Off-pump complete revascularization through a left lateral thoracotomy (ThoraCAB): the first 200 cases.

BACKGROUND: Conventional coronary bypass surgery is associated with substantial morbidity caused by cardiopulmonary bypass (CPB) and median sternotomy. This report describes an innovative technique to perform complete revascularization through a lateral thoracotomy without CPB (thoraCAB). METHODS: From February 2000 to April 2001 a total of 200 patients underwent thoraCAB. The patient is positioned with the left side elevated to 45 degrees. A 5- to 6-inch incision is made over the left fourth or fifth intercostal space from just medial to the nipple to the anterior axillary line. The left internal thoracic artery is harvested as a pedicle graft under vision. Proximal anastomoses are first completed on the ascending aorta, followed by the distal coronary anastomoses on the beating heart using a stabilizer. Intercostal nerve freezing is done using a cryoprobe. RESULTS: Complete revascularization was achieved in all patients. The number of grafts averaged 2.9 +/- 1.08 per patient. One patient (0.5%) died of renal failure. Two patients (1%) were converted to CPB. No strokes were observed. Three patients (1.5%) required prolonged ventilation (>48 hours). Five patients (2.5%) had postoperative bleeding requiring reexploration. Of the patients, 16 (8%) developed new-onset postoperative atrial fibrillation. CONCLUSIONS: ThoraCAB has been feasible in the vast majority of patients requiring coronary bypass surgery. The prevalence of postoperative atrial fibrillation was low. Postoperative pain maybe lessened with intercostal nerve freezing.

Robotically Assisted Beating Heart Totally Endoscopic Coronary Artery Bypass (TECAB). Is There a Future?

OBJECTIVE: : Since the introduction of beating heart totally endoscopic coronary artery bypass (TECAB), approximately 400 patients have undergone the procedure worldwide. Despite satisfactory results and reduced morbidity, the procedure has not gained wide acceptance. This report describes the authors' experience of beating heart TECAB with robotic assistance and the potential adoption of this technique for the future. METHODS: : Between July 2004 and December 2005, 93 patients underwent successful for beating heart TECAB (47 males and 46 females). Mean age was 67.4 + 12.3 years. Fifteen (13.8%) were excluded or converted intraoperatively to thoracotomy for completion of procedure. The procedure was performed through port incisions for the robotic arms and the endostabilizer. Single or bilateral internal thoracic arteries were used as conduits. Anastomoses were done using surgical U-clips. Eighteen (19.4%) patients underwent planned hybrid revascularization. Eighty-four (90.3%) patients underwent computed tomography or conventional angiography. RESULTS: : Details of 93 completed revascularization cases are summarized in the tables. No in-hospital mortality, myocardial infarction, or CVA was noted. Mean operative time was 272.6 + 128.9 minutes (median, 270 minutes). Mean anastomotic time was 13.8 + 3.7 minutes. Mean length of hospital stay was 3.4 + 2.0 days (median, 3 days). At the time of study, 122 of 122 (100%) grafts were found to be patent. CONCLUSIONS: : Single- and multivessel beating heart TECAB with or without hybrid revascularization may offer a less invasive approach in a selected group of patients.

Planned Simultaneous Beating-heart Totally Endoscopic Coronary Artery Bypass (TECAB) and Percutaneous Intervention in a Single Operative Setting.

BACKGROUND: : Staged hybrid revascularization integrated with minimally invasive coronary artery bypass grafting (CABG) and arrested heart totally endoscopic CABG has been reported. We report the first case of planned simultaneous hybrid coronary revascularization, integrating beating-heart TECAB, and percutaneous intervention (PCI) in the same operative setting. METHODS: : A 73-year-old woman with symptoms of angina and a history of diabetes was found to have 2-vessel coronary artery disease involving the left anterior descending (LAD) and the right coronary artery (RCA). Left internal thoracic artery (LITA) to the LAD grafting was done on a beating heart in a totally endoscopic manner using the da Vinci robotic system through 4 ports. Immediately after LITA to LAD TECAB, percutaneous angioplasty and stent placement was done through the right femoral artery using the OEC 9800 mobile C-arm in the operating room. RESULTS: : There was no stenosis noted in the RCA after the intervention. LITA angiography showed a completely patent anastomosis. The total operative time for both procedures was 165 minutes. Occlusion and anastomotic times were 14 and 8 minutes, respectively. Total PCI and fluoroscopy times were 10 and 3 minutes, respectively. The patient received clopidogrel (Plavix) and aspirin in the immediate postoperative period and was discharged home on the second postoperative day. CONCLUSION: : This planned hybrid approach involving a beating-heart single-vessel TECAB and simultaneous angioplasty-stent in a single operative setting achieved complete coronary artery revascularization in a less invasive way.

Use of bilateral internal thoracic arteries in CABG through lateral thoracotomy with robotic assistance in 150 patients.

BACKGROUND: Internal thoracic arteries (ITA) have been shown to offer longer graft patency. Off-pump coronary artery bypass graft surgery (CABG) through small lateral thoracotomy has been reported. The present study deals with feasibility of using bilateral ITAs (BITA) in CABG through small lateral thoracotomy facilitated by the da Vinci robotic system. METHODS: Since July 2002, 150 patients underwent CABG through small lateral thoracotomy using robotic assistance for harvesting of BITA. After single lung ventilation, three 1- to 2-cm incisions were made in the third, fifth, and seventh intercostal spaces 2 to 3 cm medial to the anterior axillary line. After insertion of camera and instrument arms, both ITAs were harvested in a completely skeletonized fashion. A small anterolateral thoracotomy was done, enlarging the camera port incision. Distal anastomoses were performed on a beating heart using nitinol surgical clips. Intercostal cryoanalgesia and local anesthetic infusion were used for pain management. RESULTS: Planned arterial revascularization was completed in 148 patients. Mean number of arterial grafts per patient was 2.6 +/- 0.8. All coronary arteries could be reached with BITA as in situ or composite grafts. There was no mortality, stroke, myocardial infarction, or wound infection. Seven patients had new onset atrial fibrillation. Four patients required exploration of postoperative bleeding. Mean postoperative length of stay was 3.6 +/- 2.9 days. CONCLUSIONS: The da Vinci robotic system was found to be safe and feasible for BITA harvesting in multivessel CABG through small lateral thoracotomy. Further follow-up for graft patency is necessary. Postoperative pain may be reduced with aggressive management strategies. The approach offers fast recovery. This sternum-sparing approach may be an evolutionary step toward closed-chest coronary artery bypass graft surgery.