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Lengyel BC, Chinnadurai P, Corr SJ, Lumsden AB, Bavare CS. Robot-assisted vascular surgery: literature review, clinical applications, and future perspectives. J Robot Surg 2024; 18:328. [PMID: 39174843 PMCID: PMC11341614 DOI: 10.1007/s11701-024-02087-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 08/17/2024] [Indexed: 08/24/2024]
Abstract
Although robot-assisted surgical procedures using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) have been performed in more than 13 million procedures worldwide over the last two decades, the vascular surgical community has yet to fully embrace this approach (Intuitive Surgical Investor Presentation Q3 (2023) https://investor.intuitivesurgical.com/static-files/dd0f7e46-db67-4f10-90d9-d826df00554e . Accessed February 22, 2024). In the meantime, endovascular procedures revolutionized vascular care, serving as a minimally invasive alternative to traditional open surgery. In the pursuit of a percutaneous approach, shorter postoperative hospital stay, and fewer perioperative complications, the long-term durability of open surgical vascular reconstruction has been compromised (in Lancet 365:2179-2186, 2005; Patel in Lancet 388:2366-2374, 2016; Wanhainen in Eur J Vasc Endovasc Surg 57:8-93, 2019). The underlying question is whether the robotic-assisted laparoscopic vascular surgical approaches could deliver the robustness and longevity of open vascular surgical reconstruction, but with a minimally invasive delivery system. In the meantime, other surgical specialties have embraced robot-assisted laparoscopic technology and mastered the essential vascular skillsets along with minimally invasive robotic surgery. For example, surgical procedures such as renal transplantation, lung transplantation, and portal vein reconstruction are routinely being performed with robotic assistance that includes major vascular anastomoses (Emerson in J Heart Lung Transplant 43:158-161, 2024; Fei in J Vasc Surg Cases Innov Tech 9, 2023; Tzvetanov in Transplantation 106:479-488, 2022; Slagter in Int J Surg 99, 2022). Handling and dissection of major vascular structures come with the inherent risk of vascular injury, perhaps the most feared complication during such robotic procedures, possibly requiring emergent vascular surgical consultation. In this review article, we describe the impact of a minimally invasive, robotic approach covering the following topics: a brief history of robotic surgery, components and benefits of the robotic system as compared to laparoscopy, current literature on "vascular" applications of the robotic system, evolving training pathways and future perspectives.
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Affiliation(s)
- Balazs C Lengyel
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA.
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary.
| | - Ponraj Chinnadurai
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
| | - Stuart J Corr
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
| | - Alan B Lumsden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
| | - Charudatta S Bavare
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
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Watanabe T, Kitahara H, Nisivaco S, Coleman C, Patel B, Balkhy HH. Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass: Impact of Chest Wall Dimensions in Single and Multivessel Bypass. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024:15569845241252170. [PMID: 38835206 DOI: 10.1177/15569845241252170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
OBJECTIVE There can be anatomical constraints on patient selection for minimally invasive surgery. For example, robot-assisted coronary artery bypass was reported to be more challenging when patients had a cardiothoracic ratio >50% and a sternum-vertebra anteroposterior and transverse diameter ratio <0.45. We sought to examine the impact of chest wall anatomic parameters on surgical outcomes in our totally endoscopic coronary artery bypass (TECAB) procedures. METHODS We retrospectively reviewed patients who underwent robotic TECAB, all of whom had a preoperative chest radiograph at our institution from July 2017 to October 2021. The cohort was divided into 2 groups, which were patients undergoing single-vessel grafting using the left internal thoracic artery (ITA; group 1) and patients undergoing multivessel grafting with bilateral ITA grafts (group 2). We measured several anatomical parameters from the preoperative chest radiograph. RESULTS A total of 352 patients undergoing TECAB were retrospectively analyzed. After exclusions, 193 were included in this study. In group 1 (n = 91), no parameters correlated with operative time. In group 2 (n = 102), a significant negative correlation was observed between operative time and the sternum-vertebrae anteroposterior diameter (rs = -0.228, P = 0.022) and lung anteroposterior diameter (rs = -0.246, P = 0.013). To confirm these results in group 2, a propensity-matched analysis was performed and showed a statistically significant difference in surgical time based on chest anteroposterior diameters. CONCLUSIONS In single-vessel robotic TECAB, chest wall anatomic dimensions measured on chest radiograph did not affect operative time. In multivessel cases with bilateral ITA grafts, larger anteroposterior diameter correlated with shorter operative times.
