Internal Mammary Artery Harvesting Research Articles

Osteophyte of the first costochondral joint is a reliable landmark to facilitate standardized robotic left internal mammary artery harvesting

Osteophyte of the first costochondral joint is a reliable landmark to facilitate standardized robotic left internal mammary artery harvesting

Development and Validation of a Low-Cost, High-Fidelity Simulation Model for Robotic Internal Mammary Artery Harvest Using the da Vinci Xi Robot.

We created and validated a low-cost simulation model for robotic internal mammary artery (IMA) takedown. The simulation model utilized a calf fetus thorax cavity stented open internally and secured to a table. The simulation model was validated at a 2-day robotic cardiac surgery workshop. Each participant harvested one IMA using the da Vinci Xi robot (Intuitive Surgical, Sunnyvale, CA, USA). We compared participant self-reported confidence at robotic IMA harvest before and after using the simulator. Our novel thorax-securing strategy resulted in a stable structure and allowed access to both IMAs from the same 3 ports. The cost to set up the first simulation model was $176 and $133 for every subsequent model. Fifty participants used the simulation model: 42 cardiothoracic surgery attendings and 8 fellows or residents. The feedback form response rate was 78% (n = 39). On the Likert scale, participants rated realism of the calf model to simulate robotic IMA harvesting (0 = not realistic, 10 = highly realistic) with a median of 8 out of 10 (interquartile range [IQR] 7 to 9). Participant confidence (0 = not at all confident, 10 = very confident) in robotic IMA harvesting before and after using the simulator increased (P = 0.001) from a median of 5 (IQR 1 to 7) to 9 (IQR 7 to 10). This robotic IMA harvest simulation model is affordable, realistic, and improved participant confidence in robotic IMA harvest. It may provide a valuable training tool for surgeons learning robotic coronary bypass surgery and allows for training frequency necessary to pass basic learning curves.

Internal Mammary Artery Harvesting by Harmonic Scalpel - Our experience

Internal mammary artery is considered as the priceless conduit in all forms of surgical coronary artery revascularization. Harvesting technique of this artery, as a result, was widely debated. Harmonic scalpel is showing excellent result and some of the pioneers are using it for decades together around the globe disregarding our population. We are routinely using harmonic scalpel from the year 2022 and arranged this study to observe the outcomes in our population. Cardiovasc j 2024; 16(2): 78-80

Robotic-assisted coronary artery bypass grafting: how I teach it.

The first robotic cardiac operation was performed more than two decades ago. This paper describes the distinct steps and components necessary for teaching robotic-assisted minimally invasive direct coronary artery bypass (R-MIDCAB). It also provides a general overview of the surgical robotic setup and ways to troubleshoot potential complications. The focus of robotic training is not only on the surgeon but includes an entire dedicated cardiac team and administrative institutional support. This team approach ensures that R-MIDCAB can be performed safely and reproducibly. Meticulous planning, incremental learning, and teamwork are the main factors leading to program success and optimal patient outcomes. Robotic-assisted internal mammary artery (IMA) harvesting and coronary revascularization via a small, anterior mini-thoracotomy has provided an alternative to sternotomy in selected patients with coronary artery disease (CAD). Benefits include less postoperative atrial fibrillation, fewer blood transfusion, less time in the operating room (OR), less ventilatory support, fewer strokes, decreased intensive care unit stay and shortened postoperative length of stay all of which manifests as a decrease in institutional resource utilization. Recent data show that R-MIDCAB and hybrid coronary revascularization provides good long-term outcomes. In addition to patient satisfaction, there is an additional overall cost benefit to R-MIDCAB over traditional sternotomy coronary artery bypass grafting (CABG), secondary to decreased hospital length of stay. Robotically harvesting the IMA, operating on a beating heart, and performing anastomoses through a small incision all require advanced training and incremental learning. Increased experience generally leads to shortened surgical times and fewer complications.

Diaphragmatic elevations following cardiac surgery.

