Chronic Total Occlusions and Coronary Artery Bypass Grafting Outcomes.

OBJECTIVE: Investigate the association between the presence and grafting of chronic total occlusions (CTO) and coronary artery bypass grafting (CABG) outcomes. METHODS: This was a post hoc analysis of the REGROUP trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest (2014-2017). Patients were stratified based on the presence of at least one CTO vessel (a 100% occluded coronary lesion for greater than or equal to 3 months), and according to whether all CTO vessels were bypassed. Rates of major cardiac adverse events (MACE) were compared. RESULTS: At least 1 CTO was present in 453/1,149 patients (39.4%). Over a median follow up of 4.7 years (interquartile range 3.84-5.45), MACE rates were 23.4% vs. 22.2% for the CTO vs. no CTO group, respectively (adjusted hazard ratio [AHR] 0.92, 95% CI 0.70-1.20). MACE rates for patients with complete CTO grafting vs. not were 23.1% vs. 25.0%, respectively (AHR 0.95, 95% CI 0.57-1.57) . In patients with right coronary dominance undergoing LAD grafting, bypassing a RCA CTO was associated with significantly lower rates of all-cause mortality (AHR 0.38, 95% CI 0.17-0.83). CONCLUSIONS: In this REGROUP trial subanalysis, neither CTO presence or complete grafting of CTO vessels were associated with significantly different rates of MACE. However, the finding of possible survival benefit among a subgroup of patients undergoing grafting of a dominant RCA CTO vessel alongside LAD grafting warrants additional study.

Modeling creatine-kinase MB concentrations following coronary artery bypass grafting.

OBJECTIVES: An increase in cardiac biomarkers is a prerequisite to diagnose periprocedural myocardial infarction (PMI) after coronary artery bypass grafting (CABG). Early-phase risk detection may be aided by modeling time-dependent serum creatine kinase-MB (CK-MB) concentrations. This study aimed to model the kinetics of CK-MB, while identifying its influencing factors. METHODS: Patients who underwent elective CABG and had CK-MB measurements within 72 hours postoperatively were included. The primary outcome was the modeled post-hoc kinetics of CK-MB in patients without potential PMI. These patients were defined as having no potential PMI in case of absence of: ischemic electrocardiographic abnormalities, imaging abnormalities, in-hospital cardiac arrest, mortality, or postoperative unplanned catheterization. A web-based application was created using mixed-effect modeling to provide an interactive and individualized result. RESULTS: 635 patients underwent elective isolated CABG, resulting in 1589 CK-MB measurements. Of these, 609 patients (96%) had no potential PMI, while 26 (4%) had potential PMI. Male sex, aortic cross-clamp time, and cardioplegia type significantly impacted CK-MB concentrations. The diagnostic accuracy of the model had an area under the ROC curve of 82.8% (72.6-90.2%). A threshold of 7 µg/L yielded a sensitivity of 94% and a specificity of 80% (positive predictive value, 17%; negative predictive value, 99%) for excluding potential PMI in our own study population. CONCLUSION: CK-MB release after CABG depends on the timing of measurement, sex, aortic cross-clamp time, and cardioplegia type. The model at https://www.cardiomarker.com/ckmb can be validated, reproduced, refined, and applied to other biomarkers.

Percutaneous coronary intervention with drug-eluting stents versus coronary bypass surgery for coronary artery disease: a Bayesian perspective.

OBJECTIVES: Coronary revascularization is frequently performed for coronary artery disease (CAD). This study aims to assess the totality of randomized evidence comparing percutaneous coronary intervention with drug-eluting stents (DES-PCI) to coronary artery bypass grafting (CABG) for CAD. METHODS: A systematic search was applied to three electronic databases, including randomized trials comparing DES-PCI to CABG for CAD with 5-year follow-up. A Bayesian hierarchical meta-analytic model was applied. The primary outcome was all-cause mortality at five years; secondary outcomes were stroke, myocardial infarction, and repeat revascularization. Endpoints were reported in median relative risks (RR) and absolute risk differences (ARD), with 95% credible intervals (CrI). Kaplan-Meier curves were used to reconstruct individual patient data. RESULTS: Six studies comprising 8269 patients (DES-PCI n=4134, CABG n=4135) were included. All-cause mortality at 5 years was increased with DES-PCI (median RR 1.23 (95%CrI 1.01-1.45), with a median ARD of +2.3% (95%CrI 0.1-4.5%). For stroke, MI, and repeat revascularization, the median RRs were 0.79 (95%CrI 0.54-1.25), 1.84 (95%CrI 1.23-2.75), and 1.80 (95%CrI 1.51-2.16) for DES-PCI, respectively. In a sample of 1000 patients undergoing DES-PCI instead of CABG for CAD, a median of 23 additional deaths, 46 myocardial infarctions and 85 repeat revascularizations occurred at five years, while 10 strokes were prevented. CONCLUSION: The current data suggests a clinically relevant benefit of CABG over DES-PCI at five years, in terms of mortality, myocardial infarction, and repeat revascularization, despite an increased risk of stroke. These findings may guide the heart-team and the shared decision-making process.

