Does Preoperative Imaging And Learning Curve Reduce The Conversion Rate Of Robotic-assisted Coronary Artery Bypass Grafting
Feras Khaliel, Vincenzo Giambruno, Hussein Al-amodi, Michael Chu, Kate Dillon, Kumar Sridhar, Chris Harle, Evan Iglesias, Patrick Teefy, Bob Kiaii.
London Health Science Center, Western University of Ontario, London, ON, Canada.
Robotic-assisted coronary artery bypass grafting (RA-CABG) is a minimal invasive surgical revascularization technique that decreases patient’s morbidity. Multi-factorial reasons can lead to conversion to sternotomy. Our study is to identify the effect of learning curve and pre-operative imaging on the conversion rate to sternotomy.
Between July 2000 and October 2016, 514 patients underwent RA-CABG. Isolated, off-pump, left internal thoracic artery (LITA) to the left anterior descending coronary artery (LAD) grafting was performed either through a left anterior mini-thoracotomy or totally endoscopic (TECAB) approach following robotic harvesting of the LITA.
In order to improve patient selection, we introduced as part of the preoperative work up, chest Computed Tomography (CT) initially without contrast in 2005, then with contract in 2008 following the course of the LAD. We further enhanced the preoperative imaging by analyzing the location of the LAD within epicardial adipose tissue in 2015. We considered 5 sub-group each including 100 patients who underwent RA-CABG over the 16-year period. We analyzed the trend of conversion rate with the improvement of the preoperative imaging and the progression of the learning curve.
Patients’ mean age 61.3 ± 10.7 years old, 25% female and 36.2% had morbid obesity. Total of 62 (12%) patient had conversion to sternotomy. The conversion to sternotomy rate was 20% in the first 100 patients-group, 11% in the second group, 14% in the third group, 12% in the fourth group, in the fifth group (114 patients) 4.4%, (figure-1).
In the sub-group analysis, we’ve observed a significant decrease in rate of conversion to sternotomy. We noticed a significant correlation between the decrease rate of conversion, and the improvement of the patient selection through the more accurate and sophisticated degree of imaging and learning curve progression.
The improve in learning curve and utilization of CT scan for detailed imaging analysis prior to RA-CABG surgery has significantly lowered the sternotomy conversion rate, and; hence decreased patient morbidity.
Figure-1: Sternotomy Conversion Rate Over 16-year period:
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