Intrathecal Morphine for Analgesia in Minimally Invasive Cardiac Surgery: A Randomized, Placebo-controlled, Double-blinded Clinical Trial.

BACKGROUND: Intrathecal morphine decreases postoperative pain in standard cardiac surgery. Its safety and effectiveness have not been adequately evaluated in minimally invasive cardiac surgery. The authors hypothesized that intrathecal morphine would decrease postoperative morphine consumption after minimally invasive cardiac surgery. METHODS: In this randomized, placebo-controlled, double-blinded clinical trial, patients undergoing robotic totally endoscopic coronary artery bypass received either intrathecal morphine (5 mcg/kg) or intrathecal saline before surgery. The primary outcome was postoperative morphine equivalent consumption in the first 24 h after surgery; secondary outcomes included pain scores, side effects, and patient satisfaction. Pain was assessed via visual analog scale at 1, 2, 6, 12, 24, and 48 h after intensive care unit arrival. Opioid-related side effects (nausea/vomiting, pruritus, urinary retention, respiratory depression) were assessed daily. Patient satisfaction was evaluated with the Revised American Pain Society Outcome Questionnaire. RESULTS: Seventy-nine patients were randomized to receive intrathecal morphine (n = 37) or intrathecal placebo (n = 42), with 70 analyzed (morphine 33, placebo 37). Intrathecal morphine patients required significantly less median (25th to 75th percentile) morphine equivalents compared to placebo during first postoperative 24 h (28 [16 to 46] mg vs. 59 [41 to 79] mg; difference, -28 [95% CI, -40 to -18]; P < 0.001) and second postoperative 24 h (0 [0 to 2] mg vs. 5 [0 to 6] mg; difference, -3.3 [95% CI, -5 to 0]; P < 0.001), exhibited significantly lower visual analog scale pain scores at rest and cough at all postoperative timepoints (overall treatment effect, -4.1 [95% CI, -4.9 to -3.3] and -4.7 [95% CI, -5.5 to -3.9], respectively; P < 0.001), and percent time in severe pain (10 [0 to 40] vs. 40 [20 to 70]; P = 0.003) during the postoperative period. Mild nausea was more common in the intrathecal morphine group (36% vs. 8%; P = 0.004). CONCLUSIONS: When given before induction of anesthesia for totally endoscopic coronary artery bypass, intrathecal morphine decreases use of postoperative opioids and produces significant postoperative analgesia for 48 h.

Angiographic patency after robotic beating heart totally endoscopic coronary artery bypass grafting facilitated by automated distal anastomotic connectors.

OBJECTIVES: Robotic totally endoscopic coronary artery bypass (TECAB) on the beating heart has been facilitated in our experience using distal coronary anastomotic connectors. In this study, we retrospectively reviewed graft patency in all robotic TECAB patients who underwent formal angiography at our current institution over a 5-year period. METHODS: Between July 2013 and June 2018, 361 consecutive patients underwent robotic beating-heart TECAB. Of these patients, 121 had a follow-up angiogram, which assessed graft patency. Eighty-four patients had an angiogram as part of planned hybrid procedures and 37 patients underwent an unplanned angiogram for clinical indications. Retrospective analysis of angiographic patency and clinical outcomes was performed. RESULTS: The mean Society of Thoracic Surgeons predicted risk of mortality was 1.8%. Single-vessel bypass was performed in 40 (33%) patients and multivessel grafting in 81 (67%). Average flow (ml/min) and pulsatility index in the grafts was 74.7 ± 39.1 and 1.42 ± 0.52, respectively. The number of grafts evaluated was 204 (130 left internal mammary artery and 74 right internal mammary artery grafts). The median time to angiography was 1.0 and 16.0 months and graft patency was 98% and 91% in the hybrid and non-hybrid groups, respectively. Overall graft patency was 95.6% (left internal mammary artery = 96%; right internal mammary artery = 93%). Left internal mammary artery to left anterior descending artery graft patency was 97%. Clinical follow-up was available for 316 (88%) patients at mean 22.5 ± 15.1 months. Freedom from major adverse cardiac events at 2 years was 92%. CONCLUSIONS: In this consecutive series of patients undergoing formal angiography after robotic single and multivessel TECAB, we found satisfactory graft patency and 2-year clinical outcomes. Longer-term follow-up is warranted.