Assessment of perioperative cardiac risk using preoperative quantitative flow ratio in patients with coronary artery disease undergoing noncardiac surgery: a retrospective cohort study.

Background: Quantitative flow ratio (QFR) is a novel diagnostic modality for the functional testing of coronary artery stenosis, but evidence concerning the postoperative prognostic implication of QFR in noncardiac surgery (NCS) of patients with coronary artery disease (CAD) is limited. The purpose of this study was to examine the role of QFR in perioperative risk prediction in patients with coronary heart disease. Methods: This retrospective cohort study was conducted in The First Affiliated Hospital of Wenzhou Medical University between 2013 and 2022, and consecutively included patients with CAD who had undergone NCS <1 year after coronary angiography. The primary endpoint was major adverse cardiovascular events (MACEs), which were defined as a composite of cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, cardiopulmonary arrest, malignant ventricular arrhythmia (MVA), congestive heart failure, and revascularization. Univariate and multifactorial Cox regression was used to identify the independent risk factors for perioperative cardiovascular events and to construct new models. The area under the curve (AUC), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were used to compare the newly constructed model with existing traditional models. Results: Among the 929 participants enrolled (median age 68 years; 72.0% male), the primary endpoint was met in 67 (7.2%) patients within 30 days of follow-up. There was no significant difference in the incidence of the primary endpoint between patients with QFR <0.75 and those with "gray zone" lesions (0.75≤ QFR ≤0.8) (log-rank P=0.325). Patients with QFR <0.75 and those with "gray zone" lesions (0.75≤ QFR ≤0.8) had a higher incidence of primary endpoint events compared to patients with QFR >0.8. [QFR <0.75 vs. QFR >0.8: adjusted hazard ratio (HR) =20.70, P<0.001; 0.75≤ QFR ≤0.8 vs. QFR >0.8: HR =15.99, P<0.001]. The independent predictors of MACEs events within 30 days after NCS were albumin level [HR =0.92, 95% confidence interval (CI): 0.87-0.98; P=0.008], emergency surgery (HR =4.12, 95% CI: 1.66-10.23; P=0.002), and QFR ≤0.8 (HR =15.92, 95% CI: 5.96-42.51; P<0.001). In addition, adjusting the original Revised Cardiac Risk Index (RCRI) with QFR ≤0.8 as a risk factor significantly improved the risk stratification of postoperative adverse events, with the adjusted AUC rising from 0.574 to 0.740 (P<0.001). Conclusions: QFR ≤0.8 could independently predict perioperative cardiovascular adverse events in patients with CAD undergoing NCS and improve the predictive value of original predictive index. Gray-zone lesions (0.75≤ QFR ≤0.8) should be actively treated.

Performance assessment of an artificial intelligence-based coronary artery calcium scoring algorithm in non-gated chest CT scans of different slice thickness.

