Robotic Totally Endoscopic Coronary Bypass to the Left Anterior Descending Artery: Left Versus Right Internal Thoracic Artery Grafts.

INTRODUCTION: The left internal thoracic artery (LITA) is most commonly used to bypass the left anterior descending artery (LAD) given its well-established mortality benefit. In some cases, the grafting strategy necessitates placing the right internal thoracic artery (RITA) on the LAD. We compared outcomes in our robotic beating-heart totally endoscopic coronary bypass surgery (TECAB) population between patients receiving LITA versus RITA-LAD grafts. METHODS: We retrospectively reviewed patients undergoing robotic TECAB with skeletonized ITA conduits over 9 y. Outcomes were compared between those receiving LITA (Group-1) versus RITA (Group-2) grafts to the LAD (with/without other grafts). End points were early angiographic patency (in patients undergoing hybrid revascularization) and mid-term mortality/major adverse cardiac/cerebrovascular events. A propensity matched subanalysis was performed comparing only patients who received bilateral ITA grafting in each group. RESULTS: Society of Thoracic Surgeons predicted mortality risk score was higher in Group-2. Group-1 patients had lower incidence of multivessel disease (75% versus 96%, P ≤ 0.001). Early overall graft patency (97% versus 96%, P = 0.718) and LAD graft patency (98% versus 95%, P = 0.372) were equivalent. At mean 42-mo follow-up (longest 8.5 y), Group-1 had lower all-cause mortality but no difference in cardiac mortality or repeat revascularization. In the propensity matched subanalysis, mid-term outcomes were equivalent. CONCLUSIONS: Grafting the LAD with the LITA or RITA during robotic beating-heart TECAB resulted in similar early outcomes and angiographic patency. RITA-LAD patients were more likely to have multivessel disease and higher Society of Thoracic Surgeons risk and had higher all-cause mortality at mid-term analysis but no difference in major adverse cardiac/cerebrovascular events, including cardiac mortality.

Robotic totally endoscopic excision of aortic valve papillary fibroelastoma: The least invasive approach.

INTRODUCTION: Papillary fibroelastomas (PFEs) are a rare subtype of benign primary cardiac tumors, which are most commonly found on the aortic valve (AV). They have the potential to cause severe adverse clinical consequences, thus prompting surgical excision in the majority of cases. In this article, we report on a series of 5 PFEs resected from the AV using a robotic-assisted sternal-sparing approach, and review of the literature on this approach. To our knowledge, this is the largest reported series of robotic-assisted sternal-sparing AV-PFE resections. MATERIALS AND METHODS: From May 2016 until November 2018, 5 patients at our institution underwent removal of a papillary fibroelastoma from the aortic valve using a totally endoscopic robotic-assisted approach. After obtaining institutional IRB approval, we retrospectively reviewed their data for this report. We additionally contacted the patients to acquire a last clinical follow up for this study. Results In this series of 5 patients who underwent robotic totally endoscopic excision of AV PFE, all patients had successful removal of their tumor with no significant morbidity or mortality. All 5 patients were seen at a 30-day follow-up office visit, at which time they had recovered from surgery and were back to full activity. At a mean of 24 months all patients were doing well and free of symptoms with no evidence of tumor recurrence on repeat echo evaluation. DISCUSSION: This is a series of 5 patients with AV-associated PFEs who underwent robotic totally-endoscopic excision without rib-spreading or conversion to sternotomy. This report demonstrated the successful application of robotic-assisted technology in aortic valve pathology. All PFEs were successfully removed without valve repair or replacement. We were able to offer a safe, curative, minimally-invasive surgical excision option for this group of patients. CONCLUSION: Our patients in this cohort demonstrated the well-established benefits of robotic sternal-sparing cardiac surgery, including excellent intra and postoperative outcomes and accelerated recovery.

Predictors of blood transfusion use in robotic beating-heart totally endoscopic coronary artery bypass with anastomotic connectors.

