Robotic-assisted Coronary Artery Bypass Grafting Research Articles

Evaluating the Feasibility of a Novel Micro Titanium Fastener to Facilitate Robot-Assisted Coronary Artery Bypass Grafting.

Evaluating the Feasibility of a Novel Micro Titanium Fastener to Facilitate Robot-Assisted Coronary Artery Bypass Grafting.

Robotic-assisted coronary artery bypass grafting simplified: Lessons learned after 20 years

Robotic-assisted coronary artery bypass grafting simplified: Lessons learned after 20 years

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.

Systematic review and meta-analysis of two decades of reported outcomes for robotic coronary artery bypass grafting.

Despite the well-documented safety and feasibility of robotic coronary artery bypass grafting (CABG), widespread adoption of this approach remains limited by its steep learning curve, high procedural costs and paucity of data on longer-term efficacy. This current meta-analysis aims to provide a systematic overview of the outcomes of robot-assisted CABG, with a focus on long term graft patency and freedom from major adverse cardiac and cerebrovascular events (MACCE). A systematic literature search of three electronic databases was conducted for studies reporting outcomes of robotic-assisted CABG, and were grouped based on whether patients underwent robot-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB), totally endoscopic coronary artery bypass (TECAB) or were mixed. Perioperative and mid-to-long term results from included studies were pooled using meta-analysis of proportion or means in a random effects model. In the quantitative analysis, thirty-nine eligible studies included 6,152 patients who underwent RA-MIDCAB, 1,729 patients who underwent TECAB and 21,642 patients who underwent either form of robot-assisted CABG. A high level of heterogeneity was observed amongst baseline characteristics. Perioperative mortality and complication rates were low. Conversion rate to full sternotomy overall was less than 3.2% [95% confidence interval (CI): 2.1-5.2%, I2=39%]. At a mean follow-up duration of 5.2 years, overall graft patency was 96% for both RA-MIDCAB and TECAB, and freedom from major adverse cardiac events (MACE) or MACCE was 83.2% (95% CI: 72.0-90.4%; I2=90%) for RA-MIDCAB and 91.6% (95% CI: 86.6-94.9%; I2=76%) for TECAB. Robot-assisted CABG is observed to have acceptable perioperative and mid-to-long term outcomes with promising overall graft patency.

Hybrid robotic-assisted coronary revascularization and transcatheter aortic valve replacement: a single-center experience.

The efficacy of hybrid robotic-assisted coronary artery bypass grafting (CABG) and transcatheter aortic valve replacement (TAVR) for coronary and aortic valve disease is poorly reported. Herein, we report our experience with this hybrid approach. Between January 2018 and June 2022, 10 (7 male, 3 female) patients with a mean age of 81 years underwent the hybrid procedure. Coronary revascularization was performed prior to TAVR with robotic-assisted left internal mammary artery-to-left anterior descending (LAD) bypass grafting for left main or proximal LAD lesions with or without multivessel disease with or without hybrid percutaneous coronary intervention (PCI). Five patients had left main disease, and 5 had proximal LAD disease with or without multivessel disease. All patients tolerated the robotic-assisted CABG procedure well; 9 patients were extubated in the operating room and all patients were ambulatory on postoperative day 1. Five patients underwent hybrid PCI for non-LAD lesions. TAVR was subsequently performed at intervals ranging from 3 days to 5 months after CABG. One patient with end-stage renal disease on hemodialysis required hospitalization for heart failure during the interval period. The 1-year mortality rate was 0%, and 3 patients died during late follow-up (24-43 months). This innovative, less invasive approach demonstrates the potential for early recovery in appropriately selected patients with complex coronary and aortic valve disease with promising mid-term outcomes.

Long-term clinical outcomes of robotic-assisted surgical coronary artery revascularisation.

