Lessons Learned from Robotic-Assisted Coronary Artery Bypass Surgery: Risk Factors for Conversion to Median Sternotomy

Objective Robotic-assisted coronary artery bypass is a minimally invasive alternative to traditional coronary artery bypass surgery via median sternotomy with an associated learning curve. The purpose of this study was to investigate the reasons for conversion to sternotomy. Methods From October 2009 to June 2012, two surgeons at one US academic institution performed 271 consecutive robotic-assisted coronary artery bypass procedures. For all cases, isolated, off-pump left internal mammary artery (LIMA) to left anterior descending coronary artery grafting was planned via a 3- to 4-cm sternal-sparing thoracotomy after robotic internal mammary artery harvest and pericardiotomy. Results Conversion to sternotomy occurred in 15 of 271 (5.5%) patients. The most common reason was technical difficulty with the anastomosis, which occurred in 6 (40.0%) patients. Others included LIMA dissection, 2 (13.3%); wrong vessel grafted, 2 (13.3%); ventricular fibrillation and cardiac arrest, 1 (6.7%); equipment malfunction, 1 (6.7%); adhesions, 1 (6.7%); and other. Two underwent emergent conversion. Six underwent multivessel bypass after conversion instead of hybrid coronary revascularization. No mortality occurred among converted patients. Two patients had postoperative myocardial infarction and one had a superficial sternal wound infection. Conversion rate was relatively stable among the four different time quartiles (range, 3.0%–7.4%), although the reasons for conversion were different. Conclusions Conversion to sternotomy is an infrequent complication of robotic-assisted coronary artery bypass, most commonly because of technical difficulties during the LIMA harvest and the LIMA to left anterior descending anastomosis. Anatomic and patient variables as well as inherent technical problems with minimally invasive procedures make conversion unavoidable in some patients.

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Survival benefit from a second arterial conduit to the circumflex circulation persists in elderly after coronary artery bypass surgery

Asian Cardiovascular and Thoracic Annals ◽

10.1177/0218492321997077 ◽

2021 ◽

pp. 021849232199707

Author(s):

Suvitesh Luthra ◽

Miguel M Leiva-Juárez ◽

Pietro G Malvindi ◽

John S Billing ◽

Sunil K Ohri

Keyword(s):

Coronary Artery ◽

Coronary Artery Bypass ◽

Survival Benefit ◽

Coronary Artery Bypass Surgery ◽

Bypass Surgery ◽

Internal Mammary Artery ◽

Artery Bypass ◽

Arterial Graft ◽

Arterial Conduit ◽

Internal Mammary

Background This retrospective propensity matched study investigated the impact of age on the survival benefit from a second arterial conduit to the left-sided circulation. Methods Data for isolated coronary artery bypass surgery were collected from October 2004 to March 2014. All patients with an internal mammary artery graft to left anterior descending artery and additional arterial or venous graft to the circumflex circulation were included. Propensity matching was used to balance co-variates and generate odds of death for each observation. Odds ratios (venous vs. arterial) were charted against age. Results The in-hospital mortality rate was 1.12% (arterial) vs. 1.24% (venous) (p = 0.77). The overall 10-year survival was 74.6% (venous) vs. 82.6% (arterial) (p = 0.001). A total of 1226 patients were successfully matched to the venous or arterial (second conduit to circumflex territory after left internal mammary artery to left anterior descending artery) cohorts. Odds ratio for death (venous to arterial) showed a linear decremental overall survival benefit for the second arterial graft to circumflex circulation with increasing age. Conclusions The survival benefit of a second arterial graft persists through all age groups with a gradual decline with increasing age over the decades. Elderly patients should not be denied a second arterial graft to the circumflex circulation based on age criterion alone.

