Robot-assisted coronary artery bypass surgery: a systematic review and meta-analysis of comparative studies

Coronary bypass surgery for multivessel disease after percutaneous coronary intervention in acute coronary syndromes: why, for whom, how early?

Multivessel coronary artery disease is present in ∼50% of patients with acute coronary syndrome and, compared with single-vessel disease, entails a higher risk of new ischaemic events and a worse prognosis. Randomized controlled trials have shown the superiority of 'complete revascularization' over culprit lesion-only treatment. Trials, however, only included patients treated with percutaneous coronary intervention (PCI), and evidence regarding complete revascularization with coronary artery bypass graft (CABG) surgery after culprit lesion-only PCI ('hybrid revascularization') is lacking. The CABG after PCI is an open, non-negligible therapeutic option, for patients with non-culprit left main and/or left anterior descending coronary artery disease where evidence in chronic coronary syndrome patients points in several cases to a preference of CABG over PCI. This valuable but poorly studied 'PCI first-CABG later' option presents, however, relevant challenges, mostly in the need of interrupting post-stenting dual antiplatelet therapy (DAPT) for surgery to prevent excess bleeding. Depending on patients' clinical characteristics and coronary anatomical features, either deferring surgery after a safe interruption of DAPT or bridging DAPT interruption with intravenous short-acting antithrombotic agents appears to be a suitable option. Off-pump minimally invasive surgical revascularization, associated with less operative bleeding than open-chest surgery, may be an adjunctive strategy when revascularization cannot be safely deferred and DAPT is not interrupted. Here, the rationale, patient selection, optimal timing, and adjunctive strategies are reviewed for an ideal approach to hybrid revascularization in post-acute coronary syndrome patients to support physicians' choices in a case-by-case patient-tailored approach.

Minimally Invasive Direct Coronary Artery Bypass Grafting: Sixteen Years of Single-Center Experience

Background: Coronary artery disease is a major cause of death globally. Minimally invasive direct coronary artery bypass (MIDCAB), using a small left anterior thoracotomy, aims to provide a less invasive alternative to traditional procedures, potentially improving patient outcomes with reduced recovery times. Methods: This retrospective, non-randomized study analyzed 310 patients who underwent MIDCAB between July 1999 and April 2022. Data were collected on demographics, clinical characteristics, operative and postoperative outcomes, and follow-up mortality and morbidity. Statistical analysis was conducted using IBM SPSS, with survival curves generated via the Kaplan-Meier method. Results: The cohort had a mean age of 63.3 ± 10.9 years, with 30.6% females. The majority of surgeries were elective (76.1%), with an average operating time of 129.7 ± 35.3 min. The median rate of intraoperative blood transfusions was 0.0 (CI 0.0-2.0) Units. The mean in-hospital stay was 8.7 ± 5.5 days, and the median ICU stay was just one day. Early postoperative complications were minimal, with a 0.64% in-hospital mortality rate. The 6-month and 1-year mortalities were 0.97%, with a 10-year survival rate of 94.3%. There were two cases of perioperative myocardial infarction and no instances of stroke or new onset dialysis. Conclusions: The MIDCAB approach demonstrates significant benefits in terms of patient recovery and long-term outcomes, offering a viable and effective alternative for patients suitable for less invasive procedures. Our results suggest that MIDCAB is a safe option with favorable survival rates, justifying its consideration in high-volume centers focused on minimally invasive techniques.

Robotic applications for intracardiac and endovascular procedures

The large incisions and long recovery periods that accompany traditional cardiac surgery procedures along with the constant patient demand for minimally invasive procedures have motivated cardiac surgeons to implement the robotic technologies in their armamentarium. The robotic systems have been utilized successfully in various cardiac procedures including atrial septal defect repair, left atrial myxoma resection, MAZE procedure and left ventricular lead placement, yet coronary artery bypass and mitral valve repair still comprise the vast majority of them. This review analyzes the development of the robot-assisted cardiac surgery in recent years, its outcomes, advantages, disadvantages, its patient selection criteria as well as its economic feasibility. Robotic endovascular surgery, albeit its limited applications, is presently considered an attractive alternative to conventional endovascular approaches. The increased flexibility and precision along with the wider range of accessible anatomy provided by the endovascular robotic systems, have increased the pool of patients that can be offered minimally invasive treatment options and have helped to overcome many limitations of the traditional endovascular procedures. With this review we aimed to summarize the applications of the commercially available endovascular robotic devices, as well as the limitations and the future perspectives in the field of endovascular robotic surgery.

Total arterial revascularization using robot assisted minimally invasive coronary artery bypass: an Indian experience

Objective

The aim of this study is to analyze the early outcomes of Total Arterial Revascularization using Robot Assisted Minimally Invasive Coronary Artery Bypass at our center between June 2019 and January 2023.

