Effectiveness and safety of total endoscopic left internal mammary artery bypass graft to the left anterior descending artery.

Totally endoscopic coronary artery bypass grafting (CABG) has become a feasible option using robotic technology and remote access perfusion techniques. The aim of this study was to determine the progression of the procedure's performance in the currently largest single-center series of arrested-heart totally endoscopic CABG. From 2001 to 2007, arrested-heart totally endoscopic CABG was performed in 100 patients (median age 59 years, range 46 to 70; 81 men, 19 women). All patients received left internal mammary artery grafts to the left anterior descending artery using the da Vinci Surgical System. Remote-access femoral perfusion and aortic balloon endo-occlusion were used in all patients. The series was divided into 4 phases: phase 1 (patients 1 to 25), phase 2 (patients 26 to 50), phase 3 (patients 51 to 75), and phase 4 (patients 76 to 100). The conversion rates to larger thoracic incisions were 7 of 25 (28%) in phase 1, 2 of 25 (8%) in phase 2, 1 of 25 (4%) in phase 3, and 1 of 25 (4%) in phase 4 (p = 0.018). Operative times and hospital stays decreased significantly with each subsequent phase, and clinical outcome showed corresponding improvements. There was no perioperative mortality. For the whole patient series, 5-year postoperative survival, freedom from angina, and freedom from major adverse cardiac and cerebral events were 100%, 91%, and 89%, respectively. In conclusion, after an initial steep learning curve, completely endoscopic left internal mammary artery-to-left anterior descending CABG can be performed safely, with low conversion rates. The learning curve for operative times and improvements in clinical outcome continued even at 100 procedures.

Quality of life improvement after robotically assisted coronary artery bypass grafting.

OBJECTIVES: Coronary artery bypass grafting (CABG) is associated with long rehabilitation periods and slow quality of life (QOL) improvement. Totally endoscopic coronary artery bypass grafting (TECAB) can be performed using robotic technology and remote access perfusion. The aim of this study was to evaluate whether TECAB leads to accelerated QOL improvement as compared to standard CABG. METHODS: We included 120 patients who had received robotically assisted CABG, 56 of whom were operated on using standard sternotomy. These patients were compared to 55 patients who underwent the TECAB procedure and to 9 TECAB patients who required conversion to conventional sternotomy. QOL evaluation was performed before the operation and 1, 3 and 6 months after the procedure using the SF-36 health survey and a standardized questionnaire. RESULTS: All quality of life aspects improved significantly in all study patients. At 3 months, TECAB patients showed significantly better QOL scores related to bodily pain and physical health. Hospital stay and time to restoration of daily activities were significantly shorter. Converted patients experienced similar courses to sternotomy patients in terms of QOL. CONCLUSIONS: TECAB using robotic technology leads to improved physical health, shorter hospital stay and a more rapid restoration of daily activities. Conversion from TECAB to sternotomy does not lead to QOL impairment as compared to primary sternotomy.

How to improve performance of robotic totally endoscopic coronary artery bypass grafting.

BACKGROUND: We investigated whether specific surgical measures during the learning curve can influence procedural performance in robotic totally endoscopic coronary artery bypass grafting (TECAB). METHODS: From 2001 to 2006, 70 patients underwent TECAB using the da Vinci telemanipulation system (Intuitive Surgical, Sunnyvale, CA). The following measures were employed with the intent to improve procedure performance: (1) introduction of a fixed team of surgeons at case 14; (2) application of fibrin glue to seal the anastomosis at case 28; and (3) use of a fourth port for transthoracic assistance at case 49. RESULTS: All 3 measures resulted in a reduction of operating room (OR) time (27%, 20%, and 20%). Use of a stable OR team and peri-anastomotic fibrin glue reduced the rate of conversions and on-table revisions from 39% to 9% (P = .006) and from 26% to 7% (P = .038), respectively. Peri-anastomotic fibrin glue significantly reduced postoperative revisions for bleeding. Using transthoracic assistance, anastomotic time was shortened from 35 minutes (range 23-67) to 25 minutes (range 16-100) (P < .001). CONCLUSION: The 3 measures can improve intraoperative and clinical results in TECAB.