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Affiliation(s)
- Tatsuya Watanabe
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, IL, USA
| | - Hiroto Kitahara
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, IL, USA
| | - Sarah Nisivaco
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, IL, USA
| | - Charocka Coleman
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, IL, USA
| | - Brooke Patel
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, IL, USA
| | - Husam H Balkhy
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, IL, USA
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Bhasin R, AlJamal Y, Kitahara H, Blair J, Balkhy HH. Robotic unroofing of myocardial bridge of the left anterior descending coronary artery in a patient with hypertrophic obstructive cardiomyopathy and previous septal myectomy. J Cardiol Cases 2024; 29:222-225. [PMID: 39100519 PMCID: PMC11295015 DOI: 10.1016/j.jccase.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 01/05/2024] [Accepted: 01/12/2024] [Indexed: 08/06/2024] Open
Abstract
A 56-year-old female diagnosed with hypertrophic obstructive cardiomyopathy and myocardial bridge (MB) of the left anterior descending (LAD) coronary artery underwent septal myectomy with resolution of her left ventricular outflow tract gradient. She had ongoing refractory symptoms of exertional angina and fatigue for over a decade and finally presented to our clinic to be re-evaluated for treatment. Provocative angiographic testing confirmed significant ischemia secondary to LAD MB. She underwent robotic totally endoscopic off pump unroofing of the LAD MB with complete relief of her symptoms and return to full activity. We conclude that patients undergoing septal myectomy for hypertrophic obstructive cardiomyopathy should be evaluated for MB and undergo unroofing of the bridge at the time of surgery. Learning objective A myocardial bridge (MB) is a condition in which a coronary artery, most often the left anterior descending, takes an intramuscular route and is covered by the myocardium leading to compression and potential ischemia. This case report adds to the growing body of evidence supporting the significance of considering MB in the overall management of hypertrophic obstructive cardiomyopathy, and the symptomatic relief that a patient can obtain from an unroofing procedure.
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Affiliation(s)
- Riya Bhasin
- University of Chicago, Division of Cardiac Surgery, Chicago, IL, USA
| | - Yazan AlJamal
- Mayo Clinic, Division of Cardiac Surgery, Rochester, MN, USA
| | - Hiroto Kitahara
- University of Chicago, Division of Cardiac Surgery, Chicago, IL, USA
| | - John Blair
- University of Chicago, Department of Cardiology, Chicago, IL, USA
| | - Husam H. Balkhy
- University of Chicago, Division of Cardiac Surgery, Chicago, IL, USA
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Nisivaco S, Kitahara H, Abutaleb A, Nathan S, Balkhy HH. Robotic Totally Endoscopic Coronary Bypass to the Left Anterior Descending Artery: Left Versus Right Internal Thoracic Artery Grafts. J Surg Res 2023; 291:139-150. [PMID: 37390593 DOI: 10.1016/j.jss.2023.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 04/04/2023] [Accepted: 04/29/2023] [Indexed: 07/02/2023]
Abstract
INTRODUCTION The left internal thoracic artery (LITA) is most commonly used to bypass the left anterior descending artery (LAD) given its well-established mortality benefit. In some cases, the grafting strategy necessitates placing the right internal thoracic artery (RITA) on the LAD. We compared outcomes in our robotic beating-heart totally endoscopic coronary bypass surgery (TECAB) population between patients receiving LITA versus RITA-LAD grafts. METHODS We retrospectively reviewed patients undergoing robotic TECAB with skeletonized ITA conduits over 9 y. Outcomes were compared between those receiving LITA (Group-1) versus RITA (Group-2) grafts to the LAD (with/without other grafts). End points were early angiographic patency (in patients undergoing hybrid revascularization) and mid-term mortality/major adverse cardiac/cerebrovascular events. A propensity matched subanalysis was performed comparing only patients who received bilateral ITA grafting in each group. RESULTS Society of Thoracic Surgeons predicted mortality risk score was higher in Group-2. Group-1 patients had lower incidence of multivessel disease (75% versus 96%, P ≤ 0.001). Early overall graft patency (97% versus 96%, P = 0.718) and LAD graft patency (98% versus 95%, P = 0.372) were equivalent. At mean 42-mo follow-up (longest 8.5 y), Group-1 had lower all-cause mortality but no difference in cardiac mortality or repeat revascularization. In the propensity matched subanalysis, mid-term outcomes were equivalent. CONCLUSIONS Grafting the LAD with the LITA or RITA during robotic beating-heart TECAB resulted in similar early outcomes and angiographic patency. RITA-LAD patients were more likely to have multivessel disease and higher Society of Thoracic Surgeons risk and had higher all-cause mortality at mid-term analysis but no difference in major adverse cardiac/cerebrovascular events, including cardiac mortality.
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Affiliation(s)
- Sarah Nisivaco
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Hiroto Kitahara
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Illinois
| | | | - Sandeep Nathan
- Department of Cardiology, University of Chicago Medicine, Chicago, Illinois
| | - Husam H Balkhy
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Illinois.
