Time Course of LDL Cholesterol Exposure and Cardiovascular Disease Event Risk.

BACKGROUND: Incident cardiovascular disease (CVD) increases with increasing low-density lipoprotein cholesterol (LDL-C) concentration and exposure duration. Area under the LDL-C versus age curve is a possible risk parameter. Data-based demonstration of this metric is unavailable and whether the time course of area accumulation modulates risk is unknown. OBJECTIVES: Using CARDIA (Coronary Artery Risk Development in Young Adults) study data, we assessed the relationship of area under LDL-C versus age curve to incident CVD event risk and modulation of risk by time course of area accumulation-whether risk increase for the same area increment is different at different ages. METHODS: This prospective study included 4,958 asymptomatic adults age 18 to 30 years enrolled from 1985 to 1986. The outcome was a composite of nonfatal coronary heart disease, stroke, transient ischemic attack, heart failure hospitalization, cardiac revascularization, peripheral arterial disease intervention, or cardiovascular death. RESULTS: During a median 16-year follow-up after age 40 years, 275 participants had an incident CVD event. After adjustment for sex, race, and traditional risk factors, both area under LDL-C versus age curve and time course of area accumulation (slope of LDL-C curve) were significantly associated with CVD event risk (hazard ratio: 1.053; p < 0.0001 per 100 mg/dl × years; hazard ratio: 0.797 per mg/dl/year; p = 0.045, respectively). CONCLUSIONS: Incident CVD event risk depends on cumulative prior exposure to LDL-C and, independently, time course of area accumulation. The same area accumulated at a younger age, compared with older age, resulted in a greater risk increase, emphasizing the importance of optimal LDL-C control starting early in life.

Advanced hybrid closed chest revascularization: an innovative strategy for the treatment of multivessel coronary artery disease†.

OBJECTIVES: Conventional hybrid revascularization (CHR) combines minimally invasive placement of an internal mammary artery graft to the anterior wall and percutaneous coronary intervention (PCI) of non-anterior wall targets. In this study we assess perioperative and midterm outcomes of advanced hybrid revascularization (AHR) defined as the combination of single or multivessel (MV) totally endoscopic coronary artery bypass grafting (TECAB) with single or multivessel PCI. METHODS: In total, 90 AHR patients [median age 62 years (35-86)] were compared with 90 CHR patients [median age 60 years (35-85)] in terms of perioperative and mid-term outcomes. The outcomes of the three different AHR options (MV-TECAB + PCI, MV-PCI + TECAB, MV-TECAB + MV-PCI) as well as the sequence of the interventions were further compared. Risk factors for major adverse cardiac and cerebral events (MACCEs) related to the hybrid revascularization strategy were calculated. RESULTS: No perioperative deaths occurred either in the AHR group or in the CHR group, rates of myocardial infarction (3.3% vs 3.3%, P = 0.196) were similar between CHR and AHR. Operative times were longer in the AHR group [337 (137-794) min vs 272 (148-550) min, P = 0.002] and conversion rates slightly higher (P = 0.060); however, intensive care unit length of stay (P = 0.162) and hospital length of stay (P = 0.238) were similar. There was no difference in the follow-up survival (P = 0.091), freedom from angina (P = 0.844), PCI target vessel revascularization (P = 0.563), TECAB target vessel revascularization (P = 0.135) and MACCEs (P = 0.601) between CHR and AHR at follow-up. No differences were detected between the three variations of AHR in perioperative outcome, mid-term survival, freedom from MACCEs and reintervention. Neither the number nor type of TECAB/PCI targets, nor the sequence of interventions were significant predictors for MACCEs at follow-up. CONCLUSIONS: AHR yields comparable results with CHR and can be taken into consideration as a sternum-sparing technique for the treatment of MV-coronary artery disease in selected patients.

Predictors and consequences of postoperative atrial fibrillation following robotic totally endoscopic coronary bypass surgery.

