Une Dai, Lapierre Harry, Sohmer Benjamin, Rai Vaneet, Ruel Marc
From the *Division of Cardiac Surgery, and †Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, ON Canada; and ‡McLaren Regional Medical Center Family Medicine, Michigan State University College of Human Medicine, Flint, MI USA.
Innovations (Phila). 2013 Nov-Dec;8(6):403-9. doi: 10.1097/IMI.0000000000000019.
We examined the effects of learning curve on clinical outcomes and operative time in minimally invasive coronary artery bypass grafting (MICS CABG).
We studied 210 consecutive MICS CABG cases performed by the same surgeon, composed of 3 cardiopulmonary bypass (CPB)-assisted single-vessel small thoracotomy (SVST), 87 off-pump SVST, 51 CPB-assisted multivessel small thoracotomy (MVST), and 69 off-pump MVST. For each MICS CABG technique, the frequency of early clinical events (mortality, reopening, stroke, myocardial infarction, and revascularization) was compared between the first 25 cases and the remainder. Logarithmic curve regression analysis and a cumulative summation technique were performed to assess the correlation between operative time and the performed number of each technique.
There was no mortality, and there were 10 conversions to standard sternotomy, all of which were intended as off-pump MVST (P < 0.001, vs other procedures). Experience was otherwise not associated with perioperative outcome. However, experience numbers correlated with operative time in off-pump SVST and off-pump MVST (122 ± 30 minutes, R = 0.18, P < 0.001, and 241 ± 80 minutes, R = 0.38, P < 0.001, respectively) but not in CPB-assisted MVST (258 ± 44 minutes, R = 0.004, P = 0.7). No complications occurred as a result of CPB assistance.
Minimally invasive coronary artery bypass grafting can be safely initiated, with a very low perioperative risk. Pump assistance is a good strategy to alleviate some of the learning curve and avoid conversions to sternotomy when initiating a multivessel MICS CABG program.
我们研究了学习曲线对微创冠状动脉旁路移植术（MICS CABG）临床结局和手术时间的影响。
我们研究了由同一位外科医生连续进行的210例MICS CABG病例，包括3例体外循环（CPB）辅助下单支血管小切口开胸术（SVST）、87例非体外循环SVST、51例CPB辅助下多支血管小切口开胸术（MVST）和69例非体外循环MVST。对于每种MICS CABG技术，比较前25例与其余病例的早期临床事件（死亡率、再次手术、中风、心肌梗死和血运重建）发生率。进行对数曲线回归分析和累积求和技术，以评估手术时间与每种技术实施例数之间的相关性。
无死亡病例，有10例转为标准胸骨切开术，所有这些均为计划中的非体外循环MVST（与其他手术相比，P < 0.001）。在其他方面，经验与围手术期结局无关。然而，经验例数与非体外循环SVST和非体外循环MVST的手术时间相关（分别为122 ± 30分钟，R = 0.18，P < 0.001；241 ± 80分钟，R = 0.38，P < 0.001），但与CPB辅助下的MVST无关（258 ± 44分钟，R = 0.004，P = 0.7）。CPB辅助未导致任何并发症。
微创冠状动脉旁路移植术可安全开展，围手术期风险极低。在启动多支血管MICS CABG项目时，体外循环辅助是缓解部分学习曲线并避免转为胸骨切开术的良好策略。