BACKGROUND: We sought to identify the independent predictors of blood transfusion requirement in robotic beating-heart patients with totally endoscopic coronary artery bypass (TECAB). METHODS: We retrospectively reviewed patients undergoing TECAB with distal anastomotic connectors from July 2013 to May 2017 at our institution. The cohorts were divided into patients who received a blood transfusion (BT group) and patients who did not (non-blood transfusion [NBT] group). RESULTS: Two-hundred seventy-four consecutive patients underwent TECAB, and 47 patients (17%; BT group) received BT. The BT group had a lower preoperative hemoglobin level and a higher rate of preoperative risk profiles and higher society of thoracic surgeons (STS) predicted the risk of mortality. Kaplan Meier analysis showed decreased 1-year survival in the BT group compared with the NBT group (90.9% vs 96.4%; logrank, 0.017). The Youden index identified a preoperative hemoglobin cutoff value of 12.2 g/dL (sensitivity 60.9%, specificity 79.3%) and operative time of 300 minutes (sensitivity 61.7%, specificity 59.0%) for BT requirement. Multivariate logistic regression analysis identified a preoperative hemoglobin <12.2 g/dL (odds ratio, 6.03; 95% confidence interval, 3.01-12.1) and an operative time >300 minutes (odds ratio, 2.15; 95% confidence interval, 1.07-4.33) as independent factors associated with BT requirement. CONCLUSIONS: We found that preoperative hemoglobin and operative time were independent predictors of BT requirement during robotic beating-heart TECAB. These data would help to select patients to minimize perioperative BT as well as predict outcomes after this procedure.

Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass: Impact of Chest Wall Dimensions in Single and Multivessel Bypass.

OBJECTIVE: There can be anatomical constraints on patient selection for minimally invasive surgery. For example, robot-assisted coronary artery bypass was reported to be more challenging when patients had a cardiothoracic ratio >50% and a sternum-vertebra anteroposterior and transverse diameter ratio <0.45. We sought to examine the impact of chest wall anatomic parameters on surgical outcomes in our totally endoscopic coronary artery bypass (TECAB) procedures. METHODS: We retrospectively reviewed patients who underwent robotic TECAB, all of whom had a preoperative chest radiograph at our institution from July 2017 to October 2021. The cohort was divided into 2 groups, which were patients undergoing single-vessel grafting using the left internal thoracic artery (ITA; group 1) and patients undergoing multivessel grafting with bilateral ITA grafts (group 2). We measured several anatomical parameters from the preoperative chest radiograph. RESULTS: A total of 352 patients undergoing TECAB were retrospectively analyzed. After exclusions, 193 were included in this study. In group 1 (n = 91), no parameters correlated with operative time. In group 2 (n = 102), a significant negative correlation was observed between operative time and the sternum-vertebrae anteroposterior diameter (rs = -0.228, P = 0.022) and lung anteroposterior diameter (rs = -0.246, P = 0.013). To confirm these results in group 2, a propensity-matched analysis was performed and showed a statistically significant difference in surgical time based on chest anteroposterior diameters. CONCLUSIONS: In single-vessel robotic TECAB, chest wall anatomic dimensions measured on chest radiograph did not affect operative time. In multivessel cases with bilateral ITA grafts, larger anteroposterior diameter correlated with shorter operative times.

Incidence, characteristics, and outcomes of reintervention after mitral transcatheter edge-to-edge repair.

OBJECTIVE: The use of transcatheter edge-to-edge repair (TEER) is growing substantially, and reintervention after TEER by way of repeat TEER or mitral valve surgery (MVS) is increasing as a result. In this nationally representative study we examined the incidence, characteristics, and outcomes of reintervention after index TEER. METHODS: Between July 2013 and November 2017, we reviewed 11,396 patients who underwent index TEER using Medicare beneficiary data. These patients were prospectively tracked and identified as having repeat TEER or MVS. Primary outcomes included 30-day mortality, 30-day readmission, 30-day composite morbidity, and cumulative survival. RESULTS: Among 11,396 patients who underwent TEER, 548 patients (4.8%) required reintervention after a median time interval of 4.5 months. Overall 30-day mortality was 8.6%, 30-day readmission was 20.9%, and 30-day composite morbidity was 48.2%. According to reintervention type, 294 (53.7%) patients underwent repeat TEER, and 254 (46.3%) underwent MVS. Patients who underwent MVS were more likely to be younger and female, but had a similar comorbidity burden compared with the repeat TEER cohort. After adjustment, there were no differences in 30-day mortality (adjusted odds ratio [AOR], 1.26 [95% CI, 0.65-2.45]) or 30-day readmission (AOR, 1.14 [95% CI, 0.72-1.81]). MVS was associated with higher 30-day morbidity (AOR, 4.76 [95% CI, 3.17-7.14]) compared with repeat TEER. Requirement for reintervention was an independent risk factor for long-term mortality in a Cox proportional hazard model (hazard ratio, 3.26 [95% CI, 2.53-4.20]). CONCLUSIONS: Reintervention after index TEER is a high-risk procedure that carries a significant mortality burden. This highlights the importance of ensuring procedural success for index TEER to avoid the morbidity of reintervention altogether.