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Robotically Assisted Coronary Endarterectomy

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0b013e318237cff4 ◽

2011 ◽

Vol 6 (6) ◽

pp. 391-394 ◽

Cited By ~ 1

Author(s):

Murtaza Y. Dawood ◽

Eric J. Lehr ◽

Andreas de Biasi ◽

Reyaz Haque ◽

Alina Grigore ◽

...

Keyword(s):

Coronary Artery ◽

Coronary Artery Bypass ◽

Coronary Artery Bypass Surgery ◽

Bypass Surgery ◽

Internal Mammary Artery ◽

Artery Bypass ◽

Balloon Catheter ◽

Coronary Endarterectomy ◽

Internal Mammary ◽

The Right

Robotic assistance has enabled coronary artery bypass surgery to be performed safely in a completely endoscopic fashion, but diffusely diseased target vessels may pose a technical challenge. We present a case in which coronary endarterectomy was performed on the left anterior descending coronary artery during a two-vessel totally endoscopic coronary artery bypass procedure. A 52-year-old woman presented with intermittent substernal pain. Preoperative studies showed diffuse disease in the left coronary artery system. Bilateral internal mammary arteries were harvested robotically using a skeletonized technique in a completely endoscopic fashion. Cardiopulmonary bypass was achieved via peripheral cannulation, and the heart was arrested with intermittent cold antegrade hyperkalemic blood cardioplegia delivered via an ascending aortic occlusion balloon catheter. The first obtuse marginal anastomosis was performed. The left anterior descending coronary artery was diffusely diseased and heavily calcified. An end-to-side anastomosis was attempted to the right internal mammary artery with unsatisfactory results. A localized coronary endarterectomy was performed, and an extended anastomosis was completed using the right internal mammary artery. The patient recovered uneventfully and was discharged home on postoperative day 6. Diffuse coronary artery disease was once thought to be a prohibitive challenge for minimally invasive coronary bypass procedures. This case demonstrates that local coronary endarterectomy is feasible and safe in robotic totally endoscopic coronary artery bypass surgery.

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Does the use of bilateral internal mammary artery grafts impact survival of veterans undergoing coronary artery bypass surgery?

The American Journal of Surgery ◽

10.1016/j.amjsurg.2008.07.006 ◽

2008 ◽

Vol 196 (5) ◽

pp. 726-731 ◽

Cited By ~ 1

Author(s):

Faisal G. Bakaeen ◽

Danny Chu ◽

Amandeep S. Dhaliwal ◽

Biykem Bozkurt ◽

Xing Li Wang ◽

...

Keyword(s):

Coronary Artery ◽

Coronary Artery Bypass ◽

Coronary Artery Bypass Surgery ◽

Bypass Surgery ◽

Internal Mammary Artery ◽

Artery Bypass ◽

Internal Mammary

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174 Semi-Skeletonized Versus Pedicled Internal Mammary Artery Harvesting: A Systematic Review

British Journal of Surgery ◽

10.1093/bjs/znab259.234 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

A M A Shafi ◽

S Mellor ◽

S Iddawela ◽

L Brown ◽

A Harky

Keyword(s):

