Right Internal Mammary Artery Use in 140 Robotic Totally Endoscopic Coronary Bypass Cases: Toward Multiarterial Grafting.

OBJECTIVE: Benefits of adding a second arterial graft in coronary bypass are well documented. In patients requiring mulitvessel grafting robotic totally endoscopic coronary bypass (TECAB) has allowed for routine harvesting and use of the right internal mammary artery (RIMA). We retrospectively reviewed the technical considerations and target choice in 140 cases of beating heart TECAB where a RIMA graft was used. METHODS: In 2008, we introduced beating heart TECAB with anastomotic connectors into our practice, first with single IMA and then with bilateral internal mammary artery. A robotic stabilizer was used not only to facilitate exposure of the coronary targets but also to aid the RIMA harvest using a skeletonized approach. Flow measurements were obtained routinely. We reviewed the technical aspects, target choice, and intraoperative flows in our TECAB patients who underwent grafting with RIMA grafts. RESULTS: From February 2008 to January 2015, a total of 404 patients underwent beating heart TECAB with anastomotic connectors, of which 194 (48%) were mulitvessel procedures. One hundred forty patients (35%) had a RIMA graft and constitute the patient population for this review. One hundred thirty-one RIMA grafts were harvested via left-sided ports and grafted to left coronary targets, and nine RIMA grafts were harvested via right-sided ports and grafted to the right coronary artery. Flow was greater than 25 mL/min (pulsatility index < 2) in 95% of grafts. Perioperative mortality was 0.7% and mean ± standard deviation length of hospital stay was 3.1 (1.5) days. The RIMA was used as an in situ graft in 124 cases (84%) and as a free T-graft in 24 cases (16%) cases. Right internal mammary artery graft use in all TECABS increased from 23% in the first 5 years to 53% in the last 2 years. CONCLUSIONS: Robotic TECAB allows the routine harvesting and use of the RIMA graft in a safe and reproducible manner. Skeletonization and sternal sparing allow the RIMA to reach various coronary targets. Further studies are needed for this approach to impact the adaption of multiarterial grafting.

Robotic Endoscopic Off-Pump Total Pericardiectomy in Constrictive Pericarditis.

OBJECTIVE: Although rare, constrictive pericarditis is a serious condition with debilitating symptoms and often severe heart failure. Total pericardiectomy is the most effective treatment and is traditionally performed via median sternotomy. With the increasing use of minimally invasive techniques, there have been reports of partial pericardiectomy via thoracoscopy but with suboptimal exposure and difficulty identifying both phrenic nerves. Robotic surgery offers both small incisions and enhanced visualization. We present four cases of robotic endoscopic off-pump total pericardiectomy for constrictive pericarditis. METHODS: Four patients underwent off-pump total pericardiectomy with robotic assistance for constrictive pericarditis. All had constrictive physiology demonstrated by right heart catheterization and/or echocardiogram. One was also found to have coronary artery disease and underwent concurrent totally endoscopic coronary artery bypass grafting left internal mammary artery to left anterior descending artery. Ports were placed in the left second, fourth, and sixth intercostal spaces. The left lung was isolated and deflated with CO2 insufflation, aiding in exposure. With the use of electrocautery, the pericardium was removed first posterior to the left phrenic nerve, then anteriorly all the way to the right phrenic nerve, and caudally from the diaphragmatic reflection to the great vessel cephalad. A stabilizer in the subcostal fourth robotic arm was used to assist in the dissection. RESULTS: Two of four patients were extubated within 6 hours after surgery and transferred to the floor on postoperative day 1. Both were discharged home by postoperative day 5. Two of four patients had preoperative sequelae from chronic constriction and necessitated longer hospital and intensive care unit stays but had improvement in symptoms and were discharged home within 3 weeks. CONCLUSIONS: Total pericardiectomy for constrictive pericarditis can be performed using a robotic approach. In contrast to thoracoscopy, it offers better visualization of both phrenic nerves, avoids injury, and allows a thorough pericardial dissection. In our experience, the robotic left chest approach has proven more efficacious in removing the posterior pericardium than is allowed with median sternotomy.

Combined totally endoscopic robotic coronary bypass and mitral valve repair via right-sided ports.

