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Minimally Invasive Direct Coronary Artery Bypass with Robotically Assisted Intra-Mammary Artery Harvesting
Tomoyuki Fujita, Hiroki Hata, Yusuke Shimahara, Shunsuke Sato, Junjiro Kobayashi.
National Cerebral and Cardiovascular Center, Suita, Japan.

OBJECTIVE: We evaluated the feasibility of off-pump minimally invasive direct coronary artery bypass (MIDCAB) in combination with robotically assisted left internal mammary artery (LIMA) harvesting.
METHODS: Since 2004, 33 patients (average 64 years old, 27 (82%) males) underwent MIDCAB with LIMA harvesting using the da Vinci Surgical System. All were indicated for single vessel grafting at the internal coronary conference and provided consent for the procedure. Sixteen (48%) had single vessel disease, and percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) was previously performed in 14 (42%). Target arteries were the left anterior descending (LAD) in 31, diagonal branch in 1, and high lateral branch in 1. The LIMA was harvested in a pedicle manner in 21 cases and a skeletonized manner in 12. Off-pump MIDCAB was performed through the 4th or 5th intercostal space with guidance by enhanced computed tomography (CT). Graft flow was measured intra-operatively using a transit time blood flow meter, while graft patency was evaluated 1 week postoperatively by coronary angiogram or coronary CT.
RESULTS: There were no deaths or major adverse cardiac events observed. Robotically assisted LIMA harvesting was completed in 30 (91%) of the patients, while 3 (9%) were converted to a median sternotomy due to bleeding from the LIMA. Right internal mammary artery (RIMA) was anastomosed to LAD in 2 and LIMA was repaired using RIMA patch to be utilized as a conduit in 1. Among the 30 successful cases, the average time for harvest was 67 minutes, the average amount of bleeding was 200 ml and only 2 (7%) required transfusion. Graft flow was measurable in all cases and the average was 35 ml/minute. All grafts were patent at the postoperative evaluation, though CT revealed that the LIMA was anastomosed to an untargeted artery in 1.
CONCLUSIONS: Off pump MIDCAB in combination with robotically assisted LIMA harvesting is a feasible and less invasive procedure. Potential problems include difficulty in controlling bleeding from the graft and proper identification of the target artery.

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