Five hundred cases of robotic totally endoscopic coronary artery bypass grafting: predictors of success and safety

Hybrid treatment combining robotic coronary artery bypass grafting and percutaneous catheter radiofrequency ablation

Isolated coronary artery bypass grafting associated with atrial fibrillation is routinely performed through a sternotomy, and cardiac arrest. Advancements in this surgical approach have led to better cosmesis, a quick postoperative recovery, with the same postoperative results. We report a case of a novel, less invasive hybrid treatment combining robot-assisted coronary artery bypass grafting and percutaneous radiofrequency catheter ablation.

Robotic totally endoscopic coronary artery bypass for isolated ostial stenosis of the left coronary artery

Isolated ostial stenosis (IOS) is a rare disease that encroaches on aorto-coronary junction of uncertain etiology. All distal coronary vessels present normally. IOS occurs predominantly in premenopausal young women with few risk factors for atherosclerotic disease. Here, we report a 40-year-old woman who had experienced crescendo angina for 4 months. Surgical revascularization was achieved by robotic totally endoscopic coronary artery bypass (TECAB) with left internal thoracic artery (LITA) graft. She resumed her daily tasks without difficulties 1 week after the operation. Postoperative computed tomographic angiography disclosed good opacification of the LITA graft and distal runoff. Robotic TECAB is a potentially feasible alternative for IOS patients, particularly in premenopausal young woman, with obvious benefits of cosmetic appearance and speedy recovery.

Mid-Term Follow-up of Minimally Invasive Multivessel Coronary Artery Bypass Grafting: Is the Early Learning Phase Detrimental?

OBJECTIVE

Minimally invasive coronary artery bypass grafting (MICS CABG) through a small left thoracotomy is a novel technique for surgical coronary revascularization, which is increasingly being adopted around the world. This study aimed to describe the characteristics and mid-term outcomes of a series of MICS CABG to identify areas for improvement.

METHODS

A prospective longitudinal study was performed on the 306 MICS CABG patients operated on by a single surgeon from 2005 to 2015. Minimally invasive coronary artery bypass grafting used a small left thoracotomy to enable coronary revascularization with a similar configuration to an open sternotomy technique, with left internal thoracic artery harvesting, and hand-sewn proximal radial/saphenous and distal anastomoses, under direct visualization. We compared patients who were operated on during the first and second halves of the series to ascertain the impact of a learning curve on outcomes.

RESULTS

The mean ± SD age was 62 ± 9 years, 87% were male, and 23% had three-vessel disease. Off-pump coronary artery bypass was performed in 80%, and the median number of grafts was 2 (range 1-4). Sternotomy conversion occurred in 3.3%, reoperation for bleeding in 2%, and unplanned, emergency CPB conversion in 1%. Superficial thoracotomy infection, atrial fibrillation, and left-sided pleural effusion requiring drainage were encountered in 2%, 4%, and 4%, respectively. There were no perioperative stroke, myocardial infarction, or death. At a mean ± SD follow-up of 2.8 ± 2.5 years, 97.4% of patients were free from major adverse cardiac and cerebrovascular events. Between the first and latter half of the series, there was a decrease in the rate of conversion to sternotomy (5.2%-1.3%, P = 0.05) and in the mid-term need for repeat revascularization (11% vs 2.6%, P = 0.03). Overall repeat revascularization rate was 2.5% per year. The intensive care unit and hospital lengths of stay (1.6 ± 1.5 vs 1.4 ± 0.9, P = 0.2, and 6.1 ± 2.6 vs 5.6 ± 1.8, P = 0.4) were not statistically different.

CONCLUSIONS

Minimally invasive coronary artery bypass grafting can be safely initiated as a minimally invasive, multivessel alternative to open surgical coronary revascularization, with excellent mid-term results. Learning phase effects were not observed with regard to overall procedural safety, but rather in terms of improved freedom from conversion to sternotomy and from repeat revascularization.