Coronary Artery ◽

Coronary Artery Bypass ◽

Coronary Artery Bypass Surgery ◽

Bypass Surgery ◽

Internal Mammary Artery ◽

Artery Bypass ◽

Preparation Technique ◽

Operative Outcomes ◽

Harvesting Technique ◽

Internal Mammary

Abstract Objectives To compare semi-skeletonized with pedicled harvesting technique of the internal mammary artery for coronary artery bypass surgery. Method A comprehensive literature search was performed on PubMed, Cochrane database, Embase, Google Scholar and Ovid identifying articles that compared semi-skeletonised to pedicled internal mammary artery in the use of coronary artery bypass surgery. Databases were evaluated and assessed from inception to July 2020. Results Only five studies fulfilled the criteria for this review. There was no reported incidence of sternal wound infection, myocardial infarction, or mortality. The length of the IMA graft was longer in the semi-skeletonized group compared to the pedicled group, 16.06cm versus 14.63cm respectively (p < 0.001). The intraoperative diastolic flow was significantly greater in the semi-skeletonized grafts than in the pedicled grafts during (p = 0.003) and after (p = 0.005) cardiopulmonary bypass. The incidence of pleural effusion (pedicled, 52.6%; semi-skeletonized, 23.6%; p = 0.002) and atelectasis (pedicled, 42.1%; semi-skeletonized, 20.0%, p = 0.015) were significantly higher in pedicled group. Post-operative chest tube drainage was significantly higher in the pedicled group (608 ± 58 mL compared to 470 ± 48 mL; p = 0.027). Additionally, FEV1 was significantly decreased in the pedicled group 6 days after surgery (pedicled:76.0% ± 1.6%; semi-skeletonized: 83.2% ± 1.6%; p = 0.020). Conclusions These results demonstrate that the semi-skeletonized preparation technique is associated with satisfactory outcomes during harvesting the internal mammary artery. Yet, due to limited numbers of studies, there is need for larger comparative studies to assess post-operative outcomes with a longer period of follow up.

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Respiratory Complications After Coronary Artery Bypass Surgery With Unilateral or Bilateral Internal Mammary Artery Grafting

CHEST Journal ◽

10.1378/chest.113.5.1285 ◽

1998 ◽

Vol 113 (5) ◽

pp. 1285-1289 ◽

Cited By ~ 39

Author(s):

Maria Daganou ◽

Ioanna Dimopoulou ◽

Nickolaos Michalopoulos ◽

Konstantinos Papadopoulos ◽

Anna Karakatsani ◽

...

Keyword(s):

Coronary Artery ◽

Coronary Artery Bypass ◽

Coronary Artery Bypass Surgery ◽

Bypass Surgery ◽

Internal Mammary Artery ◽

Artery Bypass ◽

Respiratory Complications ◽

Internal Mammary

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Graft Patency after Robotically Assisted Coronary Artery Bypass Surgery

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1177/1556984519836896 ◽

2019 ◽

Vol 14 (2) ◽

pp. 117-123 ◽

Cited By ~ 6

Author(s):

Hiroto Kitahara ◽

Sarah Nisivaco ◽

Husam H. Balkhy

Keyword(s):

Coronary Artery ◽

Minimally Invasive ◽

Coronary Artery Bypass ◽

Coronary Artery Bypass Surgery ◽

Bypass Surgery ◽

Artery Bypass ◽

Coronary Bypass ◽

Graft Patency ◽

Robotic Assisted

Objective With advances in robotic instrumentation and technology, both robotically assisted minimally invasive direct coronary artery bypass (RMIDCAB) and totally endoscopic coronary artery bypass (TECAB) have been widely used over the past 20 years. Graft patency is the most important outcome in coronary bypass surgery and is associated with long-term prognosis. In this article we reviewed all experts’ studies in the field of robotic assisted coronary artery bypass and investigated graft patency in patients who underwent RMIDCAB or TECAB. Methods We performed a literature search in PubMed from 1999 to 2018 using the terms “Robotic” and “Coronary bypass” and/or “Minimally invasive” and/or “Totally endoscopic.” Of the articles found, studies investigating graft patency were specifically selected. Results In 33 articles, a total of 4,000 patients underwent robotic assisted coronary artery bypass surgery either by a RMIDCAB (2,396) or by a TECAB (1,604) approach. The graft patency was assessed by invasive angiography or computed tomographic angiography in all studies. The mean graft patency at early (<1 month), midterm (<5 years), and long-term (>5 years) follow-up was 97.7%, 96.1%, and 93.2% in RMIDCAB and 98.8%, 95.8%, and 93.6% in TECAB, respectively. Conclusions The graft patency of robotic assisted coronary artery bypass was equivalent to reported outcomes of the conventional approach. These results should encourage the adoption of robotic approaches in coronary bypass surgery.

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