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

Simulation-based assessment of robotic cardiac surgery skills: An international multicenter, cross-specialty trial

Objective

This study aimed to investigate the validity of simulation-based assessment of robotic-assisted cardiac surgery skills using a wet lab model, focusing on the use of a time-based score (TBS) and modified Global Evaluative Assessment of Robotic Skills (mGEARS) score.

Methods

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.

Results

The results demonstrated a high internal consistency for all 3 tasks using mGEARS assessment tool. The mGEARS score and TBS could reliably discriminate between different levels of competence for the atrial closure and mitral stitches tasks but not for the ITA harvesting task. A generalizability study also revealed that it was feasible to assess competency of the atrial closure and mitral stitches tasks using mGEARS but not the ITA dissection task. Pass/fail scores were established for each task using both TBS and mGEARS assessment tools.

Conclusions

The study provides sufficient evidence for using TBS and mGEARS scores in evaluating robotic-assisted cardiac surgery skills in wet lab settings for intracardiac tasks. Combining both assessment tools enhances the evaluation of proficiency in robotic cardiac surgery, paving the way for standardized, evidence-based preclinical training and credentialing.

Clinical trial registry number

NCT05043064.

Early Results of Total Coronary Revascularization via Left Anterior Thoracotomy

BACKGROUND

Avoidance of sternotomy while preserving complete revascularization remains challenging in multivessel coronary disease. Technical issues and in-hospital outcomes of total coronary revascularization via a small left anterior thoracotomy (TCRAT) in nonselected patients with multivessel disease are reported.

METHODS

From November 2019 to September 2021, coronary artery bypass grafting via left anterior minithoracotomy on cardiopulmonary bypass and cardioplegic cardiac arrest was performed in 102 patients (92 males; 67 ± 10 [42-87] years). Slings were placed around ascending aorta, left pulmonary veins, and inferior vena cava for exposure of lateral and inferior ventricular wall. All patients had multivessel coronary disease (three-vessel disease: n = 72; two-vessel disease: n = 30; left main stenosis: n = 44). We included patients at old age (> 80 years, 14.7%), with severe left ventricular dysfunction (ejection fraction < 30%, 6.9%), massive obesity (body mass index > 35, 11.6%), and at increased risk (EuroSCORE II > 4, 15.7%).

RESULTS

Left internal thoracic artery (n = 101), radial artery (n = 83), and saphenous vein (n = 39) grafts were used for total (61.8%) or multiple (19.6%) arterial grafting. A total of 323 distal anastomoses (3.2 ± 0.7 [2-5] per patient) were performed to revascularize left anterior descending (100%), circumflex (91.2%), and right coronary artery (67.7%). Complete revascularization was achieved in 95.1%. In-hospital mortality was 2.9%, stroke rate was 1.0%, myocardial infarction rate was 2.9%, and repeat revascularization rate was 2.0%.

CONCLUSION

This novel surgical technique allows complete coronary revascularization in the broad majority of multivessel disease patients without sternotomy. TCRAT can be introduced into clinical routine safely. Long-term results remain to be investigated.

Minimal-Access Coronary Revascularization: Past, Present, and Future

Minimal-access cardiac surgery appears to be the future. It is increasingly desired by cardiologists and demanded by patients who perceive superiority. Minimal-access coronary artery revascularisation has been increasingly adopted throughout the world. Here, we review the history of minimal-access coronary revascularization and see that it is almost as old as the history of cardiac surgery. Modern minimal-access coronary revascularization takes a variety of forms-namely minimal-access direct coronary artery bypass grafting (MIDCAB), hybrid coronary revascularisation (HCR), and totally endoscopic coronary artery bypass grafting (TECAB). It is noteworthy that there is significant variation in the nomenclature and approaches for minimal-access coronary surgery, and this truly presents a challenge for comparing the different methods. However, these approaches are increasing in frequency, and proponents demonstrate clear advantages for their patients. The challenge that remains, as for all areas of surgery, is demonstrating the superiority of these techniques over tried and tested open techniques, which is very difficult. There is a paucity of randomised controlled trials to help answer this question, and the future of minimal-access coronary revascularisation, to some extent, is dependent on such trials. Thankfully, some are underway, and the results are eagerly anticipated.

Robot-Assisted Totally Endoscopic Mitral Valve Plasty and Coronary Artery Bypass Grafting

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.

Consensus statement on aortic valve replacement via an anterior right minithoracotomy in the UK healthcare setting

The wide uptake of anterior right thoracotomy (ART) as an approach for aortic valve replacement (AVR) has been limited despite initial reports of its use in 1993. Compared with median sternotomy, and even ministernotomy, ART is considered to be less traumatic to the chest wall and to help facilitate quicker patient recovery. In this statement, a consensus agreement is outlined that describes the potential benefits of the ART AVR. The technical considerations that require specific attention are described and the initiation of an ART programme at a UK centre is recommended through simulation and/or use of specialist instruments in conventional cases. The use of soft tissue retractors, peripheral cannulation, modified aortic clamping and the use of intraoperative adjuncts, such as sutureless valves and/or automated knot fasteners, are important to consider in order to circumvent the challenges of minimal the altered exposure via an ART.A coordinated team-based approach that encourages ownership of the programme by team members is critical. A designated proctor/mentor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases are important steps to consider.