Methods

This is a retrospective analysis of 195 patients who underwent Total Arterial Coronary Revascularization through Robot Assisted Minimally Invasive Coronary Artery Bypass procedure (RA-CABG) during the period of June 2019 and January 2023 in a quaternary care center in India. Primary outcome variables were in-hospital and 30-day mortality. Secondary outcome variables included duration of surgery, length of intensive care unit (ICU) stay, in-hospital stay and perioperative morbidity. The entire patient population was divided into two groups for a subgroup analysis based on when the surgery was conducted i.e. the years since the robotic program was begun at our institution with 81 patients in group I (2019-2021), and 114 patients in group II (2022-2023).

Results

195 patients [88.7% male, mean age of 61.34 ± 9.58 years] underwent RA-CABG during the 5-year period (2019-2023) by a single experienced surgeon and his team. Conversion to larger thoracic incisions was required in 5 cases (2.59%). In-hospital and 30-day mortality was 1.02% each. The average length of ICU stay and hospital stay were 2.82 ± 1.17 days and 5.84 ± 1.71 days respectively. The duration of ICU stay correlated with the number of internal mammary artery grafts procured (p = 0.0022). Median duration of follow-up was 11 months. Overall mortality was 3.62% and cardiac related mortality was 2.07%, and 5 patients (2.59%) underwent percutaneous coronary intervention. Results of the sub-group analysis revealed a statistically significant difference between the groups in terms of number of internal mammary artery grafts procured (p = 0.010), need for transfusions (p = 0.00031), ICU stay (p = 0.0005) and in-hospital stay (p = 0.0006).

Conclusions

Total Arterial Coronary Revascularization through RA-CABG is a viable procedure in select patients. An experienced surgeon and team are required. Further studies in the form of randomized trials with long term follow-up are required to establish the overall utility, effectiveness and benefits to the patients.

Inexpensive and Easy to Set Up Robotic Cardiac Simulator Offers "Unlimited" Endoscopic Coronary Artery Bypass Grafting Experience: Proof of Concept

OBJECTIVE

Robotic totally endoscopic coronary artery bypass (TECAB) grafting is the least invasive form of coronary bypass surgery. However, despite its advantages, this approach has not gained widespread adoption. One possible reason is the advanced and complex robotic skills required to execute a totally endoscopic sutured coronary anastomosis. We prepared a novel, inexpensive, easy to set up robotic TECAB simulator.

METHODS

A pig heart was placed in a cardboard box, and 3 holes were made on the side to mimic the exposure and surgical ergonomics of TECAB port placement. Four robotic ports were placed and docked to the da Vinci Si robot (Intuitive Surgical, Sunnyvale, CA, USA). Monofilament 7:0 suture (7 cm long) was used to perform the anastomosis to the left anterior descending artery using remnant conduit. Seven cardiac surgeons of various training levels participated and were asked to fill out a 10-point questionnaire.

RESULTS

The cost of the simulator totaled $20 per session, with 20 min to assemble. Each session allowed each trainee to practice 3 to 4 coronary anastomoses. Three cardiac surgeons completed the survey and strongly agreed that the model was easy to set up, the anastomotic exercise was realistic, and that this practice helped them gain confidence.

CONCLUSIONS

Our TECAB simulator is inexpensive, easy to set up, and allows trainees to practice endoscopic coronary suturing. We believe this to be a valuable training tool to learn how to do TECAB for established surgeons and that such a simulator may be of great value to cardiothoracic training programs and their trainees. Further studies are warranted.

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.

Clinical outcomes of different revascularization approaches for patients with multi-vessel coronary artery disease: A network meta-analysis

BACKGROUND

As surgical techniques continue to evolve, the optimal approach for revascularizing multi-vessel coronary artery disease (CAD) remains a matter of ongoing debate. Accordingly, our objective was to compare and contrast various surgical techniques utilized in the management of multi-vessel CAD.

METHODS

A systematic literature review was performed using PubMed, Embase, and Cochrane central register of controlled trials from inception to May 2022. Random-effects network meta-analysis was performed for the primary outcome; target vessel revascularization (TVR), and secondary outcomes; mortality, major adverse cardiac and cerebrovascular events, postoperative myocardial infarction, new-onset atrial fibrillation, stroke, new-onset dialysis, in patients undergoing percutaneous coronary intervention (PCI) with a stent, off-pump coronary bypass graft, on-pump coronary artery bypass graft (ONCABG), hybrid coronary revascularization, minimally-invasive coronary artery bypass, or robot-assisted coronary artery bypass (RCAB) surgeries.

RESULTS

A total of 8841 patients were included from 23 studies. The analysis showed that ONCABG had the highest freedom from TVR, with a mean (SD) absolute risk of 0.027 (0.029); although ONCABG was found to be superior to all other methods, it was only significantly better than first-generation stent PCI. While RCAB did not demonstrate significant superiority over other treatments, it showed a greater probability of preventing postoperative complications. Notably, no significant heterogeneity was calculated for any of the reported outcomes.

