Endoscopic Coronary Artery Bypass Surgery Research Articles

Learning Curve of Thoracoscopic Nonrobotic Harvest of the Left Internal Mammary Artery in Minimally Invasive Coronary Artery Bypass Grafting.

Harvest of the left internal mammary artery (LIMA) is a technically demanding element of minimally invasive coronary surgery. We aimed to evaluate the learning curve of thoracoscopic, nonrobotic LIMA harvest during endoscopic coronary artery bypass (Endo-CAB) surgery. Eighty patients undergoing Endo-CAB surgery were included. LIMA harvest was performed using commonly available video-assisted thoracoscopic instruments. Time from incision until heparin administration was defined as total LIMA harvest time (this includes opening of the pericardium and identification of coronary targets). LIMA harvest times (N = 80) and total procedure times for single-vessel grafting (n = 51) were analyzed. The mean LIMA harvest time was 58 ± 19 min, ranging from 15 to 113 min. The mean procedure time was 150 ± 39 min. Significant reductions in both LIMA harvest and total Endo-CAB procedure times were observed with increasing experience (logarithmic regression Y = 109 - 14.9*log(x), P < 0.001; Y = 227 - 24.4*log(x), P < 0.001, respectively). No damage to the LIMA occurred during thoracoscopic harvesting. Total thoracoscopic (nonrobotic) LIMA harvest is an efficient technique with a steep learning curve using routine instruments. More patients might benefit from minimally invasive coronary surgery using thoracoscopic LIMA harvest techniques.

A minimally invasive robotic surgery approach to perform totally endoscopic coronary artery bypass on beating hearts

The currently available robotic systems rely on rigid heart stabilizers to perform totally endoscopic coronary artery bypass (TECAB) surgery on beating hearts. Although such stabilizers facilitate the anastomosis procedure by immobilizing the heart and holding the surgery site steady, they can cause damage to the heart tissue and rupture of the capillary vessels, due to applying relatively large pressures on the epicardium. In this paper, we propose an advanced robotic approach to perform TECAB on a beating heart with minimal invasiveness. The idea comes from the fact that the main pulsations of the heart occur as excursions in normal direction, i.e., perpendicular to the heart surface. We devise a 1-DOF flexible heart stabilizer which eliminates the lateral movements of the heart, and a 1-DOF compensator mechanism which follows the heart trajectory in the normal direction, thus canceling the relative motion between the surgical tool and the heart surface. In fact, we bring a compromise between two radical approaches of operating on a completely immobilized beating heart with no heart motion compensation, and operating on a freely beating heart with full compensation of heart motion, considering the invasiveness of the first and the technical challenges of the second approach. We propose operating on a partially stabilized beating heart with unidirectional compensation of the heart motion; the flexible stabilizer would exert much less holding force to the heart tissue and the robotic system with unidirectional compensator would be technically feasible. In the proposed approach, a motion sensor mounted on the stabilizer measures the heart excursion data and sends it into a control unit. A predictive controller uses this data to generate an automated trajectory. The slave robots follow this trajectory, which is superimposed on the surgeon’s tele-operation commands received from a master console. Finally, the tool-activation units in the slave robots actuate the articulated laparoscopic tools to perform the anastomosis procedure. The evaluation of the hypothesis showed that our solution for the robotic TECAB on beating heart is both practical and cost effective. We showed in an in-vivo study that the flexible stabilizer can effectively restrict the heart lateral movements, while allowing for its normal excursion. We found readily available linear motors which could afford the high forces, speeds and accelerations required for following the heart trajectory. Finally, we showed that the tool-activation unit is capable of providing the maneuverability and workspace required for the most challenging task of CABG procedure, i.e., anastomosis suturing.

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

BackgroundTotally 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. MethodsA 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. ResultsSeventeen single arm TECAB articles (3721 patients, weighted mean follow-up 3.3years) 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 10.1months). 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. ConclusionsTECAB 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.

