Robotically enhanced coronary artery bypass surgery.

BACKGROUND: Robotically enhanced telemanipulation surgery is a fast developing technique which allows totally endoscopic cardiac surgery with utmost precision and perfection on both beating heart as well as arrested heart. METHODS AND RESULTS: Between December 2002 and February 2004, 125 patients underwent robotically enhanced coronary artery bypass surgery using the da Vinci telemanipulation system (Intuitive Surgical Inc., California). Eleven patients underwent totally endoscopic coronary artery bypass surgery. Of them 9 were done on beating heart while 2 were done on arrested heart. One hundred and fourteen patients had endoscopic takedown of internal mammary artery followed by minimally invasive direct coronary artery bypass in 63 patients and left anterolateral thoracotomy in 51 patients. The internal mammary artery mobilization time was 42 min (35-74 min) while the left internal mammary artery to left anterior descending artery anastomosis time ranged from 20 to 36 min for the totally endoscopic coronary artery bypass patients. In 1 patient, the right internal mammary artery was anastomosed to diagonal artery totally endoscopically. The mean internal mammary artery flow by Doppler measurement done in patients undergoing minimally invasive direct coronary artery bypass was 64 ml/min. Seven patients required conversion to median sternotomy and coronary bypass surgery on beating heart. The mean intensive care unit stay was 1.2 days and the mean hospital stay 4.5 days. There was 1 in-hospital mortality. All 11 patients who underwent totally endoscopic bypass surgery had coronary angiography done at 3 months interval which showed 100% patency in 10 patients while one patient had 50% anastomotic narrowing for which coronary angioplasty was done in the same sitting. CONCLUSIONS: Using telematic technology, a complete endoscopic anastomosis is possible in both single vessel and suitable double vessel disease patients. The use of robotics is now extended to achieve complete myocardial revascularization by harvesting both the internal mammary arteries and making a small thoracotomy for direct anastomosis as well.

Antegrade and retrograde cardioplegia with different reperfusion techniques in patients with multiple coronary artery lesions.

To evaluate the effectiveness of retrograde cardioplegia and reperfusion, a total of 266 patients undergoing coronary bypass surgery between Nov 1987 to Dec 1989 were divided into three groups depending on the method of cardioplegic fluid delivery and reperfusion. In group I (80 patients) antegrade cardioplegia and reperfusion was used. In group II (98 patients) antegrade and retrograde cardioplegia and antegrade reperfusion was used while in group III antegrade and retrograde cardioplegia and retrograde reperfusion was used. Myocardial functions were studied with the help of an on-line computer on the basis of mathematical model of heart before and after cardiopulmonary bypass. Biopsy specimens were collected before, during and after cardiopulmonary bypass in order to study myocardial structural changes. In group I patients there was decrease in myocardial function in the immediate post perfusion period while group II patients had considerable improvement in their myocardial function and groups III patients showed further improvement in it. Ultrastructural myocardial study revealed considerable detrimental changes in group I, minimal changes in group II and no change in group III patients. Thus in our experience retrograde cardioplegia and retrograde reperfusion with warm oxygenated blood provide maximum myocardial protection in patients with multiple coronary artery lesions.