Robotic-assisted off-pump sole transmyocardial revascularization: case report.

Thoracoscopic transmyocardial revascularization (TMR) has been recently demonstrated. We report 2 patients who underwent robotic-assisted thoracoscopic off-pump sole TMR. A 2-inch minimally invasive left anterolateral thoracotomy was made. Pericardial dissection and TMR were performed in an open manner facilitated by improved visualization using voice-activated robotic-assisted thoracoscopy (AESOP, Computer Motion, Santa Barbara, CA, USA). Patient 1 was a 73-year-old man with class IV angina who underwent coronary artery bypass grafting (CABG) x4 20 years earlier. Cardiac catheterization revealed occluded grafts, no native vessels that were amenable to percutaneous coronary intervention (PCI) or CABG, and an ejection fraction (EF) of 55%. Forty-five Holmium-Yag (CardioGenesis, Foothill Ranch, CA, USA) laser channels were created in the left ventricular wall. Total operating room (OR) time was 93 minutes. He was extubated in the OR and was discharged from the intensive care unit (ICU) in 18 hours and from the hospital on the second postoperative day angina free. Patient 2 was a 48-year-old woman with class IV angina who had undergone CABG x6 3 years earlier but who had persistent chest pain following the revascularization. After 12 cardiac readmissions in 1 year, including multiple PCIs, a recent catheterization showed patent grafts except for the circumflex branches and an EF of 45%. Forty-six channels were created in the left ventricle in a similar fashion. OR time was 62 minutes, ICU time was 20 hours, and postoperative length of stay was 2 days. The patient also was angina free at discharge. This report suggests that robotic-assisted thoracoscopy provides enhanced visualization and efficient delivery during off-pump sole TMR, and this technique may be associated with reduced operative times and improved recovery time.

Improved patient outcomes when transmyocardial revascularization is used as adjunctive revascularization.

BACKGROUND: Transmyocardial revascularization (TMR) has been recently used to treat patients with angina for whom angioplasty/stenting and/or coronary artery bypass grafting (CABG) is no longer an option. METHODS: A retrospective review of 255 consecutive patients who required CABG was done. Group 1 patients (n = 219) underwent complete revascularization with CABG alone. Group 2 patients (n = 36) received CABG plus TMR. TMR was performed in regions of nongraftable coronary targets. Indications for surgery in both groups were Canadian Cardiovascular Society angina scores III or IV and an ejection fraction > or = 30%. Exclusion criteria were an emergency procedure within 12 hours, unstable angina, or an acute myocardial infarction within 72 hours. Thirty-day outcomes of the two groups were compared. The means +/- SD of patient ages (63.3 +/- 1.6 years versus 65.4 +/- 1.4 years) and ejection fractions (51.6% +/- 0.9% versus 48.5% +/- 1.6%) were similar for the two groups. RESULTS: The number of grafts performed and operating room times for the two groups were similar (3.1 +/- 0.1 versus 2.9 +/- 0.1 and 276.7 +/- 4.4 minutes versus 272.3 +/- 10.7 minutes, respectively). Intensive care unit times and lengths of stay (emergency room to discharge) were significantly shorter in the CABG plus TMR group (2.1 +/- 0.2 days versus 1.6 +/- 0.2 days [P < .001] and 8.2 +/- 0.4 days versus 7.1 +/-0.6 days [P < .001], respectively). The 30-day readmission rate was lower in the CABG plus TMR group (7.8% versus 2.8%; P < .5). The frequency of atrial fibrillation was also significantly lower in the CABG plus TMR group (37.4% versus 16.7%; P < .025). Major adverse outcomes, such as reoperation for bleeding, respiratory failure, renal failure, stroke, and mortality were similar in the two groups, although there were no mortalities in the CABG plus TMR group. CONCLUSION: TMR as an adjunctive revascularization to CABG in selected patients with limited options may improve in-hospital outcomes.