Background: The coronary artery calcium score (CACS) has been shown to be an independent predictor of cardiovascular events. The traditional coronary artery calcium scoring algorithm has been optimized for electrocardiogram (ECG)-gated images, which are acquired with specific settings and timing. Therefore, if the artificial intelligence-based coronary artery calcium score (AI-CACS) could be calculated from a chest low-dose computed tomography (LDCT) examination, it could be valuable in assessing the risk of coronary artery disease (CAD) in advance, and it could potentially reduce the occurrence of cardiovascular events in patients. This study aimed to assess the performance of an AI-CACS algorithm in non-gated chest scans with three different slice thicknesses (1, 3, and 5 mm). Methods: A total of 135 patients who underwent both LDCT of the chest and ECG-gated non-contrast enhanced cardiac CT were prospectively included in this study. The Agatston scores were automatically derived from chest CT images reconstructed at slice thicknesses of 1, 3, and 5 mm using the AI-CACS software. These scores were then compared to those obtained from the ECG-gated cardiac CT data using a conventional semi-automatic method that served as the reference. The correlations between the AI-CACS and electrocardiogram-gated coronary artery calcium score (ECG-CACS) were analyzed, and Bland-Altman plots were used to assess agreement. Risk stratification was based on the calculated CACS, and the concordance rate was determined. Results: A total of 112 patients were included in the final analysis. The correlations between the AI-CACS at three different thicknesses (1, 3, and 5 mm) and the ECG-CACS were 0.973, 0.941, and 0.834 (all P<0.01), respectively. The Bland-Altman plots showed mean differences in the AI-CACS for the three thicknesses of -6.5, 15.4, and 53.1, respectively. The risk category agreement for the three AI-CACS groups was 0.868, 0.772, and 0.412 (all P<0.01), respectively. While the concordance rates were 91%, 84.8%, and 62.5%, respectively. Conclusions: The AI-based algorithm successfully calculated the CACS from LDCT scans of the chest, demonstrating its utility in risk categorization. Furthermore, the CACS derived from images with a slice thickness of 1 mm was more accurate than those obtained from images with slice thicknesses of 3 and 5 mm.

Relationship between preoperative FT3 levels and new-onset atrial fibrillation after off-pump coronary artery bypass grafting.

Background: Postoperative atrial fibrillation (POAF) is the most common arrhythmia after cardiac surgery. While thyroid dysfunction can predict POAF, the association between preoperative serum free triiodothyronine (FT3) levels and POAF in patients undergoing off-pump coronary artery bypass (OPCAB) grafting remains unclear. This study aimed to investigate the relationship between preoperative FT3 levels and POAF in OPCAB patients. Methods: This prospective observational study included patients with sinus rhythm and no history of atrial fibrillation or thyroid disease who underwent OPCAB and FT3 testing at the Tianjin Chest Hospital from June 2021 to March 2023. The relationship between FT3 level and POAF was evaluated using restricted cubic spline. Cox proportional hazards regression models were used to analyze the associations between FT3 concentration categories [low T3 syndrome (LT3S) (FT3 below the normal range), low normal FT3 (3.10-4.59 pmol/L), high normal FT3 (4.60-6.80 pmol/L)] and POAF, adjusting for potential confounders. Stratified analyses were performed to assess effect modification by gender and age (<60 vs. ≥60 years old). Results: Among 875 patients, 259 (29.6%) developed POAF within 2 days after surgery. Restricted cubic spline analysis showed an S-shaped association between FT3 concentration and POAF risk. Compared to the low normal FT3 group, LT3S was associated with an increased risk of POAF [hazard ratio (HR), 1.41; 95% confidence interval (CI): 1.90-2.19], while high normal FT3 was associated with a decreased risk (HR, 0.72; 95% CI: 0.51-0.99). The association between FT3 and increased POAF risk was more pronounced in patients aged ≥60 years (HR, 1.41; 95% CI: 1.89-2.22). Conclusions: Preoperative FT3 levels most likely could predict POAF risk after OPCAB, especially in patients aged 60 years and older. Measuring FT3 preoperatively may identify high-risk patients benefiting from close monitoring and prophylactic treatment. Further investigation of thyroid hormone replacement therapy for LT3S is warranted.

Machine learning-based prediction of off-pump coronary artery bypass grafting-associated acute kidney injury.

