Robotic Totally Endoscopic Coronary Artery Bypass Grafting in Men and Women: Are There Sex Differences in Outcome?

Review of the differences in outcomes between males and females after revascularization

PURPOSE OF REVIEW

This review aims to compare outcomes of males and females undergoing coronary artery bypass grafting (CABG), percutaneous coronary intervention (PCI), off-pump CABG (OPCAB), minimally invasive direct CABG (MIDCAB), and robotic total endoscopic CABG (TECAB).

RECENT FINDINGS

Females demonstrated increased rates of morbidity and mortality post PCI and CABG. In studies that performed risk adjustments, these differences were reduced. Although inferior outcomes were observed for females in some measures, generally outcomes between males and females were comparable post OPCAB, MIDCAB, and TECAB.

SUMMARY

Previous literature has demonstrated that females undergoing coronary revascularization experience inferior postoperative outcomes when compared to their male counterparts. The discrepancies between males and females narrow, but do not disappear when preoperative risks are accounted for and when considering minimally invasive approaches such as MIDCAB, OPCAB, and TECAB. Minimally invasive cardiac surgery has demonstrated numerous benefits with reduced morbidity, mortality, and shorter recovery times. In patients with increased comorbidities, minimally invasive approaches confer a greater advantage. As females often fall within this category, it is paramount that the diagnosis and referral process be optimized to account for preoperative differences to provide the most beneficial approach if the disparity between the sexes is to be addressed.

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.

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.

Does Robotic Beating Heart Connector Totally Endoscopic Coronary Artery Bypass Bridge the Gender Gap in Coronary Bypass Surgery?

OBJECTIVE

Previous studies have shown that women carry a higher risk of morbidity and mortality after coronary artery bypass surgery. We investigated gender differences in risk factors and outcomes in our patients undergoing robotic beating heart connector totally endoscopic coronary artery bypass.

METHODS

From July 2013 to April 2017, patients undergoing connector totally endoscopic coronary artery bypass were reviewed. We compared the outcomes of men versus women.

RESULTS

A total of 192 men and 71 women underwent connector totally endoscopic coronary artery bypass. The mean ± SD age was 65.4 ± 10.6 years. The Society of Thoracic Surgeons score was higher in women than men (median = 1.46 vs 0.73, P = 0.001), and women had a higher rate of peripheral vascular disease (22.5% vs 9.9%, P = 0.007). Intraoperative data in women and men were similar except for the rate of multi-vessel connector totally endoscopic coronary artery bypass and the rate of bilateral internal mammary artery use, which were both lower in women (49.3% vs 64.6%, P = 0.024, and 42.3% vs 56.8%, P = 0.036, respectively). The mean ± SD length of hospital stay (women vs men: 3.99 ± 4.00 vs 3.39 ± 2.42, P = 0.324) was comparable. The 30-day mortality in women and men was 0% (0/71) and 2.1% (4/192), respectively (P = 0.577). The morbidity and mortality of single- or multi-vessel connector totally endoscopic coronary artery bypass were similar between men and women.

CONCLUSIONS

We conclude that the morbidity and mortality in women after robotic beating heart connector totally endoscopic coronary artery bypass in our center were similar to those seen in men.

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.