Predictors and consequences of postoperative atrial fibrillation following robotic totally endoscopic coronary bypass surgery.

OBJECTIVES: Postoperative atrial fibrillation (AFib) is common in patients undergoing coronary artery bypass grafting. Little information is available concerning AFib following minimally invasive cardiac surgery. The aim of our study was to assess the incidence of AFib after totally endoscopic coronary artery bypass (TECAB) grafting and to investigate the factors influencing its occurrence. METHODS: Between 2001 and 2010, we performed TECAB in 384 patients, 73% male, aged 60 (37-90) years. Single-vessel bypasses were performed in 280 patients, and 104 received multivessel coronary revascularization. Procedures were performed on the beating heart in 80 cases, and 164 patients underwent a hybrid intervention. RESULTS: A total of 59 patients (15.4%) developed AFib after TECAB. Univariate analysis showed hypertension (P=0.005), increased age (P=0.007), body weight (P=0.006), body mass index (P=0.005), EuroSCORE (P=0.035) and total TECAB operation time (P=0.01) to be significantly associated with AFib. We also found an increased incidence of AFib in patients undergoing hybrid interventions (P=0.036) and beating heart TECAB (P=0.003). Age (P<0.001) and higher body weight (P=0.003) were the only predictors found to be significant in multivariate analysis. Hospital mortality was 1.7% (1 of 59) in the group of patients with AFib and 0.6% (2 of 325) in the group that showed no AFib after operation (P=n.s.). Hospital stay was 7 (4-54) days in patients with AFib and 6 (2-33) days in those without AFib (P=n.s.). There was no significant 5-year survival difference in patients with and without postoperative AFib (94 vs 94%, P=n.s.). CONCLUSIONS: We conclude that the incidence of postoperative AFib in TECAB is relatively low. Age and body weight are the most important predictors of postoperative AFib following TECAB. Short-term clinical outcome and intermediate-term survival are similar in patients with and without postoperative AFib.

Robotic total endoscopic double-vessel coronary artery bypass grafting--state of procedure development.

OBJECTIVE: Robotic total endoscopic coronary artery bypass grafting (TECAB) has been under development for 10 years. With increasing experience and technological improvement, double-vessel TECAB has become feasible. The aim of the present study was to compare the current outcomes of single- and double-vessel TECAB. METHODS: Between 2001 and 2011, 484 patients underwent TECAB by 4 surgeons at 2 institutions. The median patient age was 60 years (range, 31-90), and the median European System for Cardiac Operative Risk Evaluation was 2 (range, 0-13). Single-vessel (n = 334) and double-vessel (n = 150) procedures were performed using the da Vinci, da Vinci S, and da Vinci Si robotic systems. RESULTS: Compared with the single-vessel procedure, double-vessel TECAB required a longer operative time (median, 375 minutes; range, 168-795; vs median, 240; range, 112-605; P < .001) and had an increased conversion rate to a larger thoracic incision (31/150 [20.7%] vs 31/334 [9.3%]; P < .001). The median ventilation time was 10 hours (range, 0-288) for double-vessel versus 8 hours (range, 0-278) for single-vessel procedures (P = .006). The hospital stay was comparable, with 6 days (range, 2-27) for double-vessel TECAB and 6 days (range, 2-33) for single-vessel TECAB (P = .794). Perioperative mortality was 0.3% (1/334) with single-vessel TECAB and 2.0% (3/150) with double-vessel TECAB (P = .090). Freedom from major adverse cardiac and cerebral events at 5 years was similar after double- and single-vessel TECAB (73.5% vs 83.1%, P = .150). The 5-year survival was 95.8% and 93.9% (P = .708). CONCLUSIONS: Double-vessel TECAB appears feasible and reproducible. The operative times were longer and the conversion rates to a larger thoracic incision were greater than with single-vessel TECAB. Also, the postoperative ventilation time was longer. Other perioperative morbidity and mortality and the recovery time and long-term clinical outcomes, however, were comparable.

Surgical problems and complex procedures: issues for operative time in robotic totally endoscopic coronary artery bypass grafting.

