International Society For Minimally Invasive Cardiothoracic Surgery

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Robotic Totally Endoscopic Beating Heart Bypass To The Right Coronary Artery: First Worldwide Experience
Brian Mitzman, Hiroto Kitahara, Sarah Nisivaco, Brooke Patel, Mackenzie McCrorey, Husam Balkhy.
University of Chicago, Chicago, IL, USA.

OBJECTIVE: Totally endoscopic coronary bypass (TECAB) has been shown to be an effective means of coronary revascularization, with less morbidity, shorter length of stay (LOS) and earlier return to activity than standard bypass. Left coronary vessels are the usual targets in TECAB procedures as grafting of the right coronary artery (RCA) has been limited due to anatomic and technical difficulty. We report the first series of robotic, beating heart TECAB to the RCA via a right chest approach.
METHODS: From July 2014 to October 2017, 9 patients (age 32 to 78, 66% male) underwent single-vessel TECAB using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) with the right internal mammary artery to the RCA. Port placement in the right chest mirrored standard left sided ports. Indications for bypass were CAD not amenable to percutaneous intervention, chronic total occlusion and anomalous takeoff of the RCA. Intraoperative parameters and perioperative outcomes were evaluated. Intra-operative graft patency was assessed using transit-time flowmetry (Medistim, Oslo, Norway). Two patients had post-procedure angiograms.
RESULTS: All cases were completed without conversion to sternotomy. Beating heart cardiopulmonary bypass was required in 1 patient to expose the posterior descending artery (PDA), RCA was not graftable (due previous distal stent placement).The C-Port Flex-A distal anastomotic device (Dextera, Redwood City, CA) was used In 6 patients. 3 patients received a hand-sewn anastomosis. Mean procedure time was 287 +/- 61 minutes, with more than half the patients extubated in the operating-room. Mean intraoperative transit time flow was 88 cc/min +/- 21, and a pulsatility index of 1.2 +/- 0.2. Median ICU and hospital LOS were 1 and 2 days respectively. There was 1 readmission within 30 days for pericarditis. There were no perioperative deaths, strokes, or myocardial infarctions. Post-procedure angiograms in two patients at 2 and 6 months respectively showed widely patent grafts (Figure 1)
CONCLUSIONS: Robotic, totally endoscopic off pump, coronary artery bypass for isolated RCA lesions is a feasible operation in selected patients. This technique is possible even for PDA targets, providing excellent revascularization and minimal morbidity.
LEGEND: Angiogram showing pre(A) and post(B) robotic-TECAB of RCA lesion with RIMA.


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