Robotic Totally Endoscopic Off-Pump Unroofing of Myocardial Bridge: Early Experience and Midterm Outcomes.

OBJECTIVE: Myocardial bridging (MB) occurs when a coronary artery, commonly the left anterior descending (LAD), has an intramyocardial course. In symptomatic patients who fail medical therapy, surgical unroofing can provide symptomatic relief by improving coronary blood flow. We present a series of patients undergoing robotic totally endoscopic beating-heart MB unroofing. METHODS: There were 34 patients with an LAD-MB who failed medical therapy and underwent robotic totally endoscopic, off-pump unroofing between January 2017 and October 2023. Patients were evaluated by a multidisciplinary team and underwent provocative coronary angiography to confirm hemodynamic significance. We reviewed perioperative outcomes and contacted patients for midterm follow-up, including completion of a modified Seattle Angina Questionnaire (SAQ). RESULTS: The mean age was 48 ± 8 years, and 56% were female patients. One patient had prior septal myectomy via sternotomy. All patients had significant dobutamine Pd/Pa reduction on preoperative coronary angiography. One patient had atrial fibrillation and underwent concomitant ablation with left atrial appendage ligation. The mean procedure time was 140 ± 69 min. All were completed totally endoscopically off-pump without intraoperative conversions. The mean MB length was 4.5 ± 1.4 cm, and the mean depth was 1.6 ± 0.9 cm. Of the patients, 76% were extubated in the operating room. The mean intensive care unit and hospital length of stay were 0.97 ± 0.58 and 1.73 ± 1.1 days, respectively. There were no mortalities or strokes. There was 1 postoperative take-back for bleeding. At midterm follow-up (19 ± 14 months), 28 patients completed the SAQ; 86% reported "much less angina" during activity compared with before surgery, and 93% reported taking no antianginal medication since surgery. CONCLUSIONS: In appropriate patients with hemodynamically significant LAD-MB who fail medical therapy, robotic beating-heart unroofing is possible with good outcomes. Further studies are warranted.

550 Robotic Totally Endoscopic Mitral Valve Surgeries Within a Comprehensive Robotic Cardiac Program.

BACKGROUND: In 2013, we initiated a comprehensive multispectrum robotic cardiac surgery program with emphasis on the totally endoscopic approach. We reviewed the outcomes of mitral valve (MV) procedures within this context. METHODS: A retrospective review of 1714 robotic endoscopic cardiac surgeries performed at our institution between September 2013 and February 2024 was conducted. Of these, outcomes of 550 consecutive heterogeneous patients undergoing robotic totally endoscopic MV operations were analyzed. Data were collected according to the Mitral Valve Academic Research Consortium definitions. RESULTS: The mean age was 63 years, and 217 patients (39%) were female. The mean Society of Thoracic Surgeons risk of mortality was 2.1% (range, 0.15%-19.4%). MV repair occurred in 98% of patients with degenerative mitral regurgitation (MR). Concomitant procedures included Cox-maze cryoablation in 127 (23%) patients, tricuspid valve repair in 54 (9.8%), septal myectomy in 15 (2.7%), totally endoscopic coronary bypass in 6 (1.1%), and aortic valve replacement in 3 (0.5%). Endoaortic balloon occlusion was used in 392 patients (71%), ventricular fibrillatory arrest in 114 (21%), and transthoracic aortic clamp in 44 (8%). Observed to expected 30-day mortality was 0.6. Mean length of hospital stay was 2.8 days. MV repair 30-day surgical success was 95.9% and procedural success was 93.0%. Postoperative echocardiography revealed no or trace residual MR in 95% and mild residual MR in 5%. Five-year freedom from reoperation for recurrent MR was 95.7%. CONCLUSIONS: Robotic endoscopic MV surgery is feasible within the context of a comprehensive multispectrum robotic cardiac surgery program.

Robotic totally endoscopic aortic valve replacement with a sutured bioprosthesis.

Surgical robots have been utilized to facilitate a truly minimally invasive approach in cardiac surgery. Robotic aortic valve replacement allows for a totally endoscopic approach with better visualization in a wider range of patients with varying anatomies. It has the potential advantages of faster functional recovery and superior cosmetic outcomes compared to traditional sternotomy or thoracotomy approaches. In this case report, we show the details of robotic totally endoscopic aortic valve replacement.

Developing Proficiency in Robotic Cardiac Surgery.

