Five Hundred Cases of Robotic Totally Endoscopic Coronary Artery Bypass Grafting: Predictors of Success and Safety

doi:10.1016/j.athoracsur.2012.09.071

The Annals of Thoracic Surgery

Volume 95, Issue 3, March 2013, Pages 803-812

https://doi.org/10.1016/j.athoracsur.2012.09.071 Get rights and content

Background

Robotic technology has enabled totally endoscopic coronary artery bypass (TECAB) grafting. Little information is available on factors associated with successful and safe performance of TECAB. We report a 10-year multicenter experience with 500 cases, elucidating on predictors of success and safety in TECAB procedures.

Methods

Between 2001 and 2011, 500 patients (364 [73%] men; 136 [27%] women; median age [minimum-maximum] 60 years [31−90 years], median EuroSCORE 2 [0−13]), underwent TECAB. Single, double, triple, and quadruple TECAB was performed in 334, 150, 15, and 1 patient, respectively. Univariate analysis and binary regression models were used to identify predictors of success and safety. Success was defined as freedom from any adverse event and conversion procedure, safety was defined as freedom from major adverse cardiac and cerebral events, major vascular injury, and long-term ventilation.

Results

Success and safety rates were 80% (400 cases) and 95% (474 cases), respectively. Intraoperative conversions to larger thoracic incisions were required in 49 (10%) patients. The median operative time was 305 minutes (112−1,050 minutes), and the mean lengths of stay in the intensive unit (ICU) and in hospital were 23 hours (11−1,048 hours) and 6 days (2−4 days), respectively. Independent predictors of success were single-vessel TECAB (p = 0.004), arrested-heart (AH)-TECAB (p = 0.027), non−learning curve case (p = 0.049), and transthoracic assistance (p = 0.035). The only independent predictor of safety was EuroSCORE (p = 0.002).

Conclusions

Single-vessel and multivessel TECAB procedures can be safely performed with good reproducible results. Predictors of success include procedure simplicity and non−learning curve cases, whereas predictors of safety are mainly associated with patient selection.

Section snippets

Patients and Methods

From October 2001 to June 2011, 500 patients (364 [73%] men, 136 [27%] women; mean age ± standard deviation [SD] = 62 ± 9; mean EuroSCORE= 2.3 ± 2.1), underwent TECAB using the da Vinci, da Vinci S, and Da Vinci Si telemanipulation systems (Intuitive Surgical, Inc, Sunnyvale, CA) at the Department of Cardiac Surgery, Innsbruck Medical University and the Department of Cardiac Surgery, University of Maryland by 4 primary surgeons (J.B., T.S., N. B., E. L.). Three additional surgeons have been

Operative and Hospital Outcomes

The procedures performed included single-vessel (n = 334 [67%]) and multivessel robotically assisted TECAB (n = 166 [33%]) on the arrested heart (AH) (n = 390 [88%]) or the beating heart (BH) (n = 110 [22%]). One third of the procedures were planned as hybrid procedures. The main intraoperative data and the postoperative outcome are presented in Table 3.

Postoperative Outcomes Stratified by Successful Procedures

The overall success rate after TECAB was 80 % (n = 400). The prevalence of success rose from 76% in the first 100 patients to 87% in the last

Comment

This study was designed to analyze a 10-year dual-center experience with 500 patients who underwent TECAB on the AH or BH. To our knowledge, this is the largest series of robotically assisted thoracoscopic coronary operations ever published and the results have significant implications in adopting and establishing minimally invasive techniques in cardiac operations. In this study we show encouraging perioperative results of TECAB in terms of high success rates reaching 80% of the procedures,

