Complete Revascularization May Not Be Necessary Following Robotically-assisted Midcab
Richard Cook, MD1, Neil Wu2, Peter Skarsgard, MD1, Anthony Fung, MD1, Jacqueline Saw, MD1, David Wood, MD1.
1University of British Columbia, Vancouver, BC, Canada, 2McGill University, Montreal, QC, Canada.
Until recently, patients with multi-vessel coronary artery disease (MVCAD) who underwent incomplete revascularization were felt to have poorer outcomes. However, the COURAGE trial found that revascularization did not confer a survival benefit over medical management alone in some patients with CAD. Furthermore, some patients with MVCAD may have a high risk of peri-operative mortality when undergoing standard coronary artery bypass graft (CABG) surgery. Robotically-Assisted Minimally Invasive Direct Coronary Artery Bypass (RA-MIDCAB) surgery may allow higher risk patients to receive an internal mammary artery graft to the left anterior descending artery with less risk of mortality and morbidity than with standard CABG. However, complete revascularization would require stenting of other stenosed coronary arteries. At our institution, 77 patients with MVCAD have undergone RA-MIDCAB. Of those patients, 22 had stenting of other vessels (“Hybrid” group). We sought to compare outcomes between these patients, and the 55 patients who did not (“Non-Hybrid group).
This was a retrospective review, including patients from May 2009 (1st RA-MIDCAB case at our institution) to August 2015 (to allow for 1 year follow-up). Preoperative factors were compared between the two groups using 2-tailed Student’s t-tests. Follow-up information was collected at least one year post-operatively. Kaplan-Meier survival curves were used to compare survival between the 2 groups.
The mean STS risk score for perioperative mortality was higher in the Hybrid group than the Non-Hybrid group (6.3 +/-2.0 vs 3.1 +/-1.8, respectively), however, there were no perioperative deaths. Only 1 patient had a major CVA post-operatively, and none of the patients had a wound infection. There was no significant difference in survival observed between the Hybrid and Non-Hybrid groups (Figure 1, log rank test p = 0.57).
Our small experience suggests that in certain highly-selected patients with MVCAD, incomplete revascularization with RA-MIDCAB alone may be a reasonable and safe alternative to complete revascularization.
LEGEND: Figure 1: Kaplan Meier Survival Curves
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