Evolution Of Surgical Expertise In Minimally Invasive Coronary Artery Bypass (mics-cabg). Experience Of First 70 Consecutive Patients
Sotirios Marinakis, Karim Homsy, Badih El Nakadi.
CHU Charleroi, Lodelinsart, Belgium.
BACKGROUND: Minimally invasive procedures for coronary revascularization have been performed for over 20 years; however, their technical complexity, steep learning curves and absence of training programs explain the weak acceptance of these techniques. The aim of this study is to share our experience on how our peri and postoperative management of our MICS CABGs patients evolved over time by critically evaluating our initial 70 consecutive procedures. Moreover, we divided our cohort between initial 30 and late 40 patients and we compared their demographic data, peri and postoperative outcomes.
METHODS: All patients who benefited from an endoscopic atraumatic coronary artery bypass (Endo-ACAB) in our hospital, from July 2018 to October 2021 (n=70) were identified. Baseline demographics, peri, postoperative and laboratory data were extracted from each patient’s medical records. Results were compared between our initial and late experience.
RESULTS: In our practice, we noticed a relationship between surgical team experience and better postoperative outcome, despite the adoption of more complex surgical revascularization strategies. The cutoff point seems to be the first 30 patients. Fifty-one patients were planned for a single Left Internal Mammary Artery (LIMA) to Left anterior Descending Artery (LAD) Endo-ACAB. The remaining nineteen had a multivessel Endo-ACAB. However, after our first 30 cases we experienced a shift of our activity towards more complex revascularizations with significantly more multivessel Endo-ACABs (2/30, 7% vs 17/40, 42,5%, p=0,002) and a reduction in the observed 30-day Major Adverse Cardiac Event (MACE) rate between groups (3/30 vs 0/40, p=0,074). Other demographic, peri and postoperative data were similar and are reported in the annexed table. Moreover, our anesthesiologic management evolved over time, with a shift from single to double lung ventilation throughout the operation for all our patients after the 48th patient and the administration of spinal analgesia, systematically, after the 34th patient.
CONCLUSIONS: Endo-ACAB is a technically demanding operation. With ongoing experience, we attempted more complex surgeries along with better postoperative outcomes. A minimum learning exposure to 30 patients was necessary to obtain sufficient expertise with the technique.
| EndoACAB, initial experience (n= 30) | EndoACAB, late experience (n= 4à) | p Value | |
| Age in years, median (IQR) | 62,3 (57,3- 71) | 64,1 (58,6- 72,4) | 0,591 |
| BMI, median (IQR) | 26,6 (23,- 30,8) | 27,4 (25,3- 34,6) | 0,918 |
| Euroscore II, median (IQR) | 1,04 (0,68- 1,8) | 1,14 (0,86- 1,57) | 0,775 |
| Single vessel CABG, n (%) | 28/30 (93) | 23/40 (58) | 0,002 |
| Hybrid revascularization, n (%) | 10/30 (33) | 9/40 (23) | 0,417 |
| Surgery duration, median (IQR) (min) | 263 (236- 316) | 254 (199- 359) | 0,349 |
| Postoperative lenght of stay, median (IQR) (days) | 7 (6- 9) | 8 (6-10) | 0,841 |
| Intensive Care Unit length of stay, median (IQR) (hours) | 42 (22- 68) | 24 (22- 65) | 0,505 |
| MACE at 30 days, n (%) | 3/30 (10) | 0/40 (0) | 0,074 |
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