Robotically-assisted Midcab Using Bilateral Internal Thoracic Arteries, A Propensity Matched Study With Opcab Patients
Michiel Algoet, MD1, Dries Dewulf, BSc1, Janne Billiau, BSc1, Michiel Marynissen, MD2, Tom Verbelen, MD, PhD1, Steven Jacobs, MD, PhD1, Herbert De Praetere, MD2, Wouter Oosterlinck, MD, PhD1.
1KU Leuven - UZ Leuven, Leuven, Belgium, 2Imelda Hospital, Bonheiden, Belgium.
BACKGROUND: Robotically-assisted minimal invasive direct coronary artery bypass (RA-MIDCAB) is an attractive strategy for coronary revascularization. However, the majority of cases are limited to a LIMA-LAD anastomosis. Growing evidence supports the use of total arterial grafting in coronary surgery. Therefore we evaluated total arterial left sided coronary revascularization with bilateral internal thoracic artery (BITA) using RA-MIDCAB and compared with a propensity score matched off-pump coronary artery bypass surgery (OPCAB) population. METHODS: We retrospectively included all isolated OPCAB and RA-MIDCAB coronary surgery using BITA and no saphenous vein graft between January 1st 2015 and October 31st 2022. We analyzed all our RA-MIDCAB patients and performed a propensity score matching to compare with our OPCAB population. Primary outcomes are major adverse cardiovascular and cerebrovascular events (MACCE) and mortality. Secondary outcomes are surgical parameters and length of hospital stay. We also checked for effects of learning curve in our RA-MIDCAB group. RESULTS: We included 601 OPCAB and 75 RA-MIDCAB procedures. Propensity score matching resulted in 2 cohorts of 54 patients. Mortality and MACCE survival analysis showed no significant difference between RA-MIDCAB and OPCAB. Surgery time is significant longer in the RA-MIDCAB 364,0 min (±71,0) vs OPCAB 286,1 min (±45,8) group (p<0.01), but decreases from 400,0 min (± 70,8) to 325 min (± 38) with more experience in RA-MIDCAB BITA harvesting (p<0.01). There is less blood transfusion in RA-MIDCAB (16.7%) compared to an OPCAB (38.9%) approach (p=0.02). We see less (p<0.01) intensive care unit (ICU) admissions 24.1% vs 96.6%, shorter ICU stay 0,78 days (± 1,7) vs 1,91 days (±1,01) and shorter hospital stay 6,78 days (±2,4) vs 8,01 days (± 2,5) in respectively RA-MIDCAB vs OPCAB. Admission to ICU decreased further with more experience, after 40 cases ICU admission drops from 32,5% (13/40) towards 11,5% (4/35) (p=0.05). CONCLUSION:This is a first publication of 75 consecutive RA-MIDCAB BITA harvesting for left ventricular wall revascularization. We are able to show that this is a safe technique with outcomes equivalent to an optimized OPCAB surgical strategy. Additional advantages to RA-MIDCAB BITA harvesting are shorter length of hospital stay, less ICU admissions and less blood transfusion.LEGEND: A.Surgical results in the propensity matched population. B. Survial analysis of overall mortality in the propensity score matched population. C. Survival analysis of MACCE in the propensity score matched population. 
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