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Coronary artery bypass surgery (CABG) and percutaneous coronary intervention (PCI) are both safe and established treatment modalities of invasive revascularization for patients with coronary artery disease (CAD). However, conflicting information exists when comparing the long-term efficacy of the two methods. The optimal treatment for patients with multivessel coronary artery disease (MVD) is still subject to discussion, given the lack of fairly designed, prospective, randomized data reflecting current practice in the modern era. Furthermore, the clinical outcomes after invasive revascularization differ according to the number of diseased vessels, presence or absence of diabetes, left main disease and left ventricular dysfunction. Hence, the question arises whether we should continue to use the term 'multivessel disease'. Conflicts of available data need to be addressed and overcome so that care of patients with CAD can be successfully tailored. In this review article we try to address some of the above conflicts, in an effort to improve our understanding in the care of patients with multivessel disease. We also provide an evidence-based perspective which may differ from the current standard of practice.

Objective: The application of an endoscopic stabilizer (Intuitive Surgical, Mountain View, CA, USA) enables closed chest off-pump coronary artery bypass via a four-point stab incision avoiding sternotomy and minithoracotomy., Methods: Between May 1999 and January 2001 we operated upon a total of 37 patients (five female, 32 male, median age 62+/-9 years) suffering from coronary artery disease using totally endoscopic coronary artery bypass (TECAB), whereas an initial series of eight TECAB patients was operated upon using an endovascular bypass system (Heartport). The da Vinci surgical system was used in order to perform left internal mammary artery (LIMA) or right internal mammary artery (RIMA) harvesting and anastomoses on a beating heart in 29 patients (four female, 25 male, median age 64+/-9.8 years). Altogether 26 patients suffering from single-vessel coronary artery disease (SVCAD) were revascularized applying LIMA to the left anterior descending artery (LAD) and three patients with two diseased coronary vessels received bilateral internal mammary artery grafting (BIMA), respectively., Results: In this series we had a 100% survival rate. Conversion rate to a median sternotomy was 3.4%. Patients were operated upon via four 1-cm chest incisions using the da Vinci robot for LIMA or BIMA harvesting and for performance of anastomoses on the beating heart. In the overall series of 56 patients intended to be treated by TECAB, 19 (33.9%) were converted to a minimally invasive direct coronary artery bypass procedure., Conclusion: This new robotic-enhanced surgical technique promotes an optimistic way of thinking about the further development of this procedure and its application in patients suffering from single-vessel CAD.

Background: The introduction of robotic enhanced surgery demanded stepwise development of performed procedures on the basis of growing experience of the operating team., Methods and Results: Between May 1999 and January 2001, this new wrist-enhanced instrumentation was used in 201 patients (156 men and 45 women, median age 64+/-10.5 years, left ventricular ejection fraction 68+/-12.4%). During the development of robotic enhanced CABG, the patients were divided into 3 groups. Group A (n=156) consisted of patients in whom the robotic system was used to harvesting the left or right internal mammary artery, or both, whereas the anastomoses were performed directly through a small chest incision. In group B (n=37), the harvest of the internal mammary arteries and the coronary anastomoses were performed totally endoscopically. In a third early group C, patient (n=8) were treated with robotic enhanced CABG via a median sternotomy already preoperatively planned, whereas gradual step-by-step application of robotic instrumentation and its feasibility were assessed. The survival rate was 99.4%. One patient (0.6%) died due to pneumonia on postoperative day 16. Conversion rate to median sternotomy was 5%. The left and right internal mammary artery conduits could be successfully harvested in 98% and 100%, respectively. The time of dissection of the left internal mammary artery could be significantly reduced alone by increasing experience. All patients were discharged from the hospital after a mean of 7 days. In 9 patients (4.5%), bleeding required reexploration., Conclusions: The introduction of this new surgical tool enables the development of new endoscopic procedures. Our results gained during the development of robotic enhanced CABG motivate us to establish a set standard for the totally endoscopic treatment of patients with 1-vessel coronary artery disease.