Minimally Invasive Cardiovascular Surgery: Incisions and Approaches

Throughout the modern era of cardiac surgery, most operations have been performed via median sternotomy with cardiopulmonary bypass. This paradigm is changing, however, as cardiovascular surgery is increasingly adopting minimally invasive techniques. Advances in patient evaluation, instrumentation, and operative technique have allowed surgeons to perform a wide variety of complex operations through smaller incisions and, in some cases, without cardiopulmonary bypass. With patients desiring less invasive operations and the literature supporting decreased blood loss, shorter hospital length of stay, improved postoperative pain, and better cosmesis, minimally invasive cardiac surgery should be widely practiced. Here, we review the incisions and approaches currently used in minimally invasive cardiovascular surgery.

First in Human Totally Endoscopic Perceval Valve Implantation

Totally endoscopic cardiac operations for coronary procedures and atrial septal defect repair have demonstrated improved quality of life, but they have required longer cross-clamp times compared with open operations. Although transcatheter valve implantation remains appropriate for inoperable patients, the totally endoscopic approach could be an effective treatment for lower risk patients, including complete removal of the stenotic aortic valve, while minimizing surgical chest wall trauma, and providing excellent early quality of life. Totally endoscopic aortic valve replacement procedures were previously performed with the 3f Enable bioprosthesis. We present the first case, to our knowledge, of Sorin Perceval implantation.

Right Internal Mammary Artery Use in 140 Robotic Totally Endoscopic Coronary Bypass Cases: Toward Multiarterial Grafting

OBJECTIVE

Benefits of adding a second arterial graft in coronary bypass are well documented. In patients requiring mulitvessel grafting robotic totally endoscopic coronary bypass (TECAB) has allowed for routine harvesting and use of the right internal mammary artery (RIMA). We retrospectively reviewed the technical considerations and target choice in 140 cases of beating heart TECAB where a RIMA graft was used.

METHODS

In 2008, we introduced beating heart TECAB with anastomotic connectors into our practice, first with single IMA and then with bilateral internal mammary artery. A robotic stabilizer was used not only to facilitate exposure of the coronary targets but also to aid the RIMA harvest using a skeletonized approach. Flow measurements were obtained routinely. We reviewed the technical aspects, target choice, and intraoperative flows in our TECAB patients who underwent grafting with RIMA grafts.

RESULTS

From February 2008 to January 2015, a total of 404 patients underwent beating heart TECAB with anastomotic connectors, of which 194 (48%) were mulitvessel procedures. One hundred forty patients (35%) had a RIMA graft and constitute the patient population for this review. One hundred thirty-one RIMA grafts were harvested via left-sided ports and grafted to left coronary targets, and nine RIMA grafts were harvested via right-sided ports and grafted to the right coronary artery. Flow was greater than 25 mL/min (pulsatility index < 2) in 95% of grafts. Perioperative mortality was 0.7% and mean ± standard deviation length of hospital stay was 3.1 (1.5) days. The RIMA was used as an in situ graft in 124 cases (84%) and as a free T-graft in 24 cases (16%) cases. Right internal mammary artery graft use in all TECABS increased from 23% in the first 5 years to 53% in the last 2 years.

CONCLUSIONS

Robotic TECAB allows the routine harvesting and use of the RIMA graft in a safe and reproducible manner. Skeletonization and sternal sparing allow the RIMA to reach various coronary targets. Further studies are needed for this approach to impact the adaption of multiarterial grafting.

Robotic cardiac surgery in Brazil

BACKGROUND

Brazil, the largest country and economy in South America, is a major driving force behind the development of new medical technologies in the region. Robotic cardiac surgery (RCS) has been evolving rapidly since 2010, when the first surgery using the DaVinci^® robotic system was performed in Latin America. The aim of this article is to evaluate short and mid-term results in patients undergoing robotic cardiac surgery in Brazil.

METHODS

From March 2010 to December 2015, 39 consecutive patients underwent robotic cardiac surgery. Twenty-seven patients were male (69.2%), with the mean age of 51.3±17.9 years. Participants had a mean ejection fraction of 62±5%. The procedures included in this study were mitral valve surgery, surgical treatment of atrial fibrillation, atrial septal defect closure, resection of intra-cardiac tumors, totally endoscopic coronary artery bypass and pericardiectomy.

