Search Results (25)

Background: Minimally invasive coronary surgery (MICS) has emerged as an alternative approach in the surgical management of coronary artery disease (CAD), offering potential advantages such as reduced surgical trauma, shorter hospital stays, and faster recovery. While conventional coronary artery bypass grafting (CABG) remains the standard treatment for severe CAD, MICS has seen variable adoption due to concerns over procedural complexity, the risk of incomplete revascularization, and the increasing role of percutaneous interventional techniques. Objectives: This review examines recent clinical developments in MICS, analyzing its techniques, technological advancements, and the impact on patient outcomes, while also addressing its limitations. Methods: This narrative review incorporates studies from PubMed, tracing the evolution of coronary surgery, the refinement of minimally invasive approaches, and the innovations that have enabled the selective implementation of MICS. This review evaluates robot-assisted coronary surgery and totally endoscopic coronary revascularization, discussing their clinical indications and comparative outcomes. Results: Advances in imaging, surgical instrumentation, and anesthesia have improved procedural safety and precision, yet MICS remains a selectively utilized technique rather than a universally preferred alternative. Comparative studies demonstrate mixed clinical outcomes, highlighting both the recovery benefits and technical challenges associated with MICS. Discussion: Patient selection, preoperative planning, and individualized surgical strategies play a crucial role in optimizing the effectiveness of MICS. Challenges include technical complexity, integration into broader clinical practice, and the need for procedural refinement. While ongoing research continues to address these hurdles, the role of MICS in CAD management remains context-dependent, influenced by case complexity and institutional expertise. Conclusion: MICS presents an evolving surgical approach with defined benefits and limitations, requiring careful patient selection and procedural optimization for the best outcomes. This review provides a comprehensive evaluation of recent advances in MICS while acknowledging its challenges and selective application in coronary surgery. Full article

Background: Minimally invasive multi-vessel off-pump coronary artery bypass grafting (MICS CABG) through left anterior mini-thoracotomy avoids both extracorporeal circulation and sternotomy and is a very elegant, safe, and effective surgical technique, despite its still-limited adoption in the daily toolkit of cardiac surgeons. The goal of this retrospective, single-centre analysis was to evaluate the long-term outcomes of a large patient cohort undergoing MICS CABG. Methods: This study identified 597 consecutive MICS CABG patients from August 2008 to November 2020. We obtained follow-up data by phone or mail. Every patient had a left internal thoracic artery bypass graft. The second and possibly third grafts were radial arteries, great saphenous vein segments, or right internal thoracic arteries. Results: The median age was 69 years, and 92.1% were male. The median EuroSCORE II was 1.5. There were eight conversions to sternotomy and none to cardiopulmonary bypass. The total arterial revascularisation was 92.5%, with 90.3% complete. The 30-day mortality was 0.5%. A total of 575 patients (95.8%) were tracked for 8 years on average. A Cox regression analysis found that a left ventricular ejection fraction < 50%, peripheral vascular disease, chronic kidney disease, and a history of cerebrovascular accident independently predicted severe adverse cardiac and cerebrovascular events and late death. The actuarial survival rates for one, three, five, eight, and ten years were 99%, 95%, 91%, 85%, and 80%, respectively. Conclusions: In our study group, the technique of MICS CABG has been proven to be a safe and effective surgical revascularisation method, with a low rate of early complications and favourable long-term outcomes in eligible patients. Full article

Background: The non-robotic endoscopic harvest of the internal mammary artery (IMA) facilitates minimally invasive bypass grafting while minimizing chest wall trauma. The technique was pioneered in the early 1990s and has recently regained popularity due to its accessibility and reproducibility. This review aims to provide an overview of endoscopic IMA harvest from its inception to the present. Methods: In August 2024, a literature search was performed using the electronic databases of the Cochrane Controlled Trials Register (CCTR) and PubMed. To obtain optimal search results, the keywords “thoracoscopic”, “endoscopic”, “minimally invasive”, “video-assisted”, “video-assisted thoracoscopic surgery VATS”, and “internal mammary artery” or “internal thoracic artery” were used, excluding the term “robotic”. References from the extracted articles were also reviewed to identify additional studies on endoscopic IMA harvest. Results: A total of 17 articles were included in the final analysis. Left internal mammary artery (LIMA) harvest times of between 17 and 164 min were reported, with an injury to LIMA rates between 0.7 and 2.2%. Conclusions: After a 15-year period without scientific publications, interest in the endoscopic-assisted approach has rekindled in recent years due to the reduction in chest trauma compared to direct vision harvest and the widespread availability of conventional endoscopic tools. This renewed focus underscores the potential to make minimally invasive coronary surgery available in all centers. Full article

