International Society For Minimally Invasive Cardiothoracic Surgery

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Reasons For Conversion And Adverse Intra-operative Events In Robotically-enhanced Minimally Invasive Coronary Artery Revascularization
Johan van der Merwe, Filip Casselman, Bernard Stockman, Ivan Degrieck, Yvette Vermeulen, Frank Van Praet.
OLV-Clinic, Aalst, Belgium.

Background: The role of conventional sternotomy access for coronary artery revascularization is continuously being redefined by rapid developments in percutaneous coronary interventions (PCI) within the context of increasing patient expectations and industry driven marketing. Minimally invasive- and hybrid coronary revascularization techniques have steep learning curves, which in an era of strict quality control and clinical governance, potentially deter emerging centres of incorporating these techniques into clinical practice. This study presents a comprehensive report on factors that potentially contribute to sternotomy conversions (SC) and adverse intra-operative events in robotic-enhanced minimally invasive coronary artery revascularization (REMICAR) with the intention to assist emerging centres in developing effective risk reduction strategies. Methods: In total, 759 consecutive patients (mean age 65.910.0 years, 25.2% female, 36.8% older than 70 years, 1.3% previous cardiac surgery, multi-vessel occlusions 34.1%, planned hybrid procedure 26.9%) underwent REMICAR between July 1st2002 and November 30th2018. Single internal thoracic artery (ITA) was used in 729 (96.0%) patients. Off-pump -, cardiopulmonary bypass assisted- and endo-balloon cardioplegic arrest procedures were performed in 726 (95.7%), 24 (3.2%) and 9 (1.2%) patients respectively. Results: In total, SC was required in 30 (4.0%) patients. During the first 200 procedure, conversion rates were 4.0% (n = 8). Reasons for conversion included lung adhesions (n = 11, 1.4%), inadequate exposure (n = 3, 0.4%), ITA dysfunction (n = 11, 1.4%), ventricle perforation (n = 1, 0.1%), inadequate lung isolation (n = 1, 0.1%), acute cardiac failure (n = 1, 0.1%), arrhythmia (n = 1, 0.1%), and anastomosis dysfunction (n = 1 ,0.1%). Operative mortality associated with sternotomy conversion was 3.3% (n = 1). Conclusion: The progressive evolution in the application of PCI is redefining the role of conventional sternotomy access for coronary artery revascularization. Safe- and effective minimally invasive surgical revascularization strategies will determine our future relevance in the treatment of coronary artery disease. Surgeons need to be aware of factors that contribute to REMICAR sternotomy conversion and adverse intra-operative events to ensure that patients enjoy the maximum benefit of minimally invasive cardiac surgery and to encourage safer- and sustainable programs as an invaluable alternative to conventional sternotomy access.

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