BACKGROUND: The purpose of this review is to provide recommendations for cardiac surgeons interested in adopting a robotic platform into their programs. METHODS: The recommendations are based on the experience of the authors and cover a diverse array of cardiac surgical procedures that are currently performed with robotic assistance. The focus, as with any innovative surgical approach, is to ensure patient safety, maximize quality and efficacy, and set realistic expectations about what is required to achieve proficiency in robotic cardiac surgery. RESULTS: Even though there may be steady growth in robotic cardiac procedures, it is possible that these procedures will be concentrated in higher-volume programs that already offer expertise in mitral valve or coronary surgery. Once success and proficiency with robotic cardiac approaches to coronary or valvular heart disease is achieved, as outlined in this review, surgeons may wish to embark on more complex robotic procedures, such as reoperative mitral valve surgery, totally endoscopic coronary artery bypass, or aortic valve replacement. CONCLUSIONS: Maintaining the same principles and techniques for coronary surgery or intracardiac procedures and maintaining the fundamentals of myocardial protection and cardiopulmonary bypass are essential to ensure excellent technical and clinical outcomes and to optimize patient safety.

Robotic unroofing of myocardial bridge of the left anterior descending coronary artery in a patient with hypertrophic obstructive cardiomyopathy and previous septal myectomy.

A 56-year-old female diagnosed with hypertrophic obstructive cardiomyopathy and myocardial bridge (MB) of the left anterior descending (LAD) coronary artery underwent septal myectomy with resolution of her left ventricular outflow tract gradient. She had ongoing refractory symptoms of exertional angina and fatigue for over a decade and finally presented to our clinic to be re-evaluated for treatment. Provocative angiographic testing confirmed significant ischemia secondary to LAD MB. She underwent robotic totally endoscopic off pump unroofing of the LAD MB with complete relief of her symptoms and return to full activity. We conclude that patients undergoing septal myectomy for hypertrophic obstructive cardiomyopathy should be evaluated for MB and undergo unroofing of the bridge at the time of surgery. Learning objective: A myocardial bridge (MB) is a condition in which a coronary artery, most often the left anterior descending, takes an intramuscular route and is covered by the myocardium leading to compression and potential ischemia. This case report adds to the growing body of evidence supporting the significance of considering MB in the overall management of hypertrophic obstructive cardiomyopathy, and the symptomatic relief that a patient can obtain from an unroofing procedure.

Bilateral internal thoracic artery grafting in robotic beating-heart totally endoscopic coronary artery bypass: 10-year outcomes.

Background: Multi-arterial grafting (MAG) with bilateral internal thoracic arteries (BITAs) is superior to single internal thoracic artery (ITA) and veins, however, sternal wound infection (SWI) is a deterrent to using BITA, especially in diabetic and obese patients. Sternal-sparing approaches, including robotic totally endoscopic coronary artery bypass (TECAB), may mitigate this risk. We reviewed outcomes of robotic TECAB with BITA grafting. Methods: A total of 871 patients underwent robotic TECAB at our institution from 7/2013 to 4/2024. Of these, 406 patients received BITA grafts and are the subject of this review. Early and mid-term clinical outcomes were reviewed and angiographic patency in those undergoing hybrid revascularization with percutaneous coronary intervention (PCI) after TECAB. All cases were performed via a beating-heart robotic approach, with standard TECAB port placement. Results: The mean age of the cohort was 67±9 years and 16% were female. The mean Society of Thoracic Surgeons (STS) risk was 1.47%±2.2%. Thirty-nine percent were diabetic (15% insulin-dependent) and 39% had a body mass index (BMI) ≥30 kg/m2. Twenty percent had an ejection fraction (EF) ≤40%. Ninety-eight percent of cases were completed off-pump and there were no conversions to sternotomy. The mean number of grafts per patient was 2.2±0.4. The mean intensive care unit (ICU) and hospital length of stay (LOS) were 1.22±0.62 and 2.44±0.83 days, respectively. Postoperative complications included atrial fibrillation in 13%, acute kidney injury (AKI) in 3.4%, return to theatre for bleeding in 0.7%, postoperative myocardial infarction (MI) in 0.2%, and stroke in 0.2%. Thirty-day mortality was 1.2% [observed/expected (O/E): 0.89]. Return to full activities and work occurred at mean of 14±8.6 and 17±13 days, respectively. Two hundred and two patients (50%) had 'advanced' hybrid revascularization (with at least two arterial grafts and stents). ITA early graft patency in this cohort of patients was 271/278 (98%) with 100% left ITA to left anterior descending artery (LITA-LAD) patency. Mid-term follow-up was complete in all patients at mean of 51±36 months (longest follow-up at 10 years). All-cause mortality was 13% and cardiac-mortality was 2.5%. Freedom from angina was 96%, and freedom from repeat revascularization was 94%. Conclusions: Use of the beating-heart robotic TECAB approach facilitates BITA grafting to achieve multi-vessel arterial revascularization of the left coronary system, with excellent 10-year outcomes.

