REASONABLE INCOMPLETE REVASCULARIZATION USING MINIMALLY INVASIVE CORONARY ARTERY BYPASS GRAFTING TECHNIQUES

Highlights

In multivessel coronary artery disease coronary artery bypass grafting under cardiopulmonary bypass using the internal thoracic artery is the accepted standard of revascularization, however, it is characterized by high trauma. Minimally invasive techniques offset this disadvantage but cannot always provide complete revascularization. Determination of feasibility and combined use of incomplete revascularization with minimally invasive techniques of coronary artery bypass may be a worthy alternative to traditional coronary bypass in a certain group of patients. At the same time, literature the data are ambiguous and deficient in the world.

Aim. To justify the use of minimally invasive coronary artery bypass technique in incomplete myocardial revascularization in patients with stable ischemic heart disease from the standpoint of efficacy and safety.

Methods. The retrospective study focuses on the analysis of minimally invasive coronary artery bypass grafting (minimally invasive direct coronary artery bypass grafting and off-pump coronary artery bypass surgery using sternotomy) and traditional CABG with cardiopulmonary bypass in patients with multivessel coronary artery disease (n = 429) performed in the period from 2013 to 2017. Depending on the CABG technique and the type of revascularization (complete/incomplete), all patients were divided into 3 groups with two comparison subgroups in each. The completeness of revascularization was assessed using the residual SYNTAX score (rSS). The SYNTAX revascularization index (SRI) was calculated using the following formula: SRI = [1 – (rSS/bSS)] × 100. Subsequently, a two-stage (short- and long-term) analysis of the adverse events frequency was carried out.

Results. The minimally invasive incomplete revascularization (IR) group and the traditional complete revascularization (CR) group. The rSS in the IR group was 3.0 [2.0; 5.0] compared with the group without traditional CABG, whereas the SRI was 84.31 [75.00; 89.19] % compared with 100.00 [100.00; 100.00] %, respectively (p<0.001). The analysis of in-hospital period did not reveal significant differences in the number of primary and secondary endpoints. Taking into account the additional endpoints, the IR group had a lower level of intraoperative blood loss – 300 [200; 310] mL compared with 500 [400; 500] mL in the CR group (p<0.001). Moreover, the need for blood transfusion was significantly lower – by 4.27 times (95% CI: 0.124–0.441, p<0.001). The length of patients stay with IR in the intensive care unit was 4.12 times shorter (95% CI: 1,954–8,994, p<0.001). The 1-year follow-up visit revealed full comparability between the groups in terms of frequency of both primary and secondary endpoints. There were no differences in freedom from MACCE and mortality.

The minimally invasive CR group and the traditional CR group. The in-hospital period and 1-year follow-up visits showed similar outcomes, comparable to the minimally invasive IR and traditional CR groups. The minimally invasive IR group and the minimally invasive CR group. The analysis of in-hospital period and 1-year follow-up visits did not reveal any differences in endpoints. Freedom from MACСE and death was similar as well.

Conclusion. The data obtained indicate a similar safety profile and effectiveness of IR. Minimally invasive IR is appropriate with rSS ≤3 and SRI ≥84.3% and can be considered as an alternative approach to myocardial revascularization in patients for whom traditional CABG is undesirable.

1. Вишневский А.Г., Андреев Е.М., Тимонин С.А. Смертность от болезней системы кровообращения и продолжительность жизни в России. Демографическое обозрение. 2016;3(1):6-34. doi: 10.17323/demreview.v3i1.1761.

2. Rihal C.S., Raco D.L., Gersh B.J., Yusuf S. Indications for coronary artery bypass surgery and percutaneous coronary intervention in chronic stable angina: review of the evidence and methodological considerations. Circulation. 2003;108(20):2439-45. doi: 10.1161/01.CIR.0000094405.21583.7C.

3. Khan N.E., De Souza A., Mister R., Flather M., Clague J., Davies S., Collins P., Wang D., Sigwart U., Pepper J. A randomized comparison of off-pump and on-pump multivessel coronary-artery bypass surgery. N Engl J Med. 2004;350(1):21-8. doi: 10.1056/NEJMoa031282.

4. Hannan E.L., Wu C., Smith C.R., Higgins R.S., Carlson R.E., Culliford A.T., Gold J.P., Jones R.H. Off-pump versus on-pump coronary artery bypass graft surgery: differences in short-term outcomes and in long-term mortality and need for subsequent revascularization. Circulation. 2007;116(10):1145-52. doi: 10.1161/CIRCULATIONAHA.106.675595.