Hybrid coronary revascularisation (HCR) integrates coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) to combine the benefits of minimally invasive surgery and advanced stent technology. Typically, HCR involves off-pump left internal mammary artery (LIMA) to left anterior descending artery (LAD) bypass via minimally invasive direct coronary artery bypass (MIDCAB), complemented by PCI to non-LAD vessels. This approach avoids a full sternotomy and cardiopulmonary bypass while preserving the advantages of surgical revascularisation. Patient selection for HCR should be guided by a multidisciplinary heart team, targeting those with severe LAD disease and suitable non-LAD lesions for PCI. This review outlines the surgical techniques, anticoagulation strategies, and procedural sequencing employed in HCR, along with real-world outcomes from observational studies and randomised trials. While current evidence supports the safety and feasibility of HCR in appropriately selected patients, further large-scale randomised trials are needed to clarify its role in comparison to standalone CABG or PCI. Full article

The operative field and exposure in minimally invasive cardiac surgery (MICS) are limited. Meticulous preoperative planning and intraoperative visualization are crucial. We present our initial experience with HoloLens^® 2 as an intraoperative guide during MICS procedures: aortic valve replacement (AVR) via right anterior small thoracotomy, coronary artery bypass graft surgery (CABG) via left anterior small thoracotomy (LAST), and pulmonary valve replacement (PVR) via LAST. Three-dimensional (3D) segmentations were performed using the patient’s computer tomography (CT) data subsequently rendered into a 3D hologram on the HoloLens^® 2. The holographic image was then superimposed on the patient lying on the operating table, using the xiphoid and the clavicle as landmarks, and was used as a real-time anatomical image guide for the surgery. The incision site marking made using HoloLens^® 2 differed by one intercostal space from the marking made using a conventional surgeon’s mental reconstructed image from the patient’s preoperative imaging and was found to be a more appropriate site of entry into the chest for the structure of interest. The transparent visor of the HoloLens^® 2 provided unobstructed views of the operating field. A mixed reality (MR) device could contribute to preoperative surgical planning and intraoperative real-time image guidance, which facilitates the understanding of anatomical relationships. MR has the potential to improve surgical precision, decrease risk, and enhance patient safety. Full article

Objective: Cardiopulmonary bypass (CPB) via the right axillary artery (RAA) has become an alternative perfusion strategy, especially in complex aortic procedures. This study delineates our technique and outcome with direct axillary cannulation utilizing the Seldinger technique, which we adopted as the standard perfusion strategy in the sternum-sparing minimally invasive total coronary revascularization via left anterior thoracotomy (TCRAT) using CPB. Methods: From November 2019 to December 2023, a total of 413 consecutive patients underwent nonemergent isolated coronary artery bypass grafting (CABG) via left anterior minithoracotomy on CPB with peripheral cannulation via the RAA and cardioplegic cardiac arrest, using this technique as a default strategy in the daily routine. All patients had multivessel coronary artery disease. The primary outcome was intraoperative cannulation-related complications (bleeding, revision, ischemia, wound healing complications). The secondary outcome was cannulation-related events during follow-up (blood pressure differences, incidence of brachial plexus injury, clinical signs of circulatory problems of arm and hand, re-interventions). Mean midterm follow-up was 18.7 ± 12.3 [1.1–51.2] months. During follow-up, 16 patients died. Overall, a total of 397 patients (344 male; 67.6 ± 9.7 [32–88]) were included for follow-up (100%). Results: The RAA was successfully cannulated in 100% of patients. A cannula size of 16 Fr was used in 34.6%, 18 Fr in 63.9% and 20 Fr in 1.5% of all patients. There was no intraoperative bleeding complication. In two patients, intraoperative revision of the RAA was required, necessitating a venous patch repair. At follow-up, there were no differences between the systolic and diastolic blood pressure or the pressure gradients between the right and left arm. Transient numbness of the right hand was observed in two patients. Permanent numbness was not observed. No patient needed further intervention or surgical revision of the RAA. Conclusions: The right axillary cannulation is feasible and safe in terms of vascular injury and brachial plexus injury with excellent in-hospital and follow-up outcome. Full article

