Joseph T. McGinn, Jr.1, Vijayasimha R. Pothula1, Scott M. Sadel1, Benny Liliav1, Praveen Potluru1, William J. Molloy1, Mark Ruel2.
1Staten Island University Hospital, Staten Island, NY, USA, 2University of Ottawa Heart Institute, Ottawa, ON, Canada.
OBJECTIVE:
Minimally invasive cardiac surgery (MICS) is a novel coronary operation that does not require special infrastructure and is potentially available to all cardiac surgeons. It aims at competing with minimal invasiveness of percutaneous coronary interventions (PCI) while providing patients with the durability of surgical revascularization. We hereby examine the feasibility, safety and therapeutic relevance of MICS with the largest consecutive series of this operation to date.
METHODS:
All myocardial territories can be accessed via a 4 to 6 cm left intercostal (IC) thoracotomy. An endothoracic apical retractor and epicardial stabilizer are introduced through the subxiphoid and left 7th IC space, respectively. The procedure is performed off- pump. The left internal mammary artery (LIMA) is used to graft left anterior descending (LAD), and radial artery and /or saphenous vein segments are used to graft the lateral and inferior myocardial territories. Proximals may be performed from LIMA as T graft or directly onto aorta
RESULTS:
There were 285 consecutive minimally invasive cardiac surgeries done at our 2 centers. Mean age was 62.7±11.5 years and 87 patients were female (31%). Diabetes was prevalent in 89 (31%) and previous PCI in 60 (21%). The average number of grafts was 2.3±0.9 and 91 (32%) patients had total arterial grafting. There were 12 conversions to sternotomy (4.2%), 7 patients requiring CPB assistance (2.5%) and 3 reinterventions for bleeding (1%). Perioperative mortality was 2 patients (0.7%). Respiratory failure occurred in 22 patients (7.7%), atrial fibrillation in 50 (18%), and mean length of stay was 4 days. No stroke or deep wound infection occurred. At a mean follow up of 15.6±8.4 months 9 patients (3.2%) had required postoperative coronary interventions, 7 of which were for issues with LIMA T - grafts. Two graft failures occurred in 120 patients with proximal anastamosis onto the aorta (p= 0.1 vs. LIMA T - grafts; Fisher’s exact).
CONCLUSIONS: MICS is feasible, safe and associated with excellent procedural and short-term outcomes. The avoidance of T grafts based on LIMA may optimize long-term graft patency. This procedure has potential to make minimally invasive multi-vessel coronary surgery safe, effective and widely diffusible.
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