Endoscopic Coronary Artery Bypass Research Articles

Robot-assisted cardiac surgery.

Recognition of the significant advantages of minimizing surgical trauma has resulted in the development of minimally invasive surgical procedures. Endoscopic surgery offers patients the benefits of minimally invasive surgery, and surgical robots have enhanced the ability and precision of surgeons. Consequently, technological advances have facilitated totally endoscopic robotic cardiac surgery, which has allowed surgeons to operate endoscopically rather than through a median sternotomy during cardiac surgery. Thus, repairs for structural heart conditions, including mitral valve plasty, atrial septal defect closure, multivessel minimally invasive direct coronary artery bypass grafting (MIDCAB), and totally endoscopic coronary artery bypass graft surgery (CABG), can be totally endoscopic. Robot-assisted cardiac surgery as minimally invasive cardiac surgery is reviewed.

Ultra-minimally invasive cardiac surgery: robotic surgery and awake CABG.

The recognition of the significant advantages of minimizing surgical trauma has resulted in the development of minimally invasive surgical procedures. Endoscopic surgery confers the benefits of minimally invasive surgery upon patients, and surgical robots have enhanced the ability and precision of surgeons. Consequently, technological advances have facilitated totally endoscopic robotic cardiac surgery, which has allowed surgeons to operate endoscopically, rather than through a median sternotomy, during cardiac surgery. Thus, repairs for structural heart conditions, including mitral valve plasty, atrial septal defect closure, multivessel minimally invasive direct coronary artery bypass grafting and totally endoscopic coronary artery bypass graft surgery (CABG), can be totally endoscopic. On the other hand, general anesthesia remains a risk in patients who have severe carotid artery stenosis before surgery, as well as in those with a history of severe cerebral infarction or respiratory failure. In this study, the potential of a new awake CABG protocol using only epidural anesthesia was investigated for realizing day surgery and was found to be a promising modality for ultra-minimally invasive cardiac surgery. We herein review robot-assisted cardiac surgery and awake off-pump coronary artery bypass grafting as ultra-minimally invasive cardiac surgeries.

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

Advanced hybrid closed chest revascularization: an innovative strategy for the treatment of multivessel coronary artery disease†.

Conventional hybrid revascularization (CHR) combines minimally invasive placement of an internal mammary artery graft to the anterior wall and percutaneous coronary intervention (PCI) of non-anterior wall targets. In this study we assess perioperative and midterm outcomes of advanced hybrid revascularization (AHR) defined as the combination of single or multivessel (MV) totally endoscopic coronary artery bypass grafting (TECAB) with single or multivessel PCI. In total, 90 AHR patients [median age 62 years (35-86)] were compared with 90 CHR patients [median age 60 years (35-85)] in terms of perioperative and mid-term outcomes. The outcomes of the three different AHR options (MV-TECAB + PCI, MV-PCI + TECAB, MV-TECAB + MV-PCI) as well as the sequence of the interventions were further compared. Risk factors for major adverse cardiac and cerebral events (MACCEs) related to the hybrid revascularization strategy were calculated. No perioperative deaths occurred either in the AHR group or in the CHR group, rates of myocardial infarction (3.3% vs 3.3%, P = 0.196) were similar between CHR and AHR. Operative times were longer in the AHR group [337 (137-794) min vs 272 (148-550) min, P = 0.002] and conversion rates slightly higher (P = 0.060); however, intensive care unit length of stay (P = 0.162) and hospital length of stay (P = 0.238) were similar. There was no difference in the follow-up survival (P = 0.091), freedom from angina (P = 0.844), PCI target vessel revascularization (P = 0.563), TECAB target vessel revascularization (P = 0.135) and MACCEs (P = 0.601) between CHR and AHR at follow-up. No differences were detected between the three variations of AHR in perioperative outcome, mid-term survival, freedom from MACCEs and reintervention. Neither the number nor type of TECAB/PCI targets, nor the sequence of interventions were significant predictors for MACCEs at follow-up. AHR yields comparable results with CHR and can be taken into consideration as a sternum-sparing technique for the treatment of MV-coronary artery disease in selected patients.

