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Objective: Robot-assisted coronary artery bypass (RCAB) is typically not offered to higher risk patients with reduced cardiopulmonary function, critical coronary artery disease, and challenging chest wall anatomy. In this study, we report the novel use of nonemergency intraoperative peripheral extracorporeal membrane oxygenation as partial cardiopulmonary support during RCAB for patients who were considered high-risk candidates for conventional CAB and at the same time not eligible for RCAB without cardiopulmonary support. Methods: Forty-five high risk patients (mean age, 68 years; Society of Thoracic Surgeons score, 6.27%; ejection fraction, 45%) underwent RCAB with nonemergency peripheral extracorporeal membrane oxygenation support for the following indications: inability to tolerate single-lung ventilation (n = 17; 38%), low ejection fraction <35% (n = 17; 38%), inadequate exposure of internal thoracic artery (n = 24; 53%), critical coronary artery disease (n = 16; 36%), and hemodynamic instability after anesthesia induction (n = 3; 7%). Following robotic internal thoracic artery takedown, all patients had beating heart minimally invasive direct CAB through a 2-inch minithoracotomy. Results: Up to 30 days, there were no strokes (0%), myocardial infarctions (0%), or access vessel complications (0%). One noncardiac related mortality (2.2%) was related to hemodialysis access issues in a patient with preexisting end-stage renal disease. One redo-CAB (2.2%) patient required sternotomy to locate the target vessel. Thirty-four (75.6%) patients were extubated within 6 hours of surgery. Conclusions: Our results examine the feasibility of using peripheral extracorporeal membrane oxygenation during RCAB for high-risk patients who otherwise had limited options. The use of peripheral extracorporeal membrane oxygenation in RCAB can potentially expand the surgical treatment options in high-risk coronary artery disease patients.
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Objective: Advanced hybrid coronary revascularization is the integration of sternal-sparing multivessel coronary artery bypass grafting and percutaneous coronary intervention in patients with multivessel coronary artery disease. We sought to review our advanced hybrid coronary revascularization experience over an 8.5-year period using robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery grafts and percutaneous coronary intervention. Methods: From August 2013 to February 2022, 664 patients underwent robotic totally endoscopic coronary artery bypass at our institution. Of the 293 patients who underwent totally endoscopic coronary artery bypass assigned to a hybrid revascularization strategy, 156 patients received bilateral internal thoracic artery grafts and are the subject of this review. Patients underwent percutaneous coronary intervention with drug-eluting stents before or after totally endoscopic coronary artery bypass. We reviewed early and midterm outcomes (up to 8 years) in this cohort of patients with intent-to-treat advanced hybrid coronary revascularization. Results: The mean age of patients was 65 ± 10 years. The mean Society of Thoracic Surgeons predicted risk of mortality was 1.26 ± 1.56. Triple-vessel disease occurred in 94% of patients, and 17% of patients had 70% or more left-main disease. The mean operative time was 311 ± 54 minutes, and the mean hospital length of stay was 2.7 ± 1.1 days. All patients had bilateral internal thoracic artery grafts; the total number of grafts was 334. Eight seven percentage of patients had totally endoscopic coronary artery bypass ×2, and 13% of patients had totally endoscopic coronary artery bypass ×3. One patient received totally endoscopic coronary artery bypass ×4. The mean number of grafts per patient was 2.14 ± 0.4, and the mean number of vessels stented was 1.23 ± 0.5. There were no conversions, perioperative stroke, or myocardial infarction. Early mortality occurred in 2 patients. Early graft patency was 98% (209/214 grafts); left internal thoracic artery to left anterior descending patency was 100% (66/66 grafts). At 8-year follow-up in 155 patients (mean 39 ± 26 months), all-cause and cardiac-related mortality were 11.6% and 3.9%, respectively. Freedom from major adverse cardiac/cerebrovascular events including repeat revascularization was 94%. Conclusions: In patients with multivessel coronary artery disease, integrating robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery and percutaneous coronary intervention resulted in excellent early and midterm outcomes. Further studies are warranted.
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Objectives: We evaluated the occurrence rate of competitive flow and the fate of grafts of left internal thoracic artery (LITA)-to-left anterior descending coronary artery (LAD) anastomosis after coronary artery bypass grafting with Y-composite grafts using early and 1-year angiography. Methods: From 2008 to 2017, 923 patients underwent off-pump coronary artery bypass grafting using Y-composite grafting based on the in situ LITA. Early postoperative angiography was performed for all patients. One-year angiography (mean, 13.2 ± 3.1 months) was performed for 86.7% (800 of 923) of patients. Results: The early occlusion rate of LITA with Y-composite graft (CompLITA) to LAD was 0.7%. Among 917 patent CompLITA-LAD grafts, competitive flow was observed in 39 patients (4.3%). Multivariable analysis showed that the degree of LAD stenosis (odds ratio, 0.897; 95% CI, 0.875-0.920; P < .001) and 3-vessel disease (odds ratio, 5.632; 95% CI, 1.168-27.155; P = .031) were factors associated with the occurrence of competitive flow of CompLITA-LAD grafts. The receiver operating characteristics curve determined that the cutoff degree of LAD stenosis was 82.5% (sensitivity 82.1% and specificity 85.2%). The failure rate of CompLITA-LAD grafts seen on 1-year angiography was 58.3% in patients with competitive flow. Among patients with competitive flow, left main coronary artery disease was a protective factor (odds ratio, 0.055; 95% CI, 0.009-0.337; P = .002) against graft failure of the CompLITA-LAD seen on 1-year angiography. Conclusions: In CompLITA-LAD, the degree of LAD stenosis and combined 3-vessel disease were associated with the occurrence of competitive flow. CompLITA-LAD grafts with early competitive flow showed a high 1-year graft failure rate of 58%.