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.

Late results of chord transfer and other techniques for anterior leaflet repair without neochords.

OBJECTIVE: Anterior and bileaflet degenerative mitral regurgitation repairs are challenging. We examined our early and late outcomes for repair using 4 techniques, without neochord repair. METHODS: Between February 1, 2006, and June 30, 2021, a total of 2368 patients received mitral valve ± other surgery by 1 surgeon, including 1160 with degenerative mitral regurgitation. Clinical follow-up was conducted annually (mean 6.8 ± 4.4 years). RESULTS: Repair was performed in 1137 patients (98%) (mean age, 60.5 ± 11.9 years). Repair rate varied between groups: 99% for isolated posterior leaflet (794/799), 91% for isolated anterior leaflet (83/91), and 96% for bileaflet prolapse (260/270; P < .001). Thirty-day mortality was 0.2%. On a scale of 0 to 4+ mitral regurgitation, mean mitral regurgitation grade decreased from 3.8 ± 0.6 preoperatively to 0.07 ± 0.3 at discharge, including moderate (2+) in 0.6% (7/1137) overall and 0.9% (3/343) with anterior prolapse. None were more than 2+ at discharge. Among the 3 groups of leaflet prolapse, there was no significant difference in long-term survival (P = .26), freedom from mitral valve reintervention (P = .12; 99.4% overall), and freedom from more than moderate (2+) mitral regurgitation (P = .16; 98.3% overall). The 4 most common anterior leaflet repair techniques (chord transfer 17%; commissuroplasty 10%; Alfieri [edge-to-edge] 6%); ring with posterior resection (4.3%) had similar freedom from 10-year reintervention (99.4%, 94%, 100%, and 100%, respectively; P = .29). CONCLUSIONS: Complex anterior leaflet prolapse repairs are successful using a variety of techniques without neochord implantation. Although neochords are popular, there are other ways to repair complex valves that do not require as much judgment and experience.

Postoperative Day 1 Discharge After Robotic Totally Endoscopic Coronary Bypass: The Ultimate in Enhanced Recovery After Surgery.

OBJECTIVE: The benefits of Enhanced Recovery After Surgery (ERAS) protocols are being recognized in multiple surgical specialties, including following coronary bypass surgery to improve quality of care and decrease costs. We developed a fast-track discharge protocol for patients undergoing robotic totally endoscopic coronary bypass surgery (TECAB) to be discharged on postoperative day (POD) 1, the subjects of this study. METHODS: In a retrospective study of 720 patients undergoing robotic beating-heart TECAB over 8 years at our institution, 93 patients were selected for a fast-track POD1 discharge protocol. We compared the outcomes of this group to the remaining 627 patients who were discharged per standard protocol (non-POD1 discharge). RESULTS: The early discharge group was significantly younger, had lower Society of Thoracic Surgeons (STS) risk of mortality, and had a lower prevalence of obesity, diabetes, and chronic kidney disease. Patients discharged on POD1 were more often extubated in the operating room (56% vs 42%, P = 0.010). The readmission rate for the early discharge group was 3.2%, which was similar to the readmission rate of 6.7% for the standard discharge protocol group (P = 0.329). Time to return to work was shorter in the early discharge group, although it did not quite reach statistical significance (12 vs 18 days, P = 0.051). There was no difference in midterm cardiac mortality. CONCLUSIONS: Early discharge on POD1 after robotic TECAB is appropriate in selected patients and is associated with low readmission rates and a trend towards earlier return to work. Patients suitable for this "ultrafast-track" approach were more likely to be younger, have lower STS risk, and fewer comorbidities.