Perioperative nursing of patients undergoing hybrid coronary revascularization

Objective This study described our experience on perioperative nursing care for hybrid revascularization by endoscopic robotic coronary artery bypass on the beating heart with percutaneous coronary intervention （ PCI） in a staged approach .Methods Patients undergoing hybrid coronary revascularization from January 2007 to September 2013 were included in the study .The progressive patient care was different compared with conventional coronary artery bypass graft surgery （ CABG ） , so the health education and specific nursing were of great importance in different phases .The preoperative angina pectoris attacks therapy and pulmonary function training were necessary , and the hemodynamic monitoring , hemorrhage volume record , lung caring, pain therapy and anticoagulation after robotic assisted CABG were also important .At the same time, the intensive anticoagulation before PCI and renal injury , arterial hemorrhage prevention after PCI needed much attention.Results There was no death patients during the study phase . After the hybrid coronary revascularization, patients were stable and no severe complication was occurred .After 2 days of surgery, patients could take a walk at bedside .The mean time of ICU stay was （37.8 ±5.6） hours.After PCI, no bypass vascular stenosis occurred .Conclusions The comprehensive perioperative nursing care is necessary for patients received hybrid coronary revascularization surgery . Key words: Coronary artery bypass graft,extracorporeal circulation; Robot; Support; Hybrid; Perioperative nursing

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.

Ultra fast track anaesthesia for patients scheduled for robotic totally endoscopic coronary artery bypass is feasible and safe

Imbault, J.1; Zaouter, C.1; Champion, S.1; Coiffic, A.1; Labrousse, L.2; Ouattara, A.1 Author Information

Analysis of the learning curve for beating heart, totally endoscopic, coronary artery bypass grafting

Robotic cardiac surgery has been proved safe and feasible in dedicated centers. We systematically analyzed the learning curve issues associated with totally endoscopic coronary artery bypass grafting (TECAB) using a stepwise approach by a single surgeon who had successfully performed >650 cases of various types of robotic cardiac surgery at our single center. From January 2007 to March 2013, 230 patients underwent robotic coronary bypass grafting on the beating heart. Of these patients, 90 had successfully undergone beating heart TECAB using the da Vinci S/Si Surgical System without conversion to sternotomy. All beating heart TECAB procedures were completed using the following modules: endoscopic left internal thoracic artery (LITA) harvesting, pericardiotomy and target vessel identification, and anastomosis of the LITA to the target vessel. The perioperative outcomes were compared among 3 quintiles of 30 consecutive patients each and the learning curve results were evaluated. No in-hospital mortality or severe morbidity occurred. The comparison among the 3 quintiles showed a significant decrease in operative time (P=.000), LITA harvesting time (P=.037), and anastomotic time (P=.000). A significant learning curve was observed for the operative time [y(min)=223-17×ln(x); r2=0.217, P=.000]; LITA harvesting time [y(min)=37-3×ln(x); r2=0.097, P=.003]; and LITA-left anterior descending artery anastomotic time [y(min)=18-2×ln(x); r2=0.298, P=.000]. No differences were found in the mean transit flow (P=.102) or perioperative complications among the 3 quintiles. Modular-based TECAB procedures can be successfully performed; however, each module has a steep learning curve. A stable and well-trained robotic cardiac team and an experienced cardiac surgeon can achieve good, reproducible results after this substantial learning curve.

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.