OBJECTIVE: Robotically assisted totally endoscopic coronary artery bypass grafting (TECAB) is a viable option for closed chest coronary surgery, but it requires learning curves and longer operative times. This study evaluated the effect of extended operation times on the outcome of patients undergoing TECAB. METHODS: From 2001 to 2009, 325 patients underwent TECAB with the da Vinci telemanipulation system. Correlations between operative times and preoperative, intraoperative, and early postoperative parameters were investigated. Receiver operating characteristic analysis was used to define the threshold of the procedure duration above which intensive care unit stay and ventilation time were prolonged. Demographic data, intraoperative and postoperative parameters, and survival data were compared. RESULTS: Patients with prolonged operative times more often underwent multivessel revascularization (P < .001) and beating-heart TECAB (P =.023). Other preoperative parameters were not associated with longer operative times. Incidences of technical difficulties and conversions (P < .001) were higher among patients with longer operative times. Prolonged intensive care unit stay, mechanical ventilation, hospital stay, and with requirement of blood products were associated with longer operative times. Receiver operating characteristic analysis showed operative times >445 minutes and >478 minutes to predict prolonged (>48 hours) intensive care unit stay and mechanical ventilation, respectively. Patients with procedures >478 minutes had longer hospital stays and higher perioperative morbidity and mortality. Kaplan-Meier analysis revealed decreased survival among patients with operative times >478 minutes. CONCLUSIONS: Multivessel revascularization and conversions lead to prolonged operative times in totally endoscopic coronary artery bypass grafting. Longer operative times significantly influence early postoperative and midterm outcomes.

Hybrid coronary revascularization using robotic totally endoscopic surgery: perioperative outcomes and 5-year results.

BACKGROUND: Hybrid coronary revascularization combines minimally invasive coronary artery bypass grafting and catheter-based interventions. This treatment option represents a viable alternative to both open multivessel coronary bypass surgery through sternotomy and multivessel percutaneous coronary intervention. The surgical component of hybrid coronary intervention can be offered in a completely endoscopic fashion using robotic technology. We report on one of the largest series to date. METHODS: From 2001 to 2011, 226 patients (age, 61 years [range, 31 to 90 years]; 77.0% male; EuroSCORE, 2 [range, 0 to 13]) underwent hybrid coronary interventions on an intention-to-treat basis. Robotically assisted procedures were performed using the daVinci, daVinci S, and daVinci Si surgical telemanipulation systems (Intuitive Surgical, Inc, Sunnyvale, CA) and included 147 single, 72 double, and 7 triple endoscopic coronary artery bypass grafting procedures. Surgery was carried out first in 160 cases (70.8%), percutaneous coronary intervention was carried out first in 38 cases (16.8%), and 28 patients underwent simultaneous operations in a hybrid operating room (12.4%). Drug-eluting stents were used in 70.0% of the patients. RESULTS: Hospital mortality was 3 of 226 patients (1.3%), and hospital stay averaged 6 days (range, 3 to 54 days). Patients walked outside 7 days (range, 3 to 97 days) postoperatively and performed general household work 14 days (range, 7 to 180 days) postoperatively. Full activity was resumed at 42 days (range, 7 to 720 days). Five-year survival was 92.9%, and 5-year freedom from major adverse cardiac and cerebral events was 75.2%. At 5 years, 2.7% of bypass grafts and 14.2% of percutaneous coronary intervention targets needed reintervention. CONCLUSIONS: Robotically assisted hybrid coronary intervention enables surgical treatment of multivessel coronary artery disease with minimal trauma. Perioperative results and intermediate-term outcomes meet the standards of open coronary artery bypass grafting. Recovery time is short, and reintervention rates are acceptable.

Factors influencing blood transfusion requirements in robotic totally endoscopic coronary artery bypass grafting on the arrested heart.

OBJECTIVE: Robotic technology enables totally endoscopic coronary artery bypass grafting (TECAB) procedures. These operations can be performed on either the beating or arrested heart. One challenge of the latter version is a potentially increased need for blood transfusions. We investigated factors associated with transfusion requirements in totally endoscopic coronary artery bypass on the arrested heart (AH-TECAB). PATIENTS AND METHODS: A total of 161 patients, 124 males and 37 females, aged 59 (31-77 years) years, with European System for Cardiac Operative Risk Evaluation (EuroSCORE) 1 (0-7) underwent AH-TECAB using the daVinci telemanipulation system. The Heartport/Cardiovations™ or ESTECH-RAP™ systems were applied for remote access perfusion and aortic endoocclusion. In all cases, the operation was carried out in moderate hypothermia and cardiac arrest using cold crystalloid cardioplegia mixed with blood. RESULTS: After 20 cases, the blood-transfusion rate dropped from 69% to 44%. The overall median number of transfusions was 1 (0-21). The following pre- and intra-operative factors showed a strong association with the application of packed red blood cells (PRBCs): preoperative haemoglobin level (p < 0.001), female gender (p < 0.001), shorter height (p < 0.001), lower weight (p < 0.001), long operative time (p < 0.001) and long cardiopulmonary bypass time (p = 0.001), intra-operative surgical problem (p < 0.001) and conversion to a larger thoracic incision (p < 0.001). Postoperatively, patients with longer ventilation time (p < 0.001) and those needing revision for bleeding (p < 0.001) also received significantly more PRBCs. CONCLUSION: We conclude that multiple factors are associated with increased blood transfusion requirements in AH-TECAB. However, the transfusion rate can be reduced with experience. Identification of these factors may help in avoiding the application of blood products in the next generation of AH-TECAB procedures.