OBJECTIVES: Postoperative atrial fibrillation (AFib) is common in patients undergoing coronary artery bypass grafting. Little information is available concerning AFib following minimally invasive cardiac surgery. The aim of our study was to assess the incidence of AFib after totally endoscopic coronary artery bypass (TECAB) grafting and to investigate the factors influencing its occurrence. METHODS: Between 2001 and 2010, we performed TECAB in 384 patients, 73% male, aged 60 (37-90) years. Single-vessel bypasses were performed in 280 patients, and 104 received multivessel coronary revascularization. Procedures were performed on the beating heart in 80 cases, and 164 patients underwent a hybrid intervention. RESULTS: A total of 59 patients (15.4%) developed AFib after TECAB. Univariate analysis showed hypertension (P=0.005), increased age (P=0.007), body weight (P=0.006), body mass index (P=0.005), EuroSCORE (P=0.035) and total TECAB operation time (P=0.01) to be significantly associated with AFib. We also found an increased incidence of AFib in patients undergoing hybrid interventions (P=0.036) and beating heart TECAB (P=0.003). Age (P<0.001) and higher body weight (P=0.003) were the only predictors found to be significant in multivariate analysis. Hospital mortality was 1.7% (1 of 59) in the group of patients with AFib and 0.6% (2 of 325) in the group that showed no AFib after operation (P=n.s.). Hospital stay was 7 (4-54) days in patients with AFib and 6 (2-33) days in those without AFib (P=n.s.). There was no significant 5-year survival difference in patients with and without postoperative AFib (94 vs 94%, P=n.s.). CONCLUSIONS: We conclude that the incidence of postoperative AFib in TECAB is relatively low. Age and body weight are the most important predictors of postoperative AFib following TECAB. Short-term clinical outcome and intermediate-term survival are similar in patients with and without postoperative AFib.

Robotically assisted hybrid coronary revascularization: does sequence of intervention matter?

OBJECTIVE: Hybrid coronary revascularization (HCR) is a treatment strategy for the revascularization of multivessel coronary disease that combines the advantages of both minimally invasive surgical techniques and percutaneous coronary intervention (PCI). The optimal sequence by which revascularization should be accomplished has not been determined. We investigated clinical outcomes in a series of patients planned for HCR via robotically assisted totally endoscopic coronary artery bypass (TECAB) and standard PCI based on revascularization sequence. METHODS: A total of 238 patients planned for HCR between 2001 and 2011 were divided into three groups based on treatment sequence: (a) TECAB before PCI, (b) PCI before TECAB, and (c) same-session procedure. Multiple procedural and clinical end points before discharge and up to 2 years after the procedure were compared between the three groups in an intention-to-treat analysis. Demographic features were reviewed to determine baseline differences between each group. RESULTS: Of the 238 patients, 175 (73.5%) underwent TECAB before PCI, 38 patients (16.0%) underwent PCI before TECAB, and 25 (10.5%) underwent a simultaneous revascularization procedure. At baseline, the patients undergoing TECAB before PCI were significantly older. There was a significantly higher incidence of previous myocardial infarction in the PCI-first group (P < 0.001). There was a significant difference in intensive care unit (ICU) length of stay (LOS), with shorter ICU stays in the simultaneous revascularization group (P = 0.031) and shorter hospital LOS in the PCI before TECAB group (P = 0.021). CONCLUSIONS: In conclusion, revascularization sequence did not dramatically impact clinical outcomes in our observational study. The patients undergoing PCI-first and same-session interventions had shorter hospital and ICU LOS compared with the patients undergoing surgery first. Our findings suggest that no revascularization approach is arbitrarily superior and that revascularization sequence should be individualized on the basis of patient presentation and anatomical considerations.

Anesthetic management of robotically assisted totally endoscopic coronary artery bypass surgery (TECAB).

Over the last decade, TECAB has matured into a reproducible technique associated with low incidence of both mortality and morbidity, as well as superior quality of life, when compared with open CABG surgery. However, TECAB also is associated with important and specific challenges for the anesthesiology team, particularly with regard to the physiologic stresses of OLV, placement of special catheters, and induced capnothorax. As the technology supporting robotic surgery evolves and familiarity with, and confidence in, TECAB increases, the authors anticipate increasingly widespread use of these procedures in an increasingly fragile and problematic patient population who will require the support of a skilled and vigilant anesthesiology team.

Five hundred cases of robotic totally endoscopic coronary artery bypass grafting: predictors of success and safety.