Minimally invasive, sternum-sparing total coronary revascularization in multivessel disease via left anterior mini-thoracotomy (TCRAT) was introduced recently. Intra-aortic balloon occlusion is a conceivable option to avoid manipulation of the ascending aorta, to reduce the risk of stroke and to be able to treat patients with severe calcifications and unfavorable aortic anatomies. Background/Objectives: The aim of our study was to show that the use of the IntraClude^® device, as part of minimally invasive coronary artery bypass grafting (CABG) via left anterior mini-thoracotomy, is feasible. Methods: From May to December 2023, CABG via left anterior mini-thoracotomy on cardiopulmonary bypass and cardioplegic arrest was successfully performed in 20 patients (17 male, 67.6 ± 8.2 (51–82) years). All patients had significant coronary artery disease (three-vessel: n = 6; two-vessel: n = 11; one-vessel: n = 3) with indication for surgical revascularization. The mean EuroScore2 was 2.6. Results: All patients successfully underwent minimally invasive CABG using endo-aortic balloon occlusion. A total of 43 distal anastomoses (2.2 ± 0.6 (1–3) per patient) were performed by using left internal artery mammary (n = 20) and radial artery (n = 14) for grafting the left anterior descending (n = 19), circumflex (n = 15) and right (n = 6) coronary artery. There was no hospital mortality, no stroke, no myocardial infarction or repeat revascularization. A total of 15 out of 20 patients left hospital within 8 days after surgery. Conclusions: TCRAT by using the IntraClude^® device is feasible without compromising surgical principles while avoiding the external manipulation of the ascending aorta. The use of intra-aortic balloon occlusion instead of transthoracic clamps further reduces the invasiveness of the procedure. Full article

Objective: Renal dysfunction and acute renal failure after coronary artery bypass grafting (CABG) are among the main causes of increased mortality and morbidity. A sternum-sparing concept of minimally invasive total coronary revascularization via anterior minithoracotomy (TCRAT) was introduced with promising early and midterm outcomes in multivessel coronary artery disease. There are limited data regarding renal complications in patients undergoing the TCRAT technique. The present study analyzed renal outcomes in TCRAT compared to CABG via full median sternotomy (FS). Methods: We analyzed the records of 227 consecutive TCRAT patients (from September 2021 to June 2023) and 228 consecutive FS patients (from January 2017 to December 2018) who underwent nonemergent CABG. Following propensity score matching, preoperative baseline characteristics—including age, sex, diabetes mellitus, arterial hypertension, left ventricular ejection fraction, EuroSCORE II, preoperative serum creatinine, estimated glomerular filtration rate (eGFR), serum urea, and pre-existing chronic renal insufficiency—were comparable between the TCRAT (n = 170) and the FS group (n = 170). The examined postoperative renal parameters and complications were serum creatinine, eGFR, and serum urea on the first postoperative day. Moreover, serum creatinine, eGFR and serum urea at the time of discharge, postoperative ARF, and hemodialysis were investigated. Additionally, the duration of operation, CPB time, aortic cross-clamp time, ICU and hospital stay, ECMO support, rethoracotomy and in-hospital mortality were analyzed. The parameters were compared between groups using a Student’s t-test or Mann–Whitney U test. Results: The duration of operation (332 ± 66 vs. 257 ± 61 min; p < 0.05), CPB time (161 ± 40 vs. 116 ± 38 min; p < 0.05), and aortic cross-clamp time (100 ± 31 vs. 76 ± 26; p < 0.05) were longer in the TCRAT group. ICU (1.8 ± 2.2 vs. 2.9 ± 3.6 days; p < 0.05) and hospital (10.4 ± 7.6 vs. 12.4 ± 7.5 days; p < 0.05) stays were shorter in the TCRAT group. There were no differences between groups with regard to the renal parameters examined. Conclusions: Despite a prolonged duration of operation, CPB time, and aortic cross-clamp time when using the TCRAT technique, no increase in renal complications were found. In addition, ICU and hospital stays in the TCRAT group were shorter compared to CABG via full median sternotomy. Full article

Coronary artery bypass grafting (CABG) is an essential operation for patients who have severe coronary artery disease (CAD). Both open and minimally invasive CABG methods are used to treat CAD. This in-depth review looks at the latest research on the effectiveness of open versus minimally invasive CABG. The goal is to develop evidence-based guidelines that will improve surgical outcomes. This systematic review used databases such as PubMed, MEDLINE, and Web of Science for a full electronic search. We adhered to the PRISMA guidelines and registered the results in the PROSPERO. The search method used MeSH phrases and many different study types to find papers. After removing duplicate publications and conducting a screening process, we collaboratively evaluated the full texts to determine their inclusion. We then extracted data, including diagnosis, the total number of patients in the study, clinical recommendations from the studies, surgical complications, angina recurrence, hospital stay duration, and mortality rates. Many studies that investigate open and minimally invasive CABG methods have shown that the type of surgery can have a large effect on how well the patient recovers and how well the surgery works overall. While there are limited data on the possible advantages of minimally invasive CABG, a conclusive comparison with open CABG is still dubious. Additional clinical trials are required to examine a wider spectrum of patient results. Full article

