Off‐pump,minimally invasive and robotic coronary revascularization yield improved outcomes over traditional on‐pump CABG

Coronary artery disease is a global health concern, with increasing morbidity and mortality. Surgical coronary artery bypass grafting has been performed on cardiopulmonary bypass for nearly four decades, with excellent long‐term durability. Beating‐heart coronary surgery has been increasing in frequency in an attempt to decrease cardiopulmonary bypass‐related morbidity. Furthermore, with increasing expertise and technology, minimally invasive and robotic techniques have been developed to enhance post‐operative recovery, patient satisfaction and cosmesis. Several clinical trials have demonstrated decreased morbidity and more rapid recovery following off‐pump, minimally invasive and robotic procedures when compared to on‐pump coronary artery bypass grafts (CABGs). An equivalent extent of revascularization and medium‐term anastomotic patency has been demonstrated among all approaches. Furthermore, for a large number of patients who do not have anatomy amenable to traditional coronary revascularization, adjunctive molecular therapies may provide alternative myocardial micro‐revascularization. Copyright © 2008 John Wiley & Sons, Ltd.     

微创冠状动脉旁路术33例中期结果报告

目的总结33例经左胸小切口微创冠状动脉旁路术(minimally invasive direct coronary artery bypass,MIDCAB)的中期疗效. 方法 2000年11月～2003年4月共行MIDCAB 33例,单纯MIDCAB 29例,杂交技术4例.25例采用经典MIDCAB,4例胸腔镜辅助,4例AESOP机器人辅助. 结果全组无手术死亡,无手术并发症.呼吸机脱机时间(7.5±1.9) h,引流量(274±197)ml,输血率9.1%(3/33),术后住院(6.9±1.7)d.随访33例,时间(24.3±5.7)个月,无远期死亡,心绞痛复发率9.1%(3/33).术后再次冠状动脉造影4例,1例吻合口狭窄50%,余3例前降支与左乳内动脉吻合口通畅.术后导管再次血管化2例(6.1%). 结论 MIDCAB术中期效果满意.     

Long-term follow-up of total arterial versus conventional and hybrid myocardial revascularization: A propensity score matched analysis

Purpose

To evaluate the impact of the revascularization technique (by means of conventional, total arterial or hybrid myocardial revascularization) in patients with multivessel coronary artery disease.

冠心病外科治疗发展综述

冠心病系因冠状动脉粥样硬化所致血管腔逐渐狭窄、甚至完全堵塞,限制或完全中断了心肌的血液供应,引起临床上心绞痛、心肌梗死等一系列严重的心肌缺血病症.开展冠心病的外科治疗,是当前心血管专业医务工作者的重要任务.     

Postoperative Schmerztherapie bei minimal-invasiver direkter koronararterieller Bypass-Chirurgie (MIDCAB) i.v.-Opioid-PCA versus Interkostalblockaden

Objective. Lately introduced cardiosurgical procedures such as MIDCAB enable an early extubation immediately after surgery. This also requires an adequate anesthesia regime and especially a sufficient postoperative analgesia. Patient controlled analgesia (PCA) and intercostal nerve blockade (ICB) were evaluated for their suitability for postoperative pain relief in patients undergoing a MIDCAB procedure. Material and methods. After approval by the local ethic committee and obtaining written informed consent 43 patients were included in this study. Anesthesia was induced and maintained in a total intravenous standardised manner with propofol, remifentanil, cisatracurium and additionally glyceroltrinitrate, clonidine and esmolol were given as needed. After revascularisation patients were randomly assigned to one of two groups receiving either 7,5 mg piritramid i.v. before extubation and continuing a PCA with 2 mg boli and a 10 min lockout, or an ICB with ropivacaine 1 % (4 times 5 ml). Additionally all patients received 1 g paracetamol rectally before induction of anesthesia and 1 g metamizol i.v. at the end of surgery. A rescue medication of 3.75 mg piritramid i.v. was allowed. A pain score (NRS 0–10), the Aldrete score (AS 0–12) and oxygen saturation were obtained 1, 4, and 8 h after extubation. Results. The ICB group showed a significantly greater pain reduction in the first (5.8 ± 1.8 vs. 7.3 ± 1.9; P<0.02) and fourth h (3.6 ± 1.3 vs. 4.6 ± 1.4; P<0.02), respectively. Transfer to an intermediate care ward one hr after extubation was achieved more often in the ICB group according to the AS (ICB 9.6 ± 1.5 vs. PCA 8.9 ± 1.2; P<0.05), too. There was no difference with respect to the oxygen saturation. The additional piritramid demand was 9.3 mg in the ICP group and 5 mg in the PCA group in the first 8 hours postoperative. Conclusion. ICB gives a better pain relief in the early postoperative phase after MIDCAB procedures compared to a PCA. Both regimes are adequate in order to provide a sufficient pain relief and help to avoid prolonged postoperative mechanical ventilation. These will enable an early transfer of patients to an intermediate care station and save ICU capacity.     

Hybrid Revascularization for Multivessel Coronary Artery Disease

ObjectivesThe aim of this study was to assess the feasibility of hybrid coronary revascularization (HCR) in patients with multivessel coronary artery disease (MVCAD) referred for standard coronary artery bypass grafting (CABG).BackgroundConventional CABG is still the treatment of choice in patients with MVCAD. However, the limitations of standard CABG and the unsatisfactory long-term patency of saphenous grafts are commonly known.MethodsA total of 200 patients with MVCAD involving the left anterior descending artery (LAD) and a critical (>70%) lesion in at least 1 major epicardial vessel (except the LAD) amenable to both PCI and CABG and referred for conventional surgical revascularization were randomly assigned to undergo HCR or CABG (in a 1:1 ratio). The primary endpoint was the evaluation of the safety of HCR. The feasibility was defined by the percent of patients with a complete HCR procedure and the percent of patients with conversions to standard CABG. The occurrence of major adverse cardiac events such as death, myocardial infarction, stroke, repeated revascularization, and major bleeding within the 12-month period after randomization was also assessed.ResultsMost of the pre-procedural characteristics were similar in the 2 groups. Of the patients in the hybrid group, 93.9% had complete HCR and 6.1% patients were converted to standard CABG. At 12 months, the rates of death (2.0% vs. 2.9 %, p = NS), myocardial infarction (6.1% vs. 3.9%, p = NS), major bleeding (2% vs. 2%, p = NS), and repeat revascularization (2% vs. 0%, p = NS) were similar in the 2 groups. In both groups, no cerebrovascular incidents were observed.ConclusionsHCR is feasible in select patients with MVCAD referred for conventional CABG. (Safety and Efficacy Study of Hybrid Revascularization in Multivessel Coronary Artery Disease [POL-MIDES]; NCT01035567).