BACKGROUND: Robotic technology has enabled totally endoscopic coronary artery bypass (TECAB) grafting. Little information is available on factors associated with successful and safe performance of TECAB. We report a 10-year multicenter experience with 500 cases, elucidating on predictors of success and safety in TECAB procedures. METHODS: Between 2001 and 2011, 500 patients (364 [73%] men; 136 [27%] women; median age [minimum-maximum] 60 years [31-90 years], median EuroSCORE 2 [0-13]), underwent TECAB. Single, double, triple, and quadruple TECAB was performed in 334, 150, 15, and 1 patient, respectively. Univariate analysis and binary regression models were used to identify predictors of success and safety. Success was defined as freedom from any adverse event and conversion procedure, safety was defined as freedom from major adverse cardiac and cerebral events, major vascular injury, and long-term ventilation. RESULTS: Success and safety rates were 80% (400 cases) and 95% (474 cases), respectively. Intraoperative conversions to larger thoracic incisions were required in 49 (10%) patients. The median operative time was 305 minutes (112-1,050 minutes), and the mean lengths of stay in the intensive unit (ICU) and in hospital were 23 hours (11-1,048 hours) and 6 days (2-4 days), respectively. Independent predictors of success were single-vessel TECAB (p = 0.004), arrested-heart (AH)-TECAB (p = 0.027), non-learning curve case (p = 0.049), and transthoracic assistance (p = 0.035). The only independent predictor of safety was EuroSCORE (p = 0.002). CONCLUSIONS: Single-vessel and multivessel TECAB procedures can be safely performed with good reproducible results. Predictors of success include procedure simplicity and non-learning curve cases, whereas predictors of safety are mainly associated with patient selection.

Hybrid coronary revascularization using robotic totally endoscopic surgery: perioperative outcomes and 5-year results.

BACKGROUND: Hybrid coronary revascularization combines minimally invasive coronary artery bypass grafting and catheter-based interventions. This treatment option represents a viable alternative to both open multivessel coronary bypass surgery through sternotomy and multivessel percutaneous coronary intervention. The surgical component of hybrid coronary intervention can be offered in a completely endoscopic fashion using robotic technology. We report on one of the largest series to date. METHODS: From 2001 to 2011, 226 patients (age, 61 years [range, 31 to 90 years]; 77.0% male; EuroSCORE, 2 [range, 0 to 13]) underwent hybrid coronary interventions on an intention-to-treat basis. Robotically assisted procedures were performed using the daVinci, daVinci S, and daVinci Si surgical telemanipulation systems (Intuitive Surgical, Inc, Sunnyvale, CA) and included 147 single, 72 double, and 7 triple endoscopic coronary artery bypass grafting procedures. Surgery was carried out first in 160 cases (70.8%), percutaneous coronary intervention was carried out first in 38 cases (16.8%), and 28 patients underwent simultaneous operations in a hybrid operating room (12.4%). Drug-eluting stents were used in 70.0% of the patients. RESULTS: Hospital mortality was 3 of 226 patients (1.3%), and hospital stay averaged 6 days (range, 3 to 54 days). Patients walked outside 7 days (range, 3 to 97 days) postoperatively and performed general household work 14 days (range, 7 to 180 days) postoperatively. Full activity was resumed at 42 days (range, 7 to 720 days). Five-year survival was 92.9%, and 5-year freedom from major adverse cardiac and cerebral events was 75.2%. At 5 years, 2.7% of bypass grafts and 14.2% of percutaneous coronary intervention targets needed reintervention. CONCLUSIONS: Robotically assisted hybrid coronary intervention enables surgical treatment of multivessel coronary artery disease with minimal trauma. Perioperative results and intermediate-term outcomes meet the standards of open coronary artery bypass grafting. Recovery time is short, and reintervention rates are acceptable.

Closed chest hybrid coronary revascularization for multivessel disease - current concepts and techniques from a two-center experience.

Hybrid coronary revascularization combining minimally invasive coronary surgery and percutaneous coronary intervention (PCI) allows sternal preserving treatment of multivessel coronary disease. The main principle of the technique includes placement of mammary artery graft to the left anterior descending coronary artery (LAD) and performance of PCI in non-LAD target vessels. This principle is based on increasing data showing equivalent results of PCI with coronary revascularization using saphenous vein grafts in selected patients. Providing that perioperative and long-term results are as good as the results of conventional surgical revascularization, this option seems to be quite appealing for patients and referring cardiologists. This concept has been designed to allow rapid rehabilitation and minimize periprocedural pain under concomitant preservation of the patient's body integrity. Robotically assisted endoscopic approaches for hybrid coronary revascularization set the pace for a closed-chest treatment of multivessel coronary disease. The time point of PCI, the use of different anticoagulation protocols as well as the stent selection are some of the variables, which affect outcome. We additionally report on the midterm results of 130 after-closed-chest hybrid-coronary procedures in two institutions. Hybrid procedures using robotic technology and PCI allow closed chest treatment of multivessel coronary artery disease. Single- and double-bypass grafts are feasible and simultaneous interventions can be performed. The overall safety of the procedure seems to be adequate and perioperative clinical results are satisfactory. Intermediate term survival and freedom from angina are excellent.

