Robotic mammary takedown and off-pump bypass surgery for single-vessel disease of the left anterior descending coronary artery

Robotic-enhanced coronary surgery in octogenarians

Objectives

Robotic-enhanced minimally invasive direct coronary artery bypass grafting surgery (RE-MIDCAB) is based on the use of a robotic console and instrumentation for the dissection of the left internal thoracic artery (LITA). The LITA to left anterior descending (LAD) artery anastomosis is subsequently constructed through a mini thoracotomy. The purpose of this study is to present our experience of RE-MIDCAB outcomes in elderly patients.

Methods

From 2002 until 2015, 44 octogenarians (the mean age of 82.9 years) underwent RE-MIDCAB. The mean logistic EuroSCORE was 9.2. The majority of the patients were male with a medical history of hypertension, dyslipidaemia and previous coronary interventions. Of these patients 25% underwent RE-MIDCAB combined with percutaneous coronary intervention (PCI) for the treatment of multi-vessel disease (hybrid revascularization).

Results

All RE-MIDCABs and combined 'hybrid' PCI procedures were successfully completed. The mean intensive care unit (ICU) and hospital stay were 1.6 days and 10.9 days, respectively. There was 1 in-hospital mortality (2.3%). After an average follow-up period of 29.2 months, 5 patients required repeat revascularization procedures (9.1%). Mortality on follow-up was estimated at 25.6%.

Conclusions

Our report suggests that considering the age and frailty of the octogenarian population, RE-MIDCAB is a feasible and safe procedure which is associated with acceptable mid-term results.

Quality of life after robotically assisted atrial myxoma excision

The aim of this study was to evaluate the clinical outcome after robotically assisted myxoma surgery performed at our institution. Altogether nine patients underwent robotically assisted atrial myxoma excision. A control group was selected from 18 consecutive patients who underwent an isolated atrial myxoma excision via conventional sternotomy. Preoperative patient characteristics were similar between the two study groups. Postoperative health-related quality of life (HRQoL) was also evaluated. All robotic operations were completed successfully using the da Vinci™ telesurgical system. There was no mortality in either of the two study groups. Procedure, cardiopulmonary bypass, aortic occlusion, and ventilation times were shorter in the sternotomy group when compared to the robotic group. Length of stay was statistically significantly shorter in the robotically assisted group. Postoperative quality of life did not differ between the two study groups. We conclude that robotically assisted surgery is a feasible method for treating atrial myxomas.

Future Directions in Cardiac Surgery

The future of cardiac surgery is interesting, challenging, and changing. In coronary artery disease, operations are becoming more difficult due to previous stent placement and population aging, but there is a sense that volume is increasing, especially in centers that perform operations for diffuse disease and those that can perform truly minimally invasive procedures with robotic takedown of mammary arteries and perform anastomoses thoracoscopically. In valve disease, there will be increasing numbers of elderly patients requiring surgery, especially for aortic valve disease; a combination of minimally invasive surgery, hybrid procedures, and perhaps percutaneous valve placement in the truly high risk will be required. Mitral valve repair will become increasingly used as well as some percutaneous valve devices. In 5 years, most thoracic aneurysms will be treated by endovascular stenting and adults with congenital disease will be a small but growing population of patients.

Robot-Assisted Off-Pump Minimally Invasive Reoperative Coronary Artery Bypass Grafting: Case Report

BACKGROUND

Resternotomy for reoperative coronary artery bypass grafting (CABG) has become increasingly common with an aging patient population. Minimally invasive and robotic techniques permit us to perform these surgeries with reduced morbidity and mortality.

CASE REPORT

A 67-year-old woman was taken to the operating room for repeat CABG. A free right internal mammary graft was endoscopically harvested using the da Vinci robotic operating system. A small left thoracotomy was then used to perform an off-pump bypass from the descending aorta to the hood of a diseased saphenous vein graft.

CONCLUSION

Robotic and minimally invasive cardiac surgery undergoes continuous refinement. As the incidence of reoperative surgery in patients with multiple previous interventions rises, surgeons will have to become increasingly creative with their choice of conduits, incisions, and the use of hybrid open and endoscopic techniques.