Robotic cardiac surgery impact of a new patient-side assistant on outcomes.

OBJECTIVE: Very few studies have focused on the experience of the patient-side assistant in robotic cardiac surgery. We investigated whether the retirement of a highly experienced robotic patient-side assistant and replacement with a new assistant had an effect on surgical outcomes. METHODS: In 4/2016, the established patient-side assistant retired after spending 8 months training a new patient-side assistant. A retrospective analysis of 216 patients was performed; 108 patients over a 9 month period just prior to arrival of the new patient-side assistant (Group 1), and 108 patients over 8 months just subsequent to departure of the established assistant (Group 2). Case distribution, pre-operative characteristics, and surgical outcomes were collected and compared. RESULTS: Case volume increased in Group 2 with the new assistant. The mean age and rate of pre-op CVA for Group 1 was lower, but, otherwise, patient demographics were not significantly different. Group 1 had more intracardiac cases and group 2 had more triple-vessel TECABs. Overall operative time was not different between the two groups. Perioperative outcomes including hospital length of stay major adverse cardiovascular events and mortality were similar between the two groups. CONCLUSIONS: We conclude that the transition to a new robotic cardiac surgical patient-side assistant does not have to affect the progress of a busy robotic program. If adequate time for training and gradual assumption of responsibility is ensured, it is feasible to make this transition without loss of volume or compromise in patient outcomes.

Benefit of Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass in Octogenarians.

OBJECTIVE: An important advantage of robotic beating-heart totally endoscopic coronary artery bypass (TECAB) is early functional recovery, in which fragile patients like octogenarians (age >80 years) benefit most. The aim of this study was to investigate the safety and feasibility of TECAB in octogenarians. METHODS: We retrospectively reviewed patients undergoing TECAB from July 2013 to September 2017 at our institution. Perioperative outcomes of octogenarian patients and that of younger patients were compared. RESULTS: Of 308 patients who underwent TECAB, 28 patients (9.1%) were octogenarians (mean age 83.8 ± 3.0 years). Octogenarians had a higher rate of hypertension and atrial fibrillation compared to younger patients. TECAB was successfully performed without conversion to any larger incisions in octogenarians. Mean operative time (299 ± 83 minutes vs 281 ± 89 minutes, P = 0.309) and the rate of multivessel bypass (60.7% vs 58.2%, P = 0.798) were similar between octogenarians and younger patients. New atrial fibrillation was observed more frequently in octogenarians compared to younger patients (35.7% vs 18.6%, P = 0.031). Mean length of hospital stay was similar between the 2 groups (octogenarians: 3.9 ± 1.8 days vs younger patients: 3.5 ± 3.0 days, P = 0.475). Twenty-two octogenarians (78.6%) were discharged directly to home. In-hospital mortality was zero in octogenarians. CONCLUSIONS: Robotic beating-heart TECAB had favorable results in octogenarians with acceptable morbidity and mortality and excellent short length of stay similar to younger patients.

Predictors of blood transfusion use in robotic beating-heart totally endoscopic coronary artery bypass with anastomotic connectors.

BACKGROUND: We sought to identify the independent predictors of blood transfusion requirement in robotic beating-heart patients with totally endoscopic coronary artery bypass (TECAB). METHODS: We retrospectively reviewed patients undergoing TECAB with distal anastomotic connectors from July 2013 to May 2017 at our institution. The cohorts were divided into patients who received a blood transfusion (BT group) and patients who did not (non-blood transfusion [NBT] group). RESULTS: Two-hundred seventy-four consecutive patients underwent TECAB, and 47 patients (17%; BT group) received BT. The BT group had a lower preoperative hemoglobin level and a higher rate of preoperative risk profiles and higher society of thoracic surgeons (STS) predicted the risk of mortality. Kaplan Meier analysis showed decreased 1-year survival in the BT group compared with the NBT group (90.9% vs 96.4%; logrank, 0.017). The Youden index identified a preoperative hemoglobin cutoff value of 12.2 g/dL (sensitivity 60.9%, specificity 79.3%) and operative time of 300 minutes (sensitivity 61.7%, specificity 59.0%) for BT requirement. Multivariate logistic regression analysis identified a preoperative hemoglobin <12.2 g/dL (odds ratio, 6.03; 95% confidence interval, 3.01-12.1) and an operative time >300 minutes (odds ratio, 2.15; 95% confidence interval, 1.07-4.33) as independent factors associated with BT requirement. CONCLUSIONS: We found that preoperative hemoglobin and operative time were independent predictors of BT requirement during robotic beating-heart TECAB. These data would help to select patients to minimize perioperative BT as well as predict outcomes after this procedure.

