Treatment of Coronary Heart Disease with Minimally Invasive Surgery

In 1998, most cardiac surgical practices used cardiopulmonary bypass (CPB) and cardioplegic arrest as techniques to perform coronary artery bypass grafting (CABG) (1). More than 25% of patients undergoing CABG have ≥1 complications (e.g., atrial fibrillation, bleeding, myocardial infarction, sternal infection, stroke, or renal failure). Although some of the morbidity of CABG is directly related to patient comorbidity factors, some of these complications are due to the current technique of CABG. The goal of minimally invasive CABG is to avoid the morbid complications of standard CPB-supported CABG. The 2 most common techniques of minimally invasive CABG are minimally invasive direct coronary artery bypass (MIDCAB) and offpump coronary artery bypass (OPCAB). For example, the median sternotomy incision is avoided in techniques that gain access to the heart via a left anterior thoracotomy (MIDCAB, Port-Access). CPB is avoided in techniques that perform coronary bypasses on a beating heart (OPCAB). In MIDCAB, both the sternotomy and CPB are avoided. One of the very first attempts at using the left internal thoracic artery (LITA) to revascularize the left anterior descending coronary artery (LAD) was done in a minimally invasive fashion, avoiding CPB. Professor Vasili I. Kolessov, in his pioneering 1967 work in LITA-to-LAD anastomosis, reported on an experimental study of 14 dogs with autopsy confirmation of patency at an intermediate-term (19 months) follow-up (2). In addition, he reported on 6 human patients. The surgery was conducted through a left anterior thoracotomy in the fifth intercostal space with LITA harvesting. Ischemic preconditioning for 6 to 8 minutes was afforded by coronary occlusion of the LAD using a snare. Anastomosis on a beating heart was performed with an interrupted silk suture technique, with or without a Vineberglike intramyocardial tunnel technique. Among the human patients, Kolessov reported 4 excellent results, the return of angina in 1 patient after 1 year, and 1 perioperative death. In this paper, I will examine the controversies related to the use of different techniques, present some pertinent data about them, perform Bayesian analysis comparing minimally invasive CABG and CABG-CPB, and review some comparative trials with the goal of clarifying the best uses of each technique.