Long-term Results Of Multivessel Minimally Invasive Coronary Artery Bypass Grafting
Shantanu Pande, Surendra K. Agarwal, Amit Rastogi, Ankush Kotwal, Prabhakar Mishra, Prabhat Tewari.
Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
BACKGROUND: Minimally Invasive Coronary Artery Bypass Grafting (MICABG) has been proven to be a safe technique for revascularization of multivessel coronary artery disease. However, there are scanty literature on its long-term results. In this study we analyse the long-term result of this operation and compare it with the results of conventional and total arterial revascularization through sternotomy.
METHODS: This is a retrospective cohort study conducted between January 2012 and December 2019. A total of 1270 sternotomy CABG were operated while 221 minimally invasive CABG (MICABG) were operated during this period. Through sternotomy, 490 patients received one artery and two veins (cCABG) and 559 received total arterial revascularization (T-CABG). All patients were followed with clinical questionnaire and echocardiography. Propensity score matching (PSM) of the cohort was performed using 5% variation for continuous variable and 1:1 for categorical variables to select cases for two groups. PSM was performed for age, gender, body mass index, number of grafts, total arterial revascularization and left ventricle end diastolic dimension and ejection fraction. Two groups were formed, T-CABG (total arterial CABG through sternotomy) and MICABG, of 109 cases each. T-CABG was performed with right and left internal mammary artery as pedicled grafts while MICABG used LIMA and RIMA as ‘y’ configuration. The analysis of data was done after its retrieval from the hospital information system. Outcome measures were all cause mortality in 5 years, re-investigation for angina, readmission for cardiac reasons.
RESULTS: A mean follow-up was available for 60.2 ± 31.5 months for MICABG, 49.6 ± 26.7 months for cCABG and 32.30 ± 22.8 months for T-CABG group. Freedom from all-cause mortality was 87.6% in cCABG, 95.9% in T-CABG and 94.5% in MICABG groups (p=NS). While freedom from angina was 94.7%, 94.8% and 94.1% respectively in cCABG, T-CABG and MICABG groups (p=NS). In propensity matched cohorts of TAR and MICAB groups the preoperative risk factors, LV functions and follow-up LV functions were similar. There was significant postoperative blood drainage in T-CABG group (876 ml ± 613 vs 1105 ml ± 885, p=0.03) and more use of blood product (1.87 ± 2.09 vs 2.75 ± 2.71, p=0.009). Though there was no significant difference in hospital stay, follow-up imaging, mortality or readmissions. However, the mortality, hospital stay after operation and readmissions showed clinically relevant advantage in MICABG group when two groups were compared. There was an observed mortality of 7 out of 109, 6.4% in T-CABG vs 4, 3.7% in MICABG group. Similarly, there were 21 readmissions, 21.1% in T-CABG group vs 14, 12.8% in MICABG group and hospital stay of 110.46 hours ± 346.10 in T-CABG vs 76.53 hours ± 84.85 in MICABG group. The survival curves for all cause mortality is represented in figure 1.
CONCLUSIONS: The long-term follow-up for MICABG was comparable to sternotomy approach for total arterial revascularization. However, MICABG had superior results in matched cohort at follow-up. 
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