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International Society For Minimally Invasive Cardiothoracic Surgery

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Robotic Totally Endoscopic Coronary Bypass Surgery to Complete Three or More Grafts: Pushing the Envelope of Endoscopic Beating Heart Cabg
Sarah Nisivaco, BS, Gianluca Torregrossa, MD, Kaitlin Grady, Husam H. Balkhy, MD
University of Chicago Medicine, Chicago, IL, USA

BACKGROUND: Robotic totally endoscopic coronary bypass surgery (TECAB) is the least invasive form of coronary revascularization but is perceived to be limited by the number of distal anastomoses that can be performed. Robotic TECAB with the aid of the Endo-wrist stabilizer allows the harvesting of bilateral internal thoracic arteries (BITA) and their deployment in multiple coronary territories using sequential anastomoses. This report aims to evaluate outcomes in our patients undergoing robotic TECAB with three or more grafts. METHODS: A retrospective analysis of 570 patients who underwent TECAB at a single institution from 2013 to 2020 was performed. 41 patients had a BITA TECAB x3 or x4. Pre-operative, intraoperative, and post-operative results at 30 days and at a mean follow-up of 4026 months were analyzed. RESULTS: Mean age was 677.8 years. Mean STS risk score was 1.31.8. 80% of patients had 3-vessel disease and 44% of patients had BMI ≥30. 37% of patients were diabetic and 5 patients had a diagnosis of chronic renal failure (1 requiring hemodialysis). Mean ejection fraction was 5312%, and 34% of patients had previous percutaneous intervention. There were no conversions to sternotomy and 44% underwent staged hybrid revascularization. Intraoperative blood transfusion was required in 4 patients, and all procedures were successfully completed using an off-pump strategy. The mean LIMA flow was 5923 ml/min; mean RIMA flow was 6229 ml/min using intraoperative transit-time flow measurement. Mean hospital length of stay was 2.41.1 days. There were no re-explorations for bleeding or wound infections. At 30 days, there was one death due to carotid artery stent thrombosis. At 4026 months follow-up, 1 patient had a cardiac-related mortality (pulmonary embolism). Freedom from MI, cardiac reoperation, and culprit-vessel PCI was 90%. Graft patency in patients undergoing hybrid coronary revascularization was 95% (19/20 grafts). CONCLUSIONS: In the hands of a dedicated robotic coronary team, off-pump multivessel TECAB with BITA and 3 or more grafts is safe, feasible, and extends the benefits of multiarterial grafting to a select subset of patients using a totally endoscopic approach. Good outcomes were demonstrated in our cohort, including post-operative recovery, LOS, and midterm results. Further studies are warranted.


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