Predictors, causes, and consequences of conversions in robotically enhanced totally endoscopic coronary artery bypass graft surgery.

BACKGROUND: Totally endoscopic coronary artery bypass graft surgery (TECAB), using the da Vinci telemanipulator, has become a reproducible operation at dedicated centers. As in every endoscopic operation, conversion is an important and probably inevitable issue. METHODS: We performed robotic TECAB in 326 patients (age, 60 years; range, 31 to 90 years); 242 were single-vessel and 84 were multivessel TECAB. RESULTS: Forty-six of 326 patients (14%) were converted to a larger incision (minithoracotomy, n = 5; sternotomy, n = 41). Left internal mammary artery injury (n = 7), epicardial injury (n = 4), balloon endoocclusion problems (n = 7), and anastomotic problems (n = 18) were common reasons for conversions. Conversion rate was significantly less for single-vessel versus multivessel TECABs (10% versus 25%; p = 0.001). Non-learning-curve case (7% versus 21%; p < 0.001) and transthoracic assistance (11% versus 22%; p = 0.018) were associated with lower conversion rates. In multivariate analysis, learning-curve case was the only independent predictor of conversion (p = 0.005). Conversion translated into increased packed red blood cell transfusion in the operating room (3 versus 0 units; p < 0.001), longer ventilation time (14 versus 8 hours; p < 0.001), and intensive care unit stay (45 versus 20 hours; p = 0.001). Hospital mortality was 0.6% in this series, with 1 patient in the conversion group (2.2%) and 1 patient in the nonconverted group (0.4%; not significant). Five-year survival was 98% in nonconverted patients and 88% in converted patients (p = 0.018). There was no difference in freedom from angina or freedom from major adverse cardiac and cerebral events. CONCLUSIONS: Conversion in TECAB is primarily learning curve-dependent and associated with increased morbidity, but does not significantly affect hospital mortality. Both nonconverted and converted patients show good long-term survival, which is comparable to patients undergoing open sternotomy coronary artery bypass grafting. Long-term freedom from angina or freedom from major adverse cardiac and cerebral events is not influenced by conversion.

Robotic totally endoscopic triple coronary artery bypass grafting on the arrested heart: report of the first successful clinical case.

Robotic technology enables "port only" totally endoscopic coronary artery bypass grafting (TECAB). During early procedure development only single bypass grafts were feasible. Because current referral practice for coronary bypass surgery mostly includes multivessel disease, performance of multiple endoscopic bypass grafts is desirable. We report a case in which a patient received a right internal mammary artery bypass graft to the left anterior descending artery and a left internal mammary artery jump graft to 2 obtuse marginal branches. The procedure was performed through 5 ports on the arrested heart using the daVinci S robotic surgical system. This is the first reported triple bypass grafting procedure using an arrested heart approach.

Is an intraaortic balloon pump a contraindication to robotic totally endoscopic coronary artery bypass?

BACKGROUND: The success of robotic totally endoscopic coronary artery bypass (TECAB) in recent years has led to the expansion of the procedure to patients with more severe disease. Outcomes with these patients have not yet been well characterized, and no reports on TECAB performed in patients with a preoperatively placed intraaortic balloon pump (IABP) are available. We present our initial experience with this patient population. PATIENTS AND METHODS: We evaluated 5 patients with unstable angina or impaired left ventricular function requiring a preoperatively placed IABP who underwent TECAB using the daVinci telemanipulation system. Procedures were performed either on the beating heart using an endostabilizer (n = 2) or on the arrested heart using remote access perfusion and aortic balloon endoocclusion (n = 3). The median patient age was 67 years (range, 41-73 years), with a median preoperative ejection fraction of 43% (range, 26%-58%) and median EuroSCORE of 5 (range, 3-8). RESULTS: There were no major intraoperative technical issues. The median length of stay in the hospital and intensive care unit was 8 days (range, 5-13 days) and 66 hours (range, 41-142 hours), respectively. There were no intraoperative or 30-day mortalities. CONCLUSIONS: This early experience suggests that TECAB is feasible in patients with a preoperatively placed IABP. Both the beating heart and arrested heart versions can be used in this patient population, further broadening the spectrum of applicability of this procedure.

