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15 years experience of endoscopic robotic assisted coronary artery bypass to LAD (EndoACAB) as part of a hybrid approach with percutaneous intervention (PCI) to non-LAD vessels: a minimally invasive approach for full revascularization in multi-vessels coronary artery disease
Maria Cannoletta, Alan Soo, Rashmi Yadav, Richard Trimlett, Anthony De Souza.
Royal Brompton Hospital, London, United Kingdom.

OBJECTIVE: EndoACAB is a relative new procedure performed only in specialist centres. In our institution, this technique is often combined with PCI to the non-LAD coronary vessels as part of a "hybrid" coronary revascularization approach to achieve complete revascularization for multi-vessel coronary disease. This combined technique avoids CPB related complications and aortic manipulation compared to conventional coronary revascularization surgery. Here, we report our single institution 15 year experience of employing this approach.
METHODS: The hospital cardiac surgery database (PATS & EPR) was retrospectively reviewed over 15 year period. Patient characteristics and outcome including mortality and post-operative complications are reported.
RESULTS: Between January 2000 to August 2015, a total of 477 patients underwent Endoacab in our institution. Out of this cohort, 144 (30%) patients underwent the procedure as part of a hybrid procedure.
During this period, there were 22 conversion (4.6%) to sternotomy and conventional coronary surgery. The most common reason (6 patients, 1.2%) for conversion was pleural adhesions. In 4 (0.8%) patients, there were problems related in LIMA harveting. There were difficulty in identifying the LAD vessel in 3 patients (0.6%) and in another 3 patients there were difficulty in achieving single lung ventilation. Other reasons given for conversion include limited shoulder mobility (2 patients, 0.4%), haemodynamical instability during the procedure in 2 patients, instrumental problem in 2 patients and was unknown in 1 patient.
There in hospital mortality rate was 0.2% and 2 mortality occur 6 months after discharge.
The overall complication rate was low with the most common complication being atrial fibrillation (18 patients, 3.8%) and acute kidney injury (9 patients, 1.8%). 3 patients (0.6%) was re-explored for bleeding. Otherwise, 2 patients developed pleural effusion requiring drainage and 3 patients developed significant wound infection. Finally, 2 patients had occlusion of the LIMA graft requiring PCI to LAD.
CONCLUSIONS: EndoACAB is a safe procedure with low complication rate and good results. Combined with PCI as part of a hybrid coronary revascularization strategy, EndoACAB offers a truly minimally invasive approach to achieve complete revascularization.

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