Robotic-Assisted Third-Time Redo Mitral Valve Replacement.

Robotic-assisted approaches in cardiac surgery are becoming an increasingly common form of minimally invasive surgery. Recent literature has shown robotic-assisted techniques to be superior to traditional sternotomy in infection rates, bleeding, length of hospital stay, and postoperative quality of life. Although there are growing numbers of centers performing robotic mitral valve (MV) surgery, this approach is usually reserved for first-time MV repair. This case report describes a patient with two previous MV surgical procedures complicated by a late paravalvular leak that was unsuccessfully treated with four Amplatzer devices (AGA Medical, Inc, Plymouth, MN). A successful, totally endoscopic, robotic-assisted, third-time reoperative MV replacement was performed in this challenging patient.

Robotic Multivessel Endoscopic Coronary Bypass: Impact of a Beating-Heart Approach With Connectors.

BACKGROUND: Most robotic coronary bypass operations are single-vessel procedures. Very few centers perform totally endoscopic coronary artery bypass (TECAB), and even fewer perform multivessel grafting endoscopically. We hypothesized that a robotic beating-heart approach using distal anastomotic connectors facilitates multivessel TECAB with similar safety and efficacy to single-vessel TECAB. METHODS: We reviewed patients undergoing robotic TECAB at our institution between July 2013 and March 2018. There were 344 consecutive patients divided into two groups: multivessel (MV, group 1), and single-vessel (SV, group 2). We interrogated our prospectively collected database for preoperative, intraoperative, and postoperative outcomes to compare the groups. RESULTS: There were 197 patients in group 1 and 147 patients in group 2. Mean Society of Thoracic Surgeons scores were 1.69% ± 2.4% and 1.96% ± 3.5%, respectively (p = 0.389). Patients in group 1 were older, 67 ± 9.4 versus 63 ± 11.2 years (p < 0.001) and had more triple-vessel disease, 135 (69%) versus 31 (21%; p < 0.001). In group 1, 174 patients (88%) had bilateral internal mammary artery grafts and 13% had triple-vessel TECAB. Mean hospital stay was 3.07 ± 1.2 days in group 1 and 2.81 ± 1.4 days in group 2 (p = 0.072), and overall mortality was 1.45% (2.0% and 0.7%, respectively; p = 0.268). Graft patency (mean, 7 months) was 95.6% (151 of 158 grafts) in group 1 and 94.9% (37 of 39 grafts) in group 2 (p = 0.896). CONCLUSIONS: Multivessel grafting is feasible during robotic beating-heart connector TECAB with good outcomes. We found no significant difference in mortality, hospital stay, midterm major adverse cardiac events, and interim graft patency compared with single-vessel TECAB. Further studies are warranted.

Hybrid coronary revascularization: Midterm outcomes of robotic multivessel bypass and percutaneous interventions.

