Robotic Coronary Revascularization Versus Off-pump Coronary Artery Bypass Grafting: Comparative Effectiveness Analysis
Fadi Hage1, Ali Hage1, Bob Kiaii2.
1Western University, London, ON, Canada, 2UC Davis Medical Center, Sacramento, CA, USA.
BACKGROUND: When performed on a beating heart, robotic coronary revascularization (RCR) offers a minimally-invasive alternative to traditional off-pump coronary artery bypass grafting (OPCABG) through midline sternotomy. To this date, there is a lack of clear evidence favoring RCR over OPCABG. The objective of this study is to provide a comparative analysis of RCR versus traditional OPCABG.
METHODS: Our sample consisted of all sternotomy OPCABG (n=395) and RCR (n=319, involving off-pump robotic-assisted minimally-invasive CABG of the LITA to the LAD artery) performed at our institution between January 2008 and July 2017. We performed adjusted analyses using inverse-probability weighting based on the propensity score (PS) of receiving either the OPCABG or RCR approaches. The PS was constructed with a priori logistic regression model using covariates that were judged to strongly influence the surgical approach selected by the surgeons or to impact the primary outcomes.
RESULTS: RCR was associated with lower rates of in-hospital mortality (OPCABG 2.5%, n=10 vs. RCR 0.3%, n=1, p=0.02), post-operative atrial fibrillation (OPCABG 21.0%, n=83 vs. RCR 7.8%, n=25, p<0.001), hemodialysis (OPCABG 1.3%, n=5 vs. RCR 0%, p=0.03), mediastinitis (OPCABG 1.0%, n=4 vs. RCR 0%, p=0.045), respiratory infection (OPCABG 4.3%, n=17 vs. RCR 0.3%, n=1, p<0.001), and higher post-operative hemoglobin (OPCABG 103.7+/-42.5g/L vs. RCR 114.4+/-16.3g/L, p=0.01). RCR was associated with a higher in-hospital re-intervention rate (OPCABG 0% vs. RCR 3.8%, n=12, p=0.001), likely confounded by routine post-operative angiographic evaluation in RCR as opposed to OPCABG patients where angiography was only done when clinically indicated. Both groups had similar results in terms of perioperative myocardial infarction, stroke, re-exploration for bleeding, prolonged mechanical ventilation (>24 hours), and blood transfusion.
CONCLUSIONS: In selected patients, RCR appears to be safe and seems to offer excellent short-term outcomes when compared with traditional OPCABG. It is associated with improved in-hospital survival and lower risk of post-operative complications.
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