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

Robotic Totally Endoscopic Coronary Bypass to the Left Anterior Descending Artery: Left Versus Right Internal Thoracic Artery Grafts

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.

Urgent Combination of Robotic and MIDCAB Coronary Revascularization in a Morbidly Obese Patient

In this article, we focus on the important role of robot-assisted coronary surgery by reporting the successful case of a morbidly obese male (body mass index = 58 kg/m²) who presented to our center with severe coronary disease. A 54-year-old morbidly obese male presented with acute chest pain and was diagnosed with coronary artery disease. The culprit lesion was the left anterior descending (LAD) coronary artery. A percutaneous coronary intervention angiography attempted in a university hospital was not successful. Our heart team chose a hybrid robot-assisted revascularization (HCR) strategy based on the patient's body size. The patient underwent left internal thoracic mammary artery to LAD bypass with uneventful postoperative recovery. Robotic HCR is a valuable strategy in morbidly obese patients undergoing coronary artery bypass grafting.

Robotic advanced hybrid coronary revascularization: Outcomes with two internal thoracic artery grafts and stents

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.

Evaluation of robotic-assisted mitral surgery in a contemporary experience

AIMS

To evaluate the safety/effectiveness of a recently established robotic-assisted mitral surgery program.

METHODS

Cohort study with prospective collection of clinical data of 59 consecutive recipients (May 2019-August 2021) of robotic-assisted (fourth-generation platform, DaVinci X) mitral valve repair for degenerative disease, using a totally endoscopic technique. Patients' selection was based on defined anatomical and clinical criteria. We established a dedicated multidisciplinary protocol to facilitate postoperative fast-tracking, and a systematic in-house clinical and echocardiographic follow-up at 3, 6, and 12 postoperative months.

RESULTS

All patients (89.8% men, average age 58 ± 12 years) received mitral valve repair; there was no operative mortality, one conversion to sternotomy (1.7%) and one stroke (1.7%). Extubation within the operative theater occurred in 28.8%; average mechanical ventilation time and ICU stay was 2.8 ± 4.1 and 32.5 ± 15.8 h (after exclusion of one outlier, learning-curve period, suffering from perioperative stroke); average postoperative hospital stay was 6.8 ± 3.4 days and 96.6% of patients were discharged home. One patient was transfused (1.7%); there were no other complications. Follow-up revealed stability of the results of mitral repair, with one (1.7%) persistent (>2+/4+) mitral regurgitation, and stability of coaptation height over time. We observed optimal functional results (class I was 98% at 3 months and 96% at 12 months). Quarterly case load consistently increased during the experience.

CONCLUSION

This initial experience suggests the reliability and clinical safety of a recently established local robotic-assisted mitral surgery. This strategy can facilitate faster postoperative recovery, and its positioning in the therapeutic armamentarium needs to be defined.

Robotic-assisted coronary artery bypass grafting: current knowledge and future perspectives

Minimally invasive direct coronary artery bypass grafting (MIDCAB) and totally endoscopic coronary artery bypass grafting (TECAB) are the two existing strategies for robotic-assisted, surgical myocardial revascularization. In this review, we summarize the wide evidence available in the literature regarding the benefits of these two procedures, and detail the technical skills required to master robotic coronary surgery techniques.

Dose-response relationship among body mass index, abdominal adiposity and atrial fibrillation in patients undergoing cardiac surgery: a meta-analysis of 35 cohorts

Background

Whether overweight increases the risk of postoperative atrial fibrillation (POAF) is unclear, and whether adiposity independently contributes to POAF has not been comprehensively studied. Thus, we conducted a meta-analysis to clarify the strength and shape of the exposure-effect relationship between adiposity and POAF.

Methods

The PubMed, Cochrane Library, and EMBASE databases were searched for revelant studies (randomized controlled trials (RCTs), cohort studies, and nest-case control studies) reporting data regarding the relationship between adiposity and the risk of POAF.

Results

Thirty-five publications involving 33,271 cases/141,442 patients were included. Analysis of categorical variables showed that obesity (RR: 1.39, 95% CI [1.21–1.61]; P < 0.001), but not being underweight (RR: 1.44, 95% CI [0.90–2.30]; P = 0.13) or being overweight (RR: 1.03, 95% CI [0.95–1.11]; P = 0.48) was associated with an increased risk of POAF. In the exposure-effect analysis (BMI) was 1.09 (95% CI [1.05–1.12]; P < 0.001) for the risk of POAF. There was a significant linear relationship between BMI and POAF (P_nonlinearity = 0.44); the curve was flat and began to rise steeply at a BMI of approximately 30. Notably, BMI levels below 30 (overweight) were not associated with a higher risk of POAF. Additionally, waist obesity or visceral adiposity index was associated with the risk of POAF.

Conclusion

Based on the current evidence, our findings showed that high body mass index or abdominal adiposity was independently associated with an increased risk of POAF, while underweight or overweight might not significantly increase the POAF risk.

Robotic mitral valve operations can be safely performed in obese patients

INTRODUCTION

Robotic cardiac surgery offers mitigated risks for obese patients requiring mitral valve surgery. We aimed to study the safety of robotic mitral surgery in the obese patient population by analyzing the outcomes of mitral surgery patients in our center for robotic cardiac surgery.

METHOD

This study retrospectively included 123 consecutive patients who underwent robotic mitral valve operations in a single center for robotic cardiac surgery. Patients with body mass index (BMI) ≥ 30 were compared against patients with BMI < 30 for demographic and operative parameters as well as postoperative outcomes.

