Long-Term Follow-up of Multivessel Off-Pump Minimally Invasive Coronary Artery Bypass Surgery

Objectives: Minimally invasive, multivessel coronary artery bypass grafting (MICS-CABG) has low penetrance in the surgical therapy of coronary vascular disease, due to the challenging approach this method presents. This study evaluates the mid- and long-term follow-up results of these patients operated in our center.

Methods: A consecutive series of 387 patients undergoing MICS-CABG between 2008 and 2015 was included. Via a left-sided anterolateral minithoracotomy, the left internal thoracic artery (LITA) was used to graft the LAD ± diagonal artery, while the lateral and/or posterior myocardial territories were grafted with a T-graft from LITA using radial artery, or rarely, saphenous vein segments, both endoscopically harvested. Major adverse cardiac and cerebral events (MACCE), freedom from angina, and health status were collected by a questionnaire or direct telephone contact. Pre-, intra-, and postoperative data could be completed for all 387 patients. Long-term follow-up (mean: 54.7 ± 25.2 months) was available for 372 patients (96%).

Results: Mean patient age was 67.2 ± 10 years. 356 patients (91.9%) were male. 26.8% (104/387) had already underwent a percutaneous coronary intervention (PCI) prior to surgery. A mean of 2.1 ± 0.3 distal anastomoses were performed. 367 (94.8%) patients received exclusively arterial grafts. There were 2 (0.5%) conversions to sternotomy and cardio-pulmonary bypass (CPB). 8 patients (2%) developed a wound infection necessitating reoperation, 2 (0.5%) suffered a stroke after surgery. The 30-day mortality was 0.8% (3/387). A myocardial infarction occurred in 5 cases, 3 of them necessitated immediate reoperation. During follow-up, one patient (0.3%) underwent coronary reoperation and PCI was performed in 62 patients (16.6%). Rates of 3- and 5-year mortality were 7% (23/293) and 11% (30/199), respectively. At 3- and 5-year follow-up, MACCE-free survival rates were 99% (275/278) and 96% (171/180), respectively; freedom from angina rates were 94% (272/289) and 85% (168/204), respectively.

Conclusion: Off-pump MICS-CABG represents the best alternative revascularization strategy to PCI for patients with single-vessel or two-vessel disease, with chronic vessel occlusion or in-stent restenosis. Survival and durability are comparable with conventional CABG with a low rate of complications and conversion to sternotomy.