This study aims to investigate the incidence, prognosis, and etiology of diaphragmatic elevation following cardiac surgery. Between February 2019 and December 2019, a total of 888 patients (631 males, 257 females; mean age: 58.4±12.1 years; range, 19 to 84 years) who underwent cardiac surgery were retrospectively analyzed. A series of chest X-rays taken before and after surgery were analyzed to detect diaphragmatic elevation. The patients were divided into two groups: those without diaphragmatic elevation (Group 1, n=789) and those with diaphragmatic elevation (Group 2, n=99). Diaphragmatic elevation occurred in 11.14% of patients. Of these patients, 85% recovered within a year. Patients with concomitant chronic obstructive pulmonary disease and diaphragmatic elevation exhibited prolonged mechanical ventilation compared to chronic obstructive pulmonary disease patients without elevation. The incidence of diaphragmatic elevation was higher in coronary artery bypass grafting patients compared to others (p<0.001). A secondary analysis utilizing propensity score matching revealed topical cold slush as an independent risk factor for diaphragmatic elevation. Incidence and hospitalization duration were higher among patients exposed to topical cold slush (p=0.011 and p=0.002, respectively). Left internal mammary artery harvesting and diabetes mellitus were associated with increased incidence of diaphragmatic elevation. Diaphragmatic elevation is frequent following cardiac surgery, particularly in coronary artery bypass grafting patients with diabetes mellitus. Among chronic obstructive pulmonary disease patients, diaphragmatic elevation can lead to unfavorable clinical outcomes. Minimizing the use of topical cold slush and considering beating heart surgery may be prudent in high-risk groups to reduce diaphragmatic elevation incidence.

Historical landmarks in the development of robotic coronary bypass grafting.

Robotic technology was first used in history for the minimally invasive surgical treatment of coronary artery disease. In 1998, the first operations were carried out at the Hôpital Broussais in Paris. Thereafter, several European and United States (US) centers developed surgical concepts for robotically assisted internal mammary artery harvesting and the construction of the anastomoses, either through minithoracotomy or in a totally endoscopic fashion. Initial experiences were documented in a number of single and multicenter series published in the early and mid-2000s. Key steps in further procedure development included the introduction of a robotic endostabilizer for beating heart completely endoscopic operations, the combination with percutaneous coronary intervention in hybrid approaches, the introduction of second, third, and fourth generations of surgical robots with improvements in each iteration, the availability of anastomotic devices, and most recently, the emergence of new robotic technology companies producing interesting alternatives to the existing machines. The larger clinical series included 500 to over 1,000 patients, with clinical results that well justified the continued application of robotics. Development of robotic coronary bypass grafting has generally been slow, but at committed centers, the procedures are routine, reproducible, safe, and effective. Over 25 years of development, robotic surgical coronary revascularization has become an important component in the armamentarium of minimally invasive heart surgery.

Clipless internal mammary artery harvesting for minimally invasive coronary artery bypass grafting using a shear-tip harmonic scalpel.

Clipless internal mammary artery harvesting for minimally invasive coronary artery bypass grafting using a shear-tip harmonic scalpel.

Clipless internal mammary artery harvesting for minimally invasive coronary artery bypass grafting using the shear-tip harmonic scalpel.

The internal mammary artery (IMA) is the most commonly used graft in coronary artery bypass grafting (CABG) because of its superior long-term patency rate. However, its small diameter poses challenges in handling, and any vascular damage that may occur during harvesting can significantly affect surgical outcomes. The primary focus during IMA harvesting is to ensure safe and effective hemostasis without direct vascular injury, while ensuring secure and reliable ligation of the vascular branches. Various methods using multiple surgical instruments have been used for this purpose. Unlike traditional instruments, the shear-tip Harmonic scalpel offers more precise vessel branching control, while minimizing damage to surrounding tissues. In this study, we assessed the utility of the shear-tip Harmonic scalpel in patients undergoing minimally invasive coronary artery bypass grafting (MICABG). From April 2019 to May 2023, a total of 40 patients underwent MICABG. The IMA was harvested using the shear-tip Harmonic scalpel with a clipless skeletonized technique. In this cohort, 5 patients underwent complete endoscopic harvesting, while 34 patients underwent direct visualization harvesting through minimal thoracotomy. Graft patency was assessed by measuring a Doppler flowmeter in the bypass conduit. Successful graft patency was achieved in all patients. The mean duration of IMA harvesting was 87 min. In total, 38 of the 40 patients underwent MICABG without the need for cardiopulmonary bypass, ensuring a stable procedure. There were no graft-related events or complications observed in any of the patients, and all were discharged without any issues. During a median follow-up period of 15.2 months, only one patient experienced graft occlusion necessitating intervention. The utilization of shear-tip Harmonic scalpel for IMA harvesting in MICABG is feasible and yields stable early results.

