Intraoperative ischemia and long-term events after minimally invasive coronary surgery

Concern has been raised about the effects of prolonged left anterior descending (LAD) artery occlusion during minimally invasive direct coronary artery bypass graft surgery (MIDCABG). We sought to assess the impact of myocardial dysfunction during MIDCABG on long-term outcome and the protective role of collateral circulation on myocardial ischemia.

Myocardial function was evaluated in 92 patients by intraoperative transesophageal echocardiography during MIDCABG.

Wall motion score index increased during LAD occlusion (p < 0.00l) and reverted after LAD reopening (p < 0.001 versus occlusion and p = not significant versus baseline). The change in wall motion score index (occlusion versus baseline) was higher in patients with multivessel disease (p < 0.05) and in patients with LAD Thrombolysis in Myocardial Infarction study classification flow grade 2 or less without collateral circulation (p < 0.05). Myocardial stunning was documented in 12 patients (13%). The 5-year adverse event rate (including death, myocardial infarction, and revascularization) was 12%. By multivariate Cox regression analysis, multivessel disease, but not perioperative ischemia or stunning, was the only predictor of event-free survival.

During MIDCABG anterior wall dysfunction is transient, with prompt recovery after completion of the anastamosis in most cases; myocardial stunning can be documented in a minority of patients. Flow either antegrade or retrograde in the LAD territory plays a protective role against the development of ischemia. Multivessel disease, but not perioperative ischemia or stunning, predicts long-term event-free survival.