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Objective: Isolated coronary artery bypass grafting and aortic valve replacement are common cardiac operations performed in the United States and serve as platforms for benchmarking. The present national study characterized hospital-level variation in costs and value for coronary artery bypass grafting and aortic valve replacement. Methods: Adults undergoing elective, isolated coronary artery bypass grafting or aortic valve replacement were identified in the 2016-2018 Nationwide Readmissions Database. Center quality was defined by the proportion of patients without an adverse outcome (death, stroke, respiratory failure, pneumonia, sepsis, acute kidney injury, and reoperation). High-value hospitals were defined as those with observed-to-expected ratios less than 1 for costs and greater than 1 for quality, whereas the converse defined low-value centers. Results: Of 318,194 patients meeting study criteria, 71.9% underwent isolated coronary artery bypass grafting and 28.1% underwent aortic valve replacement. Variation in hospital-level costs was evident, with median center-level cost of $36,400 (interquartile range, 29,500-46,700) for isolated coronary artery bypass grafting and $38,400 (interquartile range, 32,300-47,700) for aortic valve replacement. Observed-to-expected ratios for quality ranged from 0.2 to 10.9 for isolated coronary artery bypass grafting and 0.1 to 11.7 for isolated aortic valve replacement. Hospital factors, including volume and quality, contributed to approximately 9.9% and 11.2% of initial cost variation for isolated coronary artery bypass grafting and aortic valve replacement. High-value centers had greater cardiac surgery operative volume and were more commonly teaching hospitals compared to low-value centers, but had similar patient risk profiles. Conclusions: Significant variation in hospital costs, quality, and value exists for 2 common cardiac operations. Center volume was associated with value and partly accounts for variation in costs. Our findings suggest the need for value-based care paradigms to reduce expenditures and optimize outcomes.
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Objective: This study aimed to examine the feasibility and safety of minimally invasive cardiac surgery coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery in the authors' initial experience. Methods: From February 2012 to May 2021, 247 consecutive patients who underwent minimally invasive coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery were reviewed retrospectively. Internal thoracic arteries were harvested in a full skeletonized fashion using an ultrasonic scalpel via left minithoracotomy. Bilateral internal thoracic arteries were used in 108 patients, and the internal thoracic arteries as in situ grafts were used in 393 anastomoses. Total arterial revascularization was performed in 126 patients, and 142 patients underwent aortic nontouch minimally invasive coronary artery bypass grafting. Results: The patients' mean (range) age was 65.9 ± 11.5 (30-90) years. The mean (range) number of anastomoses performed was 2.6 ± 1.1 (1-6). Forty-six patients (18.6%) had 4 grafts, 94 patients (38.1%) had 3 grafts, and 60 patients (24.3%) had 2 grafts. Minimally invasive coronary artery bypass grafting was completed without conversion to sternotomy in all patients. Cardiopulmonary bypass was performed in 3 patients (1.2%), reinterventions due to bleeding were performed in 7 patients (2.8%), and chest wound infections were observed in 5 patients (2.0%). There was 1 (0.4%) mortality. Conclusions: Minimally invasive coronary artery bypass grafting using an ultrasonically skeletonized internal thoracic artery is feasible and has shown good perioperative outcomes. This approach has the potential for further optimization with revascularization strategies.
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Minimally invasive direct coronary artery bypass (MIDCAB) surgery and percutaneous coronary intervention (PCI) are both well-established minimally invasive revascularization strategies in patients with proximal left anterior descending (LAD) lesions. We aimed to evaluate the 20-years' experience by performing a systematic review and meta-analysis comparing MIDCAB versus PCI in adults with proximal LAD disease. We searched MEDLINE, EMBASE and Cochrane on October 1st, 2021 for articles published in the year 2000 or later. The primary outcome was all-cause mortality. Secondary outcomes included cardiac mortality, repeat target vessel revascularization (rTVR), myocardial infarction (MI), and cerebrovascular accident (CVA). Outcomes were analysed at short-term, mid-term, and long-term follow-up. Random effects meta-analyses were performed. Events were compared using risk ratios (RR) with 95% confidence intervals (CI). Our search yielded 17 studies pooling 3847 patients. At short-term follow-up, cardiac mortality was higher with MIDCAB than with PCI (RR 7.30, 95% CI: 1.38 to 38.61). At long-term follow-up, MIDCAB showed a decrease in all-cause mortality (RR 0.66, 95% CI: 0.46 to 0.93). MIDCAB showed a decrease in rTVR at mid-term follow-up (RR 0.16, 95% CI: 0.11 to 0.23) and at long-term follow-up (RR 0.25, 95% CI: 0.17 to 0.38). MI and CVA comparisons were not significant. In conclusion, in patients with proximal LAD lesions, MIDCAB showed a higher short-term mortality in the RCTs, but the cohort studies suggested a lower all-cause mortality at long-term follow-up. We confirm a decreased rTVR at mid-term follow-up in the RCTs and long-term follow-up in the cohort studies.