OBJECTIVE: The purpose of this study was to investigate the outcomes of patients undergoing advanced hybrid coronary revascularization, defined as robotic beating-heart multivessel totally endoscopic coronary artery bypass combined with percutaneous coronary intervention. METHODS: This is a retrospective study. Among 308 consecutive patients who underwent totally endoscopic coronary artery bypass, 57 who underwent advanced hybrid coronary revascularization (mean age, 65.6 years) from July 2013 to September 2017 were included. Midterm survival and freedom from major adverse cardiac events, including death, myocardial infarction, and repeat revascularization, were analyzed. RESULTS: Multivessel totally endoscopic coronary artery bypass was successfully performed without conversion to thoracotomy. Bilateral internal thoracic artery grafting was used in 50 patients (87.7%). The mean operative time was 318.4 ± 51.0 minutes. The mean length of hospital stay was 3.0 ± 1.3 days. There was no 30-day mortality. Percutaneous coronary intervention was planned after totally endoscopic coronary artery bypass in 51 patients (89.4%). The target lesions were the right coronary artery only in 38 patients, the left circumflex artery only in 4 patients, and multiple lesions in 13 patients. Eventually, 2 patients did not receive percutaneous coronary intervention. Percutaneous coronary intervention attempt was unsuccessful in 8 lesions. Patency of the left/right internal thoracic artery was 95.2% (60/63) and 95.7% (45/47), respectively. Graft patency was 95.2% (40/42) in the left circumflex artery and 93.3% (14/15) in the diagonal branch. Three-year survival was 92.8%, and 3-year freedom from major adverse cardiac events was 80.2%. CONCLUSIONS: Advanced hybrid coronary revascularization is a safe and less-invasive approach with short hospital stay and good midterm outcomes.

Is robotic beating heart totally endoscopic coronary artery bypass feasible for BMI > 35 morbidly obese patients?

BACKGROUND: We investigated the outcomes of morbidly obese patients after robotic beating heart totally endoscopic coronary artery bypass (BH-TECAB). METHODS: This is a retrospective single center study. From July 2013 to December 2016, the outcomes of patients undergoing BH-TECAB were reviewed. RESULTS: A total of 234 patients underwent BH-TECAB (172 male, mean age 65.2 years). There were 43 morbidly obese patients defined as body mass index (BMI) greater than 35, and 191 non-morbidly obese patients. Postoperative complications, or mortality in morbidly obese and other patients were similar except for prolonged ventilation >24 h (11.6% vs 2.1%, P = 0.008). CONCLUSIONS: Morbidly obese patients had an increased incidence of prolonged ventilation after BH-TECAB, but an otherwise reasonably low morbidity and mortality similar to patients with a lower BMI. We believe that adoption of robotics technology allows for BH-TECAB and can lead to improved outcomes in this high-risk population.

Robotic Beating Heart Totally Endoscopic Coronary Artery Bypass in Higher-Risk Patients: Can It be Done Safely?

OBJECTIVE: Patients with a high Society of Thoracic Surgeons (STS) predicted risk of mortality undergoing coronary artery bypass surgery are known to have worse outcomes. Less invasive approaches have been shown to improve morbidity and mortality for these patients. In this study, we examined perioperative outcomes in higher-risk patients undergoing robotic totally endoscopic beating heart coronary artery bypass surgery. METHODS: The STS predicted risk of mortality was reviewed for patients undergoing robotic totally endoscopic beating heart coronary artery bypass surgery at our institution between January 2013 and May 2017. We identified a higher-risk cohort (n = 50) and compared them to a lower-risk cohort (n = 220) during the same period. The higher-risk group was formed from patients with the 50 highest STS scores. Perioperative data were collected retrospectively. RESULTS: There were 50 patients in the higher-risk group (mean STS score = 7.05 ± 4.9, mean age = 73 years) and 220 patients in the lower-risk group (mean STS score = 0.89 ± 0.6, mean age = 64 years). The higher-risk group had significantly greater rates of renal insufficiency, peripheral vascular disease, and lower ejection fraction. The incidence of postoperative re-exploration for bleeding, stroke, myocardial infarction, and prolonged ventilation was similar. Perioperative blood transfusion and hospital length of stay were greater in the higher-risk group. Mortality was lower in the higher-risk group (0% vs 1.8% P = 0.045). Cardiac-related mortality was similar at midterm follow-up. CONCLUSIONS: We conclude that beating heart totally endoscopic beating heart coronary artery bypass surgery can be performed in patients with a higher STS predicted risk of mortality with excellent outcomes. Further studies are warranted to evaluate long-term results of totally endoscopic beating heart coronary artery bypass surgery in this challenging group of patients.

