Robotic-assisted Minimally Invasive Direct Coronary Artery Bypass Surgery And Hybrid Revascularization - The Dutch Experience
Anne R. de Jong1, Monica Gianoli1, Kirolos A. Jacob1, Hanae F. Namba1, Maaike M. Roefs2, Sandeep K. Singh3, Patrique Segers4, Willem J.L. Suyker1.
1University Medical Center Utrecht, Utrecht, Netherlands, 2Netherlands Heart Registration, Utrecht, Netherlands, 3Isala Clinics, Zwolle, Netherlands, 4Maastricht University Medical Center, Maastricht, Netherlands.
BACKGROUND: Robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) surgery with or without hybrid coronary revascularization (HCR) are attractive minimally invasive alternative strategies to conventional coronary artery bypass surgery (CABG) in patients with isolated left anterior descending (LAD) stenosis or multi-vessel coronary artery disease in selected cases. Several studies have shown beneficial effects of these techniques but were limited by being single center experiences and having relatively small sample sizes. We analyzed a large, multicenter experience based on the Netherlands Heart Registration (NHR), a nationwide quality registry that includes all patients undergoing RA-MIDCAB.METHODS: A post-hoc analysis of prospectively collected data within the NHR was performed in 440 patients between January 2016 and December 2020. Additional data collection was performed in collaboration with the NHR and was updated on a regular basis. All patients underwent RA-MIDCAB with the left internal thoracic artery to LAD. Additionally, a certain proportion of the patients underwent percutaneous coronary intervention (PCI) of non-LAD vessels, i.e. HCR. The primary outcome was all-cause mortality at mid-term follow-up, and was subdivided into cardiac and non-cardiac mortality. Cause of death was specified. Mortality was verified by the Personal Records Database of the Netherlands. At 30-day follow-up the following secondary outcomes were included: mortality (all-cause and cardiac), ischemic cerebrovascular accident (iCVA), perioperative myocardial infarction, target vessel repeat revascularization (TVR), and reoperation for bleeding or anastomosis related problems. TVR was also collected at mid-term follow-up.RESULTS: Complete follow-up was achieved. Among all RA-MIDCAB patients, 20.7% (91/440) of patients underwent HCR. At median follow-up of 19 (IQR 8-28) months, 2.5% (11/440) of patients died. TVR occurred in 6.1% (27/440) of patients of which five underwent repeat CABG and 22 underwent repeat PCI. At 30-day follow-up, 1.8% (8/440) of patients had a perioperative myocardial infarction of whom one died. One patient (0.2%) developed an iCVA and 4.3% (19/440) of patients underwent reoperation for bleeding or anastomosis related problems. CONCLUSION: RA-MIDCAB and HCR in the Netherlands are safe and promising procedures. It provides a minimally invasive approach and results in excellent clinical outcomes at mid-term.Figure 1. Kaplan-Meier of freedom of all-cause mortality and freedom of TVR 
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