Simultaneous hybrid coronary revascularization using totally endoscopic left internal mammary artery bypass grafting and placement of rapamycin eluting stents in the same interventional session. The COMBINATION pilot study.

OBJECTIVES: Hybrid coronary revascularization procedures apply minimally invasive coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for treatment of multivessel coronary artery disease. For logistic reasons simultaneous procedures would be desirable. In a pilot study the feasibility of simultaneous robotic totally endoscopic CABG and PCI using drug eluting stents was assessed. PATIENTS AND METHODS: Five patients were scheduled to undergo simultaneous combined coronary intervention. A left internal mammary artery bypass graft was placed to the left anterior descending artery (LAD) in a completely endoscopic fashion using the daVinci telemanipulation system. PCI was carried out in the surgical operating room with the GE OEC9800 mobile coronary angiography C-arm. Rapamycin coated Cypher stents were placed into stenotic non-LAD targets. RESULTS: The procedure was feasible in 4 patients, one patient was converted to a double CABG operation. There were no significant postoperative clinical complications and patients were discharged from intensive care unit and the hospital after 19 (18-61) hours and 6 (5-7) days respectively. At 6 months postoperatively all patients are free from angina. CONCLUSION: We conclude that simultaneous robotic totally endoscopic left internal mammary artery to LAD placement and PCI to non-LAD targets using drug eluting stents is feasible in one session.

Myocardial enzyme release in totally endoscopic coronary artery bypass grafting on the arrested heart.

OBJECTIVE: Robotic totally endoscopic coronary artery bypass grafting enables coronary artery bypass grafting without sternotomy or thoracotomy. However, longer cardiopulmonary bypass and aortic endo-occlusion times are currently required compared with those of standard coronary artery bypass grafting operations. We investigated whether longer operation times affect the myocardial enzyme release and the postoperative course. METHODS: From 2001 through 2006, 85 patients with a median age of 58 years (range, 31-76 years) underwent totally endoscopic coronary artery bypass grafting on the arrested heart by using the da Vinci telemanipulator and remote access perfusion through the femoral vessels (Estech or Heartport). The operations involved the left internal thoracic artery-left anterior descending coronary artery or diagonal branch (n = 74); right internal thoracic artery-right coronary artery (n = 2); double-vessel left internal thoracic artery-obtuse marginal branch/circumflex artery and right internal thoracic artery-left anterior descending coronary artery (n = 8); and double-vessel left internal thoracic artery-left anterior descending coronary artery and saphenous vein graft-right coronary artery (n = 1). Totally endoscopic coronary artery bypass grafting duration was 254 minutes (range, 178-710 minutes), cardiopulmonary bypass time was 114 minutes (range, 57-428 minutes), and aortic endo-occlusion time was 65 minutes (range, 28-230 minutes). RESULTS: The postoperative ventilation time was 8 hours (range, 0-278 hours), and the intensive care unit stay was 20 hours (range, 11-389 hours). The postoperative stay at our department was 6 days (range, 4-22 days), and we observed no hospital deaths in this series. Forty-five percent of the patients had an increased postoperative peak creatine kinase MB level, and 75% had an increased troponin T level. Postoperative peak creatine kinase MB levels significantly increased with totally endoscopic coronary artery bypass grafting duration (r = 0.588, P < .001), cardiopulmonary bypass time (r = 0.521, P < .001), and aortic endo-occlusion time (r = 0.400, P < .001) and translated into moderately prolonged intensive care unit stay (r = 0.432, P < .001) and ventilation time (r = 0.517, P < .001). Creatine kinase MB levels were not associated with sex, age, or EuroSCORE. The postoperative left ventricular ejection fraction did not differ significantly from the preoperative left ventricular ejection fraction. CONCLUSIONS: Myocardial protection can be established in arrested heart totally endoscopic coronary artery bypass grafting operations. An influence of increased myocardial enzyme release on postoperative ventilation time and intensive care unit stay is detectable but does not translate into an early mortality or a decrease in left ventricular ejection fraction.

