Does bone wax make sense in off-pump coronary surgery? A prospective randomized study.

Introduction: The effect of bone wax on sternal infection and intraoperative bleeding in off-pump coronary surgery has not been reported in current literature. Aim: To prospectively evalute this in a cohort of high risk patients undergoing off-pump coronary artery surgery at our institution. The potential impact on cell saver utilization was also studied. Material and methods: A prospective randomized study was performed in 58 diabetic patients operated on for two-vessel coronary artery disease by the off-pump technique. They were randomly assigned to the wax or no-wax group. Results: There was no significant difference in intraoperative blood loss between the wax (550 ml) and no-wax group (750 ml; p = 0.0711). In multivariate analysis the absence (non-use) of bone wax (odds ratio = 3.9 (1.12-13.51), p = 0.027) and preoperative creatinin level (odds ratio = 1.1 (0.99-1.03), p = 0.03) were identified as independent predictors of blood loss ≥ 750 ml. The number of red blood cell units during hospital stay was similar in both groups (p = 0.42). Wound healing complications were not observed in either group. Conclusions: The use of bone wax does not lead to a higher risk of sternal wound infection. It may reduce the risk of high intraoperative blood loss, thus avoiding the need of a cell saver during off-pump coronary surgery. However, this influence remains questionable.

Impact of smoking on the outcomes of minimally invasive direct coronary artery bypass.

BACKGROUND: Tobacco smoking has been associated with an increased risk of complications after conventional coronary surgery. However, the impact of smoking on the risk of postoperative complications in minimally invasive coronary surgery is yet to be studied. We aimed to analyze the impact of the preoperative smoking status on the short- and long-term outcomes of minimally invasive direct coronary artery bypass grafting (MIDCAB) in the context of isolated surgical revascularization or in association with percutaneous coronary intervention. METHODS: This was a retrospective observational study of all patients undergoing MIDCAB at our institution between 2006 and 2020. Patients were divided into three groups: active smokers, ex-smokers who have quit smoking for at least 1 month before surgery, and non-smokers. The groups were compared using conventional statistical methods. Multivariate analysis was then performed where significant differences were found to eliminate bias. RESULTS: Throughout the study period, 541 patients underwent MIDCAB, of which 135 (25%) were active smokers, 183 (34%) were ex-smokers, and 223 (41%) were non-smokers. Smokers presented for surgery at a younger age (p < 0.0001), more frequently with a history of myocardial infarction (p < 0.001), peripheral artery disease (p < 0.001) and chronic obstructive pulmonary disease (p < 0.0001). Using multivariate analysis, active smoking was determined to be a significant risk factor for the need of urgent revascularization (odds ratio 2.36 [1.00-5.56], p = 0.049) and the composite of pulmonary complications (including pneumothorax, respiratory infection, respiratory dysfunction, subcutaneous emphysema and exacerbation of chronic obstructive pulmonary disease; odds ratio 2.84 [1.64-4.94], p < 0.001). Preoperative smoking status did not influence the long-term survival (p = 0.83). CONCLUSIONS: In our study, active smokers presented for MIDCAB at a younger age and more often with signs of atherosclerotic disease (history of myocardial infarction and peripheral artery disease). Active smoking was found to be the most significant risk factor for postoperative pulmonary complications, and is also associated with a more frequent need for urgent surgery at diagnosis. Long-term postoperative survival is not affected by the preoperative smoking status.

Robot-assisted vs. conventional MIDCAB: A propensity-matched analysis.

Background: Robotic assistance (RA) in the harvesting of internal thoracic artery during minimally invasive direct coronary artery bypass grafting (MIDCAB) provides several potential benefits for surgeon and patient in comparison with conventional MIDCAB. The two technical options have not been thoroughly compared in the literature yet. We aimed to perform this in our cohort with the use of propensity-score matching (PSM). Methods: This was a retrospective comparison of all consecutive patients undergoing conventional MIDCAB (2005-2021) and RA-MIDCAB (2018-2021) at our institution with the use of PSM with 27 preoperative covariates. Results: Throughout the study period 603 patients underwent conventional and 132 patients underwent RA-MIDCAB. One hundred and thirty matched pairs were selected for further comparison. PSM successfully eliminated all preoperative differences. Patients after RA-MIDCAB had lower 24 h blood loss post-operatively (300 vs. 450 ml, p = 0.002). They had shorter artificial ventilation time (6 vs. 7 h, p = 0.018) and hospital stay (6 vs. 8 days, p < 0.001). There was no difference in the risk of perioperative complications, short-term and mid-term mortality between the groups. Conclusions: RA-MIDCAB is an attractive alternative to conventional MIDCAB. It is associated with lower post-operative blood loss and potentially faster rehabilitation after surgery. The mortality and the risk of perioperative complications are comparable among the groups.

Female sex as a risk factor in minimally invasive direct coronary artery bypass grafting.