Incidence, predictors and vascular sequelae of distal limb ischemia in minimally invasive cardiac surgery with femoral artery cannulation: an observational cohort study

Literature regarding monitoring and consequences of distal limb ischemia due to femoral artery cannulation for Minimally Invasive Cardiac Surgery (MICS) remains limited. The primary objective was to determine its incidence, defined as a ≥ 15% difference in regional Oxygen Saturation (rSO₂) lasting ≥ four consecutive minutes between the cannulated and non-cannulated limb. The secondary objectives included: determination of distal limb ischemia, defined as a Tissue Oxygenation Index (TOI) < 50% in the cannulated limb, identification of predictors for distal limb ischemia, determination of a possible association of NIRS-diagnosed ischemia with acute kidney injury, and the need for vascular surgery up to six months after cardiac surgery. A prospective, observational cohort study with blinded rSO₂-measurements to prevent intraoperative clinical decision-making. A single-center, community-hospital, clinical study. All consecutive patients ≥ 18 years old, and scheduled for predefined MICS. Patients underwent MICS with bilateral calf muscle rSO₂-measurements conducted by Near-Infrared Spectroscopy (NIRS). In total 75/280 patients (26.79%) experienced distal limb ischemia according to the primary objective, while 18/280 patients (6.42%) experienced distal limb ischemia according to the secondary objective. Multivariate logistic regression showed younger age to be an independent predictor for distal limb ischemia (p = 0.003). None of the patients who suffered intraoperative ischemia required vascular surgery within the follow-up period. The incidence of NIRS-diagnosed ischemia varied from 6.4% to 26.8% depending on the used criteria. Short and long-term vascular sequelae, however, are limited and not intraoperative ischemia related. The added value of intraoperative distal limb NIRS monitoring for vascular reasons seems limited. Future research on femoral artery cannulation in MICS should shift focus to other outcome parameters such as acute kidney injury, postoperative pain or paresthesias.

Historical evolution of robot-assisted cardiac surgery: a 25-year journey

Many patients and surgeons today favor the least invasive access to an operative site. The adoption of robot-assisted cardiac surgery has been slow, but now has come to fruition. The development of modern surgical robots took surgeons close collaboration with mechanical, electrical, and optical engineers. Moreover, the necessary project funding required entrepreneurs, federal grants, and venture capital. Non-robotic minimally invasive cardiac surgery paved the way to the application of surgical robots by making changes in operative approaches, instruments, visioning modalities, cardiopulmonary perfusion techniques, and especially surgeons' attitudes. In this article, the serial development of robot-assisted cardiac surgery is detailed from the beginning and through clinical application. Included are references to the historical and most recent clinical series that have given us the evidence that robot-assisted cardiac surgery is safe and provides excellent outcomes. To this end, in many institutions these procedures now have become a new standard of care. This evolution reflects Sir Isaac Newton's famous 1676 quote when referring to Rene Descartes, "If have seen further [sic] than others, it is by standing on the shoulders of giants".

Novel concept of routine total arterial coronary bypass grafting through a left anterior approach avoiding sternotomy

Coronary artery bypass grafting (CABG) via full sternotomy remains a very invasive procedure, often requiring prolonged recovery of the patient. We describe a novel, less invasive approach for totally arterial CABG via a small left anterior thoracotomy in a pilot series of 20 unselected patients. From January to March 2020, 20 consecutive patients (mean age 65.9 ± 9.2 years, 100% male, STS-score: 1.6 ± 2) underwent CABG using only arterial conduits via a small left anterior thoracotomy. Patients were operated on cardiopulmonary bypass with peripheral cannulation and transthoracic aortic cross-clamping. Pulling tapes encircling the great vessels, the arrested empty heart was rotated and moved within the pericardium to enable conventional anastomotic techniques especially on lateral and inferior wall coronary targets. In all patients, left internal mammary artery and radial artery were utilized for bypass with 3.3 ± 0.7 distal coronary anastomoses per patient. Anterior, lateral, and inferior wall territories were revascularized in 100%, 85%, and 70% of patients, respectively. Complete anatomical revascularization was achieved in 95% of patients. ICU stay was 1 day in 17 patients, and 14 of patients left the hospital within 8 days. There was no hospital death, no stroke, no myocardial infarction, and no repeat revascularization. In this pilot series of 20 patients, minimally invasive, totally arterial CABG with avoidance of sternotomy was technically feasible with favorable patient outcomes.

Multi-Spectrum Robotic Cardiac Surgery: Early Outcomes

Objective

The robotic cardiac surgery program at our current institution began in 2013 with an experienced and dedicated team. This review analyzes early outcomes in the first 1103 patients.

Methods

We reviewed all robotic procedures between July 2013 and February 2021. Primary outcomes were mortality and perioperative morbidity. Our robotic approach is totally endoscopic for all cases: off-pump for coronary and epicardial procedures, and on-pump with the endoballoon for mitral valve and other intracardiac procedures.

Results

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.

Conclusions

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.

The learning curve of robotic coronary arterial bypass surgery: A report from the STS database

BACKGROUND

There is limited data to inform minimum case requirements for training in robotically assisted coronary artery bypass grafting (RA-CABG). Current recommendations rely on nonclinical endpoints and expert opinion.

OBJECTIVES

To determine the minimum number of RA-CABG procedures required to achieve stable clinical outcomes.

