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Thorac Cardiovasc Surg 2021; 69(07): 607-613
DOI: 10.1055/s-0041-1723845
Original Cardiovascular

Minimally Invasive Direct Coronary Artery Bypass in High-Risk Patients with Multivessel Disease

Grischa Hoffmann
1   Department of Cardiac and Vascular Surgery, University Hospital Schleswig-Holstein—Campus Kiel, Kiel, Germany
,
Christine Friedrich 
1   Department of Cardiac and Vascular Surgery, University Hospital Schleswig-Holstein—Campus Kiel, Kiel, Germany
,
Katharina Huenges
1   Department of Cardiac and Vascular Surgery, University Hospital Schleswig-Holstein—Campus Kiel, Kiel, Germany
,
Rainer Petzina
2   Department for Quality and Risk Management and Patient Safety, Universitatsklinikum Schleswig-Holstein Campus Kiel, Kiel, Germany
,
Astrid-Mareike Vogt
3   Department of Obstetrics and Gynecology, Stadtisches Krankenhaus Kiel, Kiel, Schleswig-Holstein, Germany
,
Joachim Cremer
1   Department of Cardiac and Vascular Surgery, University Hospital Schleswig-Holstein—Campus Kiel, Kiel, Germany
,
Christina Grothusen
1   Department of Cardiac and Vascular Surgery, University Hospital Schleswig-Holstein—Campus Kiel, Kiel, Germany
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Abstract

Background High-risk patients with multivessel disease (MVD) including a complex stenosis of the left anterior descending coronary may not be ideal candidates for guideline compliant therapy by coronary artery bypass grafting (CABG) regarding invasiveness and perioperative complications. However, they may benefit from minimally invasive direct coronary artery bypass (MIDCAB) grafting and hybrid revascularization (HCR).

Methods A logistic European system for cardiac operative risk evaluation score (logES) >10% defined high risk. In high-risk patients with MVD undergoing MIDCAB or HCR, the incidence of major adverse cardiac and cerebrovascular events (MACCEs) after 30 days and during midterm follow-up was evaluated.

Results Out of 1,250 patients undergoing MIDCAB at our institution between 1998 and 2015, 78 patients (logES: 18.5%; age, 76.7 ± 8.6 years) met the inclusion criteria. During the first 30 days, mortality and rate of MACCE were 9.0%; early mortality was two-fold overestimated by logES. Complete revascularization as scheduled was finally achieved in 64 patients (82.1%). Median follow-up time reached 3.4 (1.2–6.5) years with a median survival time of 4.7 years. Survival after 1, 3, and 5 years was 77, 62, and 48%.

Conclusion In high-risk patients with MVD, MIDCAB is associated with acceptable early outcome which is better than predicted by logES. Taking the high-risk profile into consideration, midterm follow-up showed satisfying results, although scheduled HCR was not realized in a relevant proportion. In selected cases of MVD, MIDCAB presents an acceptable alternative for high-risk patients.

Keyword

coronary artery bypass grafts surgery - CABG - minimally invasive surgery, includes port access minithoracotomy - outcomes, includes mortality morbidity