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Demirsoy E, Mavioglu I, Dogan E, Gulmez H, Dindar I, Erol MK. The Feasibility and Early Results of Multivessel Minimally Invasive Coronary Artery Bypass Grafting for All Comers. J Clin Med 2023; 12:5663. [PMID: 37685730 PMCID: PMC10488478 DOI: 10.3390/jcm12175663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 08/20/2023] [Accepted: 08/29/2023] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVES Cardiovascular surgery advancements have emerged with various minimally invasive approaches for treating multivessel coronary disease to improve outcomes and minimize the burden associated with conventional cardiac surgery. We present our clinical experience and minimally invasive coronary bypass techniques through minithoracotomy, which we apply without selection to patients who have decided to have elective surgery for multivessel isolated coronary artery disease. METHODS It consists of 230 consecutive patients operated by the same team with this method between July 2020 and September 2022. The patients were assigned to one of the two methods preoperatively to their accompanying comorbidities and operated on either with blood cardioplegia via 5 to 7 cm left anterior minithoracotomy, with on-pump clamped technique or without pump via left anterolateral minithoracotomy. RESULTS Mortality was observed in two of our patients (0.9%), but myocardial infarction was not observed in our patients in the early postoperative period. None of our patients required conversion to sternotomy (0%). Five patients' needed reoperation from the same incision due to postoperative bleeding (2.2%), and atrial fibrillation developed in 17 patients in the postoperative period (7.4%). The mean number of bypasses was found to be 3.0 ± 0.9. CONCLUSIONS Minimally invasive coronary artery bypass surgery via minithoracotomy can be routinely reproduced safely. More long-term results and more multicenter studies are needed for more widespread acceptance of the technique.
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Affiliation(s)
- Ergun Demirsoy
- Division of Cardiovascular Surgery, Sisli Kolan International Hospital, Kaptanpaşa Mahellesi Darulaceze Caddesi No 14, Sisli, 34384 Istanbul, Turkey
| | - Ilhan Mavioglu
- Division of Cardiovascular Surgery, Private Practice, Sisli, 34394 Istanbul, Turkey;
| | - Emre Dogan
- Division of Cardiovascular Surgery, Sisli Kolan International Hospital, Kaptanpaşa Mahellesi Darulaceze Caddesi No 14, Sisli, 34384 Istanbul, Turkey
| | - Harun Gulmez
- Division of Cardiovascular Surgery, Sisli Kolan International Hospital, Kaptanpaşa Mahellesi Darulaceze Caddesi No 14, Sisli, 34384 Istanbul, Turkey
| | - Ismet Dindar
- Division of Cardiology, Sisli Kolan International Hospital, 34384 Istanbul, Turkey
| | - Mustafa Kemal Erol
- Division of Cardiology, Sisli Kolan International Hospital, 34384 Istanbul, Turkey
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Ramponi F, Seco M, Vallely MP. Defining the Role of Anaortic Coronary Artery Bypass Grafting. J Clin Med 2023; 12:4697. [PMID: 37510812 PMCID: PMC10380961 DOI: 10.3390/jcm12144697] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/30/2023] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
As the population ages and co-morbidities become more prevalent, the complexity of patients presenting for coronary artery bypass surgery is increasing. Cardiopulmonary bypass and aortic cross-clamping in these patients carry increased risk and, indeed, in some patients, with ascending aortic disease, the risks are prohibitive. Total-arterial anaortic coronary artery surgery is a technique that provides complete surgical coronary artery revascularization without cardiopulmonary bypass and without manipulating the ascending aorta. The technique essentially eliminates the risk of cerebral embolization of aortic atheroma and aortic injury. Anaortic techniques are an essential skillset for coronary artery surgery centers treating higher-risk patients.
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Affiliation(s)
- Fabio Ramponi
- Department of Cardiovascular Surgery, Mount Sinai Morningside, New York, NY 10025, USA
| | - Michael Seco
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney 2065, Australia
| | - Michael P Vallely
- Department of Cardiothoracic Surgery, Monash Health, The Victorian Heart Hospital, Melbourne 3168, Australia
- Department of Surgery, Monash University, Melbourne 3168, Australia
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Watanabe T, Kitahara H, Shah AP, Blair J, Nathan S, Balkhy HH. Sternal-Sparing Surgical Options in Combined Aortic Valve and Coronary Artery Disease: Proof of Concept. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:346-351. [PMID: 37458227 DOI: 10.1177/15569845231185566] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
OBJECTIVE The standard management of concomitant aortic valve (AV) and coronary artery disease has been coronary artery bypass and AV replacement (AVR). With the advent of minimally invasive options, many isolated lesions have been successfully managed using a sternal-sparing approach. In our institution, patients with isolated AV disease are offered minimally invasive surgical or transcatheter AVR, and those with isolated coronary artery disease are routinely managed with robotic totally endoscopic coronary artery bypass or percutaneous coronary intervention. Various combinations of these techniques can be used when a sternal-sparing posture is desired because of patient risk or preference. The aim of this study was to review the outcomes in patients with combined AV and coronary disease who were managed using sternal-sparing approaches. METHODS We reviewed the records of 10 patients in our minimally invasive surgical database who presented with concomitant AV and coronary artery disease and underwent combined sternal-sparing management of these 2 lesions using various combinations of minimally invasive approaches. RESULTS Four patients had totally endoscopic coronary artery bypass and minimally invasive AVR at the same time, 2 patients underwent transcatheter AVR followed by totally endoscopic coronary artery bypass, and 4 patients underwent minimally invasive AVR with percutaneous coronary intervention. There was no 30-day mortality. The duration of postoperative surgical hospital stay was 3.1 ± 0.9 days. CONCLUSIONS Sternal-sparing approaches in combined AV and coronary artery disease are feasible with patient-specific treatment selection of minimally invasive techniques.