We present a case of combined coronary artery bypass grafting and mitral valve (MV) repair using a robotic totally endoscopic right-sided approach. A 61-year-old man presented with fatigue due to significant mitral regurgitation and was found to have a tight stenosis in the mid left anterior descending artery. Using the da Vinci robotic system, the patient underwent a left internal mammary artery graft to the left anterior descending artery using the C-Port Flex A distal anastomotic device followed by a MV repair. Both procedures were performed endoscopically via right chest ports and right femorofemoral bypass successfully. The patient was discharged from the hospital 3 days postoperatively and returned to normal activity within 3 weeks after surgery. This case study shows the feasibility of using an endoscopic robotic approach in selected patients undergoing combined MV coronary artery bypass grafting surgery.

Integrating coronary anastomotic connectors and robotics toward a totally endoscopic beating heart approach: review of 120 cases.

BACKGROUND: Endoscopic coronary bypass has been a difficult procedure to perform. The recent introduction of the Intuitive EndoWrist stabilizer (Intuitive Surgical, Sunnyvale, CA) has facilitated this procedure robotically on the beating heart. The addition of anastomotic connectors allows a significant improvement in the execution of this technically demanding procedure. We report on our first 120 cases of totally endoscopic, beating heart connector coronary artery bypass grafting integrating these technologies. METHODS: From January 2008 to April 2010, 120 patients (age range 43 to 86 years, 72% male) underwent either single or multivessel all arterial, totally endoscopic coronary artery bypass grafting using the da Vinci robot with the aid of the Flex A distal anastomotic device (Cardica, Redwood City, CA). Patients with multivessel disease involving branches of the right coronary and circumflex arteries underwent hybrid revascularization with stents. Early and midterm clinical outcomes were evaluated for all patients. Eighty-five internal mammary artery grafts in 68 patients were evaluated at a mean of 4 months using multidetector computed tomography and formal angiography (in 18 hybrid patients). RESULTS: Mean hospital stay was 3.3±2.4 days. There was 1 postoperative death (the same patient had a stroke secondary to carotid disease), and 1 postoperative myocardial infarction. Two patients were converted to minithoracotomy and 1 patient was converted to sternotomy. One patient required cardiopulmonary bypass support through the femoral cannulation during the procedure. Mean intraoperative transit time flow in all the internal mammary artery grafts was 76 cc/minute±43, and pulsatility index of 1.5±0.5. Of the 85 grafts evaluated angiographically, 80 were patent at a mean of 4 months (94.1%). CONCLUSIONS: Totally endoscopic beating heart connector coronary bypass using the da Vinci robot with the Flex A anastomotic device is a safe and reproducible procedure. A significant learning curve is involved and experience with anastomotic devices in the open setting is necessary. Long-term follow-up of graft patency and patient outcomes is warranted.

Minimally invasive atrial fibrillation ablation combined with a new technique for thoracoscopic stapling of the left atrial appendage: case report.

BACKGROUND: Surgical therapy for atrial fibrillation (AF) is becoming increasingly popular in the concomitant setting. Minimally invasive techniques are being developed for management of the patient with stand-alone AF. We report on our first case of a patient undergoing thoracoscopic microwave epicardial AF ablation combined with the incorporation of a new device for left atrial appendage (LAA) exclusion. METHODS: The patient is a 62-year-old man with a 10-year history of drug-resistant paroxysmal AF. He had failed multiple electrical cardioversions, as well as a percutaneous attempt at left and right superior pulmonary vein (PV) isolation. On October 8, 2003, he was admitted to undergo an off-pump thoracoscopic epicardial microwave ablation. While the patient was under general anesthesia, 3 thoracoscopic access ports were created in the right chest. The pericardium was widely opened. Red rubber catheters were positioned in the transverse and oblique sinuses. The 2 catheters were retrieved on the left side and tied together, forming a guide to the Flex 10 microwave ablation probe (Guidant Corporation, Fremont, CA, USA). The Flex 10 sheath was positioned to encircle all 4 pulmonary veins. The position of the ablation catheter was confirmed visually to be behind the LAA. Sequential ablation was then performed in the segments of the Flex 10 to create a continuous ablation line around the PVs. A connecting lesion to the base of the LAA was then performed. The LAA was then stapled using the SurgASSIST computer-mediated thoracoscopic stapling system (Power Medical Intervention, New Hope, PA, USA). RESULTS: The procedure was uneventful and lasted for a total of 2.5 hours. The patient was discharged home on postoperative day 2 in rate-controlled AF. He was successfully electrically cardioverted to normal sinus rhythm (NSR). At latest follow-up he remained in NSR and continued to take dofetilide (Tikosyn). CONCLUSION: Thoracoscopic epicardial microwave ablation of AF is a technically feasible procedure with minimal risk. The computer deployment and motion controlled stapling system that we used in this case has the potential to become a safe and reliable alternative to conventional stapling instruments.