Robot-assisted totally endoscopic coronary bypass surgery

Totally endoscopic coronary artery bypass (TECAB) surgery can exclusively be undertaken with the aid of operative robots. In the past two decades, surgical remote manipulator systems—predominantly the daVinci® devices—have brought us the reality of endoscopic internal mammary artery harvesting and coronary bypass anastomoses via minimally invasive thoracic port access. Single up to quadruple TECAB interventions are recently feasible; the procedure can be delivered either as beating heart applying endoscopic vacuum stabilizer or under cardioplegic arrest on heart-lung machine. Significant surgical team learning curves are involved in a stepwise development of these complex procedures, including intense dry- and wet-lab trainings, endoscopic internal mammary artery harvesting and manual coronary anastomosis building through a thoracotomy. Increasing number of papers have been published regarding clinical TECAB series in the past decade. In arrested heart TECAB procedures on cardiopulmonary bypass, the conversion rate from port access to larger thoracic incision measures 15.1% and no perioperative mortality is observed in published records. Stroke, kidney failure and atrial fibrillation rates stay at 0.6, 0.4 and 12.9%, respectively. Analysis of beating heart TECAB procedures revealed a conversion rate of 15.3%, perioperative mortality 0.4%, stroke 0.3%, kidney failure 0.6% and atrial fibrillation 9.2%. Additionally, due to the obviously smaller surgical trauma, a remarkable fast return to normal daily activities can be demonstrated in clinical series of robotic assisted coronary bypass surgery. Short-term freedom of major adverse cardiac and cerebral events (MACCE) stays over 90%. Long-term studies reveal 5-year freedom of MACCE in the 75.2 to 83.1% range. Nowadays, total endoscopic coronary artery bypass grafting is a feasible and reproducible surgical method. Advanced hybrid coronary interventions offer complex multivessel TECAB with support of percutaneous coronary interventions (PCI). Combination of the above techniques widens the spectrum of minimally invasive therapeutic solutions concerning multivessel procedure including bilateral internal mammary grafts and drug-eluting stents.

Robotic cardiac surgery: current status and future directions

Robotic cardiac surgery: current status and future directions Emmanuel Moss, Douglas A Murphy, Michael E HalkosDivision of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, USAAbstract: Since robotic cardiac surgery was first described nearly 2 decades ago, technological advance along with a growing demand for less invasive procedures have given way to increased development and adoption of robot-assisted cardiac surgery. Coronary revascularization is now being performed with varying degrees of robotic assistance. Robot-assisted single vessel and hybrid coronary artery revascularization is gaining popularity, and multivessel totally endoscopic coronary artery bypass surgery is being performed safely in select highly specialized centers. Intracardiac robot-assisted surgery has also become an attractive alternative to midline sternotomy and thoracoscopic approaches for mitral and tricuspid valve disease, atrial septal defect repair, and intracardiac tumors. This review will describe the current state of robotic cardiac surgery and offer some insight into future advancement.Keywords: robot-assisted, mitral valve, coronary artery bypass, minimally invasive surgery

Patient anatomy predicts operative time in robotic totally endoscopic coronary artery bypass surgery.

The influence of patient thoracic anatomy on operative times in robotic total endoscopic coronary artery bypass (TECAB) has not been well described. The aim of this study was to determine whether patient anatomy correlates with intraoperative time required to complete various procedural steps and overall operative time in TECAB. Preoperative multislice computed tomographic scans of the chest from 107 consecutive patients who underwent single-vessel TECAB were reviewed to measure a series of thoracic dimensions and relations. Measurements were correlated with time to complete various intraoperative procedural tasks as well as overall operative time. There was a significant correlation between left internal mammary artery (LIMA) harvest time and depth of subcutaneous tissue at the level of the nipple (r = 0.24, P = 0.018). Pericardial fat pad thickness was associated with longer resection times (r = 0.266, P = 0.008). LIMA to left anterior descending artery anastomotic time was inversely correlated with the distance from the left heart border to the chest wall (r = -0.241, P = 0.016). Total operative time was also inversely correlated with this distance (r = -0.275, P = 0.005). Anatomical measurements made on preoperative computed tomography in patients undergoing robotic TECAB can predict time requirements for various procedural steps. A shorter distance between the chest wall and the heart predicts longer anastomotic and total operative times. This information could assist the TECAB surgeon with surgical planning and help guide the TECAB trainee in patient selection.