Comparison of Intercostal and Subxiphoid Left Pleural Drain After Coronary Artery Bypass Grafting (CABG) Surgery: A Systematic Review and Meta-Analysis.

Coronary artery bypass grafting (CABG), a prevalent surgery for coronary artery disease, often involves left internal mammary artery harvesting, necessitating left pleural drain insertion. This can lead to pain, discomfort, and respiratory issues. This analysis compares outcomes between subxiphoid and intercostal left pleural drain insertion. Following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, this systematic review and meta-analysis involved searches in MEDLINE, Cochrane Central Register of Controlled Trials (CENTRAL), Scopus, Google Scholar, and Clinical Trial Registry. Studies were selected based on primary outcomes (postoperative ventilator support duration and pain score) and secondary outcomes (percentage predicted vital capacity (VC), forced VC (FVC), and partial pressure of oxygen (PO2) in arterial blood gas (ABG) analysis). Statistical analysis used a random effect model, pooled risk ratio, and I2 heterogeneity. Nine studies (seven randomized and two nonrandomized) with 412 patients met the inclusion criteria. Pooled analysis indicated reduced ventilation time and postoperative pain with the subxiphoid drain compared to the intercostal drain. Spirometry parameters showed improved VC, FVC, and PO2 in ABG analysis. This meta-analysis suggests that subxiphoid pleural drain insertion in CABG patients is associated with shorter ventilation times, lower pain scores, and improved pulmonary function compared to intercostal drain placement.

Optimizing Internal Mammary Artery Harvest and Preparation

The left internal mammary artery (LIMA) graft plays a pivotal role in coronary artery bypass surgery, offering unparalleled efficacy in revascularization. This review paper delves into the multifaceted considerations surrounding LIMA utilization, aiming to provide a comprehensive understanding of optimal approaches. The study encompasses the alleviation of spasm, selection of graft harvesting techniques, identification of ideal vasodilators, and exploration of optimal delivery methods. Through an analysis of extensive research spanning the past three decades, this review elucidates critical insights for cardiac surgeons and researchers alike. The review emphasizes the ubiquity of severe spasms in harvested LIMA and examines interventions to mitigate this challenge. Studies highlighting the efficacy of papaverine administration through various routes underscore the need for tailored approaches based on clinical context. The debate between skeletonized and pedicled LIMA harvests is explored, revealing the advantages and complexities associated with each technique. Findings suggest that while skeletonized grafts offer enhanced flow, the decision remains multifaceted due to potential complications. Addressing the quest for the ideal vasodilator, the review juxtaposes papaverine and sodium nitroprusside, presenting both as viable options. Despite ongoing discussions, the cost-effectiveness and accessibility of papaverine have positioned it as the favored choice among clinicians. Optimal delivery methods emerge as a crucial factor in graft success, with perivascular injection showing promise in promoting sustained and improved flow rates. The clinical implications of these findings are substantial. By integrating the evidence presented, cardiac surgeons can make informed decisions, maximizing graft patency and patient outcomes. Further, research avenues are identified, encompassing refined delivery techniques, comprehensive comparisons of vasodilators, and long-term clinical outcome evaluations. In conclusion, this review underscores the intricate considerations essential for successful LIMA utilization. By addressing spasms, selecting graft techniques, choosing vasodilators, and refining delivery methods, practitioners can tailor their strategies to the individual patient, enhancing the efficacy of coronary revascularization.

