Midterm Clinical Outcomes of Robotic-Assisted Reverse Hybrid Coronary Revascularization: A Single-Center Experience.

Outcomes of robotic-assisted reverse hybrid coronary revascularization (HCR) remain hindered. We aimed to analyze midterm clinical outcomes of robotic-assisted reverse HCR. All consecutive 285 patients who underwent reverse robotic-assisted HCR between September 2005 and July 2021 were included. Reverse HCR comprises percutaneous coronary intervention with stent implantation in non-left anterior descending (LAD) coronary arteries was performed within 30 days before robotic-assisted left internal thoracic artery (LITA) harvesting and LITA-to-LAD manual anastomosis through a 4-cm left minithoracotomy. Dual antiplatelet therapy was not interrupted in any patient. Preoperatively, mean age was 70.2 years (±11.2). Before surgery, 168 patients received 1 stent, 112 patients 2 stents, and 5 patients 3 stents. Intraoperatively, mean operating room time was 5.9 hours (±1); no case was converted to full sternotomy, whereas 9 patients (3.1%) received intraoperative blood product transfusions. Postoperatively, a small incidence of stroke, 1 (0.3%), reoperation for bleeding, 7 (2.4%), blood product transfusions, 48 (16.8%), and hospital stay (4.8 days) was observed. At 30-day follow-up, 1 patient (0.3%) underwent percutaneous coronary intervention with stent on a surgical LITA-LAD anastomosis owing to graft failure. Mean follow-up was 4.2 years. Reported midterm outcomes included all-cause death in 31 patients (10.9%), major adverse cardiovascular and cerebrovascular events in 102 of 285 (35.9%), nonfatal stroke in 2 of 285 (0.7%), myocardial infarction in 17 of 285 (5.9%), and repeat intervention in 50 of 285 patients (17.5%). This single-center study reports effective and safe clinical outcomes at midterm follow-up of reverse HCR procedures for treating multivessel coronary artery disease.

Long-term clinical outcomes of robotic-assisted surgical coronary artery revascularisation.

BACKGROUND: Patients who are not candidates for traditional coronary artery bypass grafting (CABG) and amenable only for percutaneous coronary intervention (PCI) with stents can receive the "gold standard" left internal thoracic artery (LITA) to left anterior descending artery (LAD) anastomosis through robotic-assisted CABG and PCI to non-LAD coronary targets. AIMS: We aimed to analyse clinical outcomes of robotic-assisted CABG. METHODS: A total of 2,280 consecutive patients who had undergone robotic-assisted CABG between May 2005 and June 2021 were included in our study. Robotic-assisted LITA harvest was followed by LITA-LAD manual anastomosis through a 4 cm left thoracotomy. Hybrid coronary intervention (HCR) consists of stent implantation in a non-LAD coronary artery performed within 7 days after robotic-assisted LITA-LAD. We performed a propensity-adjusted analysis comparison after dividing all robotic-assisted CABG patients into three time periods: 2005-2010, 615 patients; 2011-2016, 904 patients; and 2017-2021, 761 patients. RESULTS: The mean age increased from 64.5 years in the first time period to 65.8 years in the second time period to 68.1 years in the third (p<0.0001). Operative time was progressively reduced in the three periods (6.4; 6.2; 5.5 hours; p<0.001). The incidence of conversion to sternotomy remained similar for each period (1.8%; 1.7%; 1.5%; p=0.53). Thirty-day mortality in the three periods included 9 (1.4%), 9 (1.0%), and 7 (0.9%) patients, respectively (p=0.91), while 8 (0.3%) patients had PCI with stents in the entire group. The mean follow-up for the entire population was 4.2 years. At follow-up, the rates of all-cause death, major adverse cardiac and cerebrovascular events, non-fatal stroke, and repeat revascularisation with stents were significantly decreased from the first to the last period (pË0.0001). CONCLUSIONS: Robotic-assisted CABG and HCR provide good long-term outcomes in patients who are not candidates for conventional CABG.

Outcome improvement and cost reduction in an increasingly morbid cardiac surgery population.

Two studies assessed initiatives to improve the quality and the cost-effectiveness of cardiac surgery. The first evaluated a system for access and stabilization (SAS), with coronary stabilization, and a clinical effectiveness quality initiative (CEQI) in off-pump coronary artery bypass grafting. The SAS + CEQI cohort showed significantly lower mortality, a lower percentage of patients requiring prolonged ventilation, and a shorter mean postoperative length of hospital stay than the pre-SAS cohort who underwent on-pump coronary artery bypass grafting. The second study assessed the potential for noninvasive cerebral oximetry to reduce strokes related to all cardiac surgery by optimizing cerebral oxygen delivery. The incidence of permanent stroke was significantly lower in the cerebral oximetry group than in an earlier control group in which cerebral oximetry was not used, despite the fact that the study group had a significantly greater number of patients in New York Heart Association classes III and IV. The proportion of patients requiring prolonged ventilation was significantly lower, and the length of postoperative hospital stay was significantly shorter in the study group than in the control group. The incidence of cerebrovascular accident in the study group was 0.97%, compared with 2.03% in the controls. This translated to a potential avoidance of 12 cerebrovascular accidents and approximately $254,214 in direct costs and more than $425,000 in total costs. The results show that specific measures can improve outcomes and reduce costs in cardiac surgery. Therefore, the use of a clinical effectiveness quality initiative and cerebral oximetry in all cardiac surgery, with the SAS system for off-pump surgery, should be advocated.

Outcomes after usage of a quality initiative program for off-pump coronary artery bypass surgery: a comparison with on-pump surgery.

BACKGROUND: Off-pump coronary artery bypass (OPCAB) may be associated with improved outcomes when compared with on-pump coronary artery bypass. This study evaluates the use of a system for access and stabilization (SAS) with a coronary stabilizer as well as a clinical effectiveness quality initiative (CEQI) process regarding outcomes. This included the development of an expanded heart care team as well as standardization and refinement of perioperative care at The Lankenau Hospital (TLH). Our aim was to evaluate morbidity and mortality of on-pump coronary artery bypass grafting (CABG) compared with OPCAB surgery using SAS in addition to a CEQI initiative. METHODS: A retrospective consecutive cohort study using the Society of Thoracic Surgery (STS) National Database was conducted. Three cohorts were analyzed: pre-SAS (December 1, 1999-August 31, 2000); use of SAS only (September 1, 2000-April 30, 2001), and the use of SAS + CEQI process (May 1, 2001-September 30, 2002). Morbidity and mortality for all on-pump CABG procedures performed over the time period of December 1, 1999-September 30, 2002 were compared with the SAS and SAS + CEQI groups only. RESULTS: One-thousand two-hundred sixty-seven procedures were performed; 405 on-pump CABGs, 90 OPCABs pre-SAS, and 772 OPCABs with SAS, of which 552 were in the SAS + CEQI group. Statistically mortality was significantly lower in the SAS + CEQI vs the on-pump group (0.7% vs 3.0%, p < 0.01). The percentage of patients with prolonged ventilation was significantly lower statistically in the SAS + CEQI vs the on-pump group (4.2% vs 9.7%, p < 0.01). Statistically the length of stay was significantly lower in both SAS groups compared with the on-pump group (p < 0.01). CONCLUSIONS: OPCAB surgery using SAS in conjunction with a CEQI initiative improves outcomes for patients compared with on-pump CABG surgery.