RESULTS

Mean BMI was 33.9 ± 2.8 in the obesity group (n = 87) and 25.4 ± 2.7 in the no-obesity group (n = 36). Female gender (80.6% vs. 52.9%, p = .004), diabetes (25.0% vs. 10.3%, p = .036), and hypertension (48.6% vs. 26.4%, p = .018) were more common in patients with obesity. The obesity group was operated with similar cardiopulmonary bypass and total operative times with the no-obesity group. Postoperative drainage and blood transfusion requirements were similar between the groups. Mechanical ventilation times (6.1 ± 2.2 vs. 8.0 ± 4.4 h, p = .003) and intensive care unit stay (20.4 ± 1.6 vs. 29.4 ± 3.7, p = .027) were shorter in the obesity group. Other postoperative outcomes of infection, atrial fibrillation, hospital stay duration, and readmission rates were similar between the groups.

CONCLUSION

Robotic mitral surgery is safe to perform in obese patients. Obesity should not be a contraindication for robotic mitral surgery as obese patients have outcomes similar to nonobese patients despite increased challenges and risk-factors.

Is obesity associated with poorer outcomes in patients undergoing minimally invasive mitral valve surgery?

OBJECTIVES

METHODS

This is a retrospective cohort study of all patients undergoing MIMVS ± concomitant procedures over an 8-year period. Patients were stratified into 2 groups: BMI ≥ 30 kg/m2 and BMI ˂ 30 kg/m2, as per World Health Organization definitions. Baseline characteristics, operative and postoperative outcomes and 5-year survival were compared.

RESULTS

We identified 296 patients (BMI ≥30, n = 41, median 35.3, range 30–43.6; BMI &lt;30, n = 255, median 26.2, range 17.6–29.9). The groups were well matched with regard to baseline characteristics. There was only 1 in-hospital mortality, and this was in the BMI &lt; 30 group. There was no difference in repair rate for degenerative disease (100% vs 96.3%, P &gt; 0.99 respectively) or operative durations [cross-clamp: 122 min interquartile range (IQR) 100–141) vs 125 min (IQR 105–146), P = 0.72, respectively]. There were only 6 conversions to sternotomy, all in non-obese patients. There was no significant difference in any other perioperative or post-operative outcomes. Using the Kaplan–Meier analysis, there was no significant difference in 5-year survival between the 2 groups (95.8% vs 95.5%, P = 0.83, respectively).

CONCLUSIONS

In patients having MIMVS, there is insufficient evidence to suggest that obesity affects either short- or mid-term outcomes. Obesity should therefore not be considered as a contraindication to this technique for experienced teams.

The impact of body mass index on perioperative outcomes after robotic liver resection

High body mass index (BMI) is associated with other multiple comorbidities such as non-alcoholic fatty liver disease, steatohepatitis, liver cirrhosis, and cardiopulmonary diseases, which can impact the perioperative outcomes following liver resection. We aimed to study the impact of BMI on perioperative outcomes after robotic liver resection. All the patients undergoing robotic liver resection between 2013 and 2017 were prospectively followed. The patients were divided into three groups (BMI < 25, BMI 25-35, BMI > 35 kg/m²) for illustrative purposes. Demographic and perioperative outcome data were compared. Data are presented as median (mean ± SD). Thirty-eight patients underwent robotic hepatectomy, 73% were women, age was 58 (57 ± 17.6) years, and ASA class was 3 (3 ± 0.5). Indications for surgery were neoplastic lesions in 34 patients (89%), hemangioma in two patients (6%), fibrous mass in one patient (2.5%), and focal nodular hyperplasia in one patient (2.5%). 32% of the patients underwent right or left hemihepatectomy, 21% underwent sectionectomy, 5% underwent central hepatectomy and the reminder underwent non-anatomical liver resection. Operative time was 261 (254.6 ± 94.3) min. Estimated blood loss was 175 (276 ± 294.8) ml. Length of hospital stay was 3 (5 ± 4.9) days. By regression analysis of the three BMI groups, estimated blood loss, rate of postoperative complication, rate of conversion, need for transfusion, length of ICU stay, and length of hospital stay did not have a significant relationship with BMI. A total of five patients (13%) experience complications. Four patients had complications that were nonspecific to liver resection, including acute renal injury, respiratory failure, and enterocutaneous fistula. One patient had bile leak, treated with ERCP stenting. No mortality was seen in this study. Obesity should not dissuade surgeons from utilizing minimally invasive robotic approach for liver resection. Robotic technique is a safe and feasible in patients with high BMI. The impact of BMI on outcomes is insignificant.

Totally endoscopic robotic-assisted excision of right ventricular papillary fibroelastoma

Although they comprise a small number of primary tumors of the heart, papillary fibroelastomas (PFEs) are the second most common type of benign cardiac tumor. PFEs of the right heart are uncommon, and those arising from the right-ventricular (RV) wall are extremely rare, with only a handful of reported cases in the literature. Removal of these tumors has been described, primarily through a median sternotomy approach, with only one report of using a right-sided mini-thoracotomy technique. The advantages of endoscopic robotic-assisted cardiac surgery have been demonstrated and described extensively. We report on a case of an incidentally found PFE in the RV that was successfully removed with a totally endoscopic robotic-assisted approach. The focus of our report is on the uniqueness of both the right-sided nonvalvular PFE and the treatment with a robotic totally endoscopic surgical approach.