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Affiliation(s)
- Tatsuya Watanabe
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, IL, USA
| | - Hiroto Kitahara
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, IL, USA
| | - Atman P Shah
- Division of Cardiology University of Chicago Medicine, IL, USA
| | - John Blair
- Division of Cardiology University of Chicago Medicine, IL, USA
| | - Sandeep Nathan
- Division of Cardiology University of Chicago Medicine, IL, USA
| | - Husam H Balkhy
- Section of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, IL, USA
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Algoet M, Oosterlinck W, Balkhy HH. Reply to: Anaortic With No Touch to the Aorta Is a Central Technique to Decrease Invasiveness of CABG. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:296. [PMID: 37078616 DOI: 10.1177/15569845231168615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Affiliation(s)
- Michiel Algoet
- Department of Cardiovascular Sciences, Research Unit of Cardiac Surgery, KU Leuven, Belgium
| | - Wouter Oosterlinck
- Department of Cardiovascular Sciences, Research Unit of Cardiac Surgery, KU Leuven, Belgium
| | - Husam H Balkhy
- Division of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, IL, USA
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Bakaeen FG. Routine Intensive Care May Be Selectively Skipped After Robotic Coronary Bypass. Ann Thorac Surg 2023; 115:518. [PMID: 35940313 DOI: 10.1016/j.athoracsur.2022.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 07/10/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195.
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Oosterlinck W, Algoet M, Balkhy HH. Minimally Invasive Coronary Surgery: How Should It Be Defined? INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:22-27. [PMID: 36762801 DOI: 10.1177/15569845231153366] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Affiliation(s)
- Wouter Oosterlinck
- Department of Cardiovascular Sciences, Research Unit of Cardiac Surgery, KU Leuven, Belgium
| | - Michiel Algoet
- Department of Cardiovascular Sciences, Research Unit of Cardiac Surgery, KU Leuven, Belgium
| | - Husam H Balkhy
- Division of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, IL, USA
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Piperata A, Busuttil O, Jansens JL, Modine T, Pernot M, Labrousse L. A Single Center Initial Experience with Robotic-Assisted Minimally Invasive Coronary Artery Bypass Surgery (RA-MIDCAB). J Pers Med 2022; 12:1895. [PMID: 36422071 PMCID: PMC9694867 DOI: 10.3390/jpm12111895] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 11/05/2022] [Accepted: 11/09/2022] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Minimally invasive procedures have demonstrated their effectiveness in reducing the recovery times while ensuring optimal results and minimizing complications. Regarding the coronary artery surgical revascularization field, the evolution of techniques and technology is permitting new surgical strategies that are increasingly precise and suitable for each patient. We present an initial single center experience with a case series of patients successfully treated with combined robotic harvesting of the left internal mammary artery (LIMA) and minimally invasive direct coronary artery bypass graft (MIDCAB) for the anastomosis. METHODS We retrospectively reviewed the records of patients who underwent minimally invasive coronary artery revascularization with the use of two combined techniques at our Institution between January 2021 and October 2022. RESULTS A total of 17 patients underwent coronary artery bypass grafting with the described approach. The median cardiopulmonary bypass (CPB) and cross-clamp times were 83 min (76-115) and 38 min (32-58), respectively. The median intensive care unit (ICU) and hospital stay were 2 days (1-4) and 8 days (6-11), respectively. The procedure's success was achieved in 100% of patients. The 30-day mortality was 0%. CONCLUSIONS Considering all the limitations related to the small sample, the presented results of a hybrid approach for minimally invasive coronary artery bypass grafting (CABG) appears to be encouraging and acceptable. The main advantage of this approach is related to the reduction of postoperative pain and pulmonary complications.