Patients who are not candidates for traditional coronary artery bypass grafting (CABG) and amenable only for percutaneous coronary intervention (PCI) with stents can receive the "gold standard" left internal thoracic artery (LITA) to left anterior descending artery (LAD) anastomosis through robotic-assisted CABG and PCI to non-LAD coronary targets. We aimed to analyse clinical outcomes of robotic-assisted CABG. A total of 2,280 consecutive patients who had undergone robotic-assisted CABG between May 2005 and June 2021 were included in our study. Robotic-assisted LITA harvest was followed by LITA-LAD manual anastomosis through a 4 cm left thoracotomy. Hybrid coronary intervention (HCR) consists of stent implantation in a non-LAD coronary artery performed within 7 days after robotic-assisted LITA-LAD. We performed a propensity-adjusted analysis comparison after dividing all robotic-assisted CABG patients into three time periods: 2005-2010, 615 patients; 2011-2016, 904 patients; and 2017-2021, 761 patients. The mean age increased from 64.5 years in the first time period to 65.8 years in the second time period to 68.1 years in the third (p<0.0001). Operative time was progressively reduced in the three periods (6.4; 6.2; 5.5 hours; p<0.001). The incidence of conversion to sternotomy remained similar for each period (1.8%; 1.7%; 1.5%; p=0.53). Thirty-day mortality in the three periods included 9 (1.4%), 9 (1.0%), and 7 (0.9%) patients, respectively (p=0.91), while 8 (0.3%) patients had PCI with stents in the entire group. The mean follow-up for the entire population was 4.2 years. At follow-up, the rates of all-cause death, major adverse cardiac and cerebrovascular events, non-fatal stroke, and repeat revascularisation with stents were significantly decreased from the first to the last period (pË0.0001). Robotic-assisted CABG and HCR provides good long-term outcomes in patients who are not candidates for conventional CABG.

Abstract 12028: Long-Term Repeat Intervention Incidence in Octogenarians After Robotic-Assisted Coronary Artery Bypass Grafting

Introduction: We aim to analyze long-term repeat intervention incidence in octogenarians undergoing robotic-assisted coronary artery bypass grafting (CABG). Hypothesis: We hypothesize that robotic-assisted CABG has a low incidence of repeat intervention compared to other clinical trials. Methods: All consecutive octogenarians (500 patients) undergoing robotic-assisted left internal thoracic artery (LITA) harvesting and CABG through a 4-cm left minithoracotomy with LITA to left anterior descending (LAD) artery anastomosis between 2005-2021 in a single center were included. Hybrid coronary revascularization (HCR) consists in robotic-assisted CABG followed by percutaneous coronary intervention (PCI) with DES in a non-LAD target within 7-days from the operation. Results: Preoperatively, mean age was 83 (±2.9) year-olds, and mean STS-PROM risk score was 3.6% (2.1- 6.6). Intraoperatively, 478 (95.6%) patients received 1 LITA, 14 (12.8%) received bilateral ITA, and 8 (1.6%) a saphenous venous graft. A total of 303 (60.6%) patients received multiple arterial revascularizations while 140 (28%) received HCR. A total of 376 (75.2%) patients were extubated in the operating room. Postoperatively, 2 (0.4%) patients experienced non-fatal stroke, 6 (1.2%) had reoperation for bleeding, and 12 (2.4%) had renal failure. There was no 30-day mortality while 1 (0.2%) patient had PCI with DES on LITA-LAD anastomosis due to graft failure. Mean-follow-up was 2.9-years while incidence of all-cause death was 103 (20.6%) patients, MACCE 136 (27.2%), stroke 8 (1.6%), myocardial infarction 16 (3.2%), and repeat intervention with stents 39 (7.8%) were low. There was no repeat surgical intervention while PCI with drug-eluting stents for new coronary disease was 15/39 (38.4%) patients. Conclusions: Robotic-assisted CABG in octogenarians evidenced a 7.8% incidence of repeat intervention with stents.

TCT-40 Long-Term Outcomes in Octogenarians After Robotic-Assisted Coronary Artery Bypass Grafting

TCT-40 Long-Term Outcomes in Octogenarians After Robotic-Assisted Coronary Artery Bypass Grafting

TCT-1 Clinical Outcomes of Robotic-Assisted Coronary Artery Bypass Grafting

TCT-1 Clinical Outcomes of Robotic-Assisted Coronary Artery Bypass Grafting

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.