The midterm outcome and MACE of robotically enhanced grafting of left anterior descending artery with left internal mammary artery

BackgroundWe assessed the midterm outcome and the incidence of major adverse cardiovascular events in UK’s largest Da Vinci assisted robotic coronary revascularisation cohort. This study was set up at the Imperial College NHS Trust, St. Mary’s Hospital, London, United Kingdom.MethodBenchmarking approach through retrospective audit of the regional outcomes against standards in the published literature. Data was collected from the patient’s records, communication with the primary care physicians and the national strategic tracing service. The results were compared with the published literature. Patients who underwent robotic assisted coronary revascularisation were included. Other robotic procedures or minimally invasive revascularisation without the use of the Da Vinci robot were excluded. The main outcome measure was the midterm survival up to five years and the incidence of major adverse cardiovascular events (MACE) up to three years.ResultsSince April 2002, one hundred consecutive patients underwent either off pump robotic assisted single vessel small thoracotomy (SVST, n = 88), or off pump total endoscopic coronary artery bypass grafting (TCAB, n = 12). All patients were operated on by the same primary surgeon but different assisting surgeons. All patients received a left internal mammary arterial (LIMA) graft as planned. The primary outcome of total one month and three years MACE and up to five year survival was 0, 9 and 96% respectively.ConclusionsThe procedural success rates in terms of morbidity and mortality up to five years are compatible to the outcomes observed outside the United Kingdom. These results are not inferior to that of conventional off pump single vessel coronary surgery or percutaneous coronary intervention to the LAD.

Mammary artery harvesting using the Da Vinci Si robotic system.

Internal mammary artery harvesting is an essential part of any coronary artery bypass operation. Totally endoscopic coronary artery bypass graft surgery has become reality in many centers as a safe and effective alternative to conventional surgery in selected patients. Internal mammary artery harvesting is the initial part of the procedure and should be performed equally safely if one wants to achieve excellence in patency rates for the bypass. We here describe the technique for mammary harvesting with the Da Vinci Si robotic system.

Is There a Role for Robotic Totally Endoscopic Coronary Artery Bypass in Patients With a Colostomy?

Preoperative colostomy presents a significant risk of sternal wound complications, mediastinitis, and ostomy injury in patients requiring coronary artery bypass grafting. Less invasive procedures in coronary surgery have a potential to reduce the risk of sternal wound healing problems. Robotic totally endoscopic coronary artery bypass grafting in patients with a colostomy has not been reported. We describe a case of completely endoscopic coronary surgery using the da Vinci Si system in a patient with a transverse colostomy. Single left internal mammary artery grafting to the left anterior coronary artery was performed successfully on the beating heart. We regard this technique as the least invasive method of surgical coronary revascularization with a potential to reduce the risk of surgical site infection and mediastinitis in patients with a colostomy.

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.

Robotic Totally Endoscopic Coronary Artery Bypass Grafting in Men and Women: Are There Sex Differences in Outcome?

According to several studies, women are at higher risk for mortality and experience less relief of angina after coronary artery bypass graft surgery (CABG) than men. Sex-related differences in patients undergoing totally endoscopic coronary bypass grafting (TECABG) have not been investigated thus far. The aim of the present study was to evaluate the impact of sex on the outcome of patients undergoing TECABG. The data of 500 consecutive patients (364 male, 136 female) undergoing TECABG using the da Vinci telemanipulation system (Intuitive Surgical, Sunnyvale, CA) from 2001 to 2011 at two institutions were investigated regarding sex-related differences in short-term and long-term outcome. In all, 334 single, 150 double, 15 triple, and 1 quadruple TECABG procedures were carried out. Female patients were significantly older (63 years [range, 26 to 90] versus 59 years [range, 31 to 85], p = 0.001) and had higher European System for Cardiac Operative Risk Evaluation score levels (3 [range, 0 to 11] versus 2 [range, 0 to 13], p < 0.001). Male patients received slightly more grafts (1 [range, 1 to 4] versus 1 [range, 1 to 3], p = 0.028), female patients were more likely to undergo beating heart surgery (20% versus 28%, p = 0.042). In-hospital mortality was 3 of 364 men (0.8%) and 2 of 136 women (1.5%; p = 0.513). Comparison of long-term-survival revealed 1-, 3- and 5-year survival rates of 96%, 96%, and 95% in men and 96%, 96%, and 96% in women, respectively, without any significant difference. Analysis of freedom from major adverse cardiac and cerebrovascular events revealed 1-, 3-, and 5-year rates of 86%, 84%, and 82% in men and 85%, 81%, and 81% in women, respectively, without any significant difference. Our data show that women undergoing TECABG have outcomes similar to those of men.