A decade of robotic beating-heart totally endoscopic coronary bypass (TECAB) at a single institution: Outcomes with 10-year follow-up.

OBJECTIVE: Robotic beating-heart totally endoscopic coronary bypass (TECAB) is performed using single or bilateral internal thoracic arteries with good results. Despite slow adoption and limited industry support, we have evolved our practice and continue to routinely perform TECAB. We describe our series of 874 patients undergoing robotic beating-heart TECAB with up to 10-year follow-up. METHODS: A retrospective review of all patients (n = 874) undergoing robotic beating-heart TECAB (July 2013 to April 2024) was performed. Patients were contacted for midterm follow-up, and angiographic data were collected in those undergoing hybrid revascularization. Multivariate regression analysis and Cox proportional hazard modeling were used to analyze risk factors for early/midterm outcomes. Primary end points were midterm all-cause mortality and major adverse cardiac/cerebrovascular events. RESULTS: Mean Society of Thoracic Surgeons score was 1.5 ± 2.2%. In total, 470 (54%) underwent multivessel TECAB, of whom 86% received bilateral internal thoracic arteries. There was 1 intraoperative conversion (0.11%). Mean length of stay was 2.3 ± 0.8 days. Hospital mortality was 0.80% (observed/expected 0.54). A total of 393 patients (45%) underwent hybrid revascularization. Early graft patency was 97% (left internal thoracic artery-left anterior descending artery patency 98%). Midterm follow-up was 100% at mean 48 months (longest 10.6 years). Cardiac-related mortality and all-cause mortality were 2.2% and 18%, respectively. Freedom from major adverse cardiac/cerebrovascular events was 93%. In multivariate analysis, left-main disease ≥70% was a risk factor for midterm cardiac mortality (odds ratio, 6.7; confidence interval, 1.9-24, P = .003). CONCLUSIONS: In this series of 874 patients with up to 10-year follow-up, we show that robotic TECAB can be performed with excellent early and midterm results using an iterative approach, despite significant challenges. Further industry support and wider surgeon adoption are necessary to ensure sustainability of this procedure.

Maximizing Minimally Invasive Cardiac Surgery With Enhanced Recovery (ERAS).

We convened a group of cardiac surgeons, intensivists, and anesthesiologists with extensive experience in minimally invasive cardiac surgery (MICS) and perioperative care to identify the essential elements of a MICS program and the relationship with Enhanced Recovery After Surgery (ERAS). The MICS incision should minimize tissue invasion without compromising surgical goals. MICS also requires safe management of hemodynamics and preservation of cardiac function, which we have termed myocardial management. Finally, comprehensive perioperative care through an ERAS program should be provided to allow patients to achieve optimal recovery. Therefore, we propose that MICS requires 3 elements: (1) a less invasive surgical incision (non-full sternotomy), (2) optimized myocardial management, and (3) ERAS. We contend that the full benefit of MICS can be achieved only by also utilizing an ERAS platform.

Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass: Impact of Chest Wall Dimensions in Single and Multivessel Bypass.

