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Medium Term Follow Up in a Single Centre Practice of EndoACAB and Hybrid Robotic Coronary Revascularization
RASHMI YADAV, Saina Attaran, Richard Trimlett, Mindaugus Norkunas, Philip Kimberley, Eleanor Dunett, John Pepper, Anthony DeSouza.
Royal Brompton Hospital, LONDON, United Kingdom.

OBJECTIVE: Endoscopic atraumatic coronary bypass (EndoACAB) has become an attractive treatment option in single vessel disease revascularization and has been adopted in our unit since 2000. In selected cases, a hybrid approach was introduced in 2006 to reduce surgical trauma of median sternotomy for multi-vessel disease. We report our experience and short and medium term results of these procedures.
METHODS: Retrospective review of all patients undergoing EndoACAB and hybrid revascularization was performed. After a multi-disciplinary meeting, suitable patients for EndoACAB and hybrid approach were identified. The left internal mammary artery (LIMA) was harvested endoscopically. Through a non-rib spreading anterior microthoracotomy, LIMA was anastomosed to the LAD off-pump. On the third or fourth postoperative day, PCI to the remaining vessels was performed. Outcomes included mortality, morbidity and length of post-operative stay.
RESULTS: Overall, 367 patients were planned to have EndoACAB. Excluding unstable cases or instrument failure, the conversion rate to conventional sternotomy was 4.8%. 25% of patients had multivessel disease and underwent PCI after EndoACAB. There was no in-hospital mortality or stroke. Resternotomy for bleeding was 1.5%. Wound infection and renal failure were less than 2%. Adverse outcomes such as anastomosis of diagonal, poor run off and bleeding from anastomosis requiring conventional surgery was also 1.5%. Post operative length of stay was 6.354 ± 0.2636. Median follow up was 3.5 years with survival of 97.5% patients. Of the above cohort, 92 patients were treated using the hybrid strategy with PCI to the circumflex and or right coronary territories. No adverse outcomes, were reported. Narrowing of the LIMA to LAD anastomosis was identified in one case, which was stented via the LIMA graft. There was no postoperative mortality and five-year survival was 97%.
CONCLUSIONS: EndoACAB carries a low risk of morbidity and mortality, with the advantage of prognostic benefit of LIMA to LAD anastomosis. In selected cases, the hybrid approach carries a low risk of postoperative complications. Medium term survival with both procedures is excellent. Hybrid coronary revascularization may combine the best of both worlds thereby providing a viable alternative to conventional coronary revascularization.

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