Minimally invasive surgical procedures have become a part of routine cardiac surgery. The surgical techniques have been developed for the treatment of coronary artery disease in order to minimize surgical trauma. With the introduction of a 3-D-based totally endoscopically functioning system into minimally invasive cardiac (MIC) surgery, further reduction of skin incisions became possible and enhanced MIC techniques could be improved. Due to the 6 degrees freedom of motion allowed by wrist-enhanced instruments and a newly developed endoscopic stabilizer, totally endoscopic coronary artery bypass procedures on a beating heart became feasible. We present here our initial series of totally endoscopic "off-pump" coronary artery bypass grafting in patients suffering from coronary artery single vessel disease. In all patients, the procedure was successfully performed via four 1 cm chest incisions as closed-chest procedures.

With the introduction of the da Vinci robotic surgical system (Intuitive Surgical, Mountain View, CA) into minimally invasive cardiac surgery, the outlook of performing coronary artery bypass operations "closed chest" became a reality. Between May 1999 and July 2000 this wrist-enhanced instrumentation was used in 143 patients (107 men, 36 women, median age 63 10.3 y). Thirteen patients suffering from coronary artery disease (CAD) were treated as totally endoscopic coronary artery bypass (TECAB), 79 patients underwent a minimally invasive direct coronary artery bypass procedure, and 35 patients were treated using the robotic-enhanced Dresden Technique. Preoperative survival was 100%. All patients in the TECAB group were operated upon via a three- or four-point stab incision using the da Vinci robot for internal mammary artery takedown and for performance of anastomoses. These new robotic-enhanced surgical techniques promote an optimistic way of thinking about the further development of these procedures and its application in patients suffering from CAD.

Objectives: In order to evaluate the benefit provided through less invasive surgical techniques for the treatment of multivessel coronary artery disease, a prospective clinical trial was started., Methods: Group 1 included 53 patients (38 males, 15 females, age 51-79 years, mean 62.8 +/- 6.1 years) receiving conventional bypass surgery, group 2 included 69 patients (59 male, 10 female, age 43-82 years, mean 61.9 +/- 8.6 years) receiving less invasive surgical procedure including minithoracotomy in combination with cardiopulmonary bypass., Results: No perioperative death occurred in the whole series of patients. Time of operation was 267 +/- 61 min in group 2 and 162.9 +/- 53.6 min in group 1. Intensive Care Unit stay was 1 day for both groups and Hospitalization 6.9 +/- 6.0 for group 1 and 7.5 +/- 2.6 days for group 2. Perioperative bleeding was less in group 2 (P > 0.01). Back and chest pain assessment on postoperative day 3 showed less pain in group 2 (P < 0.05). Three-month follow-up revealed ischemia in stress electrocardiogram in two patients (3.8%) in group 1 and in 2 patients (2.9%) in group 2. Coronary angiograms confirmed the stress ECG findings. There was one (1.4%) redo operation in group 2 and two (3.8%) in group 1., Conclusions: Both techniques are equal efficient. Even though time of operation is longer in patients receiving less invasive procedure, intensive care unit stay and hospitalization is exactly as long. Patients receiving minimally invasive surgery bleed less and have less pain early postoperatively.

Objectives: If coronary disease is the target of a minimally invasive procedure, median sternotomy or cardiopulmonary bypass or both can be avoided. Similar to the development in other fields of surgery, minimally invasive surgical techniques are gaining increased acceptance in the field of cardiothoracic surgery. Our experience with an off pump coronary artery bypass (OPCAB) technique in a special patients group with serious risk factors for the application of cardiopulmonary bypass has been analyzed., Methods: Between March 1996 and January 1999, 88 patients (64 male, 24 female) with impaired left ventricular function, or other high risk factors jeopardizing the use of cardiopulmonary bypass, such as impaired renal or lung function or heavily calcified aorta, received a beating heart procedure using the Medtronic Octopus stabilizing system., Results: All patients survived the actual operation, however, two multimorbide patients died of pneumonia on postoperative day 31 and postoperative day 35., Conclusions: Patients with single-vessel to multivessel disease and serious risk factors for cardiopulmonary bypass can be safely treated by OPCAB surgery. At our institution this technique presents the procedure of choice in this particular patients group.