OBJECTIVE: There can be anatomical constraints on patient selection for minimally invasive surgery. For example, robot-assisted coronary artery bypass was reported to be more challenging when patients had a cardiothoracic ratio >50% and a sternum-vertebra anteroposterior and transverse diameter ratio <0.45. We sought to examine the impact of chest wall anatomic parameters on surgical outcomes in our totally endoscopic coronary artery bypass (TECAB) procedures. METHODS: We retrospectively reviewed patients who underwent robotic TECAB, all of whom had a preoperative chest radiograph at our institution from July 2017 to October 2021. The cohort was divided into 2 groups, which were patients undergoing single-vessel grafting using the left internal thoracic artery (ITA; group 1) and patients undergoing multivessel grafting with bilateral ITA grafts (group 2). We measured several anatomical parameters from the preoperative chest radiograph. RESULTS: A total of 352 patients undergoing TECAB were retrospectively analyzed. After exclusions, 193 were included in this study. In group 1 (n = 91), no parameters correlated with operative time. In group 2 (n = 102), a significant negative correlation was observed between operative time and the sternum-vertebrae anteroposterior diameter (rs = -0.228, P = 0.022) and lung anteroposterior diameter (rs = -0.246, P = 0.013). To confirm these results in group 2, a propensity-matched analysis was performed and showed a statistically significant difference in surgical time based on chest anteroposterior diameters. CONCLUSIONS: In single-vessel robotic TECAB, chest wall anatomic dimensions measured on chest radiograph did not affect operative time. In multivessel cases with bilateral ITA grafts, larger anteroposterior diameter correlated with shorter operative times.

Routine External Iliac Artery Cannulation in Robotic Cardiac Surgery: Role of the Corona "Vitae" in Distal Limb Perfusion.

OBJECTIVE: Femoral artery cannulation is the most commonly used approach for cardiopulmonary bypass (CPB) in robotic cardiac procedures. However, without adding a distal perfusion cannula, leg ischemia can occur in up to 11.5% of patients. There is a well-described 2 to 4 mm size arterial branch that originates from the medial side of the external iliac artery or inferior epigastric artery, immediately above the inguinal ligament, and connects to the obturator artery. Therefore, it was historically named the corona mortis, which means "crown of death" in Latin. When peripheral cannulation is performed above this branch in the external iliac artery, we consider it a corona "vitae" because of its role as a limb-saving collateral. We report herein our standard technique of peripheral cannulation without the need of a distal perfusion cannula and preventing limb ischemia. METHODS: We included all patients who underwent robotic cardiac surgery with peripheral cannulation over a 16-month period at our institution. We cannulated just above the level of the inguinal ligament through a 2 to 3 cm transverse skin incision. The incidence of limb ischemia and vascular complications was recorded and analyzed. RESULTS: During the study period, 133 patients underwent robotic cardiac procedures with peripheral "external iliac" CPB. The size of the cannula was 21F or larger in 73% and 23F in 54% of the patients. No leg ischemia or femoral artery complications requiring additional intervention occurred. CONCLUSIONS: External iliac cannulation can be successfully performed in robot-assisted cardiac surgery using relatively large cannulas without the need of a distal limb perfusion catheter, with good results. In our view, given the importance of the corona mortis ("crown of death" in Latin) in perfusing the limb during CPB, we propose a new name for this artery in robotic cardiac surgery, namely, the corona vitae ("crown of life" in Latin).

A Retrospective Evaluation of Endo-Aortic Balloon Occlusion Compared to External Clamping in Minimally Invasive Mitral Valve Surgery.

We compare outcomes of endo-aortic balloon occlusion (EABO) vs external aortic clamping (EAC) in patients undergoing minimally invasive mitral valve surgery (MIMVS) in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. Adults undergoing mitral valve surgery (July 2017-December 2018) were identified within the STS database (N = 60,607). Total 7,978 patients underwent a minimally invasive approach (including robotically assisted). About 1,163 EABO patients were 1:1 propensity-matched to EAC patients using exact matching on age, sex, and type of mitral procedure, and propensity score average matching for 16 other risk indicators. Early outcomes were compared. Categorical variables were compared using logistic regression; hospital and intensive care unit length of stay were compared using negative binomial regression. In the matched cohort, mean age was 62 years; 35.9% were female, and 86% underwent mitral valve repair. Cardiopulmonary bypass time was shorter for EABO vs EAC group (125.0 ± 53.0 vs 134.0 ± 67.0 minutes, P = 0.0009). There was one aortic dissection in the EAC group and none in the EABO group (P value > 0.31), and no statistically significant differences in cross-clamp time, major intraoperative bleeding, perioperative mortality, stroke, new onset of atrial fibrillation, postoperative acute kidney injury, success of repair. Median hospital LOS was shorter for EABO vs EAC procedures (4 vs 5 days, P < 0.0001). In this large, retrospective, STS database propensity-matched analysis ofpatients undergoing MIMVS, we observed similar safety outcomes for EABO and EAC, including no aortic dissections in the EABO group. The EABO group showed slightly shorter CPB times and hospital LOS.