Urgent robotic coronary revascularization in a pregnant woman

Outcomes of robotic-assisted coronary artery bypass grafting in pregnant women have not been assessed. This study aimed to understand the importance of minimally invasive robotic-assisted coronary artery bypass grafting in pregnant woman with coronary artery disease. We describe the case of a G3P1011 woman at 19+6 weeks' gestation presenting with a non-ST myocardial infarction treated with off-pump hybrid robotic-assisted revascularization. This study describes the surgical approach for a pregnant woman presenting with non-ST myocardial infarction treated with hybrid robotic-assisted revascularization. A coronary angiography demonstrated a culprit lesion of 90% stenosis in the left anterior descending coronary artery and an 80% stenosis in the right coronary artery. Because of the high rate of complications with traditional coronary artery bypass grafting, the heart team opted for hybrid robotic-assisted revascularization and the postoperative recovery was uneventful. Robotic coronary artery bypass grafting can be the preferred surgical choice to decrease maternal and fetal mortality in patients undergoing coronary artery bypass grafting, and it is an important tool in the surgical armamentarium.

Alternative Approaches to Coronary Artery Bypass Grafting Versus Percutaneous Coronary Intervention, How Do They Compare?: A Systematic Review and Meta-Analysis.

Coronary artery disease (CAD) is a leading cause of mortality worldwide. Severe symptomatic CAD is treated with coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI). Alternative CABG (ACABG) approaches including thoracotomy, off-pump, total endoscopic, and robotic-assisted CABG are increasing in prevalence to address the increased early risk of CABG. This systematic review and meta-analysis aims to review the contemporary literature comparing outcomes after ACABG and PCI. Pubmed, Medline, and Embase were systematically searched by 2 authors for articles comparing the outcomes after ACABG and PCI. A total of 1154 articles were screened, and 11 were included in this review. The RevMan 5.4 software was used to perform a meta-analysis of the pooled data. Individual studies found rates of long-term survival, major adverse cardiovascular and cerebrovascular events (MACCE), myocardial infarction (MI), and repeat revascularization either favored ACABG or did not differ significantly. Pooled estimates of the compiled data identified rates of MACCE, MI, and repeat revascularization favored ACABG. The results of this review demonstrated the favorable rates of long-term mortality, MACCE, MI, and repeat revascularization for ACABG in addition to similar short-term mortality and stroke when compared with PCI. Advancement of both CABG and PCI continues to improve patient outcomes. With the increasing prevalence of ACABG, similar studies will need to be undertaken with further direct comparisons between ACABG and PCI. Finally, hybrid revascularization should continue to be explored for its combined benefits of long-term outcomes, short-term safety, and ability to achieve complete revascularization.

Intensive Care Unit Bypass for Robotic-Assisted Single-Vessel Coronary Artery Bypass Grafting

BackgroundFast-track and enhanced recovery after cardiac surgical procedures have shown reductions in intensive care unit (ICU) and hospital lengths of stay, with unchanged outcomes. However, cost reduction by an ultra-fast-track protocol after minimally invasive cardiac operations, without compromising clinical benefits, has yet to be demonstrated. MethodsA total of 215 consecutive patients underwent robotic-assisted coronary artery bypass grafting, with 156 preoperatively stratified into conventional ICU recovery vs 59 candidates for a defined ICU-bypass protocol involving recovery room and floor care. Of these, 40 candidates completed the protocol, and 19 had conversion-to-ICU recovery. Because of right-skewed distribution, inpatient cost was log-transformed, and linear regression models were constructed to estimate geometric mean ratios (GMRs) comparing inpatient cost for these groups (conventional ICU recovery, ICU-bypass, conversion-to-ICU recovery), adjusted for The Society of Thoracic Surgeons Predicted Risk of Mortality score. ResultsCompared with the conventional ICU group, the ICU-bypass group conferred a 15% reduction in total inpatient (GMR, 0.85; P = .0007) and a 14% reduction in total variable direct costs (GMR, 0.86; P = .003). Compared with the conventional ICU group, the ICU-bypass and conversion-to-ICU groups had similar net hospital stay reductions (1.6-1.7 days). Relative to the conventional ICU group, ICU and floor duration were shortened after conversion to ICU, with a trend to reduced costs. Cardiac arrest, 30-day mortality, and stroke were absent, and other key adverse events did not differ between groups. ConclusionsA selective, successful ultra-fast-track ICU-bypass protocol for robotic-assisted coronary artery bypass grafting reduces inpatient cost without affecting short-term outcomes. Conversion-to-ICU recovery also maintains outcomes and trends toward reduced costs.

