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Francis P. Sutter, Mary Ann Wertan, RN.
Lankenau Medical Center, Wynnewood, PA, USA.

Does the ability to perform beating heart robotic-assisted small thoracotomy coronary artery bypass grafting (rCAB) change the patient population referred for coronary artery bypass (CAB)?
The safe introduction of rCAB was accomplished in 2005. We incorporated a weekly collaborative heart team approach to discuss cardiac catheterization findings for the treatment of patients with coronary artery disease (CAD). Since then we have successfully performed 1320 rCAB procedures. The robotic procedure entails three port sites: two 1 cm ports at the third and seventh intercostal space and a camera port at approximately the fifth intercostal space, all approximately at the mid clavicular line. After harvest of the left internal mammary artery and opening the pericardium, the camera port is converted to a small non-rib spreading thoracotomy (approximately 4.2 cm), and using a Medtronic non-thoracotomy stabilizer beating heart surgery is performed. Patency is checked with transit time ultrasound, local analgesia is injected and the incision is closed.
In a retrospective review of all CAB, we have seen an increase in single vessel disease (P<0.0001) and double vessel disease (P<0.05), paired T-Test; as compared with Society of Thoracic Surgery adult cardiac surgery database. 39% of all rCAB cases underwent hybrid coronary revascularization. This technique has safely and effectively reduced complications, length of stay (mean 4 days), and mortality 1% (predicted 2%).
More patients enjoy the survival benefit of left internal mammary artery (LIMA) to the left anterior descending (LAD) artery, when rCAB is available. Clearly, collaboration and a heart team approach are important in achieving these results. One could extrapolate that these same patients would otherwise be treated with medicine or stents. Offering rCAB as an alternative to on-pump CAB, sternotomy or traditional mid-CAB approach has had a significant impact on the surgical treatment of coronary artery disease at the our institution. We agree that there are many co-founding factors to these changes seen in patients referred for CAB. Finally, having the ability to perform successful rCAB offers an important alternative to the traditional treatment of coronary disease and ultimately to patient care.

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