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Affiliation(s)
- Antonio Piperata
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, Bordeaux University Hospital, 33604 Pessac, France
| | - Olivier Busuttil
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, Bordeaux University Hospital, 33604 Pessac, France
| | - Jean-Luc Jansens
- Department of Cardiac Surgery, Erasme Hospital of Brussels, Belgium free University of Brussels (ULB), Hôpital Erasme, 1070 Brussels, Belgium
| | - Thomas Modine
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, Bordeaux University Hospital, 33604 Pessac, France
| | - Mathieu Pernot
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, Bordeaux University Hospital, 33604 Pessac, France
| | - Louis Labrousse
- Department of Cardiology and Cardio-Vascular Surgery, Hopital Cardiologique de Haut-Leveque, Bordeaux University Hospital, 33604 Pessac, France
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Nisivaco SM, Kitahara H, Abutaleb AR, Nathan S, Balkhy HH. Hybrid Coronary Revascularization: Early Outcomes and Midterm Follow-Up in Patients Undergoing Single or Multivessel Robotic TECAB and PCI. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:513-520. [PMID: 36529976 DOI: 10.1177/15569845221137349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Hybrid coronary revascularization (HCR) is the integration of sternal-sparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with multivessel coronary artery disease (CAD). It is traditionally performed with single-vessel bypass (left internal mammary artery [LIMA] to left anterior descending artery [LAD]) and PCI but can also be accomplished with multiple arterial grafts using bilateral IMA conduits. We sought to review our HCR experience over an 8-year period with robotic totally endoscopic coronary artery bypass (TECAB) and PCI. METHODS Of 694 patients undergoing beating-heart TECAB from August 2013 to June 2022, 306 patients were designated as intention-to-treat HCR candidates. Patients underwent PCI prior to, the same day as, or following TECAB, performed using single or bilateral IMA grafts. We retrospectively reviewed early and midterm outcomes up to 8 years in this cohort of patients. RESULTS The mean Society of Thoracic Surgeons predicted risk of mortality was 1.5% ± 2.5%. There were 44 patients (14%) who had ≥70% left main disease and 218 patients (71%) who had triple-vessel disease. A total of 193 patients (63%) underwent multivessel grafting (advanced HCR), with 83% bilateral IMA use. Mean operative time was 263 ± 80 min, and mean length of stay was 2.6 days. The mean number of vessels bypassed per patient was 1.7 ± 0.6. The mean number of vessels stented was 1.2 ± 0.5. Of the patients, 84% underwent TECAB first, 14% PCI first, and 2% same-day TECAB/PCI. Mortality was 0.6% (observed to expected ratio: 0.42). Early graft patency was 97% (328 of 339 grafts); LIMA-LAD patency was 98%. At 8-year follow-up (mean 37 ± 26 months), all-cause and cardiac-related mortality were 13% and 2.6%, respectively. Freedom from major adverse cardiac and cerebrovascular events was 92%. CONCLUSIONS In patients with multivessel CAD, integrating robotic single and multivessel TECAB with PCI resulted in excellent early and midterm outcomes. In experienced hands, the robotic endoscopic approach allows the routine use of multiple arterial grafting during HCR.
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Affiliation(s)
- Sarah M Nisivaco
- Department of Cardiothoracic Surgery, University of Chicago Medicine, IL USA
| | - Hiroto Kitahara
- Department of Cardiothoracic Surgery, University of Chicago Medicine, IL USA
| | | | - Sandeep Nathan
- Department of Cardiology, University of Chicago Medicine, IL USA
| | - Husam H Balkhy
- Department of Cardiothoracic Surgery, University of Chicago Medicine, IL USA
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Srivastava A, Smazil J, Roark L, Shah HA, Balkhy HH, Shah AP. Transcatheter aortic valve replacement in patients undergoing robotic totally endoscopic coronary artery bypass: A case series. Front Cardiovasc Med 2022; 9:988029. [PMID: 36172589 PMCID: PMC9510675 DOI: 10.3389/fcvm.2022.988029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 08/19/2022] [Indexed: 11/13/2022] Open
Abstract
Transcatheter aortic valve replacement (TAVR) has been utilized to treat patients with symptomatic aortic stenosis (AS). Recent trials suggest comparable efficacy compared to surgical aortic valve replacement (SAVR). Robotic off-pump totally endoscopic coronary artery bypass graft surgery (TECAB) had been shown to be a minimally invasive revascularization strategy with clinical results comparable to traditional coronary artery bypass graft surgery (CABG). Traditionally, pre-surgical coronary evaluation is considered necessary to optimize coronary revascularization at the time of AVR. The 2020 ACC/AHA Guideline for the Management of Patients with Valvular Disease gives a moderate recommendation, based on limited data, for CABG at the time of AVR in patients with significant coronary artery disease (CAD). This paper presents two patients with known significant CAD awaiting robotic TECAB who were treated with TAVR, prior to surgical revascularization. Robotic TECAB is unique in that it offers patients the ability to have complete coronary revascularization without a sternotomy and with early ambulation, discharge, and recovery. The case series demonstrates a hybrid approach that offers complete sternotomy sparing cardiovascular care to treat severe symptomatic AS and CAD. Since patients with severe aortic stenosis are at high risk of developing cardiac arrest and cardiogenic shock upon induction of anesthesia, the ability to treat severe symptomatic AS with TAVR under conscious sedation prior to TECAB can be considered as a safe an effective treatment.
