Off-pump coronary artery bypass surgery with bilateral internal thoracic arteries: the Leipzig experience

Abstract

Background: Contrasting results of recent randomized controlled trials (RCTs) comparing off-pump and on-pump coronary artery bypass graft (CABG) surgery, as well as the lack of evidence for any survival benefit of bilateral internal thoracic artery (ITA) grafting over single ITA use, has intensified the debate about the role of the off-pump technique and bilateral ITA use in CABG surgery. We therefore investigated our 15-year experience in off-pump CABG with bilateral ITA grafting and evaluated temporal trends in preoperative characteristics and postoperative outcomes.Methods: Demographic, intra-operative, and outcome data of 1,199 consecutive patients undergoing offpump CABG with bilateral ITA grafting was prospectively collected in a computerized database. Patients who underwent on-pump cardiac procedures and other extra-cardiac procedures were excluded from this study.Assessment of changes in perioperative characteristics and parameters with time was performed by dividing the whole cohort into three groups (2003-2007, 2008-2012, and 2013-2017) based on the year of surgery. Results:The overall 30-day mortality was 0.6%, with no differences observed between the three time cohorts (0.6%, 0.7%, 0.5%; P=0.8). The perioperative stroke rate for whole cohort was 0.6% and demonstrated a significant reduction in the last two time cohorts (1%, 0.5%, 0.5%; P<0.0001). The overall incidence of deep sternal wound infections was 0.7%, but was marginally higher in the last time-cohort (0.6%, 0.5%, 0.9%; P=0.7). Overall survival for the entire cohort was 92.9%±1% and 78.9%±4% at 5 and 10 years follow-up, respectively. Older age at surgery and presence of peripheral vascular disease were the only predictors of late mortality.Conclusions: Off-pump CABG with bilateral skeletonized ITAs is a safe operation and is associated with a low mortality and morbidity, which can be maintained in high volume center unit over a long period of time.The long-term survival of patients undergoing such an operation is excellent.

Minimally invasive coronary bypass surgery with bilateral internal thoracic arteries: Early outcomes and angiographic patency

“…On the basis of the experience of off-pump CABG 14 and minimally invasive direct coronary artery bypass (MIDCAB) surgery 15 in our institute, we developed the technique of performing multivessel CABG with bilateral ITAs through a left anterolateral minithoracotomy for selected patients. The aim of the present study was to assess the early mortality and major postoperative complications such as myocardial infarction, stroke, wound infections, and renal and respiratory insufficiency, and evaluate the angiographic patency of grafts performed with this technique.…”

Commentary: “Do or do not. There is no try”: Which role for minimally invasive direct coronary artery bypass?

“…This encouraging report must be interpreted considering that this is a single-center experience with robust familiarity with the surgical skills required for this technique. Indeed, the proficiency of this group had been previously shown in off-pump CABG with bilateral internal mammary arteries 4 and in MIDCAB. 5 In the current study, the authors demonstrate that they are well past their learning curve, which represents one of the difficulties when adopting a new, unfamiliar technique.…”

Graft patency and completeness of revascularization in minimally invasive multivessel coronary artery bypass surgery

“…We adopted the “Nambiar technique” 10 when starting MICS CABG with the bilateral internal thoracic arteries and performed this procedure in about 50 cases. Once we had become comfortable with handsewn proximal anastomosis using a side clamp, we routinely performed the “proximal first” sequential graft 18 after LITA‐to‐LAD anastomosis. This strategy provides the greatest possible blood supply to the myocardium during manipulation of the heart, minimizing the possibility of intraoperative hemodynamic instability.…”