Does a minimally invasive approach result in better pulmonary function postoperatively when compared with median sternotomy for coronary artery bypass graft?

Abstract

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Does a minimally invasive approach result in better pulmonary function postoperatively when compared with median sternotomy for coronary artery bypass graft?'. Procedures such as limited sternotomy and minimally invasive direct coronary artery bypass (MIDCAB) though a minithoracotomy were regarded as minimally invasive. Overall, 681 papers were found, of which eight represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, evidence level, relevant outcomes and results of these papers were tabulated. Three randomized, controlled trials (RCT) were included: One study suggested that ministernotomy dividing the corpus sterni (n = 50) offers no advantage over standard sternotomy (n = 50) during the first 10 postoperative days. Two further studies reported on minithoracotomy: one trial presented data suggesting that minithoracotomy (n = 21) is as safe as standard sternotomy with (n = 18) or without (n = 19) cardiopulmonary bypass, but without the benefit ascribed to the minimally invasive incision. A two-centre report investigated pulmonary function as a secondary outcome and claimed that minithoracotomy worsens FEV1 and FVC. The study was not powered to detect these differences as pulmonary function data were available only for one of the centres. Five non-randomized reports were also included in this analysis: These investigated outcomes after minithoracotomy or limited sternotomy compared with standard sternotomy. Patient groups were small, involving <20 subjects per group. Non-randomized studies suggested a benefit to postoperative lung function in using thoracotomy. One of these reports included only patients with severe chronic obstructive pulmonary disease (COPD) (FEV1 <70% of predicted) and detected benefits in selected patients undergoing MIDCAB. A further study was in agreement with the above statement in patients without COPD. MIDCAB may be more painful initially, but results in quicker recovery of lung function. Demonstrating the benefits of ministernotomy compared with the standard sternal incision was less clear. One paper demonstrates better outcomes when compared with standard sternotomy, while another reports no difference. We conclude that non-randomized studies support the hypothesis that minimally invasive coronary artery bypass benefits postoperative lung function in patients with known respiratory problems.

Minimally Invasive Aortic Root Replacement with Valved Conduits through Partial Upper Sternotomy

“…Within the last years, the use of minimally invasive surgical access techniques such as partial upper sternotomy (PUS) increased, as its advantages could be demonstrated in numerous clinical trials. [1][2][3][4][5][6][7][8][9][10][11][12] Until now, minimally invasive surgical access is not routinely used in patients with the need for aortic root replacement (ARR), and full median sternotomy remains the standard operative access.…”

midcab-facilitates-combined-curative-treatment-in-the-high-risk-patient.pdf

“…Despite the vast effort the patient developed fat tissue necrosis and could be treated effectively, sternal infection and instability could be prevented facilitating the necessary following treatment [6]. The MIDCAB approch may be more painful initially, but results in quicker recovery of lung function demonstrating another benefit of the ministernotomy compared with traditional sternotomy for high risk patients [7]. In our case the patient received at the end of the procedure regional infiltration anaesthesia with lidcocaine to overcome early postoperative pain.…”

Continuous Procedural Full-Lung Ventilation During Minimally Invasive Coronary Bypass Grafting

“…Apart from fear of surgical complexity and technical considerations, one of the major concerns when considering a minimally invasive procedure is the potentially reduced lung function of the patient impeding prolonged singlelung ventilation. Nonetheless, comparison of minimally invasive procedures for CABG with conventional procedures through sternotomy showed evidence for thoracotomy-based approaches to benefit postoperative lung function in patients with known respiratory problems [11]. In addition, as reduced lung function is often correlated with other comorbidities, those patients might draw the largest benefit from a procedure of reduced invasiveness.…”

“…Endotracheal intubation management for procedural single-lung ventilation is challenging, however, as the application of a double-lumen endotracheal tube may promote multiple complications, such as trauma and consecutive bleeding of the oropharyngeal area, as well as bronchial rupture with bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema [9,10], and correct positioning of a single-lung ventilation tube may be difficult [11]. Further, one-sided lung occlusion-especially during extensive multivessel revascularization-may be limited by hypoventilation and hypoxemia and subsequent right-side heart failure because of increasing airway pressure and intrapulmonary shunt, depending on the patient's pulmonary reserve capacity.…”