Totally endoscopic robotic coronary artery bypass surgery

To assess the current status and methods of robotic totally endoscopic coronary artery bypass (TECAB) surgery and discuss important anesthetic considerations. Technological and surgical advances in robotics have led to the evolution of TECAB surgery from a single-vessel procedure to quadruple-vessel bypass. TECAB is now a reproducible technique, with a low incidence of mortality and morbidity and superior quality of life. Although early cohorts of patients are still being observed for long-term outcomes, initial and midterm outcomes are comparable to those of conventional coronary artery bypass. TECAB is also associated with specific challenges for the anesthesiologist. TECAB surgery is a feasible alternative to open coronary artery bypass surgery in selected patient populations. Appropriate patient selection, team training, and stepwise application of the procedure are crucial. TECAB is associated with a unique set of challenges, requiring a skilled operative team. As robotic technology and surgical expertise evolve, this technology will find wider application in an increasing high-risk patient population that will require the support of a skilled anesthesiology team.

Robotically assisted totally endoscopic coronary artery bypass surgery.

Robotically assisted totally endoscopic coronary artery bypass surgery has emerged as a feasible and efficient alternative to conventional full sternotomy coronary artery bypass graft surgery in selected patients. This minimally invasive approach using the daVinci robotic system allows fine intrathoracic maneuvers and excellent view of the coronary arteries. Both on-pump and off-pump operations can be performed to treat single and multivessel disease. Hybrid approaches have the potential of offering complete revascularization with the "best of both worlds" from surgery (internal mammary artery anastomosis in less invasive fashion) and percutaneous coronary intervention (least invasive approach). In this article we review the indications, techniques, short and long term results, as well as current developments in totally endoscopic robotic coronary artery bypass operations.

Cirurgia robótica em Cardiologia: um procedimento seguro e efetivo

ABSTRACTObjective:To evaluate the short and medium-term outcomes of patients undergoing robotic-assisted minimally invasive cardiac surgery.Methods:From March 2010 to March 2013, 21 patients underwent robotic-assisted cardiac surgery. The procedures performed were: mitral valve repair, mitral valve replacement, surgical correction of atrial fibrillation, surgical correction of atrial septal defect, intracardiac tumor resection, totally endoscopic coronary artery bypass surgery and pericardiectomy.Results:The mean age was 48.39±18.05 years. The mean cardiopulmonary bypass time was 151.7±99.97 minutes, and the mean aortic cross-clamp time was 109.94±81.34 minutes. The mean duration of intubation was 7.52±15.2 hours, and 16 (76.2%) patients were extubated in the operating room immediately after the procedure. The mean length of intensive care unit stay was 1.67±1.46 days. There were no conversions to sternotomy. There was no in-hospital death or deaths during the medium-term follow-up. Patients mean follow up time was 684±346 days, ranging from 28 to 1096 days.Conclusion:Robotic-assisted cardiac surgery proved to be feasible, safe and effective and can be applied in the correction of various intra and extracardiac pathologies.