Transit Time Flow Measurement in Robotic Totally Endoscopic Coronary Artery Bypass: What Do the Numbers Mean?

OBJECTIVE: Transit time flow measurement (TTFM) is valuable for assessing intraoperative graft patency in coronary artery bypass surgery (CAB). The significance of competitive native coronary flow on patency, as predicted by percentage of backflow (%BF) on TTFM, is unknown. This study aims to evaluate intraoperative TTFM parameters, and specifically %BF, in predicting graft patency in robotic totally endoscopic CAB (TECAB). METHODS: We reviewed TTFM parameters in 311 patients undergoing robotic off-pump TECAB at our institution between February 2016 and January 2020. Patients with sequential or Y grafts were excluded, leaving 277 patients with a total of 387 isolated end-to-side grafts (248 left internal mammary artery [LIMA], 149 right IMA [RIMA]). Mean graft flow, diastolic flow, pulsatility index, and %BF were measured intraoperatively. Early postoperative angiograms were obtained in 83 patients undergoing percutaneous coronary intervention for hybrid revascularization, with a total of 125 grafts. Angiograms were independently analyzed and separated into 2 groups based on IMA graft patency, which were patent (FitzGibbon A/B) and nonpatent (FitzGibbon O) groups. RESULTS: Early angiographic patency at a median of 31.0 days after surgery showed 123 (97.1%) patent grafts and 3 (2.9%) occluded grafts in both LIMA and RIMA grafts to both left anterior descending (LAD) and non-LAD targets. Mean graft flow was 77.4 ± 41.6 mL/min. There was no difference in mean flow, pulsatility index, or %BF between the patent and occluded grafts. CONCLUSIONS: Excellent intraoperative flow parameters and early angiographic patency can be obtained via robotic, off-pump TECAB. Our data did not demonstrate an association between intraoperative TTFM evidence of competitive native coronary flow and early angiographic graft outcomes.

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 Patients With Low Ejection Fraction.

Objective: Robotic totally endoscopic coronary bypass (R-TECAB) has been shown to be a safe and effective technique with excellent outcomes. The aim of this study is to assess the feasibility of R-TECAB in patients with low left ventricular ejection fraction (LVEF) and to report our midterm outcomes with up to 7-year follow-up. Methods: All patients undergoing R-TECAB at our institution between July 2013 and July 2020 were retrospectively reviewed. A total of 100 patients were identified with low LVEF defined as ≤40%. The preoperative characteristics, perioperative and postoperative outcomes, as well as the midterm results were reviewed. Results: The mean LVEF was 31%, and 62% of all patients had preexisting congestive heart failure. Of the cohort, 59% had 3-vessel disease and 6% underwent previous cardiac surgery. Multivessel TECAB was performed in 54%. Hybrid coronary revascularization occurred in 36 individuals. Two patients required cardiopulmonary bypass, and 35% were extubated in the operating room. No sternotomy conversions were required. One patient underwent reoperation for bleeding. No perioperative stroke, myocardial infarction, or mortality occurred. The left internal mammary artery graft patency was 97% at a mean of 1.6 months in the staged hybrid percutaneous coronary intervention group. At midterm follow-up the cardiac-related mortality was 5%. Heart transplant or left ventricular assist device was required in 4 patients, and 1 patient experienced a myocardial infarction. Freedom from major adverse cardiac events was 89%. Conclusions: Off-pump TECAB can be successfully performed in patients with low LVEF in the setting of an experienced and dedicated robotic cardiac surgery team. Our data demonstrate the feasibility of the technique with excellent perioperative and midterm outcomes.

Hybrid Coronary Revascularization: Early Outcomes and Midterm Follow-Up in Patients Undergoing Single or Multivessel Robotic TECAB and PCI.

