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A Comparison of Hospital Cost and Outcomes between Minimally-Invasive Techniques for Coronary Artery Bypass Surgery Utilizing Robotic Technology
Zachary N. Kon1, Chetan Pasrija1, Mehrdad Ghoreishi1, Eric Lehr2, James S. Gammie1, Bartley P. Griffith1, Johannes Bonatti3, Bradley Taylor1.
1University of Maryland School of Medicine, Baltimore, MD, USA, 2University of Maryland School of Medicine, Baltimore, WA, USA, 3Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates.

OBJECTIVE: Totally endoscopic coronary artery bypass (TECAB) with robotic distal anastomosis, and robotic-assisted minimally-invasive coronary artery bypass (RA-MIDCAB) with robotic internal mammary artery harvest and direct hand-sewn distal anastomosis via an anterior thoracotomy, have both been reported as safe and efficacious. We compared hospital cost and short-term outcomes between these techniques.
METHODS: Patients who underwent robotic minimally-invasive single vessel CABG between 2011 and 2014 were retrospectively reviewed. One hundred consecutive patients underwent either TECAB (N=50) or RA-MIDCAB (N=50). The two groups were sequential and non-contemporaneous with TECAB performed by one surgeon in the first portion of the study interval and RA-MIDCAB by another surgeon in the latter. All TECAB procedures were performed by an experienced surgeon (>200 cases), while all RA-MIDCAB procedures were performed by a surgeon still within a learning curve (<75 cases). Demographic and operative data, short-term outcomes, and hospital cost data were compared between the two groups.
RESULTS: Patient demographics and preoperative risk factors were similar between the TECAB and RA-MIDCAB groups, as were median operative (3.5 (IQR 2.9-3.9) vs. 3.3 (IQR 3.0-4.2) hours, p=NS) and total operating room times (5.2 (IQR 4.5-5.7) vs. 5.2 (IQR 4.6-5.8) hours, p=NS). Cardiopulmonary bypass was used for 56% of TECAB and 0% of RA-MIDCAB cases (p<0.01). Hybrid revascularization was performed in 40% of TECAB and 28% of RA-MIDCAB patients (p=NS), and was nearly universally staged postoperatively during the same hospitalization. The duration of ventilation, and lengths of ICU and hospital stay were similar between groups. Readmission rates were 12% and 14% for TECAB and MIDCAB (p=NS), respectively; and 30-day or in-hospital mortality was 2% in the TECAB and 0% in the RA-MDCAB group (p=NS). Total hospital cost was significantly higher with TECAB compared to RA-MIDCAB (33,769 (IQR 28,237-41,505) vs. 22,679 (IQR 19,293-30,106) dollars, p<0.01), which was primarily driven by operative costs (17,616 (IQR 14,888-20,451) vs. 26,803 (IQR 19,458-30,756) dollars, p<0.01).
CONCLUSIONS: TECAB and RA-MIDCAB both demonstrated excellent short-term clinical outcomes. However, TECAB was associated with significantly higher hospital costs. Further comparisons, including long-term outcomes, patient satisfaction and functional status, are needed to evaluate if this additional cost is justified.


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