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Affiliation(s)
- Ankur Srivastava
- Section of Cardiology, University of Chicago Medicine, Chicago, IL, United States
- *Correspondence: Ankur Srivastava
| | - Jennifer Smazil
- Section of Cardiology, University of Chicago Medicine, Chicago, IL, United States
| | - Lauren Roark
- Section of Cardiology, University of Chicago Medicine, Chicago, IL, United States
| | - Hayla A. Shah
- University of Chicago Laboratory Schools, Chicago, IL, United States
| | - Husam H. Balkhy
- Section of Cardiac Surgery, University of Chicago Medicine, Chicago, IL, United States
| | - Atman P. Shah
- Section of Cardiology, University of Chicago Medicine, Chicago, IL, United States
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Balkhy HH, Nisivaco S, Kitahara H, AbuTaleb A, Nathan S, Hamzat I. Robotic advanced hybrid coronary revascularization: Outcomes with two internal thoracic artery grafts and stents. JTCVS Tech 2022; 16:76-88. [PMID: 36510526 PMCID: PMC9735326 DOI: 10.1016/j.xjtc.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/06/2022] [Accepted: 07/26/2022] [Indexed: 12/15/2022] Open
Abstract
Objective Advanced hybrid coronary revascularization is the integration of sternal-sparing multivessel coronary artery bypass grafting and percutaneous coronary intervention in patients with multivessel coronary artery disease. We sought to review our advanced hybrid coronary revascularization experience over an 8.5-year period using robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery grafts and percutaneous coronary intervention. Methods From August 2013 to February 2022, 664 patients underwent robotic totally endoscopic coronary artery bypass at our institution. Of the 293 patients who underwent totally endoscopic coronary artery bypass assigned to a hybrid revascularization strategy, 156 patients received bilateral internal thoracic artery grafts and are the subject of this review. Patients underwent percutaneous coronary intervention with drug-eluting stents before or after totally endoscopic coronary artery bypass. We reviewed early and midterm outcomes (up to 8 years) in this cohort of patients with intent-to-treat advanced hybrid coronary revascularization. Results The mean age of patients was 65 ± 10 years. The mean Society of Thoracic Surgeons predicted risk of mortality was 1.26 ± 1.56. Triple-vessel disease occurred in 94% of patients, and 17% of patients had 70% or more left-main disease. The mean operative time was 311 ± 54 minutes, and the mean hospital length of stay was 2.7 ± 1.1 days. All patients had bilateral internal thoracic artery grafts; the total number of grafts was 334. Eight seven percentage of patients had totally endoscopic coronary artery bypass ×2, and 13% of patients had totally endoscopic coronary artery bypass ×3. One patient received totally endoscopic coronary artery bypass ×4. The mean number of grafts per patient was 2.14 ± 0.4, and the mean number of vessels stented was 1.23 ± 0.5. There were no conversions, perioperative stroke, or myocardial infarction. Early mortality occurred in 2 patients. Early graft patency was 98% (209/214 grafts); left internal thoracic artery to left anterior descending patency was 100% (66/66 grafts). At 8-year follow-up in 155 patients (mean 39 ± 26 months), all-cause and cardiac-related mortality were 11.6% and 3.9%, respectively. Freedom from major adverse cardiac/cerebrovascular events including repeat revascularization was 94%. Conclusions In patients with multivessel coronary artery disease, integrating robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery and percutaneous coronary intervention resulted in excellent early and midterm outcomes. Further studies are warranted.
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Key Words
- AHCR, advanced hybrid coronary revascularization
- BITA, bilateral internal thoracic artery
- BMI, body mass index
- CABG, coronary artery bypass grafting
- CAD, coronary artery disease
- DAPT, dual-antiplatelet therapy
- HCR, hybrid coronary revascularization
- LAD, left anterior descending artery
- LITA, left internal thoracic artery
- LOS, length of stay
- MACCE, major adverse cardiac/cerebrovascular events
- MAG, multi-arterial grafting
- MI, myocardial infarction
- MIDCAB, minimally invasive direct coronary artery bypass
- PCI, percutaneous coronary intervention
- RCA, right coronary artery
- RITA, right internal thoracic artery
- SITA, single internal thoracic artery
- TECAB
- TECAB, totally endoscopic coronary artery bypass
- bilateral internal thoracic arteries
- coronary artery bypass
- hybrid revascularization
- off-pump
- percutaneous coronary intervention
- robotic
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Affiliation(s)
- Husam H. Balkhy
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Ill,Address for reprints: Husam H. Balkhy, MD, Department Cardiothoracic Surgery, University of Chicago, 5841 S. Maryland Ave, E-500, Chicago, IL 60637.