Background: The interaction between chronic obstructive pulmonary disease (COPD) and coronary artery bypass grafting (CABG) is discussed controversial. Methods: In this population-based retrospective analysis including non-emergency CABG in Germany between 2015 and 2021, the aim was to compare in-hospital mortality, hospital length of stay (HLOS), and perioperative ventilation time (VT) in patients affected by COPD and not affected by COPD. In addition, we compared outcomes after off-pump coronary artery bypass (OPCAB) and on-pump coronary artery bypass (ONCAB) surgery and outcomes after CABG with a minimally invasive technique with and without cardiopulmonary bypass (CPB) in COPD patients. Results: Of the 274,792 analyzed cases undergoing non-emergency CABG, 7.7% suffered from COPD. COPD patients showed a higher in-hospital mortality (6.0% vs. 4.2%; p < 0.001), a longer HLOS (13 days (10–19) vs. 12 days (9–16); p < 0.001), and a longer VT (33 h (11–124) vs. 28 h (9–94); p < 0.001). In subgroup analyses, COPD patients undergoing OPCAB surgery showed a lower in-hospital mortality (3.5% vs. 6.4%; p < 0.001), a shorter HLOS (12 days (9–16) vs. 13 days (10–19); p < 0.001) and a shorter VT (20 h (10–69) vs. 36 h (11–135); p < 0.001) compared to ONCAB surgery. Regression analyses confirmed that using cardiopulmonary bypass in COPD patients is associated with a higher risk of in-hospital mortality (OR, 1.86; 95% CI: 1.51–2.29, p < 0.001), a longer HLOS (1.44 days; 95% CI: 0.91–1.97, p < 0.001), and a longer VT (33.67 h; 95% CI: 18.67–48.66, p < 0.001). In further subgroup analyses, COPD patients undergoing CABG with a minimally invasive technique without CPB showed a lower in-hospital mortality (3.5% vs. 16.5%; p < 0.001) and a shorter VT (20 h (10–69) vs. 65 h (29–210); p < 0.001) compared to CABG with a minimally invasive technique and CPB. Regression analyses confirmed that using CPB in COPD patients undergoing CABG with a minimally invasive technique is associated with a higher risk of in-hospital mortality (OR, 4.80; 95% CI: 2.42–9.51, p < 0.001). Conclusions: COPD negatively impacts outcomes after non-emergency CABG. According to our results, OPCAB surgery and CABG with a minimally invasive technique without CPB seem to be beneficial for COPD patients. Further studies should be performed to confirm this. Full article

Background: Minimally invasive mitral valve surgery (MIMVS) is a treatment for severe mitral valve pathologies. In redo cases, especially after coronary artery bypass grafting (CABG) surgery with patent mammary bypass grafts, establishing aortic clamping followed by antegrade cardioplegia application might be challenging. Here, we present the outcome of hypothermic ventricular fibrillation as an alternative to conventional cardioprotection. Methods: Patients who underwent MIMVS either received hypothermic ventricular fibrillation (study group, n = 48) or antegrade cardioprotection (control group, n = 840) and were observed for 30 postoperative days. Data were retrospectively analyzed and collected from January 2011 until December 2022. Results: Patients in the study group had a higher preoperative prevalence of renal insufficiency (p = 0.001), extracardiac arteriopathy (p = 0.001), insulin-dependent diabetes mellitus (p = 0.001) and chronic lung disease (p = 0.036). Furthermore, they had a longer surgery time and a lower repair rate (p < 0.001). No difference, however, was seen in postoperative incidences of stroke (p = 0.26), myocardial infarction (p = 1) and mitral valve re-operation (p = 1) as well as 30-day mortality (p = 0.1) and postoperative mitral valve insufficiency or stenosis. Conclusions: The patients who underwent redo MIMVS with hypothermic ventricular fibrillation did not have worse outcomes or more serious adverse events compared to the patients who received routine conventional cardioprotection. Therefore, the use of hypothermic ventricular fibrillation appears to be a promising cardioprotective technique in this challenging patient population requiring redo MIMVS. Full article