Prospective Randomized Pilot Trial on the Effects of Mild Hypercapnia on Cerebral Oxygen Saturation in Patients Undergoing Off-Pump Coronary Artery Bypass Grafting

A single-center prospective randomized controlled study was conducted to assess the effect of targeted mild hypercapnia (TMH) on cerebral oxygen saturation (rSO2) in patients undergoing off-pump coronary artery bypass grafting (CABG). A prospective randomized controlled study involving 100 patients undergoing off-pump CABG at U. N. Mehta Hospital, Ahmedabad, Gujarat, India. Patients were randomized to either the TMH (PaCO2 45-55 mmHg) or the targeted normocapnia (TN; PaCO2 35-45 mmHg) group, containing 50 patients in each group. Monitoring of rSO2, heart rate, mean arterial pressure (MAP), PaCO2, and peripheral oxygen saturation was done at baseline, after induction, after left internal mammary artery harvesting, at each grafting (distal and proximal), after protamine, and after shifting to the intensive care unit. The standardized minimental-state examination (SMMSE) was performed preoperatively and at 8, 12, and 24 hours postextubation. Data were analyzed using an independent sample t test. The TMH group had higher MAP during grafting (p < 0.001) and higher rSO2 on both sides during distal and proximal grafting (p < 0.001) and after protamine (p < 0.05), as compared to the TN group. Compared to preoperative values, SMMSE scores in the TN group were significantly lower at 12 and 24 hours postextubation (p < 0.001). TMH during grafting increased the cerebral blood flow and rSO2 when hemodynamic instability was very common. It has a protective role on the brain and helps maintain cognition postoperatively.

Comparison of Robot-Assisted Multivessel Minimally Invasive Direct Coronary Artery Bypass and Hybrid Revascularization

BackgroundThis study compares 2 minimally invasive coronary revascularization approaches: robot-assisted multivessel minimally invasive direct coronary artery bypass (MIDCAB) and the hybrid approach combining MIDCAB with subsequent percutaneous coronary intervention. MethodsA retrospective review was conducted on cases of robotic MIDCAB performed at our institution between 2012 and 2022. Two groups of patients were analyzed: the surgery group (undergoing robotic multivessel MIDCAB) and the hybrid group. Surgical procedures included robotic left internal mammary artery harvest and anastomosis, with percutaneous coronary intervention performed within 30 days in the hybrid group. ResultsThere were 105 patients in the surgery group and 81 patients in the hybrid group. Both groups had similar characteristics, except that the surgery group had older patients. There were no mortalities in either group. Postoperative atrial fibrillation rates were higher in the surgery group. Length of stay and other postoperative complications did not differ significantly between the groups. ConclusionsMultivessel robotic MIDCAB can be safely performed with comparable outcomes to the hybrid approach. The hybrid technique, being less demanding, is the preferred in most centers. However, multivessel robotic MIDCAB offers the advantage of complete revascularization and potentially more durable results. Patients with complex non–left anterior descending lesions may not be suitable for the hybrid approach.

Incidence and Factors Associated With Post-Sternotomy Pain Syndrome in the National Heart Institute, Malaysia

To determine the incidence of poststernotomy pain syndrome (PSPS) after open cardiac surgery in 2021. To determine characteristics and assess the severity of symptoms in patients diagnosed with PSPS. To identify factors that can be associated with patients who were positive for PSPS. This study used a retrospective observational approach. Logistic regression analysis was employed to identify factors associated with the positive group. This study included all adult patients who underwent open cardiac surgery at the National Heart Institute, Malaysia, in 2021. A total of 1,395 patients were enrolled. The study involved conducting phone interviews to assess the presence of PSPS, followed by administering the Brief Pain Inventory questionnaire in the positive group to identify characteristics and severity of chronic pain. The incidence of PSPS after open cardiac surgery in 2021 was 20.35%. A total of 17.7% of patients reported that pain affected their daily activities, sleep, or emotions. Univariate analysis identified factors associated with PSPS, including age <60 years old, body mass index >30 kg/m2, history of previous percutaneous coronary intervention, ejection fraction <50%, the absence of chronic kidney disease (CKD), and internal mammary artery harvesting (p < 0.05). Multivariate analysis revealed that 4 independent factors were associated with PSPS: age <60 years old, history of previous percutaneous coronary intervention, ejection fraction <50%, and the absence of CKD (as compared with CKD) (p < 0.05). Poststernotomy pain syndrome is a complex issue affected by various factors. Although the pain score may not be as severe as previously believed, it remains crucial to recognize PSPS because a significant proportion of patients are affected.