RESULTS

The mean time spent on cardiopulmonary bypass (CPB) during RCS was 154.9±94.2 minutes and the mean aortic cross-clamp time was 114.48±75.66 minutes. Thirty-two patients (82%) were extubated in the operating room immediately after surgery. The median intensive care unit (ICU) length of stay was 1 day (ranging from 0 to 25) and the median hospital length of stay was 5 days (ranging from 3 to 25). For each type of procedure, endpoints were individually reported. There were no conversions to sternotomy and no intra-operative complications. Patient follow-up was complete in 100% of the participants, with two early deaths unrelated to the procedures and no re-operations at mid-term.

CONCLUSIONS

Despite the heterogeneity of this series, RCS appears to be feasible, safe and effective when used for the correction of various intra- and extra-cardiac pathologies. Adopting the robotic system has been a challenge in Brazil, where its limited clinical application may be related to the lack of specific training and the high cost of technology.

Totally Endoscopic Coronary Artery Bypass for Anomalous Origin of Right Coronary Artery

Anomalous origin of the right coronary artery (ARCA) from the left Valsalva sinus is a rare but known cause of sudden cardiac death. Surgical revascularization techniques include coronary artery bypass grafting, unroofing, and reimplantation. We report 4 patients who underwent robot-assisted totally endoscopic coronary artery bypass (TECAB) for ARCA as an alternative surgical option. In 3 patients, a single aortocoronary saphenous vein bypass was performed, and in 1 patient the right internal mammary artery was used. All grafts are patent as shown by computed tomographic angiography or cardiac catheterization. We claim that totally endoscopic coronary artery bypass is feasible and safe for anomalous origin of the right coronary artery.

Predictors and Outcomes of Sternotomy Conversion and Cardiopulmonary Bypass Assistance in Minimally Invasive Coronary Artery Bypass Grafting

OBJECTIVE

This work's objective was to identify the determinants of conversion of minimally invasive coronary artery bypass grafting to sternotomy, with and without cardiopulmonary bypass assistance, and to compare clinical outcomes in patients who needed conversion.

METHODS

This is a prospectively collected data on patients who underwent minimally invasive coronary bypass done by a single surgeon from February 2005 to September 2014. Statistical analyses were expressed as mean values ± standard deviation or proportions.

RESULTS

The total number of patients was 266, with an average age of 62 years. The median number of grafted territories was 2, higher in those with pump assistance (median, 3 grafts; P ≤ 0.01). Predictors for use of cardiopulmonary bypass included diabetes, 3-vessel disease, left circumflex involvement, and small target vessels (P < 0.05). The rate for sternotomy conversion was 3.8%. Risk factors for conversion to sternotomy included smoking, preoperative bradycardia (<50 beats per minute), low intraoperative ejection fraction, inability to tolerate one-lung ventilation, inadequate surgical exposure, and hemodynamic instability. Postoperative complications included superficial thoracotomy infection (3%), sternotomy infection (10%), new atrial fibrillation (3%), and need for blood transfusion (14%). Twelve patients (5%) developed left-sided pleural effusion that required drainage. There were no perioperative deaths, major adverse cardiac event, or stroke.

CONCLUSIONS

Minimally invasive coronary bypass grafting with conversion to sternotomy and use of cardiopulmonary bypass is safe. Conversions may be alleviated by an effort to optimize modifiable risk factors and the adequacy of surgical exposure. These data may help develop objective selection criteria to identify patients who are excellent candidates for the procedure.

The future of off-pump coronary artery bypass grafting: a North American perspective