Background: The cardiac surgery-associated acute kidney injury (CSA-AKI) occurs in up to 1 out of 3 patients. Off-pump coronary artery bypass grafting (OPCABG) is one of the major cardiac surgeries leading to CSA-AKI. Early identification and timely intervention are of clinical significance for CSA-AKI. In this study, we aimed to establish a prediction model of off-pump coronary artery bypass grafting-associated acute kidney injury (OPCABG-AKI) after surgery based on machine learning methods. Methods: The preoperative and intraoperative data of 1,041 patients who underwent OPCABG in Chest Hospital, Tianjin University from June 1, 2021 to April 30, 2023 were retrospectively collected. The definition of OPCABG-AKI was based on the 2012 Kidney Disease Improving Global Outcomes (KDIGO) criteria. The baseline data and intraoperative time series data were included in the dataset, which were preprocessed separately. A total of eight machine learning models were constructed based on the baseline data: logistic regression (LR), gradient-boosting decision tree (GBDT), eXtreme gradient boosting (XGBoost), adaptive boosting (AdaBoost), random forest (RF), support vector machine (SVM), k-nearest neighbor (KNN), and decision tree (DT). The intraoperative time series data were extracted using a long short-term memory (LSTM) deep learning model. The baseline data and intraoperative features were then integrated through transfer learning and fused into each of the eight machine learning models for training. Based on the calculation of accuracy and area under the curve (AUC) of the prediction model, the best model was selected to establish the final OPCABG-AKI risk prediction model. The importance of features was calculated and ranked by DT model, to identify the main risk factors. Results: Among 701 patients included in the study, 73 patients (10.4%) developed OPCABG-AKI. The GBDT model was shown to have the best predictions, both based on baseline data only (AUC =0.739, accuracy: 0.943) as well as based on baseline and intraoperative datasets (AUC =0.861, accuracy: 0.936). The ranking of importance of features of the GBDT model showed that use of insulin aspart was the most important predictor of OPCABG-AKI, followed by use of acarbose, spironolactone, alfentanil, dezocine, levosimendan, clindamycin, history of myocardial infarction, and gender. Conclusions: A GBDT-based model showed excellent performance for the prediction of OPCABG-AKI. The fusion of preoperative and intraoperative data can improve the accuracy of predicting OPCABG-AKI.

The impact of incomplete revascularization on survival in minimal invasive off-pump coronary artery surgery: a propensity score analysis of 1,149 cases.

Background: Minimally invasive concepts are increasingly influential in modern cardiac surgery. This study aimed to evaluate the effect of completeness of revascularization on clinical outcomes and overall survival in minimally invasive, thoracoscopic coronary artery bypass grafting (CABG) surgery. Methods: We retrospectively evaluated a consecutive series of 1,149 patients who underwent minimally invasive off-pump CABG with single, double, or triple-vessel revascularization between 2007 and 2018. Of these patients, 185 (16.1%) had incomplete revascularization (IR) (group I), and 964 (83.9%) had complete revascularization (CR) (group C). We used gradient boosted propensity score estimation to account for possible confounding variables. Results: Median age was 69 years, interquartile range (IQR) 60-76 years, and median EuroSCORE II was 4, IQR 2-7. Of the 1,149 patients, 495 patients suffered from two vessel disease (VD) and 353 presented with three VD. Long-term median follow-up 5.58 (3.27-8.48) years was available for 1,089 patients (94.8%). The incidence of recurrent or persisting angina, myocardial infarction, redo-bypass surgery, and stroke during follow-up did not differ significantly between groups. During follow-up, there were 47 deaths in group I and 172 deaths in group C. The 1-, 3-, 5-, 8-, and 10-year unadjusted survival rates were 94%, 84%, 75%, 62%, and 51% for group I, and 97%, 94%, 88%, 77%, and 72% for group C, respectively (long-rank test P<0.001), favouring CR. Following risk adjustment the long-rank test P value for survival was 0.23. Conclusions: In minimally invasive coronary surgery, IR resulted in decreased long-term survival, but did not achieve statistical significance after risk adjustment. However, IR should only be used in carefully selected cases.

Factors influencing accelerated aging in patients with type 2 diabetes mellitus and coronary heart disease.

