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Page 12 of 15               Ashenhurst et al. Vessel Plus 2024;8:3  https://dx.doi.org/10.20517/2574-1209.2023.90

               experience was correlated with operative time for off-pump procedures, but not pump-assisted procedures.
               The use of pump assistance may be employed to alleviate some of the learning curve’s adverse effects before
                                                                         [56]
               reaching learning period optimization, calculated to be 45 cases . The learning curve, as shown by
               Rodriguez et al. (2016), is the most common factor causing a conversion from a minimally invasive to a
               conventional CABG approach . Increased exposure to the procedure reduced difficulties with conduit
                                         [57]
               harvest and anastomoses and concomitantly increased freedom from conversion to sternotomy . Mid-
                                                                                                   [57]
               term follow-up of MICS CABG patients found the overall procedural safety was not affected by the learning
               period; instead, with increased exposure to the procedure, they observed improved freedom from
               conversion to sternotomy and from repeat revascularization . This phenomenon was further enforced in
                                                                   [58]
               2018 by Andrawes et al. .
                                   [59]

               With the implementation of a new procedure, the cost of health care is an important factor to consider.
               Patients who experience complications associated with CABG surgery may require a longer hospitalization
               period and consume more healthcare resources [60,61] . A multi-institutional analysis found that MICS CABG
               approaches were associated with fewer transfusions, shorter intensive care unit stays, and shorter hospital
               lengths of stay than conventional CABG patients. MICS CABG patients used fewer healthcare resources
               and, on average, saved $7,000 USD compared to conventional CABG patients. Both the conventional CABG
                                                                               [62]
               and MICS CABG patients were linked with excellent short-term outcomes . However, others have called
               into question whether this research was successful in comparing the groups as the baseline characteristics
               between the groups were not well matched: the MICS CABG patients were lower risk and had, on average,
                                                 [63]
               fewer grafts which created inherent bias . That said, short-term outcomes from other trials are consistent
               with MICS CABG patients spending less time in the ICU and hospital [17,20] . Further research is required to
               explore the correlation between MICS CABG and associated costs to definitively suggest that MICS CABG
               has an economic advantage and improved resource utilization over conventional CABG.


               In our experience, the implementation of MICS CABG at our institution involved not just adopting a novel
               approach to surgical revascularization, but also innovating matched perioperative management. This
               evolution towards the delivery of minimally invasive CABG is predicated on recognizing the importance of
               multi-disciplinary collaboration to achieve patient care, with individualization of care prioritized over
                                                                                                 [64]
               protocols. The key features of perioperative optimization are outlined by Ponnambalam and Alex . Patient
               education, discharge planning, and medical optimization are offered strategically prior to admission.
               Multimodal analgesia specific to thoracotomy - including the use of intercostal and fascial plane block,
               acetaminophen, gabapentinoid, opioids, and nonsteroid anti-inflammatory drugs - are administered
               perioperatively . Early feeding and a program for early mobilization are also recommended to enhance the
                            [38]
               patient’s functional recovery after surgery to facilitate rapid discharge. The implementation of a MICS
               CABG program goes beyond satisfactory clinical outcomes, as it has the potential to improve the patient
               experience by resulting in earlier normalization and return to work. In unpublished internal quality
               assurance data from our center, an appreciable decrease in the length of hospital stay has been observed in
               patients undergoing MICS CABG since the adoption of the aforementioned strategies in 2020. Additionally,
               reduced ICU and hospital length of stays has a positive implication for organizational flow and capacity.

               Future directions should continue to include research that encompasses patient-specific and functional
               outcomes; patient satisfaction and quality-of-life data should be reported in conjunction with clinical
               outcomes. The literature indicates that MICS CABG, and associated less invasive procedures, have
               significant potential to improve care for patients on a global scale.
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