Off-pump coronary artery bypass graft (OPCAB) is currently performed routinely in a minority of specialized centers and in many more centers, utilized only when a porcelain aorta mandates a no-touch aortic technique. The OPCAB literature can be summarized as follows: (I) large-scale randomized trials in relatively low risk patients that include surgeons with a range of experience demonstrating no consistent beneficial differences in major cardiovascular and cerebrovascular outcomes but lower transfusion rates and shorter length of stay, tempered by some reports of higher rates of incomplete revascularization and lower rates of long term graft patency; (II) smaller randomized controlled trials (RCTs) from highly specialized programs demonstrating equivalent or superior outcomes with OPCAB and similar completeness of revascularization and graft patency; and (III) observational data from large databases demonstrating a consistent benefit of OPCAB, especially in higher-risk patient subsets. Our rationale for OPCAB remains that if complete and precise revascularization can be safely and routinely accomplished, then the patient should benefit by avoiding the morbidities that can be attributed to aortic cannulation/clamping, cardiopulmonary bypass (CPB), hemodilution, hypothermia and global myocardial ischemia/cardioplegia. We further believe that OPCAB procedures should emphasize the use of arterial grafts to optimize long term patency and minimize aortic manipulation to limit the risk of stroke. Moving forward, the off-pump surgical community and specialty societies must address the challenge of training surgeons and their teams to master this technically demanding procedure. Furthermore, OPCAB opens the door to minimally-invasive surgical revascularization via hybrid coronary revascularization (HCR). A large NIH-funded RCT is currently underway to determine whether hybrid revascularization can offer a superior alternative to multi-vessel percutaneous coronary intervention for patients with low SYNTAX score and proximal LAD disease.

A systematic review on robotic coronary artery bypass graft surgery

BACKGROUND

Robotic-assisted coronary artery bypass graft surgery (CABG) has been performed over the past decade. Despite encouraging results from selected centres, there is a paucity of robust clinical data to establish its clinical safety and efficacy. The present systematic review aimed to identify all relevant clinical data on robotic CABG. The primary endpoint was perioperative mortality, and secondary endpoints included perioperative morbidities, anastomotic complications, and long-term survival.

METHODS

Electronic searches were performed using three online databases from their dates of inception to 2016. Relevant studies fulfilling the predefined search criteria were categorized according to surgical techniques as (I) totally endoscopic coronary artery bypass without cardiopulmonary bypass (TECAB off-pump); (II) TECAB on-pump; and robotic-assisted mammary artery harvesting followed by minimally invasive direct coronary artery bypass (robotic MIDCAB).

RESULTS

The present systematic review identified 44 studies that fulfilled the study selection criteria, including nine studies in the TECAB off-pump group and 16 studies in the robotic MIDCAB group. Statistical analysis reported a pooled mortality of 1.7% for the TECAB off-pump group and 1.0% for the robotic MIDCAB group. Intraoperative details such as the number and location of grafts performed, operative times and conversion rates, as well as postoperative secondary endpoints such as morbidities, anastomotic complications and long-term outcomes were also summarized for both techniques.

CONCLUSIONS

A number of technical, logistic and cost-related issues continue to hinder the popularization of the robotic CABG procedure. Current clinical evidence is limited by a lack of randomized controlled trials, heterogeneous definition of techniques and complications, as well as a lack of robust clinical follow-up with routine angiography. Nonetheless, the present systematic review reported acceptable perioperative mortality rates for selected patients at specialized centres. These results should be considered as a useful benchmark for future studies, until further data is reported in the form of randomized trials.

Reviewing hybrid coronary revascularization: challenges, controversies and opportunities

Two main approaches to myocardial revascularization currently exist, coronary artery bypass and percutaneous coronary intervention. In patients with advanced coronary artery disease, coronary artery bypass surgery is associated with improved long term outcomes while percutaneous coronary intervention is associated with lower periprocedural complications. A new approach has emerged in the last decade that attempts to reap the benefits of bypass surgery and stenting while minimizing the shortcomings of each approach. This new approach, hybrid coronary revascularization, has shown encouraging early results. Minimally invasive techniques for bypass surgery have played a large part of bringing this approach into contemporary practice.

Minimally Invasive Coronary Artery Bypass Grating Using Bilateral In Situ Internal Thoracic Arteries

When performing minimally invasive coronary artery bypass grafting (MICS CABG), it is difficult to access the right internal thoracic artery (ITA) under direct vision. We successfully performed off-pump MICS CABG using the bilateral in situ ITAs through a 8-cm left thoracotomy under direct vision for a 76-year-old man. His postoperative course was uneventful and all the grafts were patent. This novel, minimally invasive approach safely preserves the sternum and delivers the benefits of bilateral in situ ITA grafting, providing an alternative to conventional CABG and off-pump CABG.