Does Robotic Beating Heart Connector Totally Endoscopic Coronary Artery Bypass Bridge the Gender Gap in Coronary Bypass Surgery?

OBJECTIVE: Previous studies have shown that women carry a higher risk of morbidity and mortality after coronary artery bypass surgery. We investigated gender differences in risk factors and outcomes in our patients undergoing robotic beating heart connector totally endoscopic coronary artery bypass. METHODS: From July 2013 to April 2017, patients undergoing connector totally endoscopic coronary artery bypass were reviewed. We compared the outcomes of men versus women. RESULTS: A total of 192 men and 71 women underwent connector totally endoscopic coronary artery bypass. The mean ± SD age was 65.4 ± 10.6 years. The Society of Thoracic Surgeons score was higher in women than men (median = 1.46 vs 0.73, P = 0.001), and women had a higher rate of peripheral vascular disease (22.5% vs 9.9%, P = 0.007). Intraoperative data in women and men were similar except for the rate of multi-vessel connector totally endoscopic coronary artery bypass and the rate of bilateral internal mammary artery use, which were both lower in women (49.3% vs 64.6%, P = 0.024, and 42.3% vs 56.8%, P = 0.036, respectively). The mean ± SD length of hospital stay (women vs men: 3.99 ± 4.00 vs 3.39 ± 2.42, P = 0.324) was comparable. The 30-day mortality in women and men was 0% (0/71) and 2.1% (4/192), respectively (P = 0.577). The morbidity and mortality of single- or multi-vessel connector totally endoscopic coronary artery bypass were similar between men and women. CONCLUSIONS: We conclude that the morbidity and mortality in women after robotic beating heart connector totally endoscopic coronary artery bypass in our center were similar to those seen in men.

Morbid Obesity Does not Increase Morbidity or Mortality in Robotic Cardiac Surgery.

OBJECTIVE: Morbid obesity (body mass index ≥ 35 kg/m) usually confers a higher perioperative risk in cardiac surgery. Robotic cardiac surgery may have many advantages for these high-risk patients. METHODS: We retrospectively reviewed patients undergoing robotic cardiac surgery from July 2013 to April 2017 at our institution. We compared the outcomes of morbidly obese patients versus nonobese patients. RESULTS: A total of 486 patients underwent robotic cardiac surgery (322 men, median age = 65 years). The robotic procedures were the following: totally endoscopic beating heart coronary artery bypass (n = 263), mitral valve surgery (n = 138), arrhythmia surgery (n = 33), adult congenital surgery (n = 16), pericardiectomy (n = 11), and others (n = 25). The cohorts were divided into the following: normal weight (body mass index < 25, n = 123), overweight (body mass index = 25 to < 30, n = 182), obesity (body mass index = 30 to < 35, n = 105), and morbid obesity (body mass index ≥ 35, n = 76). Morbidly obese patients had a higher rate of hypertension, dyslipidemia, and diabetes mellitus compared with normal or overweight patients. There were no significant differences in morbidity, mean length of intensive care unit stay (2.10 ± 4.27 days), and hospital stay (4.48 ± 5.61 days) among the groups. In-hospital mortality was 1.4% (7/486) with nonsignificant difference. CONCLUSIONS: Outcomes of robotic heart surgery in morbidly obese patients in our center were acceptable. Over a broad range of cardiac surgical procedures, morbid obesity was not associated with increased morbidity or mortality when these procedures were performed using a robotic approach. These findings can be beneficial in managing this challenging group of patients.

Redo Robotic Endoscopic Beating Heart Coronary Bypass (TECAB) After Previous TECAB.

Redo-totally endoscopic coronary artery bypass (TECAB) after previous TECAB to our knowledge has never been reported in the literature. We present a case report of a 65-year-old gentleman who underwent a second beating-heart TECAB with the right internal mammary artery (IMA) to the obtuse marginal branch, following previous TECAB (left IMA-diagonal/left anterior descending). An extensive experience in robotic coronary operation and anastomotic devices contributed to the successful outcome in this patient. We conclude that prior TECAB is not a contraindication to redo-TECAB as long as an IMA conduit is available and left lung adhesions are not prohibitive.