CONCLUSIONS

ONCABG shows a better rank probability compared to all other techniques for preventing TVR, while RCAB offers greater freedom from most postoperative complications. However, given the absence of randomized controlled trials, these results should be interpreted with caution.

Intraoperative spontaneous tension pneumothorax during robotic-assisted coronary artery bypass grafting

Patients undergoing robotic-assisted coronary artery bypass grafting are increasing. Several complications have emerged with the increasing use of minimally invasive procedures. We reported a case of spontaneous tension pneumothorax that developed in the ventilated lung during robotic assisted left internal mammary artery harvesting causing severe hemodynamic instability. A sudden rise of airway pressure occurred, and the patient became hypotensive. Immediately, the surgeon was notified to look at the right pleura. Pneumothorax was identified, the right pleura was opened using robotic arms, and the right lung was decompressed. A small emphysematous bulla was identified and stabled. Proper identification of the procedure-associated complications is essential for timely management. Tension pneumothorax is a potentially fatal complication, especially in patients under positive pressure ventilation.

Comparative efficacy of eight therapeutic methods in the treatment of left main coronary artery disease: a Bayesian network meta-analysis protocol

INTRODUCTION

As for coronary artery bypass grafting, although there are many direct comparative studies on different minimally invasive methods and traditional thoracotomy (off-pump/on-pump), there is still a lack of further ranking and summary of the efficacy of all surgical methods for left main coronary artery (LMCA) lesions. Combined with the current controversial views, this study aims to introduce a planned network meta-analysis (NMA) in detail, with a view to comparing the long-term efficacy and safety of multiple therapeutic methods in the treatment of patients with LMCA disease, and finally providing some reference bases for the best selection of clinical schemes.

METHOD AND ANALYSIS

PubMed, Embase, Web of Science and The Cochrane Library databases will be collected from inception to June 2022 to compare the efficacy of different surgical methods in randomised controlled trials (RCTs) for LMCA disease. Main outcome endpoints: major adverse cardiovascular events, including mortality, myocardial infarction, stroke and revascularisation. Secondary outcome endpoints: (1) operation-related time, (2) the amount of blood transfusion, (3) complications including secondary thoracotomy, postoperative new atrial fibrillation, wound infection, (4) physiological score and psychological score, (5) time return to work and (6) total hospitalisation costs. The methodological quality of included RCTs will be assessed according to the Cochrane bias risk table. The Bayesian NMA will be conducted by STATA V.16.0.

ETHICS AND DISSEMINATION

The essence of this study is to summarise and analyse the original data without the approval of the ethics committee. Our research does not involve ethical issues, and the results will be published in peer-review journals.

PROSPERO REGISTRATION NUMBER

CRD42021274712.

Minimally invasive surgery or stenting for left anterior descending artery disease – meta-analysis

Minimally invasive direct coronary artery bypass (MIDCAB) surgery and percutaneous coronary intervention (PCI) are both well-established minimally invasive revascularization strategies in patients with proximal left anterior descending (LAD) lesions. We aimed to evaluate the 20-years’ experience by performing a systematic review and meta-analysis comparing MIDCAB versus PCI in adults with proximal LAD disease. We searched MEDLINE, EMBASE and Cochrane on October 1st, 2021 for articles published in the year 2000 or later. The primary outcome was all-cause mortality. Secondary outcomes included cardiac mortality, repeat target vessel revascularization (rTVR), myocardial infarction (MI), and cerebrovascular accident (CVA). Outcomes were analysed at short-term, mid-term, and long-term follow-up. Random effects meta-analyses were performed. Events were compared using risk ratios (RR) with 95% confidence intervals (CI). Our search yielded 17 studies pooling 3847 patients. At short-term follow-up, cardiac mortality was higher with MIDCAB than with PCI (RR 7.30, 95% CI: 1.38 to 38.61). At long-term follow-up, MIDCAB showed a decrease in all-cause mortality (RR 0.66, 95% CI: 0.46 to 0.93). MIDCAB showed a decrease in rTVR at mid-term follow-up (RR 0.16, 95% CI: 0.11 to 0.23) and at long-term follow-up (RR 0.25, 95% CI: 0.17 to 0.38). MI and CVA comparisons were not significant. In conclusion, in patients with proximal LAD lesions, MIDCAB showed a higher short-term mortality in the RCTs, but the cohort studies suggested a lower all-cause mortality at long-term follow-up. We confirm a decreased rTVR at mid-term follow-up in the RCTs and long-term follow-up in the cohort studies.

Commentary: When will the robots come marching in?

Minimally invasive techniques for coronary artery bypass grafting (CABG), specifically robotic-assisted CABG has increased in popularity despite conflicting evidence. Here, we review a report by Yokoyama and colleagues to the Journal of Cardiac Surgery investigating outcomes of robotic versus nonrobotic CABG utilizing the National Inpatient Sample (NIS).