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).

Minimally invasive multivessel coronary grafting using a robotic totally endoscopic approach.

Totally endoscopic multi-vessel coronary artery bypass grafting is an advanced surgical technique that offers the least-invasive alternative to traditional sternotomy bypass surgery. Although robotic-assisted minimally invasive left internal thoracic artery to left anterior descending artery bypass has been adopted widely, the application of a robotic totally endoscopic approach for multi-vessel bypass still remains limited. This case report demonstrates the surgical technique of robotic totally endoscopic multi-vessel coronary artery bypass using bilateral internal thoracic artery grafts.

Robotic redo totally endoscopic coronary artery bypass to the right coronary artery in a patient with prior coronary bypass surgery.

Surgical revascularization of the right coronary artery in a patient with previous coronary bypass surgery is rare and challenging. One alternative to the resternotomy approach, the subxiphoid approach with the right gastroepiploic artery, has been safely utilized to prevent injury to prior patent grafts. However, this approach might not be suitable for a patient who has adhesions that are the result of a prior abdominal operation. We describe in this case report a technique for robotic totally endoscopic right internal thoracic artery bypass to the right coronary artery in a patient with a previous coronary artery bypass operation and abdominal surgery.

Ventricular Fibrillatory Arrest: A Safe Option in Robotic Totally Endoscopic Intracardiac Surgery.

BACKGROUND: Moderate hypothermic ventricular fibrillatory arrest during heart surgery is an alternative to cardioplegic arrest in selected patients. We reviewed our experience using a ventricular fibrillatory arrest technique in robotic totally endoscopic intracardiac surgery. METHODS: From February 2014 through July 2022, 128 patients who underwent robotic totally endoscopic intracardiac surgical procedures performed using moderate hypothermic ventricular fibrillatory arrest were reviewed. Patients were chosen based on the risk of aortic manipulation, complexity of the procedure, grade of aortic valve insufficiency and comorbidities, including history of prior cardiac surgery and peripheral vascular disease. RESULTS: Patients were a mean age of 65 ± 14 years, and the mean The Society of Thoracic Surgeons score was 2.7 ± 2.9. Fourteen patients (11%) had a history of previous cardiac surgery. The intracardiac procedures were mitral valve surgery in 84 patients (66%), isolated cryomaze procedure in 27 (21%), and other in 17 (13%). The mean ventricular fibrillatory arrest time was 79 ± 26 minutes, and the mean cardiopulmonary bypass time was 174 ± 49 minutes. There was no conversion to sternotomy. Seven patients (5.5%) required inotropic support, and 2 patients (1.6%) needed an intra-aortic balloon pump. There was no incidence of postoperative stroke or clinical myocardial infarction. The mean hospital and intensive care unit lengths of stay were 3.1 ± 1.7 and 1.4 ± 0.7 days, respectively. One death (0.78%) occurred due to respiratory failure. CONCLUSIONS: Moderate hypothermic ventricular fibrillatory arrest in robotic intracardiac surgery may be a safe and effective alternative in selected patients.

Multi-spectrum robotic cardiac surgery: Early outcomes.

Objective: The robotic cardiac surgery program at our current institution began in 2013 with an experienced and dedicated team. This review analyzes early outcomes in the first 1103 patients. Methods: We reviewed all robotic procedures between July 2013 and February 2021. Primary outcomes were mortality and perioperative morbidity. Our robotic approach is totally endoscopic for all cases: off-pump for coronary and epicardial procedures, and on-pump with the endoballoon for mitral valve and other intracardiac procedures. Results: There were 1103 robotic-assisted cardiac surgeries over 7 years. A total of 585 (53%) were off-pump totally endoscopic coronary artery bypasses, 399 (36%) intracardiac cases (including isolated and concomitant mitral valve procedures, isolated tricuspid valve repair, CryoMaze, atrial or ventricular septal defect repair, benign cardiac tumor, septal myectomy, partial anomalous pulmonary venous drainage, and aortic valve replacement); 80 (7%) epicardial electrophysiology-related procedures (epicardial atrial fibrillation ablation, left atrial appendage ligation, lead placement, and ventricular tachycardia ablation); and 39 (4%) other epicardial procedures (pericardiectomy, unroofing myocardial bridge). Mortality was 1.2% (observed/expected ratio, 0.7). In the totally endoscopic coronary artery bypass and intracardiac groups, mortality was 1.0% (observed/expected, 0.6) and 1.5% (observed/expected, 0.87), respectively. There were 8 conversions to sternotomy (0.7%) and 24 (2.2%) take-backs for bleeding. Mean hospital and intensive care unit lengths of stay were 2.74 ± 1.26 days and 1.28 ± 0.57 days, respectively. Conclusions: This experience demonstrates that a robotic endoscopic approach can safely be used in a multitude of cardiac surgical procedures both on- and off-pump with excellent early outcomes. An experienced surgeon and team are necessary. Longer-term follow-up is warranted.

