Initial experience with internal mammary artery harvesting with the da Vinci Surgical System for minimally invasive direct coronary artery bypass

Minimally invasive left internal mammary artery harvesting techniques during the learning curve are safe and achieve similar results as conventional LIMA harvesting techniques

Background

Internal thoracic arteries (ITAs) are considered to be the standard conduits used for coronary revascularization. Recently minimally invasive procedures are performed to harvest ITAs. The aim of this retrospective cohort study is to observe the effect and safety of less invasive LIMA harvesting approaches in the learning curve compared to conventional harvesting.

Methods

We retrospectively analyzed the data of 138 patients divided into three different groups based on the LIMA harvesting techniques: conventional sternotomy LIMA harvesting, CSLH (n: 64), minimally invasive direct LIMA harvesting, MIDLH (n: 42), and robotic-assisted LIMA harvesting, RALH (n: 32). The same 138 patients were also divided into sternotomy (n: 64), and non-sternotomy (n: 74) groups keeping both MIDLH and RALH in the non-sternotomy category. Parameters associated with LIMA’s quality and some other perioperative parameters such as harvesting time, LIMA damage, perioperative myocardial infarction, ventilation time, 24 h drainage, ICU stay, hospital mortality, computed tomographic angiography (CTA) LIMA patency on discharge, and after one year were recorded.

Results

The mean LIMA harvesting time was 36.9 ± 14.3, 74.4 ± 24.2, and 164.7 ± 51.9 min for CSLH, MIDLH, and RALH groups respectively (p < 0.001). One patient 1/32 (3.1%) in the RALH group had LIMA damage while the other two groups had none. One-month LIMA CTA patency was 56/57 (98.2%), 34/36 (94.4%), and 27/27 (100%) (p = 0.339), while 1 year CTA patency was 47/51 (92.1%), 30/33 (90.9%), and 24/25 (96%) for CSLH, MIDLH, and RALH groups respectively (p = 0.754). In the case of sternotomy vs non-sternotomy, the LIMA harvesting time was 36.9 ± 14.3 and 113.6 ± 59.3 min (p < 0.001). CTA patency on discharge was 56/57 (98.2%) and 61/63 (96.8%) (p = 0.619), while 1 year CTA patency was 47/51 (92.1%) and 54/58 (93.1%) (p = 0.850) for sternotomy vs non-sternotomy groups.

Conclusion

Minimally invasive left internal mammary artery harvesting techniques during the learning curve are safe and have no negative impact on the quality of LIMA. Perioperative outcomes are comparable to conventional procedures except for prolonged harvesting time. RALH is the least invasive and most time-consuming procedure during the learning curve. These procedures are safe and can be performed for selected patients even during the learning curve.

All we need to know about internal thoracic artery harvesting and preparation for myocardial revascularization: a systematic review

Internal thoracic arteries (ITAs) are the gold standard conduits for coronary revascularization because of their long-term patency and anti-atherosclerotic properties. Harvesting and preparation of ITAs for revascularization is a technically demanding procedure with multiple challenges. Over the last few decades, various methods and techniques for ITAs harvesting have been introduced by different surgeons and applied in clinical practice with different results. Harvesting of ITAs in pedicled or skeletonized fashion, with electrocautery or harmonic scalpel, with open or intact pleura, with clipping the end or keeping it perfused; papaverine delivery with intraluminal injection, perivascular injection, injecting into endothoracic fascia, and papaverine topical spray are the different techniques introduced by the number of researchers. At the same time, access to the ITAs for harvesting has also been studied. Access and harvesting through median sternotomy, mini anterolateral thoracotomy, thoracoscopic, and robotic-assisted harvesting of ITAs are the different techniques used in clinical practice. However, the single standard method for harvesting and preparation of ITAs has yet to be determined. In this review article, we aimed to discuss and analyze all these techniques of harvesting and preparing ITAs with the help of literature to find the best way for ITAs harvesting and preparation for myocardial revascularization.

Graft Patency after Robotically Assisted Coronary Artery Bypass Surgery

Objective

With advances in robotic instrumentation and technology, both robotically assisted minimally invasive direct coronary artery bypass (RMIDCAB) and totally endoscopic coronary artery bypass (TECAB) have been widely used over the past 20 years. Graft patency is the most important outcome in coronary bypass surgery and is associated with long-term prognosis. In this article we reviewed all experts’ studies in the field of robotic assisted coronary artery bypass and investigated graft patency in patients who underwent RMIDCAB or TECAB.

