BACKGROUND: Multi-arterial grafting with bilateral internal thoracic arteries (BITA) is superior to single ITA and veins. However, sternal wound infection is a deterrent to using BITA, especially in diabetic and obese patients. Sternal-sparing approaches, including robotic totally-endoscopic coronary bypass (TECAB), mitigate this risk. We reviewed outcomes of robotic beating-heart TECAB with BITA grafting. METHODS: 824 patients underwent robotic TECAB at our institution from 7/2013-11/2023. Of these, 385 patients received BITA grafts and and are the subject of this review. Early and mid-term clinical outcomes were reviewed and angiographic patency in those undergoing hybrid revascularization with PCI after TECAB. All cases were performed via a beating-heart robotic approach, with standard TECAB port placement. RESULTS: Mean age was 67+9 years and 84% were male. Mean STS risk was 1.4+2%. 38% were diabetic (15% insulin-dependent) and 40% had BMI >30. 21% had ejection fraction <40%. 98% of cases were completed off-pump and there were no conversions to sternotomy. Mean number of grafts per patient was 2.16+0.38. The most common grafting configuration was LITA-LAD and RITA to an antero-lateral or lateral wall target. The LAD was grafted using the LITA in 64% and RITA in 36%. Mean ICU and hospital LOS was 1.2+0.6 and 2.5 days+0.8 days, respectively. Postoperative complications included atrial fibrillation 14%, AKI 3.6%, return to OR for bleeding 0.8%, postop MI 0.26%, stroke 0.26%. Mortality occurred in 5 patients (O/E 0.92). Return to work and full activity occurred at mean of 14+9 and 17+12 days, respectively. 194 patients (50%) had ‘advanced’ hybrid revascularization (i.e. at least 2 arterial grafts and stents). Mean number of vessels revascularized in this group (surgical & PCI) per patient was 3.1. ITA early graft patency in this cohort of patients was 264/270 (98%) with 100% LITA-LAD patency. Follow-up was complete in all patients at mean of 48+31 months (longest follow-up 9.6 years). All-cause mortality was 14% and cardiac-mortality 2.5%. Freedom from angina was 96%, and freedom from repeat revascularization was 95%. CONCLUSIONS: Use of the beating-heart robotic TECAB approach facilitates BITA grafting to achieve multi-vessel arterial revascularization of the left coronary system. Early and mid-term clinical outcomes and early graft patency were excellent and comparable to traditional sternotomy outcomes, while completely avoiding sternal wound complications.
