Advanced hybrid coronary revascularization with robotic totally endoscopic triple bypass surgery and left main percutaneous intervention

Abstract

CLINICAL SUMMARY The patient, a 57-year-old man with a history of myocardial infarction, left anterior descending coronary artery (LAD) stent, and occluded right coronary artery, automatic implantable cardiac defibrillator implantation, was seen because of ventricular tachycardia, acute non–ST segment elevation myocardial infarction, and automatic implantable cardiac defibrillator discharge. Workup identified anteroapical ischemia, complex 70% stenosis involving the distal left main coronary artery (LMCA) and all 3 major subbranch ostia, and 30% in-stent restenosis of the LAD stent. Hybrid coronary revascularization was planned, including 3-vessel, all-arterial TECAB targeting the LAD, left circumflex coronary artery, and right posterior descending coronary artery systems with staged stenting of the distal LMCA and ramus. In the operating room, left ventricular ejection fraction was 20%; however, this was considered to be reversible because outpatient left ventricular ejection fraction was 45% and implantation of a prophylactic intraaortic balloon pump resulted in significant improvement. With the da Vinci telemanipulation system (Intuitive Surgical, Sunnyvale, Calif), bilateral internal thoracic arteries (ITAs) were harvested with simultaneous harvesting of the left radial artery. An end to side right ITA–radial artery Y anastomosis was created with robotic endoscopic