Closed chest hybrid coronary revascularization for multivessel disease - current concepts and techniques from a two-center experience.

Hybrid coronary revascularization combining minimally invasive coronary surgery and percutaneous coronary intervention (PCI) allows sternal preserving treatment of multivessel coronary disease. The main principle of the technique includes placement of mammary artery graft to the left anterior descending coronary artery (LAD) and performance of PCI in non-LAD target vessels. This principle is based on increasing data showing equivalent results of PCI with coronary revascularization using saphenous vein grafts in selected patients. Providing that perioperative and long-term results are as good as the results of conventional surgical revascularization, this option seems to be quite appealing for patients and referring cardiologists. This concept has been designed to allow rapid rehabilitation and minimize periprocedural pain under concomitant preservation of the patient's body integrity. Robotically assisted endoscopic approaches for hybrid coronary revascularization set the pace for a closed-chest treatment of multivessel coronary disease. The time point of PCI, the use of different anticoagulation protocols as well as the stent selection are some of the variables, which affect outcome. We additionally report on the midterm results of 130 after-closed-chest hybrid-coronary procedures in two institutions. Hybrid procedures using robotic technology and PCI allow closed chest treatment of multivessel coronary artery disease. Single- and double-bypass grafts are feasible and simultaneous interventions can be performed. The overall safety of the procedure seems to be adequate and perioperative clinical results are satisfactory. Intermediate term survival and freedom from angina are excellent.

Predictors, causes, and consequences of conversions in robotically enhanced totally endoscopic coronary artery bypass graft surgery.

BACKGROUND: Totally endoscopic coronary artery bypass graft surgery (TECAB), using the da Vinci telemanipulator, has become a reproducible operation at dedicated centers. As in every endoscopic operation, conversion is an important and probably inevitable issue. METHODS: We performed robotic TECAB in 326 patients (age, 60 years; range, 31 to 90 years); 242 were single-vessel and 84 were multivessel TECAB. RESULTS: Forty-six of 326 patients (14%) were converted to a larger incision (minithoracotomy, n = 5; sternotomy, n = 41). Left internal mammary artery injury (n = 7), epicardial injury (n = 4), balloon endoocclusion problems (n = 7), and anastomotic problems (n = 18) were common reasons for conversions. Conversion rate was significantly less for single-vessel versus multivessel TECABs (10% versus 25%; p = 0.001). Non-learning-curve case (7% versus 21%; p < 0.001) and transthoracic assistance (11% versus 22%; p = 0.018) were associated with lower conversion rates. In multivariate analysis, learning-curve case was the only independent predictor of conversion (p = 0.005). Conversion translated into increased packed red blood cell transfusion in the operating room (3 versus 0 units; p < 0.001), longer ventilation time (14 versus 8 hours; p < 0.001), and intensive care unit stay (45 versus 20 hours; p = 0.001). Hospital mortality was 0.6% in this series, with 1 patient in the conversion group (2.2%) and 1 patient in the nonconverted group (0.4%; not significant). Five-year survival was 98% in nonconverted patients and 88% in converted patients (p = 0.018). There was no difference in freedom from angina or freedom from major adverse cardiac and cerebral events. CONCLUSIONS: Conversion in TECAB is primarily learning curve-dependent and associated with increased morbidity, but does not significantly affect hospital mortality. Both nonconverted and converted patients show good long-term survival, which is comparable to patients undergoing open sternotomy coronary artery bypass grafting. Long-term freedom from angina or freedom from major adverse cardiac and cerebral events is not influenced by conversion.

Does obesity affect operative times and perioperative outcome of patients undergoing totally endoscopic coronary artery bypass surgery?

More and more patients undergoing coronary artery bypass grafting (CABG) are overweight. This patient group suffers from wound healing problems more often than normal-weight patients. Therefore, avoiding sternotomy in obese patients by using an endoscopic technique could be a promising approach. Robotic technology enables totally endoscopic coronary artery bypass grafting (TECAB) procedures. We investigated whether the intra-operative-times or perioperative-outcome after TECAB-procedure are negatively affected by obesity. Patients [n=127, 101 male, 26 female, median age 59 (31-77) years], undergoing arrested-heart TECAB procedure were enrolled. The median body mass index (BMI) in this patient cohort was 26 (19-38). In detail, 27 patients were normal-weight (BMI or= 34 kg/m(2)). There was no correlation between BMI (1) left internal mammary artery (LIMA) takedown-time [Spearman-rank correlation coefficient (R)=0.02; P=n.s.], (2) lipectomy and pericardiotomy-time (R=0.042, P=n.s.), (3) total operative-time (R=-0.083: P=n.s.), (4) cardiopulmonary-bypass-time (R=-0.012; P=n.s.), (5) aortic-endoocclusion-time (R=-0.055; P=n.s.), (6) mechanical-ventilation-time (R=0.001, P=n.s.), (7) length of ICU-stay (R=0.04; P=n.s.), (8) length of hospital-stay (R=-0.103; P=n.s.) or (9) occurrence of intra- and/or postoperative adverse events. In overweight, obese but also morbidly obese patients the TECAB procedure did not increase operative times or the rate of intra- or postoperative complications. This patient group, therefore, benefits from this less traumatic version of coronary surgery.

Training surgeons to perform robotically assisted totally endoscopic coronary surgery.

BACKGROUND: Robotic totally endoscopic coronary bypass (TECAB) surgery was developed during the past decade, and younger surgeons need to be trained in this new modality. This study assessed the learning curves and independent TECAB performance of 2 junior surgeons undergoing TECAB training. METHODS: Two surgeons in training performed portions of 44 of 239 robotic TECAB operations, including left (LIMA) and right interior mammary artery (RIMA) harvesting, lipectomy, pericardiotomy, and IMA to left anterior descending coronary artery (LAD) anastomotic suturing. RESULTS: The procedure portions performed faster by the senior surgeon vs trainees were, in minutes (range), lipectomy, 5 (2 to 18) vs 10 (5 to 21; p < 0.001); pericardiotomy, 5 (1 to 21) vs 7 (3 to 16; p = 0.001); RIMA takedown, 35 (25 to 48) vs 49 (40 to 55; p = 0.034); and LIMA to LAD anastomosis, 26 (12 to 100) vs 34 (24 to 67; p = 0.043). After assuming senior roles in the robotic cardiac surgery program, the 2 trained surgeons performed 14 TECABs (LIMA to LAD) without the senior surgeon. Lipectomy took 5 (3 to 8) minutes; pericardiotomy, 5 (2 to 10) minutes; LIMA takedown, 43 (27 to 70) minutes; LIMA to LAD anastomosis, 24 (15 to 60) minutes, cardiopulmonary bypass time, 73 (40 to 126) minutes; and aortic endo-occlusion time, 53 (0 to 83) minutes. No hospital deaths occurred. CONCLUSIONS: TECAB can be well taught with a stepwise training program involving portions of the procedure performed by trainees. With such an approach, independent performance after training can be within adequate time limits and yields seemingly acceptable results.

Effectiveness and safety of total endoscopic left internal mammary artery bypass graft to the left anterior descending artery.

Totally endoscopic coronary artery bypass grafting (CABG) has become a feasible option using robotic technology and remote access perfusion techniques. The aim of this study was to determine the progression of the procedure's performance in the currently largest single-center series of arrested-heart totally endoscopic CABG. From 2001 to 2007, arrested-heart totally endoscopic CABG was performed in 100 patients (median age 59 years, range 46 to 70; 81 men, 19 women). All patients received left internal mammary artery grafts to the left anterior descending artery using the da Vinci Surgical System. Remote-access femoral perfusion and aortic balloon endo-occlusion were used in all patients. The series was divided into 4 phases: phase 1 (patients 1 to 25), phase 2 (patients 26 to 50), phase 3 (patients 51 to 75), and phase 4 (patients 76 to 100). The conversion rates to larger thoracic incisions were 7 of 25 (28%) in phase 1, 2 of 25 (8%) in phase 2, 1 of 25 (4%) in phase 3, and 1 of 25 (4%) in phase 4 (p = 0.018). Operative times and hospital stays decreased significantly with each subsequent phase, and clinical outcome showed corresponding improvements. There was no perioperative mortality. For the whole patient series, 5-year postoperative survival, freedom from angina, and freedom from major adverse cardiac and cerebral events were 100%, 91%, and 89%, respectively. In conclusion, after an initial steep learning curve, completely endoscopic left internal mammary artery-to-left anterior descending CABG can be performed safely, with low conversion rates. The learning curve for operative times and improvements in clinical outcome continued even at 100 procedures.