Hybrid coronary revascularization: an overview of options for anticoagulation and platelet inhibition.

BACKGROUND: Hybrid coronary revascularization, in which coronary bypass grafting is combined with percutaneous coronary intervention, is a promising strategy for optimizing outcomes in the treatment of coronary artery disease. Balancing the risk of surgical bleeding with the risk of percutaneous coronary intervention-related thrombosis is a major challenge inherent in carrying out a successful procedure and requires careful selection of antiplatelet and anticoagulant agents. METHODS: Advantages and disadvantages of antiplatelet and anticoagulant agents in use today for hybrid coronary revascularization are reviewed. RESULTS: Currently available anticoagulants and platelet inhibitors have been used to provide safe and effective protection from thrombosis while limiting surgical bleeding in hybrid coronary revascularization, but there is no agreement on an optimal strategy, and each patient presents a unique pharmacologic and logistic puzzle. CONCLUSION: Knowledge of the salient features of the available medications will allow the cardiologist and surgeon to design the optimal strategy for each patient.

Axillary-coronary sequential vein graft for total endoscopic triple coronary artery bypass.

We describe using an axillary-coronary vein graft for robotically assisted, total endoscopic coronary artery bypass grafting. After constructing the proximal vein anastomosis to the left axillary artery under direct vision, the graft was brought into the thorax through a thoracostomy in the second left intercostal space. Under cardiopulmonary bypass with cardioplegic arrest, the distal anastomoses were completed using da Vinci (Intuitive, Sunnyvale, CA) robotic instrumentation through small portholes. This procedure marks a significant advancement in robotic total endoscopic revascularization by increasing the range of targets available for the total endoscopic approach, thereby enlarging the patient population suitable for robotic revascularization.

Hybrid coronary revascularization: which patients? When? How?

PURPOSE OF REVIEW: The aim of this review is to report on current indications and patient selection for hybrid coronary revascularization and to outline current techniques for a hybrid approach. RECENT FINDINGS: Hybrid coronary intervention is a revascularization strategy that combines surgical and catheter-based procedures for treatment of multivessel coronary artery disease. Most published studies report on application of this concept in patients with complex lesions of the left anterior descending artery and nonleft anterior descending lesions suited for percutaneous coronary intervention. Currently, the spectrum of surgical procedures in hybrid coronary revascularization ranges from left internal mammary artery bypass grafting via sternotomy and minithoracotomy to completely endoscopic robotic double vessel coronary artery bypass grafting. Percutaneous coronary intervention in hybrid procedures is performed as single or multiple coronary angioplasty with stenting using either bare metal or drug-eluting stents. Staged and simultaneous approaches can be applied. The latter are increasingly performed in the hybrid operating room. SUMMARY: Hybrid coronary intervention is an emerging interdisciplinary approach in the treatment of coronary artery disease and a potential viable alternative to open coronary bypass surgery or multivessel stenting.

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.

Poor left ventricular function is not a contraindication for robotic totally endoscopic coronary artery bypass grafting.

Robotic technology has enabled performance of totally endoscopic coronary artery bypass grafting (TECABG). Published series on TECABG were primarily performed in low-risk patients, and little is known about the outcome after totally endoscopic coronary surgery in patients with severely impaired left ventricular function. We report successful endoscopic placement of a left internal mammary artery bypass graft to the left anterior descending artery using the daVinci robotic system in a patient with a severely reduced left ventricular ejection fraction.

On-pump beating-heart with axillary artery perfusion: a solution for robotic totally endoscopic coronary artery bypass grafting?

Robotic totally endoscopic coronary artery bypass grafting (TECAB) can be performed on the arrested heart or on the beating heart without heart-lung machine support. In high-risk patients or in patients where technical difficulties are expected with a complete off-pump approach, a beating heart concept with heart-lung machine support can be an important option. Femoral arterial cannulation is associated with additional risk of retrograde cerebral embolization, and axillary cannulation is an accepted method in aortic surgery. We describe a case where an axillary artery cannulation method was used for the first time in TECAB performed with the da Vinci telemanipulation system.