation > 24 hours postoperatively

Table 3 - Postoperative outcomes of matched pairs.

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.

Limitations

Firstly, the sample size was not powered for non-inferiority. This was mitigated by the stringent criteria of propensity matching. Secondly, this was a retrospective study with some missing data for patients operated prior to 2015.

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.

REFERENCES


1. Calafiore AM, Giammarco GD, Teodori G, Bosco G, D'Annunzio E, Barsotti A, et al. Left anterior descending coronary artery grafting via left anterior small thoracotomy without cardiopulmonary bypass. Ann Thorac Surg. 1996;61(6):1658-63; discussion 1664-5. doi:10.1016/0003-4975(96)00187-7.

2. McGinn JT Jr, Usman S, Lapierre H, Pothula VR, Mesana TG, Ruel M. Minimally invasive coronary artery bypass grafting: dual-center experience in 450 consecutive patients. Circulation. 2009;120(11 Suppl):S78-84. doi:10.1161/CIRCULATIONAHA.108.840041. [MedLine]

3. Huang G, Zhang H, Chi L, You B, Bo P, Sun G. Comparing perioperative outcomes following off-pump multi-vessel minimally invasive via a single left intercostal space incision with median sternotomy coronary artery bypass grafting: a single-center retrospective cohort study. Perfusion. 2023:2676591231194454. doi:10.1177/02676591231194454.

4. Condello I, Nasso G, Fiore F, Speziale G. Evaluation of (wet) and (dry) mediastinal chest drainage in minimally invasive and conventional cardiac surgery. Surg Technol Int. 2023;42:sti42/1663. doi:10.52198/23. STI.42.CV1663.

5. Liang L, Ma X, Kong Q, Xiao W, Liu J, Chi L, et al. Comparing patient outcomes following minimally invasive coronary artery bypass grafting surgery vs. coronary artery bypass grafting: a single-center retrospective cohort study. Cardiovasc Diagn Ther. 2022;12(3):378-88. doi:10.21037/cdt-22-10.

6. Liang L, Liu JJ, Kong QY, You B, Ma XL, Chi LQ, et al. Comparison of early outcomes associated with coronary artery bypass grafting for multivessel disease conducted using minimally invasive or conventional off-pump techniques: a propensity-matched study based on SYNTAX score. J Cardiothorac Surg. 2022;17(1):144. doi:10.1186/s13019-022-01905-8.

7. Ong ZX, Wu D, Luo H, Chang G, Sazzad F, Sule JA, et al. Comparison of the safety and efficacy between minimally invasive cardiac surgery and median sternotomy in a low-risk mixed Asian population in Singapore. Singapore Med J. 2022;63(11):641-8. doi:10.11622/smedj.2021136.

8. Rajput NK, Kalangi TKV, Andappan A, Swain AK. MICS CABG: a singlecenter experience of the first 100 cases. Indian J Thorac Cardiovasc Surg. 2021;37(1):16-26. doi:10.1007/s12055-020-01048-2.

9. Teman NR, Hawkins RB, Charles EJ, Mehaffey JH, Speir AM, Quader MA, et al. Minimally invasive vs open coronary surgery: a multi-institutional analysis of cost and outcomes. Ann Thorac Surg. 2021;111(5):1478-84. doi:10.1016/j.athoracsur.2020.06.136.

10. Rabindranauth P, Burns JG, Vessey TT, Mathiason MA, Kallies KJ, Paramesh V. Minimally invasive coronary artery bypass grafting is associated with improved clinical outcomes. Innovations (Phila). 2014;9(6):421-6. doi:10.1177/155698451400900605.

11. Rogers CA, Pike K, Angelini GD, Reeves BC, Glauber M, Ferrarini M, et al. An open randomized controlled trial of median sternotomy versus anterolateral left thoracotomy on morbidity and health care resource use in patients having off-pump coronary artery bypass surgery: the sternotomy versus thoracotomy (STET) trial. J Thorac Cardiovasc Surg. 2013;146(2):306-16.e1-9. doi:10.1016/j.jtcvs.2012.04.020.

12. Birla R, Patel P, Aresu G, Asimakopoulos G. Minimally invasive direct coronary artery bypass versus off-pump coronary surgery through sternotomy. Ann R Coll Surg Engl. 2013;95(7):481-5. doi:10.1308/00358 8413X13629960047119.

13. Hirata N, Sawa Y, Takahashi T, Katoh H, Ohkubo N, Matsuda H. Is median sternotomy invasive? A comparison between minimally invasive direct coronary artery bypass and off-pump bypass. Surg Today. 2000;30(6):503-5. doi:10.1007/s005950070115.

14. Raja SG, Benedetto U, Alkizwini E, Gupta S, Amrani M; Harefield Cardiac Outcomes Research Group. Propensity score adjusted comparison of MIDCAB versus full sternotomy left anterior descending artery revascularization. Innovations (Phila). 2015;10(3):174-8. doi:10.1097/IMI.0000000000000162.

15. Tekin Aİ, Arslan Ü. Perioperative outcomes in minimally invasive direct coronary artery bypass versus off-pump coronary artery bypass with sternotomy. Wideochir Inne Tech Maloinwazyjne. 2017;12(3):285-90. doi:10.5114/wiitm.2017.67679.

16. Xu Y, Li Y, Bao W, Qiu S. MIDCAB versus off-pump CABG: comparative study. Hellenic J Cardiol. 2020;61(2):120-4. doi:10.1016/j.hjc.2018.12.004.

17. Dooley A, Asimakopoulos G. Does a minimally invasive approach result in better pulmonary function postoperatively when compared with median sternotomy for coronary artery bypass graft? Interact Cardiovasc Thorac Surg. 2013;16(6):880-5. doi:10.1093/icvts/ivt035.

18. Lamy A, Devereaux PJ, Prabhakaran D, Taggart DP, Hu S, Paolasso E, et al. Off-pump or on-pump coronary-artery bypass grafting at 30 days. N Engl J Med. 2012;366(16):1489-97. doi:10.1056/NEJMoa1200388.

19. Mizutani S, Matsuura A, Miyahara K, Eda T, Kawamura A, Yoshioka T, et al. On-pump beating-heart coronary artery bypass: a propensity matched analysis. Ann Thorac Surg. 2007;83(4):1368-73. doi:10.1016/j.athoracsur.2006.11.011.

20. Shroyer AL, Grover FL, Hattler B, Collins JF, McDonald GO, Kozora E, et al. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med. 2009;361(19):1827-37. doi:10.1056/NEJMoa0902905.

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

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