Robotic off-pump totally endoscopic coronary artery bypass in the current era: report of 544 patients.

OBJECTIVES: Robotic off-pump totally endoscopic coronary artery bypass (TECAB) is the least invasive form of surgical coronary revascularization. It has proved to be highly effective and safe. Its benefits are well-established and include fewer complications, shorter hospital stay and quicker return to normal activities. TECAB has undergone 2 decades of technological advancement to include multivessel grafting, a beating-heart approach and successful completion in multiple patient groups in experienced hands. The aim of this report was to examine outcomes of robotic off-pump TECAB at our institution over 7 years. METHODS: Data from 544 patients undergoing TECAB between July 2013 and August 2020 were retrospectively examined. The C-Port Flex-A distal anastomotic device was used for the majority of grafts (70%). Yearly follow-up was conducted. Angiographic early patency data were reviewed for patients undergoing hybrid revascularization. RESULTS: The mean age was 66 years, with 1.7% mean STS risk. Fifty-six percentage had multivessel TECAB. There was 1 conversion to sternotomy, and 46% extubation in the Operating Room (OR). Mortality was 0.9%. Early graft patency was 97%. At mid-term follow-up at 38 months, cardiac mortality was 2.7% and freedom from major adverse cardiac events was 92.5%. CONCLUSIONS: We conclude that robotic beating-heart TECAB in the current era is safe and effective with excellent outcomes and comparable early angiographic patency to standard coronary artery bypass grafting surgery when performed frequently by an experienced team. This procedure was completed in our hands both with and without an anastomotic device. Longer-term studies are warranted.

Robotic Total Endoscopic Coronary Bypass in 570 Patients: Impact of Anastomotic Technique in Two Eras.

BACKGROUND: In coronary artery bypass grafting, including robotic off-pump totally endoscopic coronary artery bypass (TECAB), the anastomotic technique is the most critical part of the procedure. We reviewed results in 570 patients over a 7-year period and compared outcomes between two eras based on predominant anastomotic technique: connectors vs running suture. METHODS: Between July 2013 and December 2020, 570 patients underwent off-pump TECAB: group 1 consisting of 378 patients, from July 2013 to August 2018, using predominantly the C-Port Flex A distal anastomotic stapler (Aesculap); and group 2 consisting of 192 patients, from September 2018 to December 2020, using predominantly a sutured technique (7-0 Pronova; Johnson & Johnson). Retrospective analysis of clinical outcomes was performed. RESULTS: Off-pump TECAB was completed in 98.8% (563 of 570 patients) with an observed/expected mortality of 0.6% (6 of 570 patients). The anastomotic device was used in 89% of 626 grafts in group 1 and only 11% of 305 grafts in group 2 (P = .001). There were no differences in multivessel TECAB (57% vs 53%; P = .331) or bilateral internal thoracic artery use (50% vs 43%; P = .127) in group 1 vs group 2, respectively. Operative time was shorter in group 1 (242 ± 84 vs 273 ± 88 minutes; P < .001). Early clinical outcomes were similar between groups, except for hospital stay, which was longer in group 1 (2.9 vs 2.3 days; P < .001). Graft patency was similar (98% vs 95%; P = .295) in group 1 vs group 2, respectively. CONCLUSIONS: Changing the predominant approach from stapled anastomosis to a sutured technique during robotic TECAB resulted in longer operative times. Both approaches led to excellent outcomes, including graft patency. The shorter operative times conferred by using staplers may flatten the learning curve and facilitate broader adoption of TECAB.