METHODS

We included isolated RA-CABG in the Society of Thoracic Surgeons (STS) registry performed between 2014 and 2019 by surgeons without prior RA-CABG experience. Outcomes were approach conversion, reoperation, major morbidity or mortality, and procedural success. Case sequence number was used as a continuous variable in logistic regression with restricted cubic splines with fixed effects. Outcomes were compared between operations performed earlier versus later in case sequences using unadjusted and adjusted metrics.

RESULTS

There were 1195 cases performed by 114 surgeons. A visual inflection point occurs by a surgeon's 10th procedure for approach conversion, major morbidity or mortality, and overall procedural success after which outcomes stabilize. There was a significant decrease in the rate of approach conversion (7.7% and 2.5%), reoperation (18.9% and 10.8%), and major morbidity or mortality (21.7% and 12.9%), as well as an increase in the rate of procedural success (72.9% and 85.3%) with increasing experience between groups. In a multivariable logistic regression model, case sequences of >10 were an independent predictor of decreased approach conversion (odds ratio [OR]: 0.27; 95% confidence interval [CI]: 0.09-0.84) and increased rate procedural success (OR: 1.96; 95% CI: 1.00-3.84).

CONCLUSIONS

The learning curve for RA-CABG is initially steep, but stable clinical outcomes are achieved after the 10th procedure.

Robotic off-pump totally endoscopic coronary artery bypass in the current era: report of 544 patients

OBJECTIVES

Robotic off-pump totally endoscopic coronary artery bypass (TECAB) is the least invasive form of surgical coronary revascularization. It has proved to be highly effective and safe. Its benefits are well-established and include fewer complications, shorter hospital stay and quicker return to normal activities. TECAB has undergone 2 decades of technological advancement to include multivessel grafting, a beating-heart approach and successful completion in multiple patient groups in experienced hands. The aim of this report was to examine outcomes of robotic off-pump TECAB at our institution over 7 years.

METHODS

Data from 544 patients undergoing TECAB between July 2013 and August 2020 were retrospectively examined. The C-Port Flex-A distal anastomotic device was used for the majority of grafts (70%). Yearly follow-up was conducted. Angiographic early patency data were reviewed for patients undergoing hybrid revascularization.

RESULTS

The mean age was 66 years, with 1.7% mean STS risk. Fifty-six percentage had multivessel TECAB. There was 1 conversion to sternotomy, and 46% extubation in the Operating Room (OR). Mortality was 0.9%. Early graft patency was 97%. At mid-term follow-up at 38 months, cardiac mortality was 2.7% and freedom from major adverse cardiac events was 92.5%.

CONCLUSIONS

We conclude that robotic beating-heart TECAB in the current era is safe and effective with excellent outcomes and comparable early angiographic patency to standard coronary artery bypass grafting surgery when performed frequently by an experienced team. This procedure was completed in our hands both with and without an anastomotic device. Longer-term studies are warranted.

Review of Contemporary Techniques for Minimally Invasive Coronary Revascularization

Minimally invasive coronary revascularization techniques aim to avoid median sternotomy with its associated complications, while facilitating recovery and maintaining the benefits of surgical revascularization. The 3 most common procedures are minimally invasive coronary artery bypass grafting, totally endoscopic coronary artery bypass, and hybrid coronary revascularization. For a variety of reasons, including cost and technical difficulty, not many centers are routinely performing minimally invasive coronary revascularization. Nevertheless, many studies have assessed the safety and efficacy of each of these procedures in different clinical contexts. Thus far results have been promising, and with the evolution of procedural techniques, these approaches have the potential to redefine coronary revascularization in the future. This review highlights the current state of minimally invasive coronary revascularization techniques by exploring their benefits, identifying barriers to their adoption, and discussing future potential paradigms.

Minimally Invasive Coronary Revascularisation Surgery: A Focused Review of the Available Literature

Minimally invasive coronary revascularisation was originally developed in the mid 1990s as minimally invasive direct coronary artery bypass (MIDCAB) grafting is a less invasive approach compared to conventional coronary artery bypass grafting (CABG) to address targets in the left anterior descending coronary artery (LAD). Since then, MIDCAB has evolved with the adoption of a robotic platform and the possibility to perform multivessel bypass procedures. Minimally invasive coronary revascularisation surgery also allows for a combination between the benefits of CABG and percutaneous coronary interventions for non-LAD lesions – a hybrid approach. Hybrid coronary revascularisation results in fewer blood transfusions, shorter hospital stay, decreased ventilation times and patients return to work sooner when compared to conventional CABG. This article reviews the available literature, describes standard approaches and considers topics, such as limited access procedures, indications and patient selection, diagnostics and imaging, techniques, anastomotic devices, hybrid coronary revascularisation and outcome analysis.

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

 

OBJECTIVES

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Minimally invasive and robotic coronary artery bypass grafting-a 25-year review

During the mid-1990s cardiac surgery started exploring minimally invasive methods for coronary artery bypass grafting (CABG) and has over a 25-year period developed highly differentiated and less traumatic operations. Instead of the traditional sternotomy mini-incisions on the chest or ports are placed, surgery on the beating heart is applied, sophisticated remote access heart lung machine systems as well as videoscopic units are available, and robotic technology enables completely endoscopic approaches. This review describes these methods, reports on the cumulative intra- and postoperative outcome of these procedures, and gives an integrated view on what less invasive coronary bypass surgery can achieve. A total of 74 patient series published on the topic between 1996 and 2019 were reviewed. Six main versions of minimal access and robotically assisted CABG were applied in 11,135 patients. On average 1.3±0.6 grafts were placed and the operative time was 3 hours 42 min ± 1 hour 15 min. The procedures were carried out with a hospital mortality of 1.0% and a stroke rate of 0.6%. The revision rate for bleeding was 2.5% and a renal failure rate of 0.9% was noted. Wound infections occurred at a rate of 1.2% and postoperative hospital stay was 5.6±2.2 days. It can be concluded that less invasive and robotically assisted versions of coronary bypass grafting are carried out with an adequate safety level while surgical trauma is significantly reduced.