Abstract 16128: The Winslow Pathway and Internal Mammary Artery Harvesting in Patients With Aortoiliac Occlusive Disease

Introduction We present a case where the left Internal Mammary Artery (IMA) was not a straightforward choice as the grafted vessel in a patient undergoing Coronary Artery Bypass Grafting (CABG). Case Presentation Patient was a 66 years old female with Hypertension, Hyperlipidemia, hypothyroidism, and tobacco use disorder. Evaluation for a motor vehicle accident secondary to a syncopal episode, and intermittent chest tightness over the past few months, showed ST depressions on ambulatory electrocardiographic monitoring, reversible ischemia in the anterior and apical walls on Exercise Stress Test and severe multivessel coronary artery disease involving the distal main left coronary artery and its branches on Coronary Angiography. CABG was advised. Preoperative peripheral angiogram showed bilateral common iliac artery occlusion, precluding IABP placement. Selective angiography of the left IMA showed the left IMA to be the major vessel supplying collateral circulation to the left iliac system. Patient subsequently underwent CABG with bilateral Saphenous Vein Harvest. Discussion IMA harvesting in patients with Aortoiliac Occlusive Disease (AOD) with prominent collaterals through the subclavian-IMA-inferior epigastric-external iliac pathway, AKA the Winslow Pathway (WP), can result in limb threatening ischemia, and elective IMA angiography and/or doppler flow evaluation before CABG can help identify this important collateral pathway. Alternative approaches in patients with AOD include simultaneous coronary and peripheral revascularization, completely avoiding IMA harvesting or in some cases, angioplasty, although there is no consensus thus far.

Incidence of brachial plexus injury after cardiac surgery: a retrospective study

Background: Brachial plexopathy is a rare but debilitating injury associated with cardiac surgery. The reported incidence varies widely. Several risk factors have been described, including both patient and surgical factors. Objectives: The aim of this study is to (1) investigate the incidence of brachial plexus injury in cardiac surgery in a three-year period in our hospital, (2) give an overview of risk factors and possible mechanisms of brachial plexopathy, and (3) consider the legal ramifications of these injuries. Design and setting: single centre retrospective study Methods: Data were collected retrospectively from all patients undergoing cardiac surgery in a major hospital in a three-year year period (N = 1305). Hospital records were screened for patients who underwent an electromyography after their surgery. Those cases were further investigated for brachial plexus injury. Patient characteristics and data applying to known risk factors for peroperative nerve injury were obtained. Results: Brachial plexus injury was observed in 7 out of 1305 patients (0.54%). All patients with brachial plexus injury underwent coronary artery bypass surgery with internal mammary artery harvesting at the side of the injury. No further analysis concerning risk factors was performed since only seven cases were identified and underreporting was suspected. Conclusion: Our data suggest that brachial plexus injury in cardiac surgery might be associated with asymmetrical sternal retraction during internal mammary artery harvesting. These findings correspond with previous reports, although it would be interesting to further investigate the importance of the exact placement and type of retractor used.

428 Progressive shortness of breath in a post CABG patient: Thinking beyond the obvious

Abstract Background Post-coronary artery bypass graft (CABG) chylothorax is rare accounting for 0.06-0.09% of the cases. Case presentation A 62 year old male patient presented with progressive shortness of breath (mMRC grade 1 to 3) for 6 months. He underwent CABG surgery 7 months prior due to ischemic heart disease. Clinical examination supplemented with radiological imaging revealed evidence of progressive bilateral pleural effusion. Pleural fluid aspiration showed bloody appearance of fluid on right side. Lipid analysis of the aspirate confirmed presence of chylomicrons along with a raised triglyceride level(138mg/dL). Clinical outcome A diagnosis of right-sided post CABG chylothorax with left sided transudative fluid was made. Patient was managed with ICD insertion on the right side and started on total parenteral nutrition (TPN). This was followed by permissible carbohydrate intake and TPN for 11 days. Gradual decrease in collection was noticed in the follow-up x-ray with no recurrence of symptoms. Discussion Most likely that the anterior mediastinal lymphatic chain got injured during the harvesting of internal mammary artery causing leakage of chyle into the thoracic cavity leading to dyspnoea and chest discomfort. Conclusion Lipid measurements may be indicated in all patients with undiagnosed pleural effusion in order to rule out chylothorax. Chylothorax can meet criteria of transudate if associated with congestive cardiac failure, cirrhosis, or nephrotic syndrome. However, the colour of pleural fluid is not always indicative of a chylothorax. While most of the patients can be managed conservatively, surgery is recommended if drainage lasts for more than 1-3 weeks, and daily drainage is 200-500mL.