| | - Sarah Nisivaco
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Ill
| | - Hiroto Kitahara
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Ill
| | | | - Sandeep Nathan
- Department of Cardiology, University of Chicago Medicine, Chicago, Ill
| | - Ibraheem Hamzat
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Ill
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15
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Torregrossa G, Sá MP, Van den Eynde J, Malin JH, Dokollari A, Erten O, Sun T, Sicouri S, Wertan MC, Ramlawi B, Sutter FP. Robotic-assisted versus conventional off-pump coronary surgery in women: A propensity-matched study. J Card Surg 2022; 37:3525-3535. [PMID: 35998275 DOI: 10.1111/jocs.16878] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/06/2022] [Accepted: 07/28/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Off-pump coronary artery bypass (OPCAB) previously demonstrated its potential benefits in women; however, robotic-assisted OPCAB was scarcely studied. OBJECTIVES To investigate whether robotic-assisted OPCAB could further improve the outcomes in women and the potential impact of hybrid approaches with stents and completeness of revascularization on the late outcomes. METHODS Women who underwent robotic-assisted or conventional OPCAB (with sternotomy) between May 2005 and January 2021 at Lankenau Heart Institute were included. Propensity score matching was used to match 273 pairs on 27 characteristics. RESULTS In the intraoperative period, women who underwent robotic-assisted OPCAB presented longer operative times (6.00 vs. 5.38 h; p < 0.001), higher rates of extubation in the operating room (83.9% vs. 75.5%; p = 0.019) and lower rates of blood transfusion (13.2% vs. 32.2%; p < 0.001). In the postoperative period, women who underwent robotic-assisted OPCAB presented lower rates of new onset atrial fibrillation (16.8% vs. 25.6%; p = 0.016), need of blood transfusion (33.0% vs. 54.9%; p < 0.001), shorter intensive care unit (ICU) (46.1 vs. 49.8 h; p = 0.006) and hospital length of stay (5.0 vs. 6.0 days; p < 0.001). We observed no statistically significant differences in the rates of operative death between the groups (1.47% vs. 1.47%; p = 0.771). In the follow-up, we observed no differences in terms of overall survival regardless of hybrid procedures with stents and completeness of revascularization. CONCLUSIONS Robotic-assisted OPCAB in women is as safe as conventional OPCAB and may further improve outcomes. Hybrid coronary revascularization was a valuable adjunct in the robotic scenario and completeness of revascularization did not play a role in this setting.
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Affiliation(s)
- Gianluca Torregrossa
- Department of Cardiac Surgery, Lankenau Medical Center, Main Line Health, Lankenau Heart Institute, Wynnewood, Pennsylvania, USA.,Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Michel Pompeu Sá
- Department of Cardiac Surgery, Lankenau Medical Center, Main Line Health, Lankenau Heart Institute, Wynnewood, Pennsylvania, USA.,Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | | | - John H Malin
- Department of Cardiac Surgery, Philadelphia College of Osteopathic Medicine, Bala Cynwyd, Pennsylvania, USA
| | - Aleksander Dokollari
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Ozgun Erten
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Tian Sun
- Department of Cardiac Surgery, Lankenau Medical Center, Main Line Health, Lankenau Heart Institute, Wynnewood, Pennsylvania, USA.,Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Serge Sicouri
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - MaryAnn C Wertan
- Department of Cardiac Surgery, Lankenau Medical Center, Main Line Health, Lankenau Heart Institute, Wynnewood, Pennsylvania, USA
| | - Basel Ramlawi
- Department of Cardiac Surgery, Lankenau Medical Center, Main Line Health, Lankenau Heart Institute, Wynnewood, Pennsylvania, USA.,Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Francis P Sutter
- Department of Cardiac Surgery, Lankenau Medical Center, Main Line Health, Lankenau Heart Institute, Wynnewood, Pennsylvania, USA
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16
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Nisivaco SM, Balkhy HH. Sparing Not Only the Sternum but also the Pain: Why Port-Only is Best. Eur J Cardiothorac Surg 2022; 62:6633310. [PMID: 35799363 DOI: 10.1093/ejcts/ezac382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 07/06/2022] [Indexed: 11/13/2022] Open
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17
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Squiccimarro E, Margari V, Paparella D. Bilateral mini-thoracotomy for combined minimally invasive direct coronary artery bypass and mitral valve repair. Eur J Cardiothorac Surg 2022; 62:6584819. [PMID: 35552396 DOI: 10.1093/ejcts/ezac306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 04/14/2022] [Accepted: 05/05/2022] [Indexed: 11/14/2022] Open
Abstract
Consistent evidence recognizes minimally invasive valve surgery as the top-tier surgical approach for heart valve pathology. Conversely, the overall adoption of minimally invasive coronary surgery remains low. Notwithstanding, excellent clinical outcomes have been recently reported, further consolidating a technique that addresses major concerns associated with the traditional approach for the most frequently performed cardiac operation, including sternal dehiscence (i.e., sternal sparing), stroke (i.e., no-touch aorta), but that also guarantees a reduced resort to blood transfusions, diminished pain, and faster recovery. More to the point, the suitability of minimally invasive strategies for combined coronary and valve procedures remains debatable. Almost no reports of such combined procedures are available in literature and the very few published experiences appear scarce and heterogeneous about the surgical access (i.e., single versus bilateral mini-thoracotomy). However, bilateral mini-thoracotomy has been proposed as a feasible and safe strategy for different cardiac operations like surgical ablation and left ventricular assist device implantation, but also for isolated multivessel minimally invasive coronary surgery. Here we describe feasibility of combined minimally invasive mitral valve and coronary surgery performed through bilateral mini-thoracotomy and we report outcomes of our initial series of 3 cases.