Early home discharge after robot-assisted coronary artery bypass grafting.

OBJECTIVESRobot-assisted coronary artery bypass grafting (CABG) has been developed as a less invasive alternative for conventional CABG to enhance postoperative recovery, patient satisfaction and early discharge to home. Furthermore, it may provide a basis for hybrid coronary revascularization. To determine the feasibility of this procedure, we compared robot-assisted with conventional off-pump CABG.METHODSAll consecutive patients undergoing a robot-assisted left internal mammary artery-to-left anterior descending coronary artery procedure were compared to consecutive patients undergoing conventional off-pump CABG for single-vessel disease from October 2016 to July 2019. The primary outcome was discharge to home within 5 days after the operation. Secondary outcomes were total hospital stay, reoperations within 48 h, transfusions, atrial fibrillation, 30-day mortality and quality of life 1 month postoperatively. A propensity matched cohort was assembled to correct for possible confounders.RESULTSA total of 107 patients who had robot-assisted CABG were compared to 194 patients who had conventional off-pump CABG. The primary outcome was reached in 51% of the robot-assisted group versus 19% of the conventional off-pump group (P < 0.01). The median postoperative hospital stay was 5 days for the robot-assisted group versus 7 days in the conventional off-pump group (P < 0.01). Other secondary outcomes did not differ significantly between the groups, and the quality of life 1 month after the operation was equal. The results after propensity matching were similar.CONCLUSIONSEarly discharge to home is more frequent for patients who have robot-assisted CABG than in those who have conventional off-pump CABG, with no difference in health-related quality of life. Therefore, this approach may reduce healthcare resources and provide a solid basis for hybrid coronary revascularization.

Long-term results of robotic-assisted coronary artery bypass grafting with composite arterial grafts for multiple coronary anastomoses: 10-year experience.

Currently, robotic-assisted coronary artery bypass grafting (RACABG) is a feasible choice for myocardial revascularization. Acceptable outcomes have been reported for RACABG with single target vessels; however, the long-term benefits of multivessel RACABG with composite arterial grafts have rarely been studied. Therefore, our study investigated the long-term results of multivessel RACABG with composite arterial grafts by reviewing the clinical data of patients from Taichung Veterans General Hospital. From December 2005 to June 2015, 562 patients underwent robotic-assisted robotic minimally invasive direct coronary bypass (MIDCAB) at Taichung Veterans General Hospital. Two major composite arterial graft configurations (i.e., inverted T-graft and Y-graft) were used. Data regarding the short-term and long-term outcomes of robotic-assisted MIDCAB were obtained from the medical records. For data regarding long-term outcomes of the patients not followed up at our institution, telephone interviews were conducted in June 2019. The in-hospital mortality rate and complication rate were 2.5% and 17.6%, respectively. We completed the follow-up for 486 patients (86.4%), and postoperative coronary imaging-based evaluation performed for 157 patients. The 5-year and 10-year survival rates were 82.7% and 65.2%, respectively. The 5-year and 10-year major adverse cardiac and cerebral events-free survival rates were 86.9% and 70.9%, respectively. The 5-year patency rate of various coronary anastomoses was 85.1-100%. Our study revealed that multivessel robotic-assisted MIDCAB with composite arterial grafts provided acceptable long-term outcomes, irrespective of the composite graft configuration.

Robotic-assisted coronary artery bypass grafting

Robotic-assisted coronary artery bypass grafting

Commentary: When will the robots come marching in?

