Is There An Impact Of The Learning Curve On Early Outcomes Following The Robotic-assisted Minimally Invasive Direct Access Coronary Artery Bypass
Ismail Bouhout, Carole Sirois, Hugues Jeanmart.
Hôpital du Sacré-Coeur de Montréal, Montreal, QC, Canada.
Background: The robotic-assisted minimally invasive coronary artery bypass (MIDCAB) consist of facilitating the endoscopic harvesting of the left internal mammary artery. As many centers are increasingly implanting minimally invasive programs, we sought to evaluate the impact of the learning curve on early outcomes following robotic-assisted MIDCAB. Methods: From 2006 to 2018, 236 consecutive robotic-assisted MIDCAB procedures were performed, representing the entire inaugural experience. The cohort was divided into 2 consecutive periods of 118 patients according to the period of surgery (P1 and P2). Efficiency endpoints (surgery and coronary occlusion duration) and safety (including mortality and major morbidity). A cumulative sum analysis (CUSUM) was performed for a composite endpoint including early mortality, reintervention for bleeding, prolonged intubation, stroke, myocardial infarction, hemofiltration and urgent conversion. The expected major complication was set at 10%. Results: There were 2 operative mortalities (0.8%). In terms of safety, there was no difference in the incidence of major complications between the two periods (P1: 13 [11%] and P2: 9 [8%]; p=0.37). The CUSUM analysis showed that the rate of major complications remained constant during the study period. In terms of efficiency, there was a statistically significant improvement of surgery duration after the first period (P1: 2.5 [1.6-5.5] hours vs P2: 2.2 [1.6-5.3] hours; p=0.01). However, the duration of the coronary occlusion was similar across the two study periods (P1: 9.5 +/- 4.3 min vs P2: 8.8 +/- 2.9 min). The median length of hospital was similar between the two periods (5 [1-33] days). Conclusion: In conclusion, there is no significant impact of the learning curve on early complications following robotic-assisted MIDCAB. However, surgery duration improves over time. 
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