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.

Systematic review of robotic-assisted, totally endoscopic coronary artery bypass grafting.

Advancements in surgical robotic technology over the last two decades have enabled coronary artery bypass grafting to be performed totally endoscopically, and have the potential to significantly change clinical practice in the future. A systematic review of studies reporting clinical outcomes of total endoscopic coronary artery bypass grafting (TECABG) was performed. 14 appraised studies included 880 beating heart TECABGs, 360 arrested heart TECABGs, 633 one-vessel operations and 357 two-vessel operations. Patients were generally low-risk. There was a significant learning curve. The weighted means for short-term beating heart and arrested heart TECABG results respectively were: intraoperative exclusion rate of 5.7% and 1.9%, intraoperative conversion rate of 5.6% and 15.0%, all-cause mortality of 1.2% and 0.4%, stroke of 0.7% and 0.8%, myocardial infarction of 0.8% and 1.8%, new onset atrial fibrillation of 10.7% and 5.1% and post-operative reintervention rate of 2.6% and 2.3%. The overall rate of short term postoperative graft patency for beating heart and arrested heart TECABG was 98.3% and 96.4% respectively. Appropriate patient selection was important in minimizing the risk of intraoperative and postoperative complications. Short-term outcomes of both beating and arrested heart TECABG were acceptable, but results so far have been heterogeneous. There were fewer studies reporting intermediate to long-term outcomes, but results were encouraging, and further investigation and development of the procedure is warranted.

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.

Predictors and consequences of postoperative atrial fibrillation following robotic totally endoscopic coronary bypass surgery

Postoperative atrial fibrillation (AFib) is common in patients undergoing coronary artery bypass grafting. Little information is available concerning AFib following minimally invasive cardiac surgery. The aim of our study was to assess the incidence of AFib after totally endoscopic coronary artery bypass (TECAB) grafting and to investigate the factors influencing its occurrence. Between 2001 and 2010, we performed TECAB in 384 patients, 73% male, aged 60 (37-90) years. Single-vessel bypasses were performed in 280 patients, and 104 received multivessel coronary revascularization. Procedures were performed on the beating heart in 80 cases, and 164 patients underwent a hybrid intervention. A total of 59 patients (15.4%) developed AFib after TECAB. Univariate analysis showed hypertension (P=0.005), increased age (P=0.007), body weight (P=0.006), body mass index (P=0.005), EuroSCORE (P=0.035) and total TECAB operation time (P=0.01) to be significantly associated with AFib. We also found an increased incidence of AFib in patients undergoing hybrid interventions (P=0.036) and beating heart TECAB (P=0.003). Age (P<0.001) and higher body weight (P=0.003) were the only predictors found to be significant in multivariate analysis. Hospital mortality was 1.7% (1 of 59) in the group of patients with AFib and 0.6% (2 of 325) in the group that showed no AFib after operation (P=n.s.). Hospital stay was 7 (4-54) days in patients with AFib and 6 (2-33) days in those without AFib (P=n.s.). There was no significant 5-year survival difference in patients with and without postoperative AFib (94 vs 94%, P=n.s.). We conclude that the incidence of postoperative AFib in TECAB is relatively low. Age and body weight are the most important predictors of postoperative AFib following TECAB. Short-term clinical outcome and intermediate-term survival are similar in patients with and without postoperative AFib.

Systematic Review of Total Endoscopic Coronary Artery Bypass Graft Outcomes

Systematic Review of Total Endoscopic Coronary Artery Bypass Graft Outcomes