Objective: To investigate the factors influencing accelerated aging in patients with type 2 diabetes mellitus (T2DM) and coronary heart disease (CHD). Methods: A total of 216 patients diagnosed with T2DM and CHD between August 2019 and August 2023 at Xuzhou Central Hospital were selected. Patients were divided into an aging group and a non-aging group, based on the positive or negative values of phenotypic age acceleration (PhenoAgeAccel). Logistic regression analysis was conducted. Variables that had a univariate analysis P< 0.05 were included in the multivariate analysis to identify factors influencing aging in patients with T2DM and CHD, and the area under the curve of the model was reported. Results: This study included 216 patients, with 89 in the accelerated aging group, and 127 in the non-accelerated aging group. The average age of patients was 70.40 (95% CI: 69.10-71.69) years, with 137 males (63.4%). Compared with the non-accelerated aging group, patients in the accelerated aging group were older, with a higher proportion of males, and a higher prevalence of hypertension, stable angina pectoris, and unstable angina pectoris. Multivariate Logistic regression analysis indicated that the absolute value of neutrophils (NEUT#), urea (UREA), adenosine deaminase (ADA), and the triglyceride-glucose index (TyG) were risk factors for accelerated aging, while cholinesterase (CHE) was a protective factor. For each unit increase in NEUT#, UREA, ADA, and TyG, the risk of aging increased by 64%, 48%, 10%, and 789%, respectively. The overall area under the receiver operating characteristic (ROC) curve of the model in the training set was 0.894, with a 95% confidence interval (CI) of 0.851-0.938. Conclusion: NEUT#, CHE, UREA, ADA, and TyG are predictors of accelerated aging in patients with T2DM and CHD, with the model showing favorable overall predictive performance.

HPV and coronary diseases in menopausal women: an integrative review.

High-risk human papillomavirus (HPV) infection is associated with cervical cancer while low-risk HPV strains mostly cause benign lesions. Multiple studies have also associated HPV with coronary artery (CAD) disease in women. Furthermore, the climacteric period in women, triggers chronic inflammation and has major implications for CAD and associated lipid disorders. The association of HPV with coronary artery disease in climacteric women has few studies, and the objective of this review is to gather and analyse scientific data on the subject. This is an integrative review performed on PubMed and Google Scholar using the keywords "HPV", "coronary heart disease" and "climacteric", among these keywords the boolean operator AND and the publication date filter. (2018 onwards). Five articles were found, whose main results show presence of high-risk vaginal HPV in climacteric women. Climacterium and HPV were associated with a three-fold increased risk of CAD, as well as with factors related to menopause that promote atheroma formation, lipid disorders and chronic inflammation. Thus, these results support the association between HPV infection and CAD in climacteric women, possibly via chronic inflammation, hormonal factors related to menopause and dyslipidemia.

Takayasu arteritis with recurrent coronary artery disease.

Takayasu arteritis is a rare type of large vessel vasculitis that commonly affects individuals of Asian descent. Coronary artery involvement is rare. We report the case of a young female with history of Takayasu arteritis who underwent stenting and reported with in-stent restenosis. She was managed with robot-assisted coronary artery bypass grafting using bilateral internal mammary arteries.

Saphenous Vein Graft Pseudoaneurysm Treated With Covered Stenting.

Saphenous vein graft (SVG) pseudoaneurysms are an infrequent, but life-threatening complication of coronary artery bypass grafting (CABG) surgery if left untreated. Here, we discuss the case of a 77-year-old patient, with a prior history of CABG and transcatheter aortic valve implantation (TAVI), who was incidentally found on computed tomography angiography (CTA) to have a pseudoaneurysm of his SVG with an initial chief complaint of dizziness. Despite increasing reports of SVG pseudoaneurysm, there is no consensus on definitive treatment. Due to the high mortality risk of this patient with surgical intervention, a minimally invasive percutaneous coronary intervention was performed. The patient was effectively treated with two overlapping Viabahn-covered stents, which completely excluded the pseudoaneurysm. Follow-up imaging at two months showed two well-positioned overlapping self-expanding stents with total occlusion of the pseudoaneurysm.

Sternum-sparing multivessel coronary surgery as a routine procedure: Midterm results of total coronary revascularization via left anterior thoracotomy.