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Affiliation(s)
- Enrico Squiccimarro
- Division of Cardiac Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy.,Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Vito Margari
- Division of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy
| | - Domenico Paparella
- Division of Cardiac Surgery, Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy.,Division of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari, Italy
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18
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Torregrossa G, Sá MP, Van den Eynde J, Malin JH, Sicouri S, Wertan MC, Ramlawi B, Sutter FP. Hybrid robotic off‐pump versus conventional on‐pump and off‐pump coronary artery bypass graft surgery in women. J Card Surg 2022; 37:895-905. [DOI: 10.1111/jocs.16247] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 12/24/2021] [Accepted: 12/25/2021] [Indexed: 01/26/2023]
Affiliation(s)
- Gianluca Torregrossa
- Department of Cardiac Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
- Department of Cardiac Surgery Research Lankenau Institute for Medical Research, Main Line Health Wynnewood Pennsylvania USA
| | - Michel Pompeu Sá
- Department of Cardiac Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
- Department of Cardiac Surgery Research Lankenau Institute for Medical Research, Main Line Health Wynnewood Pennsylvania USA
| | - Jef Van den Eynde
- Department of Cardiovascular Sciences Katholieke Universiteit Leuven Leuven Belgium
- Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine Baltimore Maryland USA
| | - John H. Malin
- Philadelphia College of Osteopathic Medicine Bala Cynwyd Pennsylvania USA
| | - Serge Sicouri
- Department of Cardiac Surgery Research Lankenau Institute for Medical Research, Main Line Health Wynnewood Pennsylvania USA
| | - MaryAnn C. Wertan
- Department of Cardiac Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
| | - Basel Ramlawi
- Department of Cardiac Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
- Department of Cardiac Surgery Research Lankenau Institute for Medical Research, Main Line Health Wynnewood Pennsylvania USA
| | - Francis P. Sutter
- Department of Cardiac Surgery Lankenau Heart Institute, Lankenau Medical Center, Main Line Health Wynnewood Pennsylvania USA
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19
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Torregrossa G, Sá MP, Van den Eynde J, Sicouri S, Wertan MC, Ramlawi B, Sutter FP. Robotic hybrid coronary revascularization versus conventional off-pump coronary bypass surgery in women with two-vessel disease. J Card Surg 2021; 37:501-511. [PMID: 34811803 DOI: 10.1111/jocs.16146] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 11/03/2021] [Accepted: 11/06/2021] [Indexed: 01/05/2023]
Abstract
BACKGROUND Hybrid coronary revascularization (HCR) treats coronary artery disease (CAD) by combining a minimally invasive surgical approach with the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery and percutaneous coronary intervention (PCI) for non-LAD vessels. This study aimed to compare immediate and long-term outcomes between robotic HCR and off-pump coronary artery bypass (OPCAB) via sternotomy in women with two-vessel CAD. METHODS AND RESULTS We compared all robotic HCR (LIMA-to-LAD plus stent; n = 55) and OPCAB (LIMA-to-LAD plus saphenous vein graft; n = 54) performed at a single institution between May 2005 and January 2021. To adjust for the selection bias of receiving either HCR or OPCAB, we performed a propensity score analysis of 31 matched pairs. In the immediate postoperative period, no statistically significant difference was observed for operative mortality and HCR was associated with lower rates of blood transfusion (25.8% vs. 54.8%; p = .038), and shorter hospital length of stay (4.0 vs. 6.0 days; p = .009). After a mean follow-up of 7.0 ± 4.9 years, we observed no statistically significant differences between the groups for overall survival (hazard ratio [HR]: 0.48, 95% confidence interval [CI]: 0.09-2.64, p = .401), myocardial infarction (HR: 1.60, 95% CI: 0.14-17.64, p = .703), stroke (HR not assessable; almost zero events), target vessel revascularization (HR: 0.45, 95% CI: 0.08-2.47, p = .359), angina (HR: 0.64, 95% CI: 0.20-2.01, p = .444) and major adverse cardiac and cerebrovascular events (HR: 0.46, 95% CI: 0.14-1.52, p = .202). CONCLUSIONS Robotic HCR provides for women with two-vessel CAD a shorter postoperative recovery with fewer blood transfusions, with similar long-term outcomes when compared with conventional OPCAB via sternotomy.
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Affiliation(s)
- Gianluca Torregrossa
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania, USA.,Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Michel Pompeu Sá
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania, USA.,Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Jef Van den Eynde
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Helen B. Taussig Heart Center, The Johns Hopkins Hospital and School of Medicine, Baltimore, USA
| | - Serge Sicouri
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - MaryAnn C Wertan
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Basel Ramlawi
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania, USA.,Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Main Line Health, Wynnewood, Pennsylvania, USA
| | - Francis P Sutter
- Department of Cardiac Surgery, Lankenau Heart Institute, Lankenau Medical Center, Main Line Health, Wynnewood, Pennsylvania, USA
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