Publication History

Received: 01 November 2020

Accepted: 29 December 2020

Article published online:
27 May 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Mohr FW, Morice MC, Kappetein AP. et al. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 2013; 381 (9867): 629-638
    CrossrefPubMedGoogle Scholar
  • 2 Repossini A, Di Bacco L, Nicoli F. et al. Minimally invasive coronary artery bypass: twenty-year experience. J Thorac Cardiovasc Surg 2019; 158 (01) 127-138.e1 , e121
    CrossrefPubMedGoogle Scholar
  • 3 Nashef SA, Roques F, Michel P, Gauducheau E, Lemeshow S, Salamon R. European system for cardiac operative risk evaluation (EuroSCORE). Eur J Cardiothorac Surg 1999; 16 (01) 9-13
    CrossrefPubMedGoogle Scholar
  • 4 Holzhey DM, Cornely JP, Rastan AJ, Davierwala P, Mohr FW. Review of a 13-year single-center experience with minimally invasive direct coronary artery bypass as the primary surgical treatment of coronary artery disease. Heart Surg Forum 2012; 15 (02) E61-E68
    CrossrefPubMedGoogle Scholar
  • 5 Repossini A, Tespili M, Saino A. et al. Hybrid revascularization in multivessel coronary artery disease. Eur J Cardiothorac Surg 2013; 44 (02) 288-293 , discussion 293–294
    CrossrefPubMedGoogle Scholar
  • 6 Jacobs S, Holzhey D, Falk V, Garbade J, Walther T, Mohr FW. High-risk patients with multivessel disease--is there a role for incomplete myocardial revascularization via minimally invasive direct coronary artery bypass grafting?. Heart Surg Forum 2007; 10 (06) E459-E462
    CrossrefPubMedGoogle Scholar
  • 7 Lichtenberg A, Klima U, Paeschke H. et al. Impact of multivessel coronary artery disease on outcome after isolated minimally invasive bypass grafting of the left anterior descending artery. Ann Thorac Surg 2004; 78 (02) 487-491
    CrossrefPubMedGoogle Scholar
  • 8 Nashef SA, Roques F, Sharples LD. et al. EuroSCORE II. Eur J Cardiothorac Surg 2012; 41 (04) 734-744 , discussion 744–745
    CrossrefPubMedGoogle Scholar
  • 9 Stone GW, Kappetein AP, Sabik JF. et al; EXCEL Trial Investigators. Five-year outcomes after PCI or CABG for left main coronary disease. N Engl J Med 2019; 381 (19) 1820-1830
    CrossrefPubMedGoogle Scholar
  • 10 Kettering K. Minimally invasive direct coronary artery bypass grafting: a meta-analysis. J Cardiovasc Surg (Torino) 2008; 49 (06) 793-800
    PubMedGoogle Scholar
  • 11 Raja SG, Uzzaman M, Garg S. et al. Comparison of minimally invasive direct coronary artery bypass and drug-eluting stents for management of isolated left anterior descending artery disease: a systematic review and meta-analysis of 7,710 patients. Ann Cardiothorac Surg 2018; 7 (05) 567-576
    CrossrefPubMedGoogle Scholar
  • 12 Hoffmann G, Friedrich C, Barrabas M. et al. Short- and long-term follow-up after minimally invasive direct coronary artery bypass in octogenarians. Interact Cardiovasc Thorac Surg 2016; 23 (03) 377-382
    CrossrefPubMedGoogle Scholar
  • 13 Chang M, Lee CW, Ahn JM. et al. Coronary artery bypass graft surgery versus drug-eluting stent implantation for high-surgical-risk patients with left main or multivessel coronary artery disease. Eur J Cardiothorac Surg 2017; 51 (05) 943-949
    CrossrefPubMedGoogle Scholar
  • 14 Biancari F, Vasques F, Mikkola R, Martin M, Lahtinen J, Heikkinen J. Validation of EuroSCORE II in patients undergoing coronary artery bypass surgery. Ann Thorac Surg 2012; 93 (06) 1930-1935
    CrossrefPubMedGoogle Scholar
  • 15 Lemesle G, Bonello L, de Labriolle A. et al. Prognostic value of the Syntax score in patients undergoing coronary artery bypass grafting for three-vessel coronary artery disease. Catheter Cardiovasc Interv 2009; 73 (05) 612-617
    CrossrefPubMedGoogle Scholar
  • 16 Campos CM, van Klaveren D, Farooq V. et al; EXCEL Trial Investigators. Long-term forecasting and comparison of mortality in the evaluation of the Xience Everolimus Eluting Stent vs. coronary artery bypass surgery for effectiveness of left main revascularization (EXCEL) trial: prospective validation of the SYNTAX score II. Eur Heart J 2015; 36 (20) 1231-1241
    CrossrefPubMedGoogle Scholar
  • 17 de Mulder M, Gitt A, van Domburg R. et al. EuroHeart score for the evaluation of in-hospital mortality in patients undergoing percutaneous coronary intervention. Eur Heart J 2011; 32 (11) 1398-1408
    CrossrefPubMedGoogle Scholar
  • 18 Kofidis T, Gerd Paeschke H, Lichtenberg A. et al. Factors affecting post minimally invasive direct coronary artery bypass grafting incidence of myocardial infarction, percutaneous transluminal coronary angioplasty, coronary artery bypass grafting and mortality of cardiac origin. Interact Cardiovasc Thorac Surg 2009; 8 (01) 49-53
    CrossrefPubMedGoogle Scholar
  • 19 Garcia S, Sandoval Y, Roukoz H. et al. Outcomes after complete versus incomplete revascularization of patients with multivessel coronary artery disease: a meta-analysis of 89,883 patients enrolled in randomized clinical trials and observational studies. J Am Coll Cardiol 2013; 62 (16) 1421-1431
    CrossrefPubMedGoogle Scholar
  • 20 Farooq V, Serruys PW, Bourantas CV. et al. Quantification of incomplete revascularization and its association with five-year mortality in the synergy between percutaneous coronary intervention with taxus and cardiac surgery (SYNTAX) trial validation of the residual SYNTAX score. Circulation 2013; 128 (02) 141-151
    CrossrefPubMedGoogle Scholar
  • 21 Ahn JM, Park DW, Lee CW. et al. Comparison of stenting versus bypass surgery according to the completeness of revascularization in severe coronary artery disease: patient-level pooled analysis of the SYNTAX, PRECOMBAT, and BEST trials. JACC Cardiovasc Interv 2017; 10 (14) 1415-1424
    CrossrefPubMedGoogle Scholar
  • 22 Zimarino M, Ricci F, Romanello M, Di Nicola M, Corazzini A, De Caterina R. Complete myocardial revascularization confers a larger clinical benefit when performed with state-of-the-art techniques in high-risk patients with multivessel coronary artery disease: a meta-analysis of randomized and observational studies. Catheter Cardiovasc Interv 2016; 87 (01) 3-12
    CrossrefPubMedGoogle Scholar
  • 23 Gąsior M, Zembala MO, Tajstra M. et al; POL-MIDES (HYBRID) Study Investigators. Hybrid revascularization for multivessel coronary artery disease. JACC Cardiovasc Interv 2014; 7 (11) 1277-1283
    CrossrefPubMedGoogle Scholar
  • 24 Shen L, Hu S, Wang H. et al. One-stop hybrid coronary revascularization versus coronary artery bypass grafting and percutaneous coronary intervention for the treatment of multivessel coronary artery disease: 3-year follow-up results from a single institution. J Am Coll Cardiol 2013; 61 (25) 2525-2533
    CrossrefPubMedGoogle Scholar