Methods

We performed a literature search in PubMed from 1999 to 2018 using the terms “Robotic” and “Coronary bypass” and/or “Minimally invasive” and/or “Totally endoscopic.” Of the articles found, studies investigating graft patency were specifically selected.

Results

In 33 articles, a total of 4,000 patients underwent robotic assisted coronary artery bypass surgery either by a RMIDCAB (2,396) or by a TECAB (1,604) approach. The graft patency was assessed by invasive angiography or computed tomographic angiography in all studies. The mean graft patency at early (<1 month), midterm (<5 years), and long-term (>5 years) follow-up was 97.7%, 96.1%, and 93.2% in RMIDCAB and 98.8%, 95.8%, and 93.6% in TECAB, respectively.

Conclusions

The graft patency of robotic assisted coronary artery bypass was equivalent to reported outcomes of the conventional approach. These results should encourage the adoption of robotic approaches in coronary bypass surgery.

Minimally invasive cardiac surgery in Japan: history and current status

This review examines the historical and current status of minimally invasive cardiac surgery (MICS) in Japan, based on reports that have been published in English. Although enthusiasm for MICS in Japan increased during the 1990s, it waned during the early 2000s because of various limitations. However, the introduction of minimally invasive mitral valve surgery, aortic valve replacement, atrial septal defect closure, and coronary artery bypass has led to the resurgence of MICS in Japan during recent years. Academic societies and a national registry system will play an important role in ensuring that this new wave of MICS is implemented safely and effectively. Off-the-job training and team building are also key factors for implementing a successful MICS program.

Medical robots in cardiac surgery - application and perspectives

Medical robots offer new standards and opportunities for treatment. This paper presents a review of the literature and market information on the current situation and future perspectives for the applications of robots in cardiac surgery. Currently in the United States, only 10% of thoracic surgical procedures are conducted using robots, while globally this value remains below 1%. Cardiac and thoracic surgeons use robotic surgical systems increasingly often. The goal is to perform more than one hundred thousand minimally invasive robotic surgical procedures every year. A surgical robot can be used by surgical teams on a rotational basis. The market of surgical robots used for cardiovascular and lung surgery was worth 72.2 million dollars in 2014 and is anticipated to reach 2.2 billion dollars by 2021. The analysis shows that Poland should have more than 30 surgical robots. Moreover, Polish medical teams are ready for the introduction of several robots into the field of cardiac surgery. We hope that this market will accommodate the Polish Robin Heart robots as well.

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.

Minimally invasive direct coronary artery bypass grafting with an improved rib spreader and a new-shaped cardiac stabilizer: results of 200 consecutive cases in a single institution

Background

Performing minimally invasive direct coronary artery bypass (MIDCAB) grafting via small chest incisions on a beating heart is challenging. We report our experiences of MIDCAB with the utilization of both an improved rib spreader to harvest the left internal mammary artery (LIMA) and a new-shaped cardiac stabilizer to facilitate LIMA-left anterior descending (LAD) coronary anastomosis.

Methods

Between May 2012 and June 2104, a total of 200 patients who were consecutively operated on in this period were enrolled in this study. Data reported included demographic information, preoperative clinical and cardiac status, LIMA harvest time, postoperative in-hospital outcomes, and 30-day mortality.

Results

The average LIMA harvest time was 43 min. The mean age was 62.59 ± 10.19 years, and 45 of the 200 were females. The 30-day mortality was 0.5 % (one patient) due to perioperative myocardial infarction. Duration of mechanical ventilation and length of stay in intensive care unit was 9.27 ± 7.65 and 24.27 ± 17.85 h, respectively. The unit of packed RBC transfusion was 0.79 ± 1.58. Postoperative atrial fibrillation was observed in 14 (7 %) patients. There was no postoperative stroke, renal failure, or incision complication.

Conclusion

Performing MIDCAB with the improved retractor and stabilizer utilized in this study showed favorable outcomes in terms of harvesting the LIMA, postoperative morbidities, and 30-day mortality.