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MICS CABG: The Learning Curve - Lessons Learned
Odeaa Al jabbari, MD, Walid K. Abu Saleh, MD, Basel Ramlawi, MD, Mahesh Ramchandani, MD.
Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA.
OBJECTIVE: Minimally invasive cardiac surgery (MICS) for coronary artery bypass grafting (CABG) can achieve durable revascularization without the need for a conventional sternotomy. We describe our early and recent experiences with MICS CABG. The differences in outcomes reflect lessons from the learning curve.
METHODS: In a large retrospective analysis at our institution, we analyzed data from181 patients who underwent MICS CABG from March 2005 to June 2014. Early cases (before August 2009) and late cases (from August 2009 onward) were sub-stratified and analyzed for postoperative outcome using a student t test for continuous variables, chi squared test for categorical variables, and Cox regression.
RESULTS: We have seen significant improvement in our operative proficiency as well as post-operative outcomes in our MICS CABG patients over the past 5 years compared to our first 4 years. From March 2005 to August 2009, one-month mortality was 3.45% compared to 0% from August 2009 onwards (p = 0.013). There was also a significant reduction in the need for intraoperative blood products (30.61% vs. 13.5%, p = 0.026).
The following variables showed no significant difference between early and late groups. Postoperative morbidity at one month - defined as significant bleeding, valve dysfunction, graft occlusion, TIA, stroke, ventilation dependence, or renal failure (36.73% vs. 36.09% respectively, p = 0.943). Postoperative length of stay (10.31 days vs. 8.00 days, p = 0.081). Surgery duration (4.95 hrs vs. 4.26 hrs, p = 0.099). Average hours in the ICU (137.18 hrs vs. 57.8 hours, p = 0.078) and readmission rate to the ICU (8.16% vs. 3.0%, p = 0.238).
CONCLUSIONS: MICS CABG is a surgical approach that can be performed safely and effectively. In the second group of or experience, we were able to achieve significantly better mortality rates at one month and require less intraoperative blood products when compared to the first group of our experience. Valuable lessons were learned in technique, patient selection and teamwork that could help to shorten the learning curve for others embarking on such a program
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