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Robotic Totally Endoscopic Off-pump Unroofing Of Myocardial Bridge: Early Experience And Midterm Outcomes
Sarah M. Nisivaco, Ibraheem Hamzat, John Blair, Amit Patel, Brooke Patel, Charocka Coleman, Husam H. Balkhy.
University of Chicago Medicine, Chicago, IL, USA.

BACKGROUND: Myocardial bridging (MB) occurs when a coronary artery has an intramyocardial course and most commonly involves the left anterior descending (LAD). In symptomatic patients who have failed medical therapy, surgical unroofing can be offered for relief of symptoms and improvement in coronary blood flow. We present a series of patients undergoing robotic totally endoscopic beating-heart MB unroofing.
METHODS: 21 patients with LAD MB who failed medical therapy underwent robotic totally-endoscopic, off-pump unroofing (using the DaVinci Si robot with the Endowrist stabilizer) between 2017-2021. All patients were evaluated by a multidisciplinary team and underwent CT angiography and coronary physiology studies with dobutamine to confirm hemodynamic significance. We reviewed perioperative outcomes and contacted patients by telephone and asked them to complete a modified Seattle Angina Questionnaire (SAQ) to assess midterm outcomes. RESULTS: Mean age was 46+7 years, and 48% were female. 62% had hypertension. Mean ejection fraction was 64+6%. All patients had significant FFR reduction on pre-operative stress coronary angiography. 1 patient had preoperative atrial fibrillation and underwent concomitant ablation with left atrial appendage ligation. Mean procedure time was 127+53 minutes. All procedures were completed totally-endoscopically off-pump without conversions (Figure-1). Mean MB length was 4.5cm. All patients were extubated within 6 hours of the procedure (81% in the OR). Mean ICU and hospital length of stay were 0.86+0.65, and 1.76+1.14 days, respectively. There were no mortalities. 1 patient whose MB extended to the apex had a postoperative angiogram showing distal LAD occlusion without a troponin rise. There was no incidence of postoperative atrial fibrillation, stroke, or take-back for bleeding. 3 patients (14%) had postoperative pleural effusion and 2 had postoperative pericarditis (10%). At midterm follow-up of 20+14 months, all patients were reached and 19 patients completed the modified SAQ. 80% of patients reported having ‘much less angina’ during strenuous activity compared to before surgery, and 84% reported taking no anti-anginal medication since surgery. CONCLUSIONS: In appropriate patients with hemodynamically significant LAD MB who fail medical therapy, robotic beating-heart unroofing is possible with good outcomes. To our knowledge this is the largest series of robotic-assisted unroofing of coronary MB. Further studies are warranted.

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