Objective Conversion to sternotomy is a primary bailout method for robotically assisted coronary artery bypass grafting procedures. The aims of this study were to identify the primary reasons for conversion from robotically assisted coronary artery bypass grafting to sternotomy and to evaluate the in-hospital outcomes in such patients. Methods Prospectively collected data from February 2004 to April 2017 were reviewed for 72 patients (56 men; mean age = 63.8 years) who required conversion to sternotomy during a robotically assisted coronary artery bypass grafting procedure with planned endoscopic left internal thoracic artery harvest and anastomosis to the left anterior descending on the beating heart. Results The overall rate of conversion was 12.4% (72/581). Conversions occurred either during attempted endoscopic left internal thoracic artery harvest (31.9%), during endoscopic left anterior descending isolation (40.3%), during manual isolation and anastomosis of the left anterior descending (19.4%), or after anastomosis due to unsatisfactory flow (8.3%). Overall, the most common reason for conversion was an intramyocardial left anterior descending (43.1%). The median stay in the intensive care unit was 1 day (range = 0–20) and the median hospital length of stay was 5 days (range = 3–43). In-hospital complications included new atrial fibrillation (16.7%), need for blood transfusion (20.8%), mediastinitis (4.2%), postoperative myocardial infarction (2.8%), exploration for bleeding (2.8%), and 1 in-hospital death. Conclusions The reasons for conversion were primarily related to anatomical factors that created difficulties for endoscopic left internal thoracic artery harvesting and left anterior descending identification. Patients who required conversion to sternotomy from robotically assisted coronary artery bypass grafting demonstrated acceptable outcomes and low complication rates.

BACKGROUND:Minimally invasive robot-assisted direct coronary artery bypass (RADCAB) has emerged as a feasible minimally invasive surgical technique for revascularization that might offer several potential advantages over conventional approaches. We present our 18-year experience in RADCAB.METHODS:Between February 1998 and February 2016, 605 patients underwent RADCAB. Patients underwent post-procedural selective graft patency assessment using cardiac catheterization.RESULTS:The mortality rate was 0.3%. The rate of conversion to sternotomy for any cause was reduced from 16.0% of the first 200 cases to 6.9% of the last 405 patients. The patency rate of the LITA-to-LAD anastomosis was 97.4%. Surgical re-exploration for bleeding occurred in 1.8% of patients, and the transfusion rate was 9.2%. Average ICU stay was 1.2 ± 1.4 days, and average hospital stay was 4.8 ± 2.9 days.CONCLUSIONS:Robot-assisted coronary artery bypass grafting is safe, feasible and it seems to represent an effective alternative to traditional coronary artery bypass grafting in selected patients.

Endoscopic radial artery harvest (ERAH) for coronary artery bypass grafting (CABG) offers the potential for decreased pain, infection, neurological complications of the arm with dramatically improved cosmesis compared to an open/conventional harvest. Because of these potential benefits and our experience with endoscopic saphenous vein harvest (ESVH), we adopted ERAH as standard of care for CABG patients at our institution. Here we present our experience and outcomes with this technique after more than 1000 harvests. From July 2004 to present, our centre performed endoscopic radial artery harvest (ERAH) in 1003 patients. We adapted a reusable ESVH system (Karl Storz Endoscopy) with the addition of a harmonic ultrasonic scalpel/shears (Ethicon Endosurgery) to facilitate the removal of the radial artery (RA) for use in our CABG patients. Data was collected prospectively regarding harvest technique (harvest times, graft length, incision length, histology) and patient outcomes (infection, cosmesis, hematomas, gross neurological impairment, patient satisfaction and all MACE’s). Thirty-two patients underwent angiographic assessment of their RA grafts at >5 years. RA Harvest times ranged from 21-125