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International Society For Minimally Invasive Cardiothoracic Surgery

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How to Set Up a Minimally Invasive Coronary Revascularization Program
Sotirios Marinakis, Elly Chaskis, Serge Cappeliez, Karim Homsy, Yasmine De Bruyne, Claire Viste, Steeve Dangotte, Adrien Poncelet, Christophe Lelubre, Badih El Nakadi
CHU Charleroi, Lodelinsart, Belgium

BACKGROUND: Minimally invasive procedures for coronary revascularization are in practice since more than 20 years. However, technical difficulty, steep learning curves and absence of training programs did not permit a wide acceptance of the technique. The aim of this study is to describe step-by-step our learning process experience on how to establish a minimally invasive direct coronary artery program with thoracoscopic left internal mammary artery (LIMA) harvesting in a center with limited previous experience in beating heart coronary surgery.
METHODS: We started our minimal invasive coronary program on July 2018 being accompanied for the first three procedures by a highly experienced surgeon. All consecutive patients who were operated for an endoscopic atraumatic coronary artery bypass (EACAB) in our hospital from July 2018 to Mai 2020 (n = 30) were identified through our computerized database. We did not apply any physiognomic or comorbidity exclusion criteria in our series. Baseline demographics, perioperative data, postoperative outcomes, and laboratory data were recorded after consultation of each patientís medical history. All patients were operated by a single surgeon.
RESULTS: Patients' demographics, perioperative and postoperative data and postoperative complications are summarized in the annexed table. Twenty-eight of 30 patients were planned for a single LIMA to left anterior descending artery EACAB. The remaining two had a T-graft double EACAB. Ten patients had a hybrid revascularization with the culprit lesion being first treated. Three patients were converted to sternotomy because of LIMA lesion during thoracoscopic harvesting. All three patients had an uneventful postoperative recovery. We accounted 3 major adverse cardiovascular events (MACE) in our series. One patient necessitated a target vessel revascularization due to LIMA dissection and two patients had an acute myocardial infarction concerning a non-bypassed artery.
CONCLUSIONS: EACAB is a technically demanding operation, however, it can be safely introduced in centers with no previous experience if a rigorous learning procedure is respected. Thoracoscopic LIMA harvesting seems to be the most demanding surgical skill to acquire.
LEGEND: Patientsí demographic and postoperative data (EACAB: Endoscopic Atraumatic Coronary Artery Bypass, IQR: Interquartile Range, LVEF: Left Ventricular Ejection Fraction, MACE: Major Adverse Cardiovascular Event)

Table: Patientsí demographic and postoperative data
Patientsí Demographics (n= 30)
Single Vessel EACAB, n (%)28/30 (93)Recent myocardial infarction, n (%)6/30 (20)
Hybrid Revascularization, n (%)10/30 (33)Extracardiac Arteriopathy, n (%)6/30 (20)
Age, median (IQR) (years)62 (57,8- 71)Diabetes, n (%)8/30 (27)
Euroscore II, median (IQR)0,85 (0,65- 1,51)Good LVEF (> 50%), n (%)21/30 (70)
Postoperative data (n=30)
Postoperative length of stay, median (IQR) (days)7 (6- 10)Myocardial Infarction, n (%)2/30 (6,7)
Intensive Care Unit length of stay, median (IQR) (hours)42 (22- 68)Target vessel revascularization, n (%)1/30 (3,3)
Postoperative intubation time, median (IQR) (hours)8 (5- 14)Stroke, n0/30
MACE at 30 days, n (%)3/30 (10)Mortality, n0/30

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