Ultrasonic scalpel versus electrocautery for internal mammary artery harvesting: a meta-analysis.

Although an ultrasonic harmonic scalpel (HS) has been used to harvest the internal mammary artery (IMA) for coronary artery bypass grafting, the benefits and risks compared to conventional electrocautery (EC) are not clear. We aimed to compare the outcomes of HS versus EC for IMA harvesting. An electronic search was performed to identify all relevant studies. Baseline characteristics, perioperative variables, and clinical outcomes were extracted and pooled for meta-analysis. This meta-analysis included 12 studies. Pooled analyses demonstrated that both groups had comparable preoperative baseline characteristics including age, gender, and left ventricular ejection fraction. HS included more diabetic patients [33% (95% CI 30, 35) vs. 27% (23, 31), p = 0.01]. Harvest time for unilateral IMA was significantly longer with HS than EC [39 (31, 47) minutes vs. 25 (17, 33) minutes, p < 0.01]. However, the rate of pedicled unilateral IMA was significantly higher for EC compared with HS [20% (17, 24) vs. 8% (7, 9), p < 0.01]. The rate of intact endothelium was significantly higher with HS than EC [95% (88, 98) vs. 81% (68, 89), p < 0.01). There was no significant difference in postoperative outcomes including bleeding [3% (2, 4)], sternal infection [3% (2, 4)], and operative/30-day mortality [3% (2, 4)]. HS required longer IMA harvest times which could be partially attributed to a higher skeletonization rate in this category. HS may cause less endothelial injury than EC; however, no significant differences in postoperative outcomes were seen between the groups.

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.

Mastering the Learning Curve for Robotic-Assisted Coronary Artery Bypass Surgery

BackgroundPrevious studies have evaluated the learning curve to achieve competency in robotic-assisted coronary artery bypass grafting (CABG) but have not identified thresholds for mastery. Robotic-assisted CABG is a minimally invasive alternative to sternotomy CABG. The purpose of this study was to evaluate the short- and long-term outcomes of this procedure and to estimate the threshold for achieving mastery. MethodsFrom 2009 to 2020, 1000 robotic-assisted CABG procedures were performed at a single institution. Robotic left internal mammary artery (LIMA) harvest followed by off-pump, LIMA–left anterior descending artery grafting using a 4-cm thoracotomy was performed. Short-term outcomes were obtained from The Society of Thoracic Surgeons database, and long-term follow-up was obtained by telephone questionnaires from dedicated research nurses for all patients more than 1 year from surgery. ResultsMean patient age was 64 ± 11 years, Society of Thoracic Surgeons predicted risk of mortality was 1.1% ± 1.5%, and 76% (758) of patients were men. Thirty-day mortality occurred in 6 patients (0.6%; observed-to-expected ratio, 0.53), 5 patients (0.5%) experienced a postoperative stroke, and postoperative LIMA patency was 97.2% (491/505). Mean procedure time decreased from 195 minutes to 176 minutes, and conversion to sternotomy decreased from 4.4% (22/500) to 1.6% (8/500) after 500 cases. Short-term outcomes suggested expertise was reached between 250 and 500 cases. Long-term follow-up was completed in 97% of patients (873/896) with a median follow-up of 3.9 years (interquartile range, 1.8-5.8), and the overall survival rate was 89% (777). ConclusionsRobotic-assisted CABG can be performed safely with excellent results even during a surgeon’s early experience. However the learning curve to achieve mastery is longer than required to achieve competency, with a threshold of approximately 250 to 500 cases.

Internal Mammary Artery Skeletonization - Review Of Current Evidence.

Internal mammary artery (IMA) harvesting is a central part in coronary artery bypass grafting (CABG). The technique of harvesting the IMA - pedicled, skeletonized, or semi-skeletonized, may influence intra-operatory and postoperatory outcomes. We aim to review current evidence regarding the advantages and disadvantages of these techniques, and their performance in certain subsets of patients.