BISMICS consensus statement: implementing a safe minimally invasive mitral programme in the UK healthcare setting

Disseminating the practice of minimally invasive mitral surgery (mini-MVS) can be challenging, despite its original case reports a few decades ago. The penetration of this technology into clinical practice has been limited to centres of excellence, and mitral surgery in most general cardiothoracic centres remains to be conducted via sternotomy access as a first line. The process for the uptake of mini-MVS requires clearer guidance and standardisation for the processes involved in its implementation. In this statement, a consensus agreement is outlined that describes the benefits of mini-MVS, including reduced postoperative bleeding, reduced wound infection, enhanced recovery and patient satisfaction. Technical considerations require specific attention and can be introduced through simulation and/or use in conventional cases. Either endoballoon or aortic cross clamping is recommended, as well as femoral or central aortic cannulation, with the use of appropriate adjuncts and instruments. A coordinated team-based approach that encourages ownership of the programme by the team members is critical. A designated proctor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases, is an important step to consider. The importance of pre-empting complications and dealing with adverse events is described, including re-exploration, conversion to sternotomy, unilateral pulmonary oedema and phrenic nerve injury. Accounting for both institutional and team considerations can effectively facilitate the introduction of a mini-MVS service. This involves simulation, team-based training, visits to specialist centres and involvement of a designated proctor to oversee the initial cases.

Angiographic patency after robotic beating heart totally endoscopic coronary artery bypass grafting facilitated by automated distal anastomotic connectors

OBJECTIVES

Robotic totally endoscopic coronary artery bypass (TECAB) on the beating heart has been facilitated in our experience using distal coronary anastomotic connectors. In this study, we retrospectively reviewed graft patency in all robotic TECAB patients who underwent formal angiography at our current institution over a 5-year period.

METHODS

Between July 2013 and June 2018, 361 consecutive patients underwent robotic beating-heart TECAB. Of these patients, 121 had a follow-up angiogram, which assessed graft patency. Eighty-four patients had an angiogram as part of planned hybrid procedures and 37 patients underwent an unplanned angiogram for clinical indications. Retrospective analysis of angiographic patency and clinical outcomes was performed.

RESULTS

The mean Society of Thoracic Surgeons predicted risk of mortality was 1.8%. Single-vessel bypass was performed in 40 (33%) patients and multivessel grafting in 81 (67%). Average flow (ml/min) and pulsatility index in the grafts was 74.7 ± 39.1 and 1.42 ± 0.52, respectively. The number of grafts evaluated was 204 (130 left internal mammary artery and 74 right internal mammary artery grafts). The median time to angiography was 1.0 and 16.0 months and graft patency was 98% and 91% in the hybrid and non-hybrid groups, respectively. Overall graft patency was 95.6% (left internal mammary artery = 96%; right internal mammary artery = 93%). Left internal mammary artery to left anterior descending artery graft patency was 97%. Clinical follow-up was available for 316 (88%) patients at mean 22.5 ± 15.1 months. Freedom from major adverse cardiac events at 2 years was 92%.

CONCLUSIONS

In this consecutive series of patients undergoing formal angiography after robotic single and multivessel TECAB, we found satisfactory graft patency and 2-year clinical outcomes. Longer-term follow-up is warranted.

Does Intolerance of Single-Lung Ventilation Preclude Robotic Off-Pump Totally Endoscopic Coronary Bypass Surgery?

Objective

Robotic off-pump totally endoscopic coronary artery bypass (TECAB) usually requires isolated single (right) lung ventilation to adequately expose the surgical site. However, in some patients, persistent oxygen desaturation may occur and conversion to cardiopulmonary bypass (CPB) or sternotomy may be necessary. We reviewed the characteristics and clinical outcomes in patients who did not tolerate single-lung ventilation during TECAB surgery.

Methods

After Institutional Review Board approval we reviewed 440 patients undergoing robotic TECAB at our institution between July 2013 and April 2019. Patients were separated into 2 groups based on their ability to tolerate single-lung ventilation during the procedure. Group 1 included patients able to tolerate single-lung ventilation and Group 2 were patients who required double-lung ventilation to tolerate the procedure. Early and mid-term outcomes were compared.

Results

Group 2 (121 patients) had higher Society of Thoracic Surgeons scores, higher body mass index, and more triple-vessel disease than Group 1 (319 patients). Group 2 had more bilateral internal mammary artery use, multivessel grafting, and longer operative times. One patient underwent conversion to sternotomy and 5 required CPB (all in Group 1). Intensive care unit and hospital length of stay were longer in Group 2. Observed/expected mortality did not differ between groups (1.06% in Group 2 vs 0.4% in Group 1; P = 0.215). At mid-term follow-up, cardiac-related/overall mortality and freedom from major adverse cardiac events were similar.