Pro: Robotic Surgery Is the Preferred Technique for Coronary Artery Bypass Graft (CABG) Surgery

OBOTICALLY ASSISTED totally endoscopic coronary artery bypass (TECAB) surgery represents the most advanced procedural development in the field of minimally invasive coronary artery surgery. TECAB surgery is an innovative surgical procedure that utilizes robotic technology to perform the entire coronary revascularization endoscopically in the closed chest. Robotic coronary artery surgery encompasses utilization of robotic assistance in varying degrees from robotically-assisted minimally invasive direct coronary artery bypass (MIDCAB) procedures to TECAB. MIDCAB procedures involve harvesting of the internal mammary artery (IMA) robotically with the coronary anastomoses being performed through a small minithoracotomy under direct visualization. In TECAB procedures, IMA harvesting as well as the coronary anastomoses are performed in a closed chest with robotic assistance through small ports, making this procedure truly minimally invasive.

Anesthetic Management of Robotically Assisted Totally Endoscopic Coronary Artery Bypass Surgery (TECAB)

Over the last decade, TECAB has matured into a reproducible technique associated with low incidence of both mortality and morbidity, as well as superior quality of life, when compared with open CABG surgery. However, TECAB also is associated with important and specific challenges for the anesthesiology team, particularly with regard to the physiologic stresses of OLV, placement of special catheters, and induced capnothorax. As the technology supporting robotic surgery evolves and familiarity with, and confidence in, TECAB increases, the authors anticipate increasingly widespread use of these procedures in an increasingly fragile and problematic patient population who will require the support of a skilled and vigilant anesthesiology team.

Robotically Assisted Coronary Endarterectomy

Robotic assistance has enabled coronary artery bypass surgery to be performed safely in a completely endoscopic fashion, but diffusely diseased target vessels may pose a technical challenge. We present a case in which coronary endarterectomy was performed on the left anterior descending coronary artery during a two-vessel totally endoscopic coronary artery bypass procedure. A 52-year-old woman presented with intermittent substernal pain. Preoperative studies showed diffuse disease in the left coronary artery system. Bilateral internal mammary arteries were harvested robotically using a skeletonized technique in a completely endoscopic fashion. Cardiopulmonary bypass was achieved via peripheral cannulation, and the heart was arrested with intermittent cold antegrade hyperkalemic blood cardioplegia delivered via an ascending aortic occlusion balloon catheter. The first obtuse marginal anastomosis was performed. The left anterior descending coronary artery was diffusely diseased and heavily calcified. An end-to-side anastomosis was attempted to the right internal mammary artery with unsatisfactory results. A localized coronary endarterectomy was performed, and an extended anastomosis was completed using the right internal mammary artery. The patient recovered uneventfully and was discharged home on postoperative day 6. Diffuse coronary artery disease was once thought to be a prohibitive challenge for minimally invasive coronary bypass procedures. This case demonstrates that local coronary endarterectomy is feasible and safe in robotic totally endoscopic coronary artery bypass surgery.

Single-Lung Ventilation Time Does Not Increase Lung Injury after Totally Endoscopic Coronary Artery Bypass Surgery

Over the last decade, totally endoscopic procedures on the beating heart and on the arrested heart have made their way into cardiac surgery. Single-lung ventilation (SLV) is a prerequisite for performing totally endoscopic coronary artery bypass surgery (TECAB). The aim of the present study was to evaluate the influence of SLV on perioperative respiratory parameters and to determine additional predictors of respiratory problems in these patients. We investigated 16 female and 69 male patients (median age, 59 years; range, 38-90 years) who underwent either arrested heart TECAB (n = 76) or beating heart TECAB (n = 9). We analyzed the correlations of the SLV, cardiopulmonary bypass (CPB), aortic cross-clamping, and overall procedure times with perioperative respiratory parameters and length of intensive care unit (ICU) stay. Preoperative values for forced vital capacity and the forced expiratory volume in 1 second were negatively correlated with postoperative pulmonary dysfunction. Longer total operative times were correlated with prolonged mechanical ventilation, tube continuous positive airway pressure ventilation (tube CPAP) time, and ICU and hospital stays. Increased CPB times were associated with longer tube CPAP times, higher grades of pulmonary dysfunction, and a prolonged hospital stay. A prolonged aortic-occlusion time increased the postoperative time to extubation and the hospital stay. Postoperative pulmonary dysfunction was associated with a history of smoking, a poor preoperative respiratory status, and a prolonged CPB time. SLV, however, did not correlate with postoperative time to extubation or with length of ICU stay. Only in patients who underwent conversion to sternotomy (n = 13) was SLV associated with prolonged mechanical ventilation. Preoperative respiratory status showed no major influence on postoperative respiratory outcome in selected patients. Longer operative, CPB, and aortic crossclamping times led to reversible lung injury after TECAB. Prolonged SLV times, however, did not increase the postoperative time to extubation or the length of ICU stay in TECAB patients.