Robotic endoscopic left internal mammary artery harvesting: what have we learned after 100 cases?

BACKGROUND: The development of robotic devices has recently offered the possibility of performing coronary artery bypass graft surgery (CABG) in a totally endoscopic way. An important step of this procedure is endoscopic harvesting of the left internal mammary artery (LIMA). It was the aim of our study to find factors influencing LIMA harvesting time and to describe the challenges associated with robotic endoscopic LIMA harvesting. METHODS: From June 2001 to December 2005, a total of 100 patients underwent robotically assisted CABG. In all cases, the LIMA was harvested by using the robotic DaVinci device. Coronary artery bypass grafting procedures were completed through sternotomy, minithoracotomy, or in a totally endoscopic fashion. RESULTS: The median LIMA harvesting time was 48 minutes (19 to 180). A significant learning curve was observed: y (min) = 151 - 26 x ln (x), x = LIMA takedown number, p less than 0.001. Takedown time decreased from 140 minutes in the first 10 cases to 34 minutes in the last 10 cases. There was no independent demographic factor that significantly influenced the LIMA harvesting time. The LIMA takedown time also showed no significant correlation with thorax dimensions. Injury to the LIMA occurred in 3 patients (6%) during the first half of the experience and in 1 patient (2%) during the second half (p = not significant). CONCLUSIONS: Robotic-enhanced LIMA takedown is a prerequisite for totally endoscopic CABG. After passing through a significant learning curve, IMA takedown can be performed safely and within an acceptable time frame. Demography and chest size do not seem to influence IMA harvesting time. The rate of LIMA injuries is within the limits of conventional thoracoscopic harvesting.

Robotically assisted totally endoscopic atrial septal defect repair: insights from operative times, learning curves, and clinical outcome.

BACKGROUND: Remote access perfusion and robotics have enabled totally endoscopic closure of atrial septal defect and patent foramen ovale. The aim of this study was to address learning curve issues of totally endoscopic atrial septal defect repair on the basis of a single-center experience and to investigate whether long cardiopulmonary bypass and aortic occlusion times influence intraoperative and postoperative outcomes. METHODS: Seventeen patients (median age, 35 years; range, 16 to 55 years) underwent totally endoscopic atrial septal defect repair using remote access perfusion and robotic technology (da Vinci telemanipulation system). Learning curves were assessed by means of regression analysis with logarithmic curve fit. The effect of operative variables on clinical outcome was analyzed by linear regression using the Spearman's rho coefficient. RESULTS: No operative mortality or serious surgical complications were observed. No residual shunt was detected at intraoperative or postoperative echocardiography. Significant learning curves were noted for total operative time: y(min) = 406 - 49 ln(x) (r2 = 0.725; p = 0.002); cardiopulmonary bypass time: y(min) = 225 - 42 ln(x) (r2 = 0.699; p = 0.003); and aortic occlusion time: y(min) = 117 - 25 ln(x) (r2 = 0.517; p = 0.04), x = number of procedures. Median ventilation time, intensive care unit stay, and hospital length of stay were 7 hours (range, 2 to 19 hours), 26 hours (range, 15 to 120 hours), and 8 days (range, 5 to 14 days), respectively. No correlation was detected between cardiopulmonary bypass time and intubation time (r2 = 0.283; p = 0.326), intensive care unit stay (r2 = -0.138; p = 0.639), or total length of stay (r2 = 0.013; p = 0.962). CONCLUSIONS: Totally endoscopic atrial septal defect repair can be performed safely, and learning curves for operative times are steep. Longer cardiopulmonary bypass times had no negative impact on intraoperative and postoperative outcome.