Conclusions

In our cohort, intolerance of single-lung ventilation did not preclude robotic off-pump TECAB. Double-lung ventilation is feasible during the procedure and may prevent conversions to sternotomy or use of CPB, resulting in excellent early and mid-term outcomes.

Robotic totally endoscopic beating-heart bypass to the right coronary artery: first worldwide experience

OBJECTIVES

Left coronary vessels are the usual targets in totally endoscopic coronary artery bypass (TECAB). Grafting of the right coronary artery (RCA) has been limited using this approach because of anatomic and technical difficulties. We report a first series of robotic beating-heart TECAB to the RCA via a right-chest approach.

METHODS

From July 2013 to April 2019, patients who underwent robotic beating-heart TECAB with the right internal mammary artery to the RCA were reviewed. Port placement in the right chest mirrored standard left-sided ports. Indications for right internal mammary artery to RCA bypass were RCA disease not amenable to percutaneous intervention and anomalous origin of the RCA.

RESULTS

Right internal mammary artery-RCA bypass was performed in 16 patients (mean age 60.6 ± 13.5, 75% male). All cases were completed without conversion to sternotomy or mini-thoracotomy. Cardiopulmonary bypass was required in 1 patient to expose the posterior descending artery. Mean procedure time was 223 ± 49 min, with half of the patients extubated in the operating room (50%). Mean intraoperative transit-time graft flow was 87.0 ± 19.3 ml/min, and a pulsatility index of 1.2 ± 0.2. Mean length of stay was 2.3 ± 1.2 days. No mortality was observed at mean follow-up time of 20.6 months. One patient required repeat RCA revascularization for progression of native disease 43.7 months after the surgery.

CONCLUSIONS

Robotic beating-heart TECAB for isolated RCA disease is a feasible operation in selected patients. This technique is possible even for the posterior descending artery.

Robotic totally endoscopic coronary artery bypass grafting: current status and future prospects

Introduction: Totally endoscopic coronary artery bypass grafting (TECAB) can only be performed in a reproducible manner using robotic technology. This operation has been developed for more than 20 years seeing three generations of surgical robots. TECAB can be carried out beating heart but also on the arrested heart. Single and multiple grafts can be placed and TECAB can be combined with percutaneous coronary intervention in hybrid procedures.Areas covered: This review outlines indications for the procedure, the surgical technique, and the postoperative care. Intra- and postoperative results as available in the literature are reported. Further areas focus on technological development, training methods, learning curves as well as on cost. Finally, we give an outlook on the potential future of this operation.Expert opinion: Robotic TECAB represents a complex, sophisticated but safe, and over-the-years grown procedure. Even though results seem to be in line with conventional coronary surgery worldwide adoption still has been slow probably due to procedure times, costs and learning curves. Main advantages of TECAB are minimized surgical trauma and subsequent reduction of postoperative healing time. With the current introduction of new robotic devices, a new era of procedure development is on its way.

A new viewpoint on endoscopic CABG: technique description and clinical experience

BACKGROUND

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.

METHODS

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.

RESULTS

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%).

CONCLUSIONS

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.

Robotic Cardiac Surgery Part II: Anesthetic Considerations for Robotic Coronary Artery Bypass Grafting

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.

Hybrid Coronary Artery Revascularization: A Review and Current Evidence

OBJECTIVE

The role of hybrid coronary revascularization (HCR), which utilizes the combination of minimally invasive surgical coronary artery bypass grafting of the left anterior descending artery and percutaneous coronary intervention (PCI) of non-left anterior descending vessels to treat multivessel coronary artery disease, is expanding. We set out to provide a review of this technology.

METHODS

We conducted a retrospective analysis of all minimally invasive hybrid operations performed at our institution from September 2004 to December 2018. An effective analysis comparing patients undergoing HCR vs off-pump or on-pump surgical coronary artery revascularization was undertaken using an adjusted analysis with inverse-probability weighting based on the propensity score. Outcomes that were assessed include death, myocardial infarction, stroke, atrial fibrillation, renal failure, requirement of blood transfusion, conversion to open procedure (in the hybrid group), length of stay in intensive care unit, and total length of stay in hospital. Intention-to-treat analysis was performed. An up-to-date literature review of HCR complements this study.

RESULTS

Since 2004 a total of 191 consecutive patients (61.4±11.1 years; 142 males and 49 females) underwent HCR (robotic-assisted coronary artery bypass graft of the left internal thoracic artery to the left anterior descending coronary artery (LAD) and PCI of a non-LAD vessel) in a single- or double-stage fashion. Successful HCR occurred in 183 of the 191 patients (8 patients required intraoperative conversion to conventional coronary bypass). From our comparative analysis and literature review we found no significant difference between HCR and coronary artery bypass grafting groups with respect to in-hospital and 1-year follow-up.

CONCLUSIONS

Current evidences suggest that HCR is a feasible, safe, and effective coronary artery revascularization strategy in selected patients with multivessel coronary artery disease.

Nonrobotic Total Endoscopic Coronary Artery Bypass Grafting: A Proof-of-Concept Study in 20 Patients

OBJECTIVE

At present, minimal invasive direct coronary artery grafting is the least invasive nonrobotic surgical approach to revascularize the left anterior descending artery with the left internal mammary artery. Total endoscopic coronary bypass grafting is performed with the help of a telemanipulator ("robot"). A prospective proof-of-concept study was initiated to investigate a nonrobotic total endoscopic coronary bypass grafting approach.