Objectives: New less invasive surgical techniques for the treatment of coronary artery single-vessel disease have been developed by either avoiding median sternotomy or cardiopulmonary bypass or both, however, until now no prospective randomized trial has been carried out to compare these techniques to the conventional approach with special respect to the psychosomatical effects., Methods: In a prospective randomized trial four different surgical techniques were compared. Group 1: conventional technique (median sternotomy, cardiopulmonary bypass) in ten patients (eight male, two female, age 59.6 +/- 11.0 years); Group 2: off-pump coronary artery bypass with median sternotomy in nine patients (six male, three female, age 65.7 +/- 11.1 years); Group 3: lateral minithoracotomy and cardiopulmonary bypass in eight patients (five male, three female, age 62.3 +/- 9.9 years). Group 4: off-pump procedure and lateral minithoracotomy in nine patients (eight male, one female, age 63.8 +/- 11.3 years). All patients due to coronary artery single-vessel disease. The tests used for psychosomatic situation were post-traumatic stress disorders scale, pain behavior rating scale, pain visual analog scale, and 6' walking-distance. For detection of false results due to surgical technical failures 3-month follow-up was undertaken including echocardiography and coronary angiogram., Results: There were no deaths or major complications. Operative time was longer in lateral minithoracotomy procedures, but intensive care unit stay and hospitalization were equal in all groups. Pain visual analog scale and pain behavior rating scale showed a peak on post-operative day 4 in median sternotomy procedures. Post-traumatic stress disorder scale revealed higher values on post-operative day 4 and equalizing with lateral minithoracotomy procedures 1 month post-operatively. Six-minutes walking distance on post-operative day 4 was longer in the group with lateral minithoracotomy. Three-month follow-up revealed patency of all grafts., Conclusions: Even if surgery is successful in all procedures, operative time is longer in lateral minithoracotomy procedures without compromising intensive care unit stay and hospital stay. More pain with multiple post-traumatic stress disorders is related to median sternotomy, and post-operative convalescence is superior for lateral minithoracotomy procedures.

Objective: The treatment of coronary single vessel disease under minimally invasive surgical conditions was followed by the treatment of coronary multivessel disease using a new technique., Methods: Using this technique 100 patients (80 male, 20 female, median age 61.0+/-8.9 years, ranged from 39 to 82 years) with coronary single vessel disease, double vessel disease or multivessel disease were treated between November 1996 and December 1997. Via a small (6-9 cm) left lateral chest incision in the second or third intercostal space, the left internal thoracic mammary artery (LIMA) was harvested and access to the central portion of the heart including the ascending aorta was obtained. In parallel, saphenous vein segments were harvested. Arterial cannulation was instituted via the ascending aorta, thus avoiding retrograde flow. In all patients except three the LIMA was used for the left anterior descending artery (LAD). In addition vein grafts were used for revascularization of the other coronary arteries. All cardiac anastomoses were performed during cardioplegic arrest after external aortic cross clamping and antegrade application of cardioplegia., Results: No death or intraoperative complications were observed in this series. The median hospital stay was 6.0+/-1.4 days (median+/-SEM). Postoperative complications were reexplored for bleeding (n = 1), delayed wound healing (n = 2), wound infections (n = 4), lymphatic fistulas (n = 4), and a chest wall hernia (n = 1)., Conclusions: This minimally invasive surgical technique presents a safe alternative to conventional coronary artery surgery avoiding sternotomy related complications and decreasing hospital stay and morbidity.