Minimally invasive techniques for coronary artery bypass grafting (CABG), specifically robotic-assisted CABG has increased in popularity despite conflicting evidence. Here, we review a report by Yokoyama and colleagues to the Journal of Cardiac Surgery investigating outcomes of robotic versus nonrobotic CABG utilizing the National Inpatient Sample (NIS).

Eleven-year outcomes of U-clips in totally robotic coronary artery bypass grafting versus standard hand-sewn running suture in robotic-assisted coronary artery bypass grafting.

The aim of this study was to evaluate the clinical outcomes of patients undergoing off-pump robotic coronary artery bypass grafting (CABG) with either interrupted nitinol U-Clips in totally endoscopic coronary artery bypass (TECAB) or standard running suture anastomosis in robotically assisted direct coronary artery bypass (RADCAB) over a decade. From January 2007 to December 2017, 280 patients underwent robotic off-pump CABG using the da Vinci S/Si Surgical System in our centre. TECAB with interrupted nitinol U-Clips anastomosis was performed in the left internal mammary artery (LIMA) to LAD grafting in 126 patients and RADCAB (n = 154) of the LIMA to LAD was completed with standard running suture. After discharge, patients were contacted through telephone interview and were invited to attend the outpatient clinic every 6 months or 1 year. The graft patency was assessed by coronary angiography or computed tomography angiography. All cases were completed without conversion to median sternotomy or cardiopulmonary bypass. A total of 275 single internal mammary artery (IMA) grafts (271 LIMAs, 4 right internal mammary arteries) and 5 bilateral IMA grafts were used as single graft or composite grafts. All the patients were discharged without in-hospital mortality or adverse outcomes. The average follow-up was 89.7 ± 30.4 months (range, 14-143 months). The cumulative survival rates (P = 0.53), the cumulative IMA patency rates (P = 0.83), and the rates of freedom from major adverse cerebrovascular and cardiovascular events (P = 0.41) between TECAB and RADCAB all showed no significant difference in the follow-up. Robotic off-pump CABG using IMA grafts is safe and can provide reliable long-term outcomes. Compared with the standard hand-sewn running suture technique in RADCAB, interrupted suture with the nitinol U-Clips in TECAB showed similar long-term clinical results and graft patency in LIMA to LAD bypass grafting.

Hiatal hernia after robotic-assisted coronary artery bypass graft surgery.

BackgroundThe aim of the present study is to determine the incidence/progression of hiatal hernia (HH) after robotic-assisted coronary artery bypass grafting (RA-CABG) surgery.MethodsWe reviewed the pre- and post-operative computed tomography (CT) of 491 patients who underwent RA-CABG between 2000 and 2017. Post-operative CT was acquired prospectively in a research protocol. CT was reviewed to assess the presence and the size of HH.ResultsWe found 444/491 (90.4%) had pre-operative CT, while 201/491 (40.9%) had post-operative CT. In total, 155/491 (31.6%) had both pre- and long-term post-operative CT with a mean follow-up of 6.2 (±3.5) years. HH was more prevalent on post-operative CT, 64/155 (41.3%) compared to pre-operative CT, 44/155 (28.4%), P<0.0001. The diameter of pre-existing HH 2.8 (±1.8) cm was significantly greater after surgery 3.9 (±2.5) cm, P<0.0001. As well the volume of the pre-existing HH 5.8 (4.4–9.2) mL (quartile) was significantly greater after surgery 14.1 (7.2–64.9) mL, P<0.0001. 20/155 (12.9%) had a newly developed HH after RA-CABG. A binary multivariate regression including HH risk factors showed that male gender is a predictor of developing a HH after RA-CABG with Hazard Ratio of 3.038, confidence interval (1.10–8.43), P=0.033.ConclusionsRA-CABG is associated with an increased risk of developing HH and increases the size of pre-existing HH.

Robotic-assisted coronary artery bypass grafting: current knowledge and future perspectives.

Minimally invasive direct coronary artery bypass grafting (MIDCAB) and totally endoscopic coronary artery bypass grafting (TECAB) are the two existing strategies for robotic-assisted, surgical myocardial revascularization. In this review, we summarize the wide evidence available in the literature regarding the benefits of these two procedures, and detail the technical skills required to master robotic coronary surgery techniques.