A new telesurgical platform--preliminary clinical results

A new European telesurgical system, the Telelap Alf-x, is introduced. Its main features are individual arms, which enable free access to the patient throughout surgery, a large range of reusable surgical instruments, an open console with eye-tracking system, where the camera follows the eye and head movements of the surgeon, and the existing force feedback enables for the first time to feel the consistency of the tissues and avoid tearing of the stitches while suturing. The system combines the benefits of open surgery and endoscopy. The first clinical application, which involved 146 operations at the gynecological department of the Gemelli University Hospital in Rome, proved the safety and the surgical team's quick adaptation to the system.

Current Trend of Robotic Thoracic and Cardiovascular Surgeries in Korea: Analysis of Seven-Year National Data

Background

Robotic surgery is an alternative to minimally invasive surgery. The aim of this study was to report on current trends in robotic thoracic and cardiovascular surgical techniques in Korea.

Methods

Data from the National Evidence-based Healthcare Collaborating Agency (NECA) between January 2006 and June 2012 were used in this study, including a total of 932 cases of robotic surgeries reported to NECA. The annual trends in the case volume, indications for robotic surgery, and distribution by hospitals and surgeons were analyzed in this study.

Results

Of the 932 cases, 591 (63%) were thoracic operations and 340 (37%) were cardiac operations. The case number increased explosively in 2007 and 2008. However, the rate of increase regained a steady state after 2011. The main indications for robotic thoracic surgery were pulmonary disease (n=271, 46%), esophageal disease (n=199, 34%), and mediastinal disease (n=117, 20%). The main indications for robotic cardiac surgery were valvular heart disease (n=228, 67%), atrial septal defect (n=79, 23%), and cardiac myxoma (n=27, 8%). Robotic thoracic and cardiovascular surgeries were performed in 19 hospitals. Three large volume hospitals performed 94% of the case volume of robotic cardiac surgery and 74% of robotic thoracic surgery. Centralization of robotic operation was significantly (p<0.0001) more common in cardiac surgery than in thoracic surgery. A total of 39 surgeons performed robotic surgeries. However, only 27% of cardiac surgeons and 23% of thoracic surgeons performed more than 10 cases of robotic surgery.

Conclusion

Trend analysis of robotic and cardiovascular operations demonstrated a gradual increase in the surgical volume in Korea. Meanwhile, centralization of surgical cases toward specific surgeons in specific hospitals was observed.

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.

Strategies for the coronary surgeon to remain "competitive and co-operative" in the PCI era

BACKGROUND

The advent of percutaneous intervention has made surgical treatment of coronary artery disease less favored by patients though the evidence that supports CABG in certain patient subsets is strong.

METHODS

Literature review was done using Pubmed, Scopus, Google and Google Scholar with MeSH terms-coronary artery bypass grafting, internal mammary artery, drug eluting stent, stroke, myocardial revascularization.

RESULTS

The adoption of evolving techniques like anaortic off pump grafting, bilateral internal mammary artery use, hybrid and minimally invasive coronary revascularization techniques, intra-operative graft assessment, and heart team approach can lead to better outcomes following surgery as is evidenced by recent literature.

CONCLUSIONS

Though the adoptability of the newer strategies may vary between centers a close coalition between coronary surgeons and cardiologists would ensure that the management of coronary artery disease is based on evidence for the benefit of the patient.

Robot-assisted cardiac surgery using the da vinci surgical system: a single center experience

BACKGROUND

We report our initial experiences of robot-assisted cardiac surgery using the da Vinci Surgical System.

METHODS

Between February 2010 and March 2014, 50 consecutive patients underwent minimally invasive robot-assisted cardiac surgery.

RESULTS

Robot-assisted cardiac surgery was employed in two cases of minimally invasive direct coronary artery bypass, 17 cases of mitral valve repair, 10 cases of cardiac myxoma removal, 20 cases of atrial septal defect repair, and one isolated CryoMaze procedure. Average cardiopulmonary bypass time and average aorta cross-clamping time were 194.8±48.6 minutes and 126.1±22.6 minutes in mitral valve repair operations and 132.0±32.0 minutes and 76.1±23.1 minutes in myxoma removal operations, respectively. During atrial septal defect closure operations, the average cardiopulmonary bypass time was 128.3±43.1 minutes. The median length of stay was between five and seven days. The only complication was that one patient needed reoperation to address bleeding. There were no hospital mortalities.

