Robotic Coronary Artery Bypass Grafting Research Articles

A Rare Case of Robotic Revascularization for Obstructed Left Main with Automated Suture Fastener

In comparison to traditional, manual knot-tying, the use of an automated titanium suture fastening device has demonstrated a considerable reduction in cardiopulmonary bypass time, aortic cross-clamp time, and operative time in valve procedures. However, there aren't many reports in the literature on the side effects related to using such device. Here we present a case in which the automated titanium suture fastener resulted in left main coronary artery ostium obstruction following its use in the aortic position and subsequent treatment with robotic Coronary Artery Bypass Grafting (CABG).

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.

Avoiding Adverse Outcomes While Changing Anastomotic Technique in Totally Endoscopic Robotic Coronary Artery Bypass Grafting

Totally endoscopic robotic coronary artery bypass grafting (TECAB) is arguably the least invasive method of surgical coronary revascularization. The robotic approach is technically demanding, but it facilitates sternal-sparing use of bilateral internal mammary arteries to perform multiarterial grafting of up to 4 vessels through 4 to 5 ports and can be performed both with and without cardiopulmonary bypass. Although it is elegant, the procedure is technically demanding and requires surgeons to learn a new approach to all phases of the procedure.

Hybrid robotic coronary artery bypass grafting: how do we do it

Hybrid robotic coronary artery bypass grafting: how do we do it

Outcomes of robotic coronary artery bypass versus nonrobotic coronary artery bypass.

Robotic coronary artery bypass graft (CABG) has developed in recent decades, however, prior studies showed conflicting result of robotic CABG compared to nonrobotic CABG in terms of mortality, morbidity, and cost. Herein, we sought to analyze the in-hospital outcomes and health care utilization after robotic CABG compared to nonrobotic CABG, based on data from a nationally representative sample. Patients who underwent CABG were identified using the national inpatient sample. Endpoints were in-hospital outcomes, length of stay, and total cost. Procedure-related complications were identified via international classification of diseases (ICD)-9 and ICD-10 coding and propensity score matching analysis was performed. A total of 1,204,125 weighted adults underwent nonrobotic CABG and 7355 underwent robotic CABG in the United States between 2012 and 2017. The comparison of 7330 pairs after propensity score matching showed that in-hospital mortality was higher for those who underwent nonrobotic CABG compared to those who underwent robotic CABG (2.1% vs. 1.1%, p = .029). Similarly, the rates of acute kidney injury, transfusion, postoperative hemorrhage, length of stay, and total cost were higher for nonrobotic CABG compared to robotic CABG (all p < .05). The proportions of routine discharges with (34.5% vs. 40.0%) or without (39.7% vs. 45.0%) home health care were higher among those who underwent robotic, whereas the proportion of transfer to skilled nursing facility/nursing home was more frequent for cases of nonrobotic CABG (22.4% vs. 13.4%). Robotic CABG was associated with lower rates of in-hospital mortality, acute kidney injury, transfusion, postoperative hemorrhage, total cost, and shorter hospital stay compared to nonrobotic CABG.

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.

New Strategies for Surgical Myocardial Revascularization.

We summarize the evidence on the new strategies for coronary artery bypass grafting (CABG). Hybrid CABG implies surgical grafting of the left anterior descending artery and percutaneous treatment of the other target vessels, with the promise of combining the durable benefits of surgery with the less invasive approach of percutaneous coronary interventions. Robotic CABG and minimally invasive CABG are performed through minimal incision or port access with dedicated equipment and instruments. Anaortic coronary artery bypass refers to off-pump CABG using only in-situ grafts. The use of multiple arterial grafts has been shown to improve patency and is potentially associated with better clinical outcomes. All these techniques require dedicated training and are more complex than conventional CABG but can significantly improve the results of surgery. Validation of the results of these new approaches in large randomized trials is a priority for the surgical community.

The narrow field of view: challenges in sustaining a robotic open-heart program

Robotic coronary artery bypass grafting has struggled to be adopted over the last decade, in part because of a dichotomy between its quality and safety. The existing evidence is clear that robotic coronary artery bypass grafting (CABG) improves the morbidity and recovery time of this procedure. On the other hand, there have been persistent problems with the safety during early implementation. These problems can be overcome, but require a culture shift from the way that conventional CABG is often performed. The purpose of this manuscript is to outline the methods that will help generate this culture shift and enable robotic CABG to be more safe.

Is There a Role for Diagonal Coronary Artery Stenting in Patients Undergoing Robotic Coronary Artery Bypass Graft Surgery?

