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Mid-Term Follow-up of Minimally Invasive Multivessel Coronary Artery Bypass Grafting: Is the Learning Curve Detrimental?
Maria Lorena Rodriguez, Harry Lapierre, Benjamin Sohmer, David Glineur, Marc Ruel.
University of Ottawa Heart Institute, Ottawa, ON, Canada.

OBJECTIVE: Multivessel small thoracotomy coronary artery bypass grafting (MVST CABG) is a novel minimally invasive technique for surgical coronary revascularization which is increasingly being adopted around the world. This study aims to describe the characteristics and medium-term outcomes of a series of MICS CABG, in order to identify areas for improvement.
METHODS: A prospective longitudinal study was performed on the 306 MICS CABG patients operated by a single surgeon from 2005 to 2015. MICS CABG utilized a small left thoracotomy to enable coronary revascularization with a similar configuration to an open sternotomy technique, with left internal thoracic artery harvesting, and hand-sewn proximal radial/saphenous and distal anastomoses, under direct visualization. We compared patients who were operated during the first and second halves of the series in order to ascertain the impact of a learning curve on outcomes.
RESULTS: The average age was 62 +/- 9 years, 87% were male, and 23% had 3-vessel disease. OPCAB was performed in 80% and the median number of grafts was 2 (range 1-4). Sternotomy conversion occurred in 3.3%, reoperation for bleeding in 2%, and unplanned, emergency CPB conversion in 1%. Superficial thoracotomy infection, atrial fibrillation, and left-sided pleural effusion requiring drainage were encountered in 2%, 4%, and 4%, respectively. There were no perioperative stroke, myocardial infarction or death. At a mean follow-up of 1,024 days, 97.4% of patients were free from major adverse coronary and cerebrovascular events. Between the first and latter half of the series, there was a decrease in the rate of conversion to sternotomy (5.2% to 1.3%, p=0.05) and in the mid-term need for repeat revascularization (11% vs. 2.6% at 3 years, p=0.03). The ICU and hospital lengths of stay (1.6±1.5 vs 1.4±0.9, p=0.2; and 6.1±2.6 vs 5.6±1.8, p=0.4) were not statistically different.
CONCLUSIONS: MICS CABG can be safely initiated as a minimally invasive, multivessel alternative to open surgical coronary revascularization, with excellent mid-term results. Learning curve effects were not observed with regards to overall procedural safety, but rather in terms of improved freedom from conversion to sternotomy and from repeat revascularization.

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