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BACKGROUND: Hybrid coronary revascularization (HCR) is an emerging approach for multivessel coronary artery disease (MVD) which combines the excellent long-term outcomes of surgery with the early recovery and reduced short-term complications of percutaneous coronary intervention (PCI). Here, we evaluated the effectiveness of HCR compared to PCI in patients with MVD. METHODS: A systematic database search in PubMed/MEDLINE, Embase, Scopus, and CENTRAL/CCTR was conducted by June 2021. Random-effects meta-analysis was performed, comparing major adverse cardiac and cerebrovascular events (MACCE) at 30 days and at latest follow-up between patients undergoing HCR versus PCI. RESULTS: A total of 27,041 patients (HCR: 939 patients, PCI: 26,102 patients) were included from seven studies published between 2013 and 2021. At latest follow-up, HCR was associated with lower rates of myocardial infarction (OR 0.40, 95% CI 0.20-0.80, p = 0.010) and target vessel revascularization (OR 0.49, 95% CI 0.37-0.64, p < 0.001), while the difference for MACCE did not reach statistical significance (OR 0.46, 95% CI 0.20-1.05, p = 0.061). No differences were observed in terms of 30-day outcomes, nor rates of mortality or stroke at latest follow-up. CONCLUSIONS: HCR might be a valid alternative to multivessel PCI, demonstrating a lower incidence of MI and TVR. Center experience, well-coordinated heart team discussions, and good patient selection likely remain essential to ensure optimal outcomes. Future comparative studies are required to define the optimal target population.
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Sotos syndrome, characterized by cerebral gigantism with neurologic disorders, is an overgrowth syndrome caused by mutations of the NSD1 gene, with an estimated prevalence of 1:10,000-1:50,000. We herein describe the first case of Sotos syndrome complicated by acute coronary syndrome, for which emergency coronary artery bypass grafting was performed. (Level of Difficulty: Intermediate.).
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Objectives: Cardiac surgery has evolved significantly since the turn of the century. The objective of this study was to investigate trends in cardiac surgery activity and outcomes in the United Kingdom utilizing a mandatory national cardiac surgical clinical database in the context of a comprehensive public health care system (ie, the UK National Health Service). Methods: Data for all cardiac surgery procedures performed between 2002 and 2016 were extracted from the UK National Adult Cardiac Surgery Audit database. Data are validated and cleaned using reproducible algorithms. Trends in activity and outcomes were analyzed by fiscal year using linear regression. Results: A total of 534,067 procedures were performed during the study period with the number of cases per year peaking in 2008/2009 at 41,426. Despite an increase in patient age and mean logistic European System for Cardiac Operative Risk Evaluation score, the in-hospital mortality rate for all cardiac surgery has fallen from 4.0% to 2.8% (P < .001). The number of isolated coronary artery bypass graft procedures has steadily declined but the total number of valve procedures has steadily increased (both P values < .001). The number of thoracic aortic procedures performed each year has doubled (P < .001), but the incidence of redo procedures has steadily declined. The proportion of emergency and salvage procedures has remained stable. Conclusions: This study, which covers all cardiac surgery procedures performed in the United Kingdom for fiscal years between 2002 and 2016, demonstrates that despite an increase in patient risk profile, there has been a consistent reduction in in-hospital mortality. A number of other markers associated with quality have also improved.
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Patients referred for aortic valve replacement are often elderly and may have increased surgical risk associated with ascending aortic calcification, left ventricular dysfunction, presence of coronary artery disease, previous surgery, and/or presence of several co-morbidities. Some of these patients may not be considered candidates for conventional surgery because of their high risk profile. While transcatheter aortic valve replacement constitutes a widely accepted alternative, some patients may not be eligible for this modality due to anatomic factors. Apico-Aortic Conduit (AAC) insertion (aortic valve bypass surgery) constitutes a possible option in those patients. Apico-Aortic Conduit is not a new technique, as it has been used for decades in both pediatric and adult populations. However, there is a resurging interest in this technique due to the expanding scope of elderly patients being considered for the treatment of aortic stenosis. Herein, we describe our surgical technique and provide a systematic review of recent publications on AAC insertion, reporting that there is continued use and several modifications of this technique, such as performing it through a small thoracotomy without the use of the cardiopulmonary bypass.