BackgroundThe efficacy of diagonal coronary artery stenting in patients undergoing robotic left internal thoracic artery-to-left anterior descending (LITA-to-LAD) anastomosis is not well defined. The objective of this study was to assess graft and stent patency in a single-stage hybrid revascularization with LITA-to-LAD anastomosis and PCI to a diagonal coronary artery.MethodsFrom 2004 to 2014, a total of 25 patients consented to robotic-assisted LITA harvesting and a small left anterior thoracotomy for off-pump coronary artery bypass anastomosis onto the LAD along with concomitant PCI to the diagonal coronary artery. PCI to the diagonal coronary artery was performed in the same fluoroscopy-equipped hybrid operating room.ResultsPatients were on average 66 ± 11 years with 32% female. Pre-operative characteristics of these patients included 8% with a grade 3 or 4 left ventricle, 16% with a recent MI, and 92% with CCS III/IV symptoms. There were no death, one patient required an intra-aortic balloon pump, and one patient required re-operation for bleeding. The average ICU stay was 1.1 ± 0.53 days, and the average hospital stay was 4.6 ± 2.4 days. Fitzgibbon Grade A LITA-to-LAD patency at 6-month follow-up was 100%. As well, at 6-month follow-up the DES to the diagonal coronary artery had a patency rate of 96%.ConclusionsSingle-stage hybrid revascularization strategy for bifurcating lesions of the LAD and diagonal coronary arteries with LITA-to-LAD anastomosis and PCI to a diagonal coronary artery appears to have acceptable clinical results with excellent 6-month angiographic patency results.

Robotic Versus Conventional Coronary Artery Bypass Grafting: Direct Comparison of Long-Term Clinical Outcome.

Robotic coronary artery bypass grafting (CABG) was shown to be a safe and feasible method for the treatment of coronary artery disease in highly selected patients. However, long-term outcome data comparing robotic CABG with conventional CABG are still missing. Therefore, we aimed to compare robotic with conventional CABG in terms of perioperative and long-term outcomes. Of 2947 consecutive elective patients with coronary artery disease operated at a single center between 2001 and 2013, 280 underwent robotic CABG. After propensity score matching, 134 pairs of robotic versus conventional CABG (age = 62 ± 10 years, log EuroScore = 2.4 ± 2.4% vs. mean ± SD age = 63 ± 10 years, log EuroScore 2.5 ± 1.7%, respectively; all P > 0.05) were formed. The mean ± SD follow-up was 6.6 ± 3.2 years. There was no difference in perioperative mortality (robotic = 0% vs. conventional = 1.5%, P = 0.154), myocardial infarction (robotic = 0% vs. conventional = 2.2%, P = 0.08), and stroke rate (robotic = 0% vs. conventional = 0.7%, P = 0.318) between the groups. Longer cardiopulmonary bypass (robotic = 112 ± 100 minutes vs. conventional = 67 ± 48 minutes, P < 0.0001) and cross-clamp times (robotic = 68 ± 54 minutes vs. conventional = 38 ± 27 minutes, P < 0.0001) were observed in robotic patients. Long-term follow-up yielded equivalent results in terms of survival (1, 5, and 10 years: robotic = 99.3%, 96.9%, and 81.3% vs. conventional = 96.3%, 92.2%, and 82.6%, respectively; log-rank P = 0.187) and freedom from major adverse cardiac and cerebral events at 1, 5, and 10 years after procedure (robotic = 90.6%, 77.7%, 70.1% vs. conventional = 94.1%, 82.2%, 66.6%; log-rank P = 0.790). Long-term outcomes of robotic CABG are comparable with conventional CABG for selected patients. Longer operative times of robotic CABG do not influence the excellent long-term outcomes.

Robotic versus Conventional Coronary Artery Bypass Grafting

Robotic versus Conventional Coronary Artery Bypass Grafting

Robotic coronary artery bypass graft surgery.

Robotic coronary artery bypass graft surgery.

The Impact of Robotic versus Conventional Coronary Artery Bypass Grafting on In-Hospital Narcotic Use: A Propensity-Matched Analysis

The Impact of Robotic versus Conventional Coronary Artery Bypass Grafting on In-Hospital Narcotic Use: A Propensity-Matched Analysis

Robotic Total Arterial Off-Pump Coronary Artery Bypass Grafting: Seven-Year Single-Center Experience and Long-Term Follow-Up of Graft Patency

Coronary artery bypass grafting (CABG) is the gold-standard treatment for coronary artery disease, but the long-term benefits of robotic CABG remain unclear. Between January 2007 and November 2014, 240 consecutive patients (187 male and 53 female, average age 59 years) underwent robotic off-pump CABG with the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) in our center. Totally endoscopic coronary artery bypass (TECAB) (n = 100) or mini-thoracotomy coronary artery bypass (MINICAB) (n = 140) grafting was performed with skeletonized internal mammary arteries (IMA). Patients were followed up and graft patency was assessed every 6 months by coronary angiography or 64-multi-slide computed tomographic angiography. All cases were completed without conversion to median sternotomy or cardiopulmonary bypass. A total of 237 single IMA grafts (98.3%) and 4 bilateral IMA grafts (1.7%) were used. No operative mortality was observed. Hybrid revascularization of non-left anterior descending vessels was performed in 24 patients (10%). No death, stroke, or myocardial infarction occurred in the follow-up of 41.1 ± 12.9 months. All grafts were patent before discharge. The IMA graft patency was 97.1% in TECAB and 96.4 % in MINICAB over 3 years (up to 91 months) postoperatively. Robotic off-pump CABG using IMA grafts is a safe and effective procedure in selected patients. The long-term outcome and patency of IMA grafts are excellent.

