Figure Legend:
Rachel Eikelboom, Rashmi Nedadur, Roberto Vanin Pinto Ribeiro, Bobby
Yanagawa (Left to Right)
We congratulate Zhang and colleagues on their successful minimally
invasive multivessel coronary artery bypass surgery (MICS CABG)
program.1 They present a series of 186 consecutive
patients who underwent MICS CABG by expert surgeons at their center.
They report excellent graft patency and complete revascularization (CR)
rates. Graft patency was assessed by protocolized pre-discharge coronary
angiograms, demonstrating overall 96% patency. Complete
revascularization, as defined as number of grafts performed compared to
the surgeon’s preoperative plan, was achieved in all but one patient.
These are world-class results for conventional CABG, let alone MICS
CABG.
Zhang and colleagues’ series illustrates important principles in the
establishment of a MICS program. First, the quality of MICS surgery
should be as good as the conventional technique. Here, the surgeons
assessed graft patency with protocolized pre-discharge coronary
angiograms, which is the gold standard for assessing patency although
less invasive alternatives such as cardiac CT angiography may also be
reasonable.2 Their graft patency comparable favorably
to results from other conventional CABG in experienced
centers.3
Next, the surgeons confirmed complete revascularization. The definition
of CR include: 1) one graft per viable myocardial territory, 2) one
graft to every vessel >1.5mm with a >70%
stenosis, and 3) comparison of preoperative plan to actual grafts
performed.4 Here, the surgeons achieved exceptionally
high rates of CR. Even in CORONARY, which randomized patients to off-
versus on-pump CABG performed by expert surgeons, there was a 10% rate
of incomplete revascularization comparing preoperative plan to actual
grafts,5 compared with 99% CR in this trial.
Finally, surgical procedures need to be matched to both surgeon and
patient. Here, surgeons had experience in both off-pump CABG and single
vessel MICS CABG before attempting multivessel MICS CABG, and this is
likely why they were able to achieve such high rates of CR and graft
patency. Patients were carefully selected, with a mean age of 63 and a
mean BMI of 24, few comorbidities, and preserved left ventricular
function.
Zhang and colleagues’ approach of ensuring CR and graft patency is well
thought out and should be the standard for all surgeons performing MICS
CABG, at least for the initial cohort of patients. Long-term follow-up
will be crucial in order to demonstrate continued graft patency without
increased need for repeat revascularization. This excellent series
demonstrates that high quality revascularization is attainable with MICS
CABG and provides a blueprint for other surgeons interested in
establishing a MICS program.
References
1. Zhang L, Fu Y, Gong Y, Zhao H, et al. Graft patency and completeness
of revascularization in
minimally invasive multivessel coronary artery bypass
surgery. J Card Surg. 2021; In Press.
2. Andreini D, Pontone G, Ballerini G, et al. Bypass graft and native
postanastomotic coronary artery patency: assessment with computed
tomography. Ann Thorac Surg. 2007;83:1672-8.
3. Puskas JD, Williams WH, Mahoney EM, et al. Off-pump vs conventional
coronary artery bypass grafting: early and 1-year graft patency, cost,
and quality-of-life outcomes: a randomized trial. Jama. 2004;291:1841-9.
4. Ong AT, Serruys PW. Complete revascularization: coronary artery
bypass graft surgery versus percutaneous coronary intervention.
Circulation. 2006;114:249-55.
5. Lamy A, Devereaux PJ, Prabhakaran D, et al. Off-pump or on-pump
coronary-artery bypass grafting at 30 days. N Engl J Med.
2012;366:1489-97.