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Off-pump Totally Endoscopic Coronary Artery Bypass In Patients With Low Ejection Fraction
Miroslav P. Peev, Sarah Nisivaco, Gianluca Torregrossa, Sajid Shahul, Husam H. Balkhy.
University of Chicago, Chicago, IL, USA.

BACKGROUND: Robotic totally endoscopic coronary bypass (TECAB) has been shown to be a safe technique with excellent clinical outcomes. The aim of this study is to assess the feasibility of off-pump TECAB in patients with low left ventricular ejection fraction (LVEF) and to report our midterm outcomes in this group of patients. METHODS: All patients undergoing robotic off-pump TECAB at our institution between 7/2013 and 7/2020 were retrospectively reviewed. Of 536 patients undergoing robotic TECAB by an experienced robotic cardiac surgery team a total of 100 patients had low LVEF. Low ejection fraction was defined as LVEF of 40% or less. The preoperative characteristics, perioperative and postoperative outcomes, as well as the midterm results up to 70 months (mean 30+21) were reviewed. RESULTS: The mean age of the cohort was 66 years with predominately male patients (76%). The mean LVEF was 31%, with 62% of all patients having congestive heart failure. More than half of the cohort had triple vessel disease (59%) and 6% had a previous open-heart surgery. Single-vessel TECAB was performed in 46% versus 54% of the patients underwent a multivessel TECAB (n=46 double-vessel; n=8 triple-vessel). Hybrid coronary revascularization occurred in 36 individuals. Two patients required cardiopulmonary bypass support and 35% of all patients were successfully extubated in the operating room. No conversions to sternotomy were required. Postoperatively, 14 patients experienced atrial fibrillation, 4 had acute kidney injury, and one required return to the OR for bleeding. There was no perioperative stroke, myocardial infarction (MI), or mortality. The LIMA-LAD patency was 95% at mean of 1.6 months in the patients undergoing angiography for staged Hybrid PCI. Mid-term follow-up was available for 90% of the patients. Cardiac related mortality occurred in 5 patients (5.6%), another cardiac surgery was required in 4 patients (3 heart transplants, 1 LVAD) and only one patient experienced a MI. Freedom from MACE was 89%. CONCLUSIONS:Off-pump TECAB can be successfully performed in patients with low ejection fraction in the setting of an experienced and dedicated robotic cardiac surgery team. Our data demonstrate the feasibility of the technique with excellent perioperative and acceptable mid-term outcomes.

Selected Variables of Low ejection fraction off-pump TECAB patients
VariablesLow LVEF (n=100)
Ejection Fraction (%), mean SD31.2 8.5
STS score (%), mean SD3.31 4.3
Multivessel Grafting; BIMA Use, n (%)54 (54%); 49 (49%)
Hospital LOS; ICU LOS (days), mean SD3.06 1.5; 1.54 0.9
Mortality, n (%)0 (0.0)

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