METHODS

Twenty patients with significant left anterior descending artery or left main stem lesion were operated on via three or four left thoracic access ports. Under exclusive endoscopic vision, the left internal mammary artery was harvested and anastomosed to the left anterior descending artery manually. Cardiopulmonary bypass and cardioplegic arrest were planned in all cases.

RESULTS

In 10 patients, the operation was completed successfully as nonrobotic total endoscopic coronary bypass grafting. Reasons for conversions to minimal invasive direct coronary artery grafting or conventional sternotomy were dense pleural adhesions (3 patients), bleeding of the anastomosis (3), diffuse bleeding during left internal mammary artery harvesting (2), identification problems of the target artery (1), or left internal mammary artery failure (1). Postoperative angiography in five primarily successful nonrobotic total endoscopic coronary bypass grafting patients showed patent anastomoses in four cases. One patient was reoperated on for early anastomotic failure in a 1.0-mm target vessel. Until now, a percutaneous coronary intervention of remaining lesions as staged hybrid procedure was performed in three patients (2 nonrobotic total endoscopic coronary bypass grafting, 1 minimal invasive direct coronary artery grafting).

CONCLUSIONS

With a thoroughly surveyed learning curve, nonrobotic total endoscopic coronary bypass grafting procedure could become an alternative to other available treatment options; however, the value of the procedure has to be further investigated.

Robotic Totally Endoscopic Coronary Artery Bypass Grafting: Systematic Review of Clinical Outcomes from the Past two Decades

Robotic totally endoscopic coronary artery bypass grafting (TECAB) was introduced in 1998 and has over a period of two decades gradually emerged from single-vessel revascularization to multivessel bypass grafting. Dedicated centers have continuously evolved and further developed this minimally invasive method of coronary bypass surgery. A literature review was conducted to assess intra- and postoperative outcomes of TECAB. PubMed returned 19 comprehensive articles on TECAB. Investigation was focused on perioperative outcome parameters, i.e.: operative time, conversion to larger incision, revision for bleeding, atrial fibrillation, stroke, acute renal failure, and mortality. Outcome from the analysis of 2,397 reported cases showed an average operative time of 291 ± 57 minutes (range 112 to 1,050), conversion rate to larger incisions at 11.5%, and perioperative mortality at 0.8%. Pooled data demonstrated 4.2% operative revision rate due to postoperative hemorrhage, 1.0% stroke incidence, 1.6% acute renal failure, and 13.3% de novo atrial fibrillation. The mean length of hospital stay measured 5.8 ± 1.7 days. Conversion rates and operative times decreased over time. According to data in the literature, coronary bypass surgery carried out in completely endoscopic fashion utilizing robotic assistance can require relatively extensive operative times and conversion rates are somewhat higher than in other robotic cardiac surgery. However, major postoperative events lie in an acceptable range. TECAB remains the surgical revascularization method with the least tissue trauma and represents an opportunity for coronary artery bypass grafting via port access. Rates of major complications are at least similar to conventional surgical access procedures.

Initiation and modification of minimally invasive coronary artery bypass grafting

Minimally invasive coronary artery bypass grafting (MICS CABG) via a small left thoracotomy has been proposed as an alternative to standard coronary artery bypass grafting. However, this technique is still limited to skillful surgeons. Off-pump multi-vessel bypass grafting and the use of bilateral internal thoracic arteries are particularly challenging via a small thoracotomy, while they are widely performed via a full median sternotomy. The purpose of this review is to serve as a guide for the proper introduction of MICS CABG in the current era. We examine the advances, current techniques, outcomes and learning curves of MICS CABG and discuss the safe introduction.

Cost and Outcome of Minimally Invasive Techniques for Coronary Surgery Using Robotic Technology

OBJECTIVE

Totally endoscopic coronary artery bypass (TECAB) with robotic distal anastomosis and robotic-assisted minimally invasive coronary artery bypass (RA-MIDCAB) with robotic internal mammary artery harvest and direct hand-sewn distal anastomosis via an anterior thoracotomy have both been reported as safe and efficacious. We compared hospital cost and short-term outcomes between these techniques.

METHODS

Patients who underwent robotic-assisted minimally invasive single-vessel Coronary artery bypass grafting (2011-2014) were retrospectively reviewed. One hundred consecutive patients underwent either TECAB (n = 50) or RA-MIDCAB (n = 50). The two groups were sequential with TECAB performed by one surgeon in the first portion of the study interval and RA-MIDCAB by another surgeon in the latter. Demographics, short-term outcomes, and hospital cost data were compared between the two groups.

RESULTS

Patient demographics and preoperative risk factors were similar between the TECAB and RA-MIDCAB groups, as total operating room time. Cardiopulmonary bypass was used for 56% of TECAB and 0% of RA-MIDCAB cases (P < 0.001). Intensive care unit and hospital lengths of stay, along with postoperative morbidities, were similar between the two groups. Operative mortality was 2% in the TECAB and 0% in the RA-MIDCAB group (P = NS). Total hospital cost was significantly higher with TECAB compared with RA-MIDCAB (US $33,769 vs. $22,679, P < 0.001), which was primarily driven by operative costs (US $17,616 vs. $26,803, P < 0.001).