Objective: A sternum-sparing approach of minimally invasive total coronary revascularization via left anterior thoracotomy demonstrated promising early outcomes in unselected patients with coronary artery multivessel disease. Follow-up data are still missing. Methods: From November 2019 to September 2023, coronary artery bypass grafting via left anterior minithoracotomy on cardiopulmonary bypass and cardioplegic cardiac arrest was performed as a routine procedure in 392 consecutive, nonemergency patients (345 men; 67.0 ± 9.9 years; range, 32-88 years). All patients had multivessel coronary artery disease (77.6% 3-vessel-disease, 22.4% 2-vessel-disease, and 32.9% left main stenosis). Patients at old age (older than a 80 years, 12.5%), with severe left ventricular dysfunction (ejection fraction <30%, 7.9%), diabetes mellitus (34.9%), massive obesity (body mass index > 35, 8.9%), and chronic lung disease (17.1%) were included. Mean European System for Cardiac Operative Risk Evaluation II score was 2.9 ± 2.8. Mean midterm follow-up (100%) was 15.2 ± 10.7 months (range, 0.1-39.5 months). Results: Left internal thoracic artery (99.0%), radial artery (70.4%), and saphenous vein grafts (57.4%) were used, and 70.4% of patients received at least 2 arterial grafts. A total of 3.0 ± 0.8 anastomoses (range, 2-5 anastomoses) per patient were performed to revascularize the territories of left anterior descending (98.7%), circumflex (91.6%), and right coronary (70.9%) artery. Complete anatomical revascularization was achieved in 95.1%. At follow-up, all-cause-mortality, myocardial infarction, repeat revascularization, and stroke was 3.1%, 1.5%, 5.4%, and 0.7%, respectively. Overall major adverse cardiac and cerebrovascular events rate was 8.7%. Conclusions: This is the first report of midterm follow-up after routine sternum-sparing total coronary revascularization via left anterior thoracotomy for multivessel coronary artery disease with a high rate of multiple arterial grafting and complete anatomical revascularization. Outcome was favorable and similar to that of contemporary conventional coronary artery bypass grafting.

Exploring anesthetic-induced gene expression changes and immune cell dynamics in atrial tissue post-coronary artery bypass graft surgery.

Background: This study leverages the GSE4386 dataset, obtained from atrial tissue samples post-coronary artery bypass graft (CABG) surgery, to investigate the impact of anesthetic agents (sevoflurane and propofol) on gene expression and immune cell infiltration. Methods: Hierarchical clustering and box plots were employed for dataset preprocessing, highlighting a significant outlier (sample GSM99282), subsequently removed to ensure data integrity. Differentially expressed genes (DEGs) were identified using volcano plots based on specific log-fold-change and P-value thresholds. Additional analyses included the Friends approach, Spearman's correlation, and gene set enrichment analysis (GSEA), exploring functional annotations and pathways. Results: Heatmaps and bubble plots depicted DEGs, revealing distinct expression patterns between the sevoflurane and propofol groups. Friends analysis identified top genes based on log fold changes, further correlated using Spearman's method. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes enrichment analyses illustrated functional annotations of DEGs, while GSEA highlighted enriched biological categories. Immune cell infiltration analysis showcased varied cellular presence post-CABG. ESTIMATE algorithm scores demonstrated differences in immune, stroma, and estimate scores. Microenvironment Cell Populations-counter (MCPcounter) revealed an increased abundance of cytotoxic lymphocytes in the sevoflurane group, confirmed by a single sample GSEA. CIBERSORT algorithm identified distinct immune cell compositions, highlighting differences in macrophage M0 prevalence between sevoflurane and propofol groups. Conclusions: This comprehensive analysis provides insights into anesthetic-induced gene expression changes and immune cell dynamics in atrial tissue post-CABG surgery. The identified DEGs and immune cell compositions offer potential biomarkers and therapeutic targets for refining anesthetic strategies in cardiac surgeries.

Robotic-assisted coronary artery bypass grafting: how I teach it.

The first robotic cardiac operation was performed more than two decades ago. This paper describes the distinct steps and components necessary for teaching robotic-assisted minimally invasive direct coronary artery bypass (R-MIDCAB). It also provides a general overview of the surgical robotic setup and ways to troubleshoot potential complications. The focus of robotic training is not only on the surgeon but includes an entire dedicated cardiac team and administrative institutional support. This team approach ensures that R-MIDCAB can be performed safely and reproducibly. Meticulous planning, incremental learning, and teamwork are the main factors leading to program success and optimal patient outcomes. Robotic-assisted internal mammary artery (IMA) harvesting and coronary revascularization via a small, anterior mini-thoracotomy has provided an alternative to sternotomy in selected patients with coronary artery disease (CAD). Benefits include less postoperative atrial fibrillation, fewer blood transfusion, less time in the operating room (OR), less ventilatory support, fewer strokes, decreased intensive care unit stay and shortened postoperative length of stay all of which manifests as a decrease in institutional resource utilization. Recent data show that R-MIDCAB and hybrid coronary revascularization provides good long-term outcomes. In addition to patient satisfaction, there is an additional overall cost benefit to R-MIDCAB over traditional sternotomy coronary artery bypass grafting (CABG), secondary to decreased hospital length of stay. Robotically harvesting the IMA, operating on a beating heart, and performing anastomoses through a small incision all require advanced training and incremental learning. Increased experience generally leads to shortened surgical times and fewer complications.

