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Right Internal Mammary Artery (RIMA) Use in Robotic Totally Endoscopic Coronary Bypass (TECAB) Grafting: Towards Adapting a Multi-arterial Grafting Strategy
Husam H. Balkhy, Sandeep Nathan, Dorothy Krienbring, Susan Arnsdorf.
University of Chicago Medicine & Biological Sciences, Chicago, IL, USA.

OBJECTIVE: Benefits of adding a second arterial graft in coronary bypass are well documented. In patients requiring mulitvessel grafting robotic TECAB has allowed routine harvesting and use of RIMA grafts. We retrospectively reviewed technical considerations and target choice in 113 cases of beating heart TECAB where a RIMA graft was used.
METHODS: In 2008 we introduced beating heart TECAB with anastomotic connectors into our practice, first with single IMA and then with BIMA. A robotic stabilizer was used to facilitate not only exposure of the coronary targets but also in aiding the RIMA harvest using a skeletonized approach. Flow measurements were obtained routinely. We reviewed the technical aspects, target choice and intraoperative flows in our TECAB patients who underwent grafting with RIMA grafts.
RESULTS: From 2/2008 to 11/2014, 356 patients underwent beating heart TECAB with anastomotic connectors, of which 165 (46.3%) were mulitvessel procedures.
113 patients had a RIMA graft and constitute the patient population for this review. 104 were harvested via left sided ports and grafted to left coronary targets (100 with the LIMA in mulitvessel procedures; 4 as a single vessel procedure), and 9 via right sided ports grafted to the RCA. Flow was > 25 cc/min (PI <2) in 95% of grafts. Perioperative mortality was 0 and mean LOS was 3.3+/-1.5 days. The RIMA graft was used as free T graft in 17 (15%) of cases and as an in-situ graft in 96 (85%). In in-situ cases it was routed under the innominate vein and covered with anterior mediastinal fat. Targets are shown in Table 1. RIMA graft use in all TECABS increased from 23% in the first 5 years to 50% in the last 2 years.
CONCLUSIONS: Robotic TECAB allows the routine harvesting and utilization of the RIMA graft in a safe and reproducible manner. Skeletonization and sternal sparing allow the RIMA to reach various coronary targets. Further studies are needed for this approach to impact the adaption of multi-arterial grafting.
Use of the RIMA graft in 113 Robotic beating heart TECAB procedures.
TECAB 112LAD49In-situ RIMA96Sternotomy2
TECAB 281Diagonal11RIMA T off LIMA17Femoral CPB4
TECAB 320OM129RIMA T off RIMA7Total6
Total113Ramus17sequential RIMA1

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