CONCLUSIONS

Totally endoscopic coronary artery bypass and RA-MIDCAB both demonstrated excellent short-term clinical outcomes. However, TECAB was associated with significantly higher hospital costs. Further comparisons, including long-term outcomes, patient satisfaction, and functional status, are needed to evaluate whether this additional cost is justified.

Robotic Beating Heart Totally Endoscopic Coronary Artery Bypass in Higher-Risk Patients: Can It be Done Safely?

OBJECTIVE

Patients with a high Society of Thoracic Surgeons (STS) predicted risk of mortality undergoing coronary artery bypass surgery are known to have worse outcomes. Less invasive approaches have been shown to improve morbidity and mortality for these patients. In this study, we examined perioperative outcomes in higher-risk patients undergoing robotic totally endoscopic beating heart coronary artery bypass surgery.

METHODS

The STS predicted risk of mortality was reviewed for patients undergoing robotic totally endoscopic beating heart coronary artery bypass surgery at our institution between January 2013 and May 2017. We identified a higher-risk cohort (n = 50) and compared them to a lower-risk cohort (n = 220) during the same period. The higher-risk group was formed from patients with the 50 highest STS scores. Perioperative data were collected retrospectively.

RESULTS

There were 50 patients in the higher-risk group (mean STS score = 7.05 ± 4.9, mean age = 73 years) and 220 patients in the lower-risk group (mean STS score = 0.89 ± 0.6, mean age = 64 years). The higher-risk group had significantly greater rates of renal insufficiency, peripheral vascular disease, and lower ejection fraction. The incidence of postoperative re-exploration for bleeding, stroke, myocardial infarction, and prolonged ventilation was similar. Perioperative blood transfusion and hospital length of stay were greater in the higher-risk group. Mortality was lower in the higher-risk group (0% vs 1.8% P = 0.045). Cardiac-related mortality was similar at midterm follow-up.

CONCLUSIONS

We conclude that beating heart totally endoscopic beating heart coronary artery bypass surgery can be performed in patients with a higher STS predicted risk of mortality with excellent outcomes. Further studies are warranted to evaluate long-term results of totally endoscopic beating heart coronary artery bypass surgery in this challenging group of patients.

Vasovasostomy and vasoepididymostomy: Review of the procedures, outcomes, and predictors of patency and pregnancy over the last decade

BACKGROUND

In the era of improving assisted reproductive technology (ART), patients with obstructive azoospermia (OA) have 2 options: vasal repair or testicular sperm extraction with intracytoplasmic sperm injection. Vasal repair, including vasovasostomy (VV) and vasoepididymostomy (VE), is the only option that leads to natural conception.

METHODS

This article reviews the surgical techniques, outcomes, and predictors of postoperative patency and pregnancy, with a focus on articles that have reported over the last 10 years, using PubMed database searches.

MAIN FINDINGS

The reported mean patency rate was 87% and the mean pregnancy rate was 49% for a patient following microscopic VV and/or VE for vasectomy reversal. Recently, robot-assisted techniques were introduced and have achieved a high rate of success. The predictors and predictive models of postoperative patency and pregnancy also have been reported. The obstructive interval, presence of a granuloma, and intraoperative sperm findings predict postoperative patency. These factors also predict postoperative fertility. In addition, the female partner's age and the same female partner correlate with pregnancy after surgery.

CONCLUSION

In the era of ART, the physician should present and discuss with both the patient with OA and his partner the most appropriate procedure to conceive by using these predictors.

Long-Term Clinical and Computed Tomography Angiographic Follow-up After Totally Endoscopic Coronary Artery Bypass Grafting

OBJECTIVE

Totally endoscopic coronary artery bypass grafting was shown to be feasible and safe, with excellent clinical and angiographic mid-term results. Data on long-term outcome are lacking. Therefore, we aimed to investigate the long-term rate of major adverse cardiac and cerebrovascular events and left internal mammary artery patency rate in patients undergoing arrested heart totally endoscopic coronary artery bypass grafting.

METHODS

From 2001 to 2012, a total of 208 arrested heart-totally endoscopic coronary artery bypass grafting patients were prospectively included. Mean ± SD age was 58.8 ± 9.4 years, and mean ± SD Society of Thoracic Surgeons score was 0.5 ± 0.5%. Major adverse cardiac and cerebrovascular events were defined as a composite of death, myocardial infarction, stroke, re-percutaneous coronary intervention, re-coronary artery bypass graft, and target vessel revascularization. Left internal mammary artery patency was assessed using cardiac computed tomography and depicted according to the established Fitzgibbon classification. Mean ± SD follow-up was 6.9 ± 2.3 years.

RESULTS

At 1, 5, and 10 years, survival rate was 100%, 98.3%, and 95.8%, respectively. The freedom from clinical events at 1, 5, and 10 years were major adverse cardiac and cerebrovascular events (93.5%, 85.9%, and 83.0%), myocardial infarction (99.0%, 97.4%, and 95.9%), target vessel revascularization (96.0%, 94.3%, and 91.7%), re-percutaneous coronary intervention (94.5%, 91.6%, and 84.2%), and re-coronary artery bypass graft (100%, 99.5%, and 99.5%), respectively. Left internal mammary artery patency rate at 1, 5, and 10 years was 100%, 94.9%, and 88.1%, respectively.

CONCLUSIONS

Arrested heart-totally endoscopic coronary artery bypass grafting shows excellent clinical long-term results with a left internal mammary artery patency rate comparable with conventional coronary artery bypass graft at 10 years after surgery.