TCT-389: Evaluation of Total Endoscopic Coronary Artery Bypass Surgery (TECAB) by Intraoperative Angiography and Postoperative Multislice Computer Tomography

TCT-389: Evaluation of Total Endoscopic Coronary Artery Bypass Surgery (TECAB) by Intraoperative Angiography and Postoperative Multislice Computer Tomography

Does obesity affect operative times and perioperative outcome of patients undergoing totally endoscopic coronary artery bypass surgery?☆

More and more patients undergoing coronary artery bypass grafting (CABG) are overweight. This patient group suffers from wound healing problems more often than normal-weight patients. Therefore, avoiding sternotomy in obese patients by using an endoscopic technique could be a promising approach. Robotic technology enables totally endoscopic coronary artery bypass grafting (TECAB) procedures. We investigated whether the intra-operative-times or perioperative-outcome after TECAB-procedure are negatively affected by obesity. Patients [n=127, 101 male, 26 female, median age 59 (31-77) years], undergoing arrested-heart TECAB procedure were enrolled. The median body mass index (BMI) in this patient cohort was 26 (19-38). In detail, 27 patients were normal-weight (BMI <or= 25 kg/m(2)), 67 patients were overweight (BMI 25.1-30 kg/m(2)), 29 patients were obese (BMI 30.1-33.9 kg/m(2)) and four patients were morbidly obese (BMI >or= 34 kg/m(2)). There was no correlation between BMI (1) left internal mammary artery (LIMA) takedown-time [Spearman-rank correlation coefficient (R)=0.02; P=n.s.], (2) lipectomy and pericardiotomy-time (R=0.042, P=n.s.), (3) total operative-time (R=-0.083: P=n.s.), (4) cardiopulmonary-bypass-time (R=-0.012; P=n.s.), (5) aortic-endoocclusion-time (R=-0.055; P=n.s.), (6) mechanical-ventilation-time (R=0.001, P=n.s.), (7) length of ICU-stay (R=0.04; P=n.s.), (8) length of hospital-stay (R=-0.103; P=n.s.) or (9) occurrence of intra- and/or postoperative adverse events. In overweight, obese but also morbidly obese patients the TECAB procedure did not increase operative times or the rate of intra- or postoperative complications. This patient group, therefore, benefits from this less traumatic version of coronary surgery.

Difficulties in Beating-Heart Totally Endoscopic Coronary Artery Bypass Grafting: How to Handle the Problem Endoscopically

We describe 2 cases of successful conversion from beating-heart (BH) to arrested-heart (AH) totally endoscopic coronary artery bypass surgery (TECAB). The preoperative computed tomographic (CT) scan of the first patient showed significant artherosclerosis of the femoral vessels in both groins. Therefore we tried to avoid inguinal cannulation by performing an off-pump BH-TECAB. But the target vessel was strongly fissured, and bleedings from the surrounding tissue made anastomotic suturing impossible. Therefore we cannulated the groin cautiously and endoclamped the aorta. The preoperative CT scan of the second patient showed a soft plaque in the ascending aorta. Therefore we tried to perform an on-pump BH-TECAB to avoid clamping of the aorta. Even though we snared the target vessel, significant backbbleeding occurred. Therefore we performed endoclamping of the aorta distal to the aortic plaque. In both cases the following AH-TECAB procedure was performed successfully without any problems.

