Minimally-invasive Direct Coronary Artery Bypass (midcab): An Evolving Paradigm Over The Past Twenty-five Years
Iam Claire Sarmiento, Michael Varrone, Jonathan Hemli, Luigi Pirelli, Derek R. Brinster, Varinder Singh, Michael C. Kim, S Jacob Scheinerman, Nirav C. Patel.
Northwell Health Lenox Hill Hospital, New York, NY, USA.
BACKGROUND: Our institution has employed minimally-invasive direct coronary artery bypass (MIDCAB) for surgical revascularization of the left anterior descending (LAD) and other coronary artery targets for the past 25 years. We sought to analyze the changes that have taken place during this time in order to describe how minimal-access LAD grafting has evolved over the past quarter century.
METHODS: A total of 2169 patients who underwent MIDCAB between 1996 and 2020 were divided into three groups, by year of surgery: Group A, 1996 - 2002, n = 758 (34.9%), left internal mammary artery (LIMA) harvested almost exclusively using open techniques; Group B, 2003 - 2009, n = 454 (20.9%), LIMA harvested using a combination of open and endoscopic methods; Group C, 2009 - 2020, n = 957 (44.1%), LIMA mobilized utilizing robotic assistance. The risk profiles of each patient group were compared, as were their short-term postoperative outcomes.
RESULTS: Overall 30-day mortality for the entire 25-year cohort was 1.2% (27 deaths), not significantly different between the 3 groups. Patients in Group A had more comorbidities than those in group C, including peripheral vascular disease (17.7% vs. 10.2%, p < 0.001), congestive heart failure (39.4% vs. 17.1%, p < 0.001), and a history of stroke (18.1% vs. 10.7%, p < 0.001), although diabetics were more commonly seen in Group C (50.7%) vs. Group A (31.0%) and Group B (31.5%) (p < 0.001). A greater proportion of cases in Group A had already undergone coronary artery surgery prior to their MIDCAB (40.6%) vs. Group B (21.1%) and Group C (4.8%) (p < 0.001). Perioperative stroke was more frequent in Group A (1.2%) vs. Group B (0.0%) and Group C (0.2%) (p = 0.004), as was the need for prolonged ventilation (3.6% vs. 0.2% vs. 0.9%, respectively, p < 0.001).
CONCLUSIONS: MIDCAB is now performed using robotic-assisted techniques. MIDCAB patients have less comorbidities than previously, implying a more liberal use of this approach, rather than it being reserved for the higher-risk cases only. 
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