Robotics in cardiac surgery

A summary of its uses in mitral valve surgery and coronary artery revascularisation.

Morbid Obesity Does not Increase Morbidity or Mortality in Robotic Cardiac Surgery

OBJECTIVE

Morbid obesity (body mass index ≥ 35 kg/m) usually confers a higher perioperative risk in cardiac surgery. Robotic cardiac surgery may have many advantages for these high-risk patients.

METHODS

We retrospectively reviewed patients undergoing robotic cardiac surgery from July 2013 to April 2017 at our institution. We compared the outcomes of morbidly obese patients versus nonobese patients.

RESULTS

A total of 486 patients underwent robotic cardiac surgery (322 men, median age = 65 years). The robotic procedures were the following: totally endoscopic beating heart coronary artery bypass (n = 263), mitral valve surgery (n = 138), arrhythmia surgery (n = 33), adult congenital surgery (n = 16), pericardiectomy (n = 11), and others (n = 25). The cohorts were divided into the following: normal weight (body mass index < 25, n = 123), overweight (body mass index = 25 to < 30, n = 182), obesity (body mass index = 30 to < 35, n = 105), and morbid obesity (body mass index ≥ 35, n = 76). Morbidly obese patients had a higher rate of hypertension, dyslipidemia, and diabetes mellitus compared with normal or overweight patients. There were no significant differences in morbidity, mean length of intensive care unit stay (2.10 ± 4.27 days), and hospital stay (4.48 ± 5.61 days) among the groups. In-hospital mortality was 1.4% (7/486) with nonsignificant difference.

CONCLUSIONS

Outcomes of robotic heart surgery in morbidly obese patients in our center were acceptable. Over a broad range of cardiac surgical procedures, morbid obesity was not associated with increased morbidity or mortality when these procedures were performed using a robotic approach. These findings can be beneficial in managing this challenging group of patients.

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

OBJECTIVE

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.

METHODS

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.

RESULTS

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).

CONCLUSIONS

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.

Is robotic beating heart totally endoscopic coronary artery bypass feasible for BMI > 35 morbidly obese patients?

BACKGROUND

We investigated the outcomes of morbidly obese patients after robotic beating heart totally endoscopic coronary artery bypass (BH-TECAB).

METHODS

This is a retrospective single center study. From July 2013 to December 2016, the outcomes of patients undergoing BH-TECAB were reviewed.

RESULTS

A total of 234 patients underwent BH-TECAB (172 male, mean age 65.2 years). There were 43 morbidly obese patients defined as body mass index (BMI) greater than 35, and 191 non-morbidly obese patients. Postoperative complications, or mortality in morbidly obese and other patients were similar except for prolonged ventilation >24 h (11.6% vs 2.1%, P = 0.008).

CONCLUSIONS

Morbidly obese patients had an increased incidence of prolonged ventilation after BH-TECAB, but an otherwise reasonably low morbidity and mortality similar to patients with a lower BMI. We believe that adoption of robotics technology allows for BH-TECAB and can lead to improved outcomes in this high-risk population.

Comparative Analysis of Perioperative and Mid-Term Results of TECAB and MIDCAB for Revascularization of Anterior Wall

OBJECTIVE

Totally endoscopic coronary artery bypass (TECAB) and minimally invasive direct coronary artery bypass (MIDCAB) grafting through minithoracotomy are currently the two minimally invasive surgical techniques of left ventricular anterior wall revascularization. We aimed to compare both techniques in terms of perioperative and mid-term results.

METHODS

Arrested heart TECAB was carried out in 204 patients with a median (range) age of 60 (53-76) years and a median (range) EuroSCORE I of 2 (0-3). Minimally invasive direct coronary artery bypass was performed in 60 patients with a median (range) age of 66 (54-75) years and a median (range) EuroSCORE I of 2 (1-5). Both techniques were used for single or sequential internal mammary artery grafts to the anterior wall. Operative times, conversion rates, and surgical complications as well as mid-term results were compared between the groups after a median follow-up of 36 months.

RESULTS

No perioperative deaths were noted. Rates of myocardial infarction (TECAB: 1.5% vs MIDCAB: 0%, P = 0.463) and stroke (TECAB: 1.5% vs MIDCAB: 0%, P = 0.454) were not significantly different between the groups. Total operative times were longer in the TECAB compared with the MIDCAB group [292 (250-345) minutes in TECAB versus 201 (173-289) minutes in MIDCAB (P < 0.001)]. Intensive care unit stay and total length of stay were similar between the groups. There was no difference in mid-term survival (TECAB: 1.5% vs MIDCAB: 1.7%, P = 0.298) and freedom from major adverse cardiac and cerebrovascular events (TECAB: 12.4% vs MIDCAB: 5.1%, P = 0.358).

CONCLUSIONS

Robotically assisted arrested heart TECAB and robotic MIDCAB perform equally in terms of perioperative results and mid-term follow-up in this single-center patient cohort.

Fifty years of coronary artery bypass grafting

Coronary artery bypass grafting (CABG) remains the most common cardiac surgery performed today worldwide. The history of this procedure can be traced back for more than 100 years, and its development has been touched by several pioneers in the field of cardiac surgery, who have contributed with both their successes and failures. With ever increasing follow up and number of patients treated, thinking regarding optimal CABG technique evolves continually. This article reviews the history of CABG from its early experimental work to recent technological advances.