Objectives. Female sex has been generally accepted as a risk factor for short-term mortality and adverse events in surgical myocardial revascularization. However, there have been no data published yet about sex differences in minimally invasive settings. The aim of our study was to analyse short- and long- term outcomes of minimally invasive direct coronary artery bypass grafting (MIDCAB) in terms of sex comparison. Design. We retrospectively analysed the in-hospital data of all patients (n = 384) undergoing MIDCAB at our department in years 2006-2016. Subsequently, the data were enriched by long-term outcomes from national registries. Results. There were 96 women in our group (25%). Females were significantly older (67.1 vs 63.8 years; p < .01) and were more often diabetic (43.8% vs. 31.8%; p < .01). Surgery time was longer in females (160 vs 155 min; p = .02), and also the need for blood transfusion (19.8% vs 10.4%; p = .02) and wound complications (15.6% vs 2.4%; p < .001) were more frequent in women. After multivariate analysis, the wound complications risk (p < .001) and longer surgery times (p < .01) remained associated with sex. All-cause in-hospital mortality (2.1% vs 0.7%; p = .26), long-term mortality (p = .73), and the risk of coronary intervention post-operatively (p = .16) were the same in both sexes. Higher incidence of cardiac cause of death in women was observed from long-term aspect (69.6% vs 38.7%; p = .01). However, after adjustment it lost its significance. Conclusions. Female sex is not connected with higher risk of mortality or other major events in MIDCAB. Wound healing complications remain the leading attribute associated with female sex.

Elective minimally invasive coronary artery bypass: shunt or tournique occlusion? Assessment of a protective role of perioperative left anterior descending shunting on myocardial damage. A prospective randomized study.

BACKGROUND: To determine impact of intraluminal-left anterior descending shunt to prevent myocardial damage in minimally invasive coronary artery bypass. METHODS: 38 patients were randomly assigned to external tournique occlusion (n = 19) or intraluminal-left anterior descending shunt group (n= 19). Blood samples for cardiac troponin T were collected at 30 minutes prior to, 6 and 24 hours after surgery. RESULTS: One patient in external tournique occlusion and two patients in intraluminal-left anterior descending shunt group were excluded from futher analysis due to preoperative cardiac troponin T level above the 99th-percentile. Postoperatively, each six patients in external tournique occlusion (33.3%) and intraluminal-left anterior descending shunt (35.3%) group were above the 99th-percentile. Two patients from each group (external tournique occlusion group 11.1% vs. intraluminal-left anterior descending shunt group 11.8%) had peak values above 10-% coeficient of variation cutoff (p = 1). There were no significant differences in between both groups at all studied timepoints. CONCLUSION: There was no protective effect of intraluminal shunting on myocardial damage compared to short-term tournique occlusion. It is upon the surgeon's discretion which method may preferrably be used to achieve a bloodless field in grafting of the non-occluded left anterior descending in minimally invasive coronary artery bypass.

Early and long-term results of minimally invasive coronary artery bypass grafting in elderly patients.

BACKGROUND: Standard (conventional) coronary artery bypass grafting (CABG) is an invasive procedure which requires full median sternotomy and is performed with extracorporeal circulation (ECC), which can lead to serious complications. AIM: To analyse the results of minimally invasive CABG (MIDCAB) in elderly patients. METHODS: Between 1999 and 2007, a total of 698 MIDCAB procedures were performed at our institution. We present the data on 235 elderly (≥ 70 years) patients (160 males, mean age 74.5 ± 3.2 years, range: 70-83 years) who were consecutively operated on in this period. Early mortality, post-operative complications, long-term survival, impact of multivessel disease (MVD) and hybrid coronary artery revascularisation on total mortality were analysed. Logistic EuroSCORE was 8.7%. The survival of 235 elderly patients was compared to the survival of the remaining 463 MIDCAB patients aged < 70 years (including risk factors for total mortality). RESULTS: The 30-day mortality was 2.5% (six patients). During follow-up, two patients underwent coronary reoperation and percutaneous coronary intervention (PCI) was performed in 16 patients. Kaplan-Meier analysis revealed a 1.5-year survival of 89.8% (95% CI 85.9-93.7%) and five-year survival of 79.7% (95% CI 74.3-85%). Compared to single vessel disease (SVD) patients, the MVD patients had significantly higher total mortality (p = 0.0038). Our study revealed MVD (p = 0.0016) and male sex (p = 0.0091) as important independent factors of total mortality in this group of elderly patients. The difference in total mortality between non-hybrid vs hybrid MIDCABs was not significant (p = 0.63). The younger MIDCAB patients (< 70 years) have a tendency to better survival, but the difference did not achieve statistical significance (p = 0.088). They had the same independent factors of total mortality as in the elderly group: MVD (p = 0.0001) and male sex (p = 0.0059). CONCLUSIONS: The MIDCAB is a reasonable option for elderly patients with SVD, and in selected patients with MVD. The decision to perform MIDCAB rather than PCI in these high risk patients should always be very carefully considered in conjunction with the interventional cardiologist.

[Techniques of saphenous vein harvesting in myocardial revascularization]. / Techniky odberu zilních stepu k revaskularizaci myokardu.

As in other branches of surgery also in myocardial revascularization modern less invasive procedures are used. We can appreciate this gentle approach even in saphenous vein harvesting. Till this time published papers prove that this procedure has less percentage of complications and does not influence graft quality.