Conversion To Sternotomy While Performing Minimally Invasive Coronary Artery Bypass Grafting
Shantanu Pande, Surendra K. Agarwal, Devendra Gupta, Amit Rastogi, Chetna Shamsherey, Prabhat Tewari.
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
Background: Over past two decades, the efficacy and safety of minimally invasive technique has proven to be equivalent to conventional surgical revascularization. However, it remains a skilled operation with prolonged learning curve. Conversion to sternotomy is the safest proposition when encountered with difficulty in completing the procedure through a limited exposure. We analyze the rate of conversion and its possible reasons during performance of this procedure spread over the experience of ten years. Material and Method: This study includes patients operated with MICABG between January 2009 and April 2019. The period is divided into quartiles of 3 years each with the fourth one of one and a quarter of an year. First quartile was the establishment phase (n=27), Second the consolidation phase (n=68 ), the third one expansion phase (n=74 ) and the fourth is expert phase (n=41 ). Hospital information system was used to access data. This study is approved by the institute ethics committee. Results: Total conversions were 3.33 % with 1 each in 1st and 2nd phase while 5 in 3rd phase. Body mass index expressed as median value remained similar in each phase (24.2, 23.8, 24.35 and 25.0 respectively). There was rising mean number of grafts 1.41, 1.8, 1.78 and 1.98 respectively in each phase. There were higher 2 grafts cases in phase 2 to 4 (25.9%, 54.5%, 45.9% and 53.9%). Similarly 3 graft cases rise in each phase (7.4%, 14.5%, 16.2% and 22%) respectively. The number of cases with severe left ventricular dysfunction (Ejection fraction <40%) was maximum in phase 3 (14.2%). There was a significant rise in number of grafts done per patient from phase 1 to 2 (p=0.005) and similarly more patients with poor ventricles operated when comparing phase 1 and 2 (p=0.04) and phase 2 and 3 (p=0.001). All the patients requiring conversion has no mortality. Conclusion: The conversions can be limited with gradual and cautious choice of patients in initial phase. But there is a an increase in rate of conversion when complexity of cases is increased. However, with increasing experience the conversions can be avoided in complex cases.
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