Best practices in coronary revascularization procedures: are we where we should be?

To address the most recent evidence bases for coronary artery bypass grafting (CABG) and stenting in patients with multivessel and left main coronary artery disease (CAD) and for optimizing the performance of CABG with particular reference to multiple arterial grafts, off-pump and less invasive CABG, graft flow measurements and external stenting of vein grafts. Current evidence confirms that CABG results in markedly superior survival to stenting for most patients with multivessel and/or left main stem CAD, as well as a significant reduction in subsequent myocardial infarction and repeat revascularization. Whereas there is strong circumstantial evidence of important survival benefits with bilateral internal mammary arteries, there is no evidence for clinical benefits of off-pump CABG, except perhaps in higher-risk patients. There appears to be increasing justification for routine graft flow measurements, while minimally invasive and robotic CABG remains as a niche specialty. CABG remains the most effective revascularization strategy in terms of survival and freedom from myocardial infarction and repeat revascularization in most patients with multivessel and/or left main stem CAD. There is a strong case for much wider use of bilateral internal mammary arteries during CABG, and off-pump CABG may be beneficial in higher-risk patients with particular reference to reducing neurologic injury. There is a strong rationale for the routine use of graft flow measurement, and particularly when using composite arterial grafts. There is a potential role for the development of an external stent to reduce the development of intimal hyperplasia in vein grafts.

Robotic Coronary Artery Bypass Grafting Decreases 30-Day Complication Rate, Length of Stay, and Acute Care Facility Discharge Rate Compared with Conventional Surgery

Robotic Coronary Artery Bypass Grafting Decreases 30-Day Complication Rate, Length of Stay, and Acute Care Facility Discharge Rate Compared with Conventional Surgery

Challenges facing totally endoscopic robotic coronary artery bypass grafting.

Robot-assisted surgery is growing in popularity; however, robotic totally endoscopic coronary artery surgery (TECAB) remains challenging, particularly in multi-vessel disease. A review of the current literature surrounding TECAB using the da Vinci® system. The da Vinci robot is the only commercially available system, operating on a master-slave paradigm with the surgeon controlling the robotic arms from a remote console. Robotic surgery today is presented with challenges, including dealing with a non-perfect robot without haptic control, a steep learning curve, lack of established training criteria and high cost. Strategies such as structured, simulated training and novel anastomotic devices may potentially shorten the learning curve, improve patency and facilitate grafting in multi-vessel disease. Future challenges will include the ability to demonstrate long-term patency, morbidity and mortality at least comparable to conventional CABG, whilst also offering cost effectiveness in this increasingly difficult economic environment.

Letter to the Editor

We read with great interest the recent Pro and Con section of the Journal regarding robotic coronary artery bypass grafting.1,2 We would like to call your attention to a recently published study from our institution that sheds additional light on this topic and was not referenced by either side.3 Our results suggest that addressing multivessel coronary artery disease using total edoscopic coronary artery bypass offers no obvious clinical benefits and might increase morbidity and mortality.

Bleeding outcomes in patients given clopidogrel within 5 days of robotic coronary artery bypass graft procedure.

Current guidelines recommend that clopidogrel should be held for 5 days prior to coronary artery bypass graft (CABG) procedure. However, it is unknown if this recommendation should apply to robotic-assisted (rCABG), which is less invasive because it does not involve sternotomy and thus reduces the risk of bleeding. To compare postoperative bleeding for rCABG patients who were taking clopidogrel within 5 days of the procedure with those who were not taking clopidogrel. This was a retrospective cohort study conducted between January 1, 2012 and December 31, 2012 of consecutive patients undergoing rCABG. Patients were categorized into 2 groups based on whether or not clopidogrel was administered within 5 days prior to the date of surgery. The primary outcome measure was the occurrence of the Bleeding Academic Research Consortium (BARC) definition for CABG-related bleeding. The secondary outcome measure was a comparison of chest tube output during the first 24-hour postoperative period. A total of 136 rCABG patients were included in the final analyses. Of these, 39 (29%) received clopidogrel within 5 days of surgery. CABG-related bleeding using the BARC definition occurred in 26% of patients who received clopidogrel and 8% of patients who did not (P = .011). Median chest tube output during the first 24-hour postoperative period was also greater in patients who received clopidogrel (900 vs 735 mL, P = .002). The use of clopidogrel within 5 days of rCABG is associated with greater postoperative bleeding and chest tube output, as defined by the BARC criteria.