Super resolution in robotic-assisted minimally invasive surgery

In minimally invasive surgery, a small field of view is often required to achieve a large magnification factor during micro-scale tasks such as coronary anastomosis. However, constantly changing the orientation and focal length of the laparoscope camera is cumbersome, and can impose extra visual and cognitive load on the operating surgeon in terms of realigning the visual pathways and anatomical landmarks. The purpose of this paper is to investigate the use of fixational movements in robotic-assisted minimally invasive surgery, such that the perceived resolution of the foveal field of view is greater than the intrinsic resolution of the laparoscope camera. The proposed technique is based on super resolution imaging using projection onto convex sets for monochrome images, and a maximum a posteriori method with a novel YIQ space-based prior for color images. Validation with both phantom and in vivo data from totally endoscopic coronary artery bypass surgery is provided.

Robotically enhanced coronary artery bypass surgery.

Robotically enhanced telemanipulation surgery is a rapidly developing technique which enables totally endoscopic cardiac surgery with utmost precision and perfection on both beating heart and arrested heart. Between December 2002 and September 2006, 268 patients underwent robotically enhanced coronary artery bypass surgery using the da Vinci telemanipulation system. Fourteen patients underwent total endoscopic coronary artery bypass surgery. Of these 12 were performed on a beating heart and 2 on an arrested heart. Two-hundred and fifty-four patients had endoscopic takedown of the internal mammary artery followed by minimally invasive direct coronary artery bypass in 193 patients and left anterolateral thoracotomy in 61 patients. The internal mammary artery mobilization time was 36 min (28–76 min) and the left internal mammary artery to left anterior descending artery anastomosis time ranged from 20 to 36 min for the totally endoscopic coronary artery bypass patients. The right internal mammary artery of one patient was anastomosed to diagonal artery totally endoscopically. The mean internal mammary artery flow by Doppler measurement in patients undergoing minimally invasive direct coronary artery bypass was 58 ml min−1. Seven patients required conversion to median sternotomy and coronary bypass surgery on the beating heart. The mean intensive care unit stay was 1.2 days and the mean hospital stay 4.5 days. There was one in-hospital mortality. All 14 patients who underwent total endoscopic bypass surgery had coronary angiography 3 months later which showed 100% patency in 13 patients. One patient had 50% anastomotic narrowing for which coronary angioplasty was performed in the same sitting. By using telematic technology, a complete endoscopic anastomosis is possible in both single vessels and suitable double vessel disease patients. The use of robotics is now extended to achieve complete myocardial revascularization by harvesting both the internal mammary arteries and making a small thoracotomy for direct anastomosis also.

Multislice Computed Tomography for Preoperative and Postoperative Assessment in Totally Endoscopic Coronary Artery Bypass Grafting

This article reviews the clinical value of noninvasive multi-slice computed tomography (MSCT) angiography before and after totally endoscopic coronary artery bypass surgery. The use of coronary and aorto-iliaco-femoral MSCT angiography in the preoperative assessment is addressed and the use of bypass MSCT angiography for postoperative control of bypass graft patency is discussed.

Super resolution in robotic-assisted minimally invasive surgery

In minimally invasive surgery, a small field of view is often required to achieve a large magnification factor during micro-scale tasks such as coronary anastomosis. However, constantly changing the orientation and focal length of the laparoscope camera is cumbersome, and can impose extra visual and cognitive load on the operating surgeon in terms of realigning the visual pathways and anatomical landmarks. The purpose of this paper is to investigate the use of fixational movements in robotic-assisted minimally invasive surgery, such that the perceived resolution of the foveal field of view is greater than the intrinsic resolution of the laparoscope camera. The proposed technique is based on super resolution imaging using projection onto convex sets for monochrome images, and a maximum a posteriori method with a novel YIQ space-based prior for color images. Validation with both phantom and in vivo data from totally endoscopic coronary artery bypass surgery is provided.