Issues and considerations in perioperative management of robotic coronary bypass grafting.

Minimally invasive approaches to address coronary artery disease, such as robotic coronary bypass grafting, are emerging in surgery and have been shown to be beneficial with a reduction in morbidity. The perioperative management of this subset of patients is crucial to the success of the operation as there are several preoperative and postoperative issues and considerations that need to be addressed. A meticulous preoperative workup with an extensive history, physical exam, and appropriate imaging are instrumental to ensure a successful operation. Protocolized postoperative care is also essential to garnish the most benefit from this minimally invasive approach. All of these factors, in conjunction with a heart team approach and surgeon experience, are imperative for the successful outcome of robotic coronary artery revascularization.

Systematic review and meta-analysis of two decades of reported outcomes for robotic coronary artery bypass grafting.

Background: Despite the well-documented safety and feasibility of robotic coronary artery bypass grafting (CABG), widespread adoption of this approach remains limited by its steep learning curve, high procedural costs and paucity of data on longer-term efficacy. This current meta-analysis aims to provide a systematic overview of the outcomes of robot-assisted CABG, with a focus on long term graft patency and freedom from major adverse cardiac and cerebrovascular events (MACCE). Methods: A systematic literature search of three electronic databases was conducted for studies reporting outcomes of robotic-assisted CABG, and were grouped based on whether patients underwent robot-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB), totally endoscopic coronary artery bypass (TECAB) or were mixed. Perioperative and mid-to-long term results from included studies were pooled using meta-analysis of proportion or means in a random effects model. Results: In the quantitative analysis, thirty-nine eligible studies included 6,152 patients who underwent RA-MIDCAB, 1,729 patients who underwent TECAB and 21,642 patients who underwent either form of robot-assisted CABG. A high level of heterogeneity was observed amongst baseline characteristics. Perioperative mortality and complication rates were low. Conversion rate to full sternotomy overall was less than 3.2% [95% confidence interval (CI): 2.1-5.2%, I2=39%]. At a mean follow-up duration of 5.2 years, overall graft patency was 96% for both RA-MIDCAB and TECAB, and freedom from major adverse cardiac events (MACE) or MACCE was 83.2% (95% CI: 72.0-90.4%; I2=90%) for RA-MIDCAB and 91.6% (95% CI: 86.6-94.9%; I2=76%) for TECAB. Conclusions: Robot-assisted CABG is observed to have acceptable perioperative and mid-to-long term outcomes with promising overall graft patency.

Historical landmarks in the development of robotic coronary bypass grafting.

Robotic technology was first used in history for the minimally invasive surgical treatment of coronary artery disease. In 1998, the first operations were carried out at the Hôpital Broussais in Paris. Thereafter, several European and United States (US) centers developed surgical concepts for robotically assisted internal mammary artery harvesting and the construction of the anastomoses, either through minithoracotomy or in a totally endoscopic fashion. Initial experiences were documented in a number of single and multicenter series published in the early and mid-2000s. Key steps in further procedure development included the introduction of a robotic endostabilizer for beating heart completely endoscopic operations, the combination with percutaneous coronary intervention in hybrid approaches, the introduction of second, third, and fourth generations of surgical robots with improvements in each iteration, the availability of anastomotic devices, and most recently, the emergence of new robotic technology companies producing interesting alternatives to the existing machines. The larger clinical series included 500 to over 1,000 patients, with clinical results that well justified the continued application of robotics. Development of robotic coronary bypass grafting has generally been slow, but at committed centers, the procedures are routine, reproducible, safe, and effective. Over 25 years of development, robotic surgical coronary revascularization has become an important component in the armamentarium of minimally invasive heart surgery.

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.