Totally endoscopic coronary artery bypass surgery: A meta-analysis of the current evidence

Background: Totally endoscopic coronary artery bypass (TECAB) has emerged as an alternative to other minimally invasive techniques. However, limited TECAB results are available to date. The purpose of this systematic review is to examine the existing literature to give an objective estimate of the outcomes of TECAB using a meta-analytical approach. Methods: A comprehensive online review was performed in Ovid MEDLINE® Ovid EMBASE and The Cochrane Library from 2000 to July 2017. Eligible studies included single arm TECAB studies as well as comparative studies (TECAB vs minimally invasive direct coronary artery bypass (MIDCAB)). Pooled event rates and odds ratios (ORs) for operative mortality, perioperative myocardial infarction (MI), perioperative stroke, graft patency and repeat revascularization were estimated. Single arm and pairwise comparisons were performed. Results: Seventeen single arm TECAB articles (3721 patients, weighted mean follow-up 3.3 years) were included. The pooled event rate was 0.80% (95%CI: 0.60–1.2%) for operative mortality, 2.28% (95%CI: 1.7–3%) for perioperative MI, 1.50% (95%CI: 1.1–2.0%) for perioperative stroke, 2.99% (95%CI: 1.6–5.4%) for repeat revascularization and 94.8% (95%CI: 89.3–97.5%) for early graft patency (weighted mean follow-up 10.1 months). On pairwise meta-analysis 376 patients (263 TECAB and 113 MIDCAB) were included. No difference in operative mortality (OR = 0.25, 95%CI: 0.02–2.83), perioperative MI (OR = 3.09, 95%CI: 0.37–26.12) or perioperative stroke (OR = 1.33, 95%CI: 0.17–10.26) was found between the two techniques. Conclusions: TECAB has an acceptably low operative risk and a good early patency rate. The incidence of perioperative MI requires further investigation. The dearth of data comparing TECAB to open approaches compels the need for future comparative trials.