The harvesting of conduits for coronary artery bypass surgery has evolved over the last decade to include endoscopic approaches to access the saphenous vein, radial artery, and internal mammary artery. These minimally invasive techniques reduce the morbidity associated with open procedures by decreasing pain and recovery time and increasing mobility post operatively. This review highlights the differences in morbidity, quality, and patency between the most common conduits that are harvested minimally invasively for coronary artery bypass grafting surgery. Full article

Background: Coronary artery disease is a major cause of death globally. Minimally invasive direct coronary artery bypass (MIDCAB), using a small left anterior thoracotomy, aims to provide a less invasive alternative to traditional procedures, potentially improving patient outcomes with reduced recovery times. Methods: This retrospective, non-randomized study analyzed 310 patients who underwent MIDCAB between July 1999 and April 2022. Data were collected on demographics, clinical characteristics, operative and postoperative outcomes, and follow-up mortality and morbidity. Statistical analysis was conducted using IBM SPSS, with survival curves generated via the Kaplan–Meier method. Results: The cohort had a mean age of 63.3 ± 10.9 years, with 30.6% females. The majority of surgeries were elective (76.1%), with an average operating time of 129.7 ± 35.3 min. The median rate of intraoperative blood transfusions was 0.0 (CI 0.0–2.0) Units. The mean in-hospital stay was 8.7 ± 5.5 days, and the median ICU stay was just one day. Early postoperative complications were minimal, with a 0.64% in-hospital mortality rate. The 6-month and 1-year mortalities were 0.97%, with a 10-year survival rate of 94.3%. There were two cases of perioperative myocardial infarction and no instances of stroke or new onset dialysis. Conclusions: The MIDCAB approach demonstrates significant benefits in terms of patient recovery and long-term outcomes, offering a viable and effective alternative for patients suitable for less invasive procedures. Our results suggest that MIDCAB is a safe option with favorable survival rates, justifying its consideration in high-volume centers focused on minimally invasive techniques. Full article

Background/Objectives: The minimally invasive approach through left mini-thoracotomy is a promising alternative to the median sternotomy for coronary artery bypass. The aim of this study was to compare the short-term outcomes of patients undergoing minimally invasive coronary artery bypass (MIDCAB) with off-pump coronary artery bypass through sternotomy (OPCAB) for single-vessel disease. Methods: From January 2017 to February 2023, 377 consecutive patients aged above 18 years undergoing off-pump bypass of the left anterior descending artery (LAD) with left internal thoracic artery underwent OPCAB. Propensity score matching was then applied. Primary endpoints were in-hospital mortality and 30-day mortality. Results: Prior to matching, 30-day mortality occurred in 2 (0.7%) patients in the MIDCAB group vs. 1 (1%) patient in the OPCAP group (p = 1). Transfusion of red blood cells (RBC) was required in 9.4% and 29% of patients within the MIDCAB and the OPCAB groups, respectively (p < 0.001). Median intensive care stay (ICU) was 1 [1–2] day in the MIDCAB group, vs. 2 [1–3] in the OPCAB (p < 0.001). In the matched cohort, 10% of MIDCAB patients received RBCs vs. 27.5% of OPCAB patients (p = 0.006). Median ICU stay was significantly lower in the MIDCAB group, 1 [1–2] vs. 2 [1–3] days. Conclusions: MIDCAB is as safe and effective as OPCAB for single coronary artery bypass of the LAD with the LITA in select patients. It is associated with a decreased ICU stay and lower transfusion rates when compared with OPCAB. Full article

Simultaneous carotid artery stenosis (CS) and coronary artery disease (CAD) is a common condition among patients with several cardiovascular risk factors; however, its optimal management still remains under investigation, such as the assumption that carotid disease is causally related to perioperative stroke and that preventive carotid revascularization decrease the risk of this complication. Synchronous surgical approach to both conditions, performing carotid endarterectomy (CEA) before coronary artery bypass graft (CABG) during the same procedure, should still be considered in selective patients, in order to reduce the risk of perioperative stroke during coronary cardiac surgery. For the same purpose, staged approaches, such as CEA followed by CABG or CABG followed by CEA during the same hospitalization or a few weeks later have been described. Hybrid approach with carotid artery stenting (CAS) and CABG can also be an option in selected cases, offering a minimally invasive procedure to treat CS among patients whom CABG cannot be postponed. When carotid intervention is indicated in patients with concomitant CAD requiring CABG, a personalized and tailored approach is mandatory, especially in asymptomatic patients, in order to define the ideal surgical strategy. The aim of this paper is to summarize the current “state of the art” of the different approaches to carotid artery diseases in patients undergoing CABG. Full article