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We tested 3 wet lab tasks (atrial closure, mitral annular stitches, and internal thoracic artery [ITA] dissection) with both experienced robotic cardiac surgeons and novices from multiple European centers. The tasks were assessed using 2 tools: TBS and mGEARS score. Reliability, internal consistency, and the ability to discriminate between different levels of competence were evaluated.
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We experienced 3 cases of port-access robot-assisted totally endoscopic technique for mitral valve repair and concomitant coronary artery bypass. The right internal mammary artery was harvested, mitral valve was fixed, and the right internal mammary artery to right coronary artery anastomosis was carried out on the arrested heart. The use of cardiac arrest and a V-shaped hook technique facilitated the coronary anastomosis and the da Vinci Firefly test (Intuitive Surgical Inc., Sunnyvale, CA) could confirm patency of the graft.
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There were 1103 robotic-assisted cardiac surgeries over 7 years. A total of 585 (53%) were off-pump totally endoscopic coronary artery bypasses, 399 (36%) intracardiac cases (including isolated and concomitant mitral valve procedures, isolated tricuspid valve repair, CryoMaze, atrial or ventricular septal defect repair, benign cardiac tumor, septal myectomy, partial anomalous pulmonary venous drainage, and aortic valve replacement); 80 (7%) epicardial electrophysiology-related procedures (epicardial atrial fibrillation ablation, left atrial appendage ligation, lead placement, and ventricular tachycardia ablation); and 39 (4%) other epicardial procedures (pericardiectomy, unroofing myocardial bridge). Mortality was 1.2% (observed/expected ratio, 0.7). In the totally endoscopic coronary artery bypass and intracardiac groups, mortality was 1.0% (observed/expected, 0.6) and 1.5% (observed/expected, 0.87), respectively. There were 8 conversions to sternotomy (0.7%) and 24 (2.2%) take-backs for bleeding. Mean hospital and intensive care unit lengths of stay were 2.74 ± 1.26 days and 1.28 ± 0.57 days, respectively.
This experience demonstrates that a robotic endoscopic approach can safely be used in a multitude of cardiac surgical procedures both on- and off-pump with excellent early outcomes. An experienced surgeon and team are necessary. Longer-term follow-up is warranted.
Robotic totally endoscopic coronary artery bypass grafting: It's now or never!
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Robotic Cardiac Surgery Part II: Anesthetic Considerations for Robotic Coronary Artery Bypass Grafting
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Citation Excerpt :
The anastomosis in TECAB can be performed with a running suture via the trocars with the patient on bypass and with an arrested heart, or it can be performed off-pump via a distal anastomotic device in the form of a stapler (C-Port; Dextera Surgical Inc, Redwood City, CA) (Fig 1).8,9 TECAB represents a technical challenge but has benefits for patients, including a fast recovery as a result of minimal postoperative pain and the possibility to take down left and right internal thoracic arteries (bilateral internal mammary artery [BIMA]) (both using the robotic instruments from the left side of the patient) to perform 2 or 3 arterial bypasses in different coronary targets and to maximize the use of an arterial conduit with lower risk of wound infection.10,11 The use of BIMA as a conduit has been shown to decrease long-term mortality and may increase overall survival.
Coronary artery bypass grafting represents one of the most commonly performed cardiac surgeries worldwide. Recently, interest has increased in providing patients with a less invasive approach to cardiac surgery, such as thoracotomy and endoscopic techniques using robotic technology as an alternative to traditional sternotomy. As the population gets older, the need for additional methods to provide care for sick patients will continue to expand. These advancements will further allow physicians to provide cardiac surgical procedures with less pain and faster recovery for patients.
A new viewpoint on endoscopic CABG: technique description and clinical experience
2020, Journal of Cardiology
Citation Excerpt :
Third, it is less time-consuming than robotic techniques. Fourth, in contrast to other CABG techniques [9], individual patient selection is unnecessary, making this a suitable technique to treat also patients with increased risk factors such as old age, obesity, and diabetes. Indeed, 30-day mortality in our cohort of octogenarians (5.5%) is strongly reduced compared to the 16.8% mortality after a conventional CABG procedure in octogenarians [26].
The aim of this paper is to describe a newly developed endoscopic coronary artery bypass graft (Endo-CABG) technique to treat patients with single- and multi-vessel disease and discuss the short-term clinical results in a large patient cohort. This technique avoids a median sternotomy by combining a thoracoscopic technique via three ∼5 mm thoracic ports and a mini-thoracotomy utility 3–4 cm port through the intercostal space.
From January 2016 to January 2018, data from consecutive patients undergoing an elective Endo-CABG were prospectively entered into a customized database and retrospectively reviewed. Patients scheduled for a combined hybrid intervention were excluded. Conversion rate to sternotomy, incidence of surgical revision and postoperative graft failure, one-month survival, morbidity, and length of stay (LOS) were investigated. Subgroup analyses were performed.
A total of 342 patients undergoing an Endo-CABG with one (n = 53) or multiple (n = 289) bypasses were included. No conversion to sternotomy occurred and incidence of surgical revision, graft failure, and 30-day mortality was 7.3%, 1.5%, and 1.8%, respectively. Adverse neurological outcomes were rare: cerebrovascular accident, transient ischemic attack, epilepsy, and postoperative delirium were observed in 0.6%, 0.3%, 0.3%, and 5.3% of patients, respectively. Median intensive care unit and hospital LOS were 2.75 (IQR 1.8 to 3.8) and 8.0 days (IQR 7.0 to 10.0), respectively. Thirty-day mortality in obese patients, diabetics, and octogenarians was 0%, 3.6%, and 5.6%, respectively. EuroSCORE II > 5% was associated with a high 30-day mortality (25%).
Endo-CABG can be considered a safe and effective procedure to treat single- and multi-vessel coronary artery disease. Individual patient selection seems not necessary to apply this technique.

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Original articleAdult cardiacFive Hundred Cases of Robotic Totally Endoscopic Coronary Artery Bypass Grafting: Predictors of Success and Safety

Background

Methods

Results

Conclusions

Section snippets

Patients and Methods

Operative and Hospital Outcomes

Postoperative Outcomes Stratified by Successful Procedures

Comment

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Can J Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

Am J Cardiol

Eur J Vasc Endovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Port-access coronary artery bypass with cardioplegic arrest: acute and chronic canine studies

Ann Thorac Surg

Results of the prospective multicenter trial of robotically assisted totally endoscopic coronary artery bypass grafting

Ann Thorac Surg

Original article
Adult cardiac
Five Hundred Cases of Robotic Totally Endoscopic Coronary Artery Bypass Grafting: Predictors of Success and Safety