CONCLUSION

Robot-assisted cardiac surgery is safe and effective for mitral valve repair, atrial septal defect closure, and cardiac myxoma removal surgery. Reducing operative time depends heavily on the experience of the entire robotic surgical team.

Association of Robotic Totally Endoscopic Coronary Artery Bypass Graft Surgery Associated With a Preliminary Cardiac Enhanced Recovery After Surgery Program: A Retrospective Analysis

OBJECTIVES

The robotic totally endoscopic coronary artery bypass graft (TECAB) surgery reduces patients' recovery time. The present trial investigated the feasibility and safety of an initial enhanced recovery after surgery (ERAS) path for patients undergoing robotic beating-heart TECAB and compared it with both conventional surgery and traditional perioperative care. It was hypothesized that the preliminary ERAS pathway associated with a beating-heart TECAB procedure could have a synergistic effect on postoperative patient care.

DESIGN

Observational retrospective study.

SETTING

University hospital.

PARTICIPANTS

Patients scheduled for coronary artery bypass graft and undergoing robotic beating-heart TECAB (n = 38) were compared with those undergoing standard surgery and perioperative care (n = 33). The outcomes were the possibility of tracheal extubation at the end of the surgery and the incidence of postoperative complications.

MEASUREMENTS AND MAIN RESULTS

The main comorbidities were similar between the 2 groups. Extubation on the operating table in the TECAB group was possible in all cases without requiring prompt endotracheal tube reinsertion. The proportion of patients transfused was significantly lower in the TECAB group (p = 0.009). In addition, the duration of intensive care unit and hospital stay were reduced significantly by 24 hours and by 4 days, respectively, in the TECAB group compared with the standard group (p< 0.05).

CONCLUSIONS

The present results suggested that a program coupling a beating-heart TECAB with a preliminary ERAS path for patients requiring a single coronary revascularization is feasible and safe. This approach could reduce postoperative mechanical ventilation time, transfusion rate, and both intensive care unit and hospital stay.

How to perform a coronary artery anastomosis in complete endoscopic fashion with robotic assistance

Current technology in robotic surgery allows us to perform myocardial revascularization procedures in a totally endoscopic fashion. We will describe the technique of choice for left internal mammary artery to left anterior descendent artery anastomosis with the use of cardiopulmonary bypass machine. The method is efficient and there is long term follow-up showing similar patency of the graft when compared to conventional methods (when performed through sternotomy).

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.

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

OBJECTIVES

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Atrial Fibrillation After Robotic Cardiac Surgery

Atrial fibrillation is one of the commonest complications after cardiac surgery and it is associated with considerable morbidity and increase in mortality. Recently, robotic approach to many heart operations has become feasible and reproducible. We here investigate and review the incidence of atrial fibrillation after robotic cardiac surgery. We found that its incidence is overall low and less than in conventional heart surgery.

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.

Coronary artery bypass grafting: Part 2--optimizing outcomes and future prospects

Since first introduced in the mid-1960s, coronary artery bypass grafting (CABG) has become the standard of care for patients with coronary artery disease. Surprisingly, the fundamental surgical technique itself did not change much over time. Nevertheless, outcomes after CABG have dramatically improved over the first 50 years. Randomized trials comparing percutaneous coronary intervention (PCI) to CABG have shown converging outcomes for select patient populations, providing more evidence for wider use of PCI. It is increasingly important to focus on the optimization of the short- and long-term outcomes of CABG and to reduce the level of invasiveness of this procedure. This review provides an overview on how new techniques and widespread consideration of evolving strategies have the potential to optimize outcomes after CABG. Such developments include off-pump CABG, clampless/anaortic CABG, minimally invasive CABG with or without extending to hybrid procedures, arterial revascularization, endoscopic vein harvesting, intraprocedural epiaortic scanning, graft flow assessment, and improved secondary prevention measures. In addition, this review represents a framework for future studies by summarizing the areas that need more rigorous clinical (randomized) evaluation.

Robotic surgery in cardiology: a safe and effective procedure

Objective:

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.