5. Shroyer A.L., Grover F.L., Hattler B., Collins J.F., McDonald G.O., Kozora E., Lucke J.C., Baltz J.H., Novitzky D.; Veterans Affairs Randomized On/Off Bypass (ROOBY) Study Group. On-pump versus off-pump coronary-artery bypass surgery. N Engl J Med. 2009;361(19):1827-37. doi: 10.1056/NEJMoa0902905.

6. Lev-Ran O., Loberman D., Matsa M., Pevni D., Nesher N., Mohr R., Uretzky G. Reduced strokes in the elderly: the benefits of untouched aorta off-pump coronary surgery. Ann Thorac Surg. 2004;77(1):102-7. doi: 10.1016/s0003-4975(03)01334-1.

7. Zhao D.F., Edelman J.J., Seco M., Bannon P.G., Wilson M.K., Byrom M.J., Thourani V., Lamy A., Taggart D.P., Puskas J.D., Vallely M.P. Coronary Artery Bypass Grafting With and Without Manipulation of the Ascending Aorta: A Network Meta-Analysis. J Am Coll Cardiol. 2017;69(8):924-936. doi: 10.1016/j.jacc.2016.11.071.

8. Wittwer T., Cremer J., Boonstra P., Grandjean J., Mariani M., Mügge A., Drexler H., den Heijer P., Leitner E.R., Hepp A., Wehr M., Haverich A. Myocardial "hybrid" revascularisation with minimally invasive direct coronary artery bypass grafting combined with coronary angioplasty: preliminary results of a multicentre study. Heart. 2000;83(1):58-63. doi: 10.1136/heart.83.1.58.

9. Fournier S., Toth G.G., De Bruyne B., Johnson N.P., Ciccarelli G., Xaplanteris P., Milkas A., Strisciuglio T., Bartunek J., Vanderheyden M., Wyffels E., Casselman F., Van Praet F., Stockman B., Degrieck I., Barbato E. Six-Year Follow-Up of Fractional Flow Reserve-Guided Versus Angiography-Guided Coronary Artery Bypass Graft Surgery. Circ Cardiovasc Interv. 2018;11(6):e006368. doi: 10.1161/CIRCINTERVENTIONS.117.006368.

10. Kobayashi Y., Nam C.W., Tonino P.A., Kimura T., De Bruyne B., Pijls N.H., Fearon W.F.; FAME Study Investigators. The Prognostic Value of Residual Coronary Stenoses After Functionally Complete Revascularization. J Am Coll Cardiol. 2016;67(14):1701-11. doi: 10.1016/j.jacc.2016.01.05.

11. Rastan A.J., Walther T., Falk V., Kempfert J., Merk D., Lehmann S., Holzhey D., Mohr F.W. Does reasonable incomplete surgical revascularization affect early or long-term survival in patients with multivessel coronary artery disease receiving left internal mammary artery bypass to left anterior descending artery? Circulation. 2009;120(11 Suppl):S70-7. doi: 10.1161/CIRCULATIONAHA.108.842005..

12. Подкаменный В.А., Лиханди Д.И., Желтовский Ю.В., Шаравин А.А., Вырупаев А.В. Неполная коронарная реваскуляризация как независимый фактор риска ухудшения прогноза коронарного шунтирования без искусственного кровообращения у больных ишемической болезнью сердца. Acta Biomedica Scientifica. 2017;2(2):40-44. doi:10.12737/article_59a614f8afcde0.78457348.

13. Généreux P., Campos C.M., Farooq V., Bourantas C.V., Mohr F.W., Colombo A., Morel M.A., Feldman T.E., Holmes D.R.Jr., Mack M.J., Morice M.C., Kappetein A.P., Palmerini T., Stone G.W., Serruys P.W. Validation of the SYNTAX revascularization index to quantify reasonable level of incomplete revascularization after percutaneous coronary intervention. Am J Cardiol. 2015;116(2):174-86. doi: 10.1016/j.amjcard.2015.03.056.

14. Xu B., Bettinger N., Guan C., Redfors B., Yang Y., Li B., Han Y., Su X., Yuan Z., Généreux P. Impact of completeness of revascularization in complex coronary artery disease as measured with the SYNTAX revascularization index: An SEEDS Substudy. Catheter Cardiovasc Interv. 2017;89(S1):541-548. doi: 10.1002/ccd.26916.

15. Généreux P., Palmerini T., Caixeta A., Rosner G., Green P., Dressler O., Xu K., Parise H., Mehran R., Serruys P.W., Stone G.W. Quantification and impact of untreated coronary artery disease after percutaneous coronary intervention: the residual SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) score. J Am Coll Cardiol. 2012;59(24):2165-74. doi: 10.1016/j.jacc.2012.03.010.