OBJECTIVE: Hybrid coronary revascularization (HCR) is the integration of sternal-sparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with multivessel coronary artery disease (CAD). It is traditionally performed with single-vessel bypass (left internal mammary artery [LIMA] to left anterior descending artery [LAD]) and PCI but can also be accomplished with multiple arterial grafts using bilateral IMA conduits. We sought to review our HCR experience over an 8-year period with robotic totally endoscopic coronary artery bypass (TECAB) and PCI. METHODS: Of 694 patients undergoing beating-heart TECAB from August 2013 to June 2022, 306 patients were designated as intention-to-treat HCR candidates. Patients underwent PCI prior to, the same day as, or following TECAB, performed using single or bilateral IMA grafts. We retrospectively reviewed early and midterm outcomes up to 8 years in this cohort of patients. RESULTS: The mean Society of Thoracic Surgeons predicted risk of mortality was 1.5% ± 2.5%. There were 44 patients (14%) who had ≥70% left main disease and 218 patients (71%) who had triple-vessel disease. A total of 193 patients (63%) underwent multivessel grafting (advanced HCR), with 83% bilateral IMA use. Mean operative time was 263 ± 80 min, and mean length of stay was 2.6 days. The mean number of vessels bypassed per patient was 1.7 ± 0.6. The mean number of vessels stented was 1.2 ± 0.5. Of the patients, 84% underwent TECAB first, 14% PCI first, and 2% same-day TECAB/PCI. Mortality was 0.6% (observed to expected ratio: 0.42). Early graft patency was 97% (328 of 339 grafts); LIMA-LAD patency was 98%. At 8-year follow-up (mean 37 ± 26 months), all-cause and cardiac-related mortality were 13% and 2.6%, respectively. Freedom from major adverse cardiac and cerebrovascular events was 92%. CONCLUSIONS: In patients with multivessel CAD, integrating robotic single and multivessel TECAB with PCI resulted in excellent early and midterm outcomes. In experienced hands, the robotic endoscopic approach allows the routine use of multiple arterial grafting during HCR.

Robotic advanced hybrid coronary revascularization: Outcomes with two internal thoracic artery grafts and stents.

Objective: Advanced hybrid coronary revascularization is the integration of sternal-sparing multivessel coronary artery bypass grafting and percutaneous coronary intervention in patients with multivessel coronary artery disease. We sought to review our advanced hybrid coronary revascularization experience over an 8.5-year period using robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery grafts and percutaneous coronary intervention. Methods: From August 2013 to February 2022, 664 patients underwent robotic totally endoscopic coronary artery bypass at our institution. Of the 293 patients who underwent totally endoscopic coronary artery bypass assigned to a hybrid revascularization strategy, 156 patients received bilateral internal thoracic artery grafts and are the subject of this review. Patients underwent percutaneous coronary intervention with drug-eluting stents before or after totally endoscopic coronary artery bypass. We reviewed early and midterm outcomes (up to 8 years) in this cohort of patients with intent-to-treat advanced hybrid coronary revascularization. Results: The mean age of patients was 65 ± 10 years. The mean Society of Thoracic Surgeons predicted risk of mortality was 1.26 ± 1.56. Triple-vessel disease occurred in 94% of patients, and 17% of patients had 70% or more left-main disease. The mean operative time was 311 ± 54 minutes, and the mean hospital length of stay was 2.7 ± 1.1 days. All patients had bilateral internal thoracic artery grafts; the total number of grafts was 334. Eight seven percentage of patients had totally endoscopic coronary artery bypass ×2, and 13% of patients had totally endoscopic coronary artery bypass ×3. One patient received totally endoscopic coronary artery bypass ×4. The mean number of grafts per patient was 2.14 ± 0.4, and the mean number of vessels stented was 1.23 ± 0.5. There were no conversions, perioperative stroke, or myocardial infarction. Early mortality occurred in 2 patients. Early graft patency was 98% (209/214 grafts); left internal thoracic artery to left anterior descending patency was 100% (66/66 grafts). At 8-year follow-up in 155 patients (mean 39 ± 26 months), all-cause and cardiac-related mortality were 11.6% and 3.9%, respectively. Freedom from major adverse cardiac/cerebrovascular events including repeat revascularization was 94%. Conclusions: In patients with multivessel coronary artery disease, integrating robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery and percutaneous coronary intervention resulted in excellent early and midterm outcomes. Further studies are 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.

