International Society For Minimally Invasive Cardiothoracic Surgery

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Does Intolerance Of Single Lung Ventilation Preclude Robotic Beating Heart Totally Endoscopic Coronary Bypass Surgery?
Husam H. Balkhy, Sarah Nisivaco, Avery Tung, Sachin Mehta.
University of Chicago Medicine, Chicago, IL, USA.

Background: Robotic beating-heart totally-endoscopic coronary bypass (TECAB) is a routine procedure at our institution. Lung isolation for TECAB procedures is achieved using a bronchial-blocker to collapse the non-ventilated lung. In patients who become hypoxemic, the bronchial-balloon is deflated and partial lung ventilation is allowed. We examined the characteristics and clinical outcomes of TECAB in patients who did not tolerate single-lung ventilation. Methods: After IRB approval we reviewed patients undergoing robotic TECAB at our institution between 7/2013 and 11/2018 and separated them into two groups depending on tolerance of single-lung ventilation. Group 1 included patients who maintained relatively normal oxygen saturation on one-lung ventilation; Group 2 included patients who required two-lung ventilation. Early and mid-term outcomes were compared. Results: 393 patients were included. 281 patients (Group 1) tolerated single-lung ventilation. 112 patients (Group 2) did not. Group 2 had higher STS scores (2.33 vs 1.54 p=0.012), higher BMI (31.1 vs 29.5 p=0.021) and more triple vessel disease (61.6% vs 42.7% p=0.001) than Group 1. Other demographics were similar including incidence of COPD. (Table 1) Group 2 had more BIMA use (63.4% vs 42.7% p=0.001), multi-vessel grafting (68.8% vs 51.2% p=0.015), and longer operative times (268 vs 231 min p=0.001). OR extubation was less in Group 2 (39.3% vs 51.6% p=0.027), and ICU and hospital LOS were longer (1.43 vs 1.19 days p=0.001 and 3.11 vs 2.81 days p=0.043, respectively). Cardiopulmonary bypass was less in Group 2 (0% vs 2.1% p=0.014). Conversion to sternotomy was similar (0 vs 0.4% p=0.225). Postoperative atrial fibrillation was higher in Group 2 (20.5% vs 12.2% p=0.032); but other adverse events (prolonged intubation, MI, CVA and re-exploration for bleeding); as well as mortality (1.8% vs 1.1% p=0.225) were not. Mid-term follow-up was available for 101 (90%) patients in Group 2 and 215 (76%) patients in Group 1 at mean 22-months. Cardiac-related and overall mortality as well as MACE were similar. Conclusions: In our single center experience of robotic beating-heart TECAB, intolerance of single-lung ventilation did not preclude completion of the procedure. Two-lung ventilation is possible and can prevent conversions, resulting in excellent outcomes. Further studies are warranted.

Table 1: Outcomes in patients who did (Group 1) and did not Group 2) tolerate one lung ventilation d
VariableAll Patients (N=393)Group 1 Single Lung (n=281)Group 2 Double Lung (n=112) P value
STS score, mean [range]1.76 [0.16-28.01]1.54 [0.16-17.86]2.33 [0.17-28.01]0.012
BMI, mean [range]30.0 [18.7-59.0]29.5 [18.7-59.0]31.1 [19.6-48.8]0.021
COPD, n (%)38 (9.7)26 (9.3)12 (10.7)0.667
BIMA Use, n (%)191 (48.6)120 (42.7)71 (63.4)< 0.001
Multi-vessel TECAB, n (%)221 (56.2)144 (51.2)77 (68.8)0.015
Robotic time (dock to undock), min, mean [range]241 [93-462]231 [93-454]268 [111-462]< 0.001
Cardiopulmonary bypass, n (%)6 (1.5)6 (2.1)0 (0.0)0.014
Conversion to sternotomy, n (%)1 (0.25)1 (0.4)0 (0.0)0.318
Hospital length of stay, days, mean + SD2.90 1.302.81 1.333.11 1.220.043
Mortality, n (%)5 (1.3)3 (1.1)2 (1.8)0.225

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