Robotic technology-probably a safe tool for development of completely endoscopic coronary revascularization procedures.

BACKGROUND: : Totally endoscopic coronary artery bypass grafting (TECAB) requires telemanipulation technologies because attempts using conventional thoracoscopic instrumentation have completely failed. These complex operations require individual and team learning curves and necessitate a stepwise approach. The aim of this study is to assess risk adjusted outcome in robotically assisted coronary artery bypass grafting (CABG) after the first 6 years of application. METHODS: : From 2001 to 2007, 177 CABG procedures were performed using the da Vinci system. A low risk patient population [age 59 (31-76) years, EuroSCORE 1 (0-7)] was treated. The following procedures were carried out: endoscopic internal mammary artery takedown in minimally invasive direct coronary artery bypass, Off-pump coronary artery bypass, and CABG (n = 26); robotic suturing of left internal mammary artery to left anterior descending artery anastomoses through sternotomy (n = 32); TECAB on the arrested heart (n = 108); TECAB on the beating heart (n = 11). RESULTS: : There was no hospital mortality, and cumulative risk adjusted mortality plots showed that 2.76 predicted events did not occur. Given 177 event free procedures Clopper Pearson estimations revealed a 95% confidence interval between 0.0% and 2.3% for perioperative mortality. CONCLUSIONS: : Introduction of robotic TECAB grafting appears to meet current CABG safety standards. Initial application in low risk patients and a stepwise approach towards completely endoscopic versions of the operation are worthwhile. Despite a high grade of innovation and despite learning curves, perioperative mortality may be lower than predicted.

Myocardial enzyme release in totally endoscopic coronary artery bypass grafting on the arrested heart.

OBJECTIVE: Robotic totally endoscopic coronary artery bypass grafting enables coronary artery bypass grafting without sternotomy or thoracotomy. However, longer cardiopulmonary bypass and aortic endo-occlusion times are currently required compared with those of standard coronary artery bypass grafting operations. We investigated whether longer operation times affect the myocardial enzyme release and the postoperative course. METHODS: From 2001 through 2006, 85 patients with a median age of 58 years (range, 31-76 years) underwent totally endoscopic coronary artery bypass grafting on the arrested heart by using the da Vinci telemanipulator and remote access perfusion through the femoral vessels (Estech or Heartport). The operations involved the left internal thoracic artery-left anterior descending coronary artery or diagonal branch (n = 74); right internal thoracic artery-right coronary artery (n = 2); double-vessel left internal thoracic artery-obtuse marginal branch/circumflex artery and right internal thoracic artery-left anterior descending coronary artery (n = 8); and double-vessel left internal thoracic artery-left anterior descending coronary artery and saphenous vein graft-right coronary artery (n = 1). Totally endoscopic coronary artery bypass grafting duration was 254 minutes (range, 178-710 minutes), cardiopulmonary bypass time was 114 minutes (range, 57-428 minutes), and aortic endo-occlusion time was 65 minutes (range, 28-230 minutes). RESULTS: The postoperative ventilation time was 8 hours (range, 0-278 hours), and the intensive care unit stay was 20 hours (range, 11-389 hours). The postoperative stay at our department was 6 days (range, 4-22 days), and we observed no hospital deaths in this series. Forty-five percent of the patients had an increased postoperative peak creatine kinase MB level, and 75% had an increased troponin T level. Postoperative peak creatine kinase MB levels significantly increased with totally endoscopic coronary artery bypass grafting duration (r = 0.588, P < .001), cardiopulmonary bypass time (r = 0.521, P < .001), and aortic endo-occlusion time (r = 0.400, P < .001) and translated into moderately prolonged intensive care unit stay (r = 0.432, P < .001) and ventilation time (r = 0.517, P < .001). Creatine kinase MB levels were not associated with sex, age, or EuroSCORE. The postoperative left ventricular ejection fraction did not differ significantly from the preoperative left ventricular ejection fraction. CONCLUSIONS: Myocardial protection can be established in arrested heart totally endoscopic coronary artery bypass grafting operations. An influence of increased myocardial enzyme release on postoperative ventilation time and intensive care unit stay is detectable but does not translate into an early mortality or a decrease in left ventricular ejection fraction.