Robotic totally endoscopic beating-heart bypass to the right coronary artery: first worldwide experience.

OBJECTIVES: Left coronary vessels are the usual targets in totally endoscopic coronary artery bypass (TECAB). Grafting of the right coronary artery (RCA) has been limited using this approach because of anatomic and technical difficulties. We report a first series of robotic beating-heart TECAB to the RCA via a right-chest approach. METHODS: From July 2013 to April 2019, patients who underwent robotic beating-heart TECAB with the right internal mammary artery to the RCA were reviewed. Port placement in the right chest mirrored standard left-sided ports. Indications for right internal mammary artery to RCA bypass were RCA disease not amenable to percutaneous intervention and anomalous origin of the RCA. RESULTS: Right internal mammary artery-RCA bypass was performed in 16 patients (mean age 60.6 ± 13.5, 75% male). All cases were completed without conversion to sternotomy or mini-thoracotomy. Cardiopulmonary bypass was required in 1 patient to expose the posterior descending artery. Mean procedure time was 223 ± 49 min, with half of the patients extubated in the operating room (50%). Mean intraoperative transit-time graft flow was 87.0 ± 19.3 ml/min, and a pulsatility index of 1.2 ± 0.2. Mean length of stay was 2.3 ± 1.2 days. No mortality was observed at mean follow-up time of 20.6 months. One patient required repeat RCA revascularization for progression of native disease 43.7 months after the surgery. CONCLUSIONS: Robotic beating-heart TECAB for isolated RCA disease is a feasible operation in selected patients. This technique is possible even for the posterior descending artery.

Does Intolerance of Single-Lung Ventilation Preclude Robotic Off-Pump Totally Endoscopic Coronary Bypass Surgery?

OBJECTIVE: Robotic off-pump totally endoscopic coronary artery bypass (TECAB) usually requires isolated single (right) lung ventilation to adequately expose the surgical site. However, in some patients, persistent oxygen desaturation may occur and conversion to cardiopulmonary bypass (CPB) or sternotomy may be necessary. We reviewed the characteristics and clinical outcomes in patients who did not tolerate single-lung ventilation during TECAB surgery. METHODS: After Institutional Review Board approval we reviewed 440 patients undergoing robotic TECAB at our institution between July 2013 and April 2019. Patients were separated into 2 groups based on their ability to tolerate single-lung ventilation during the procedure. Group 1 included patients able to tolerate single-lung ventilation and Group 2 were patients who required double-lung ventilation to tolerate the procedure. Early and mid-term outcomes were compared. RESULTS: Group 2 (121 patients) had higher Society of Thoracic Surgeons scores, higher body mass index, and more triple-vessel disease than Group 1 (319 patients). Group 2 had more bilateral internal mammary artery use, multivessel grafting, and longer operative times. One patient underwent conversion to sternotomy and 5 required CPB (all in Group 1). Intensive care unit and hospital length of stay were longer in Group 2. Observed/expected mortality did not differ between groups (1.06% in Group 2 vs 0.4% in Group 1; P = 0.215). At mid-term follow-up, cardiac-related/overall mortality and freedom from major adverse cardiac events were similar. CONCLUSIONS: In our cohort, intolerance of single-lung ventilation did not preclude robotic off-pump TECAB. Double-lung ventilation is feasible during the procedure and may prevent conversions to sternotomy or use of CPB, resulting in excellent early and mid-term outcomes.

Robotic cardiac surgery impact of a new patient-side assistant on outcomes.

OBJECTIVE: Very few studies have focused on the experience of the patient-side assistant in robotic cardiac surgery. We investigated whether the retirement of a highly experienced robotic patient-side assistant and replacement with a new assistant had an effect on surgical outcomes. METHODS: In 4/2016, the established patient-side assistant retired after spending 8 months training a new patient-side assistant. A retrospective analysis of 216 patients was performed; 108 patients over a 9 month period just prior to arrival of the new patient-side assistant (Group 1), and 108 patients over 8 months just subsequent to departure of the established assistant (Group 2). Case distribution, pre-operative characteristics, and surgical outcomes were collected and compared. RESULTS: Case volume increased in Group 2 with the new assistant. The mean age and rate of pre-op CVA for Group 1 was lower, but, otherwise, patient demographics were not significantly different. Group 1 had more intracardiac cases and group 2 had more triple-vessel TECABs. Overall operative time was not different between the two groups. Perioperative outcomes including hospital length of stay major adverse cardiovascular events and mortality were similar between the two groups. CONCLUSIONS: We conclude that the transition to a new robotic cardiac surgical patient-side assistant does not have to affect the progress of a busy robotic program. If adequate time for training and gradual assumption of responsibility is ensured, it is feasible to make this transition without loss of volume or compromise in patient outcomes.

Angiographic patency after robotic beating heart totally endoscopic coronary artery bypass grafting facilitated by automated distal anastomotic connectors.

OBJECTIVES: Robotic totally endoscopic coronary artery bypass (TECAB) on the beating heart has been facilitated in our experience using distal coronary anastomotic connectors. In this study, we retrospectively reviewed graft patency in all robotic TECAB patients who underwent formal angiography at our current institution over a 5-year period. METHODS: Between July 2013 and June 2018, 361 consecutive patients underwent robotic beating-heart TECAB. Of these patients, 121 had a follow-up angiogram, which assessed graft patency. Eighty-four patients had an angiogram as part of planned hybrid procedures and 37 patients underwent an unplanned angiogram for clinical indications. Retrospective analysis of angiographic patency and clinical outcomes was performed. RESULTS: The mean Society of Thoracic Surgeons predicted risk of mortality was 1.8%. Single-vessel bypass was performed in 40 (33%) patients and multivessel grafting in 81 (67%). Average flow (ml/min) and pulsatility index in the grafts was 74.7 ± 39.1 and 1.42 ± 0.52, respectively. The number of grafts evaluated was 204 (130 left internal mammary artery and 74 right internal mammary artery grafts). The median time to angiography was 1.0 and 16.0 months and graft patency was 98% and 91% in the hybrid and non-hybrid groups, respectively. Overall graft patency was 95.6% (left internal mammary artery = 96%; right internal mammary artery = 93%). Left internal mammary artery to left anterior descending artery graft patency was 97%. Clinical follow-up was available for 316 (88%) patients at mean 22.5 ± 15.1 months. Freedom from major adverse cardiac events at 2 years was 92%. CONCLUSIONS: In this consecutive series of patients undergoing formal angiography after robotic single and multivessel TECAB, we found satisfactory graft patency and 2-year clinical outcomes. Longer-term follow-up is warranted.

Graft Patency after Robotically Assisted Coronary Artery Bypass Surgery.

OBJECTIVE: With advances in robotic instrumentation and technology, both robotically assisted minimally invasive direct coronary artery bypass (RMIDCAB) and totally endoscopic coronary artery bypass (TECAB) have been widely used over the past 20 years. Graft patency is the most important outcome in coronary bypass surgery and is associated with long-term prognosis. In this article we reviewed all experts' studies in the field of robotic assisted coronary artery bypass and investigated graft patency in patients who underwent RMIDCAB or TECAB. METHODS: We performed a literature search in PubMed from 1999 to 2018 using the terms "Robotic" and "Coronary bypass" and/or "Minimally invasive" and/or "Totally endoscopic." Of the articles found, studies investigating graft patency were specifically selected. RESULTS: In 33 articles, a total of 4,000 patients underwent robotic assisted coronary artery bypass surgery either by a RMIDCAB (2,396) or by a TECAB (1,604) approach. The graft patency was assessed by invasive angiography or computed tomographic angiography in all studies. The mean graft patency at early (<1 month), midterm (<5 years), and long-term (>5 years) follow-up was 97.7%, 96.1%, and 93.2% in RMIDCAB and 98.8%, 95.8%, and 93.6% in TECAB, respectively. CONCLUSIONS: The graft patency of robotic assisted coronary artery bypass was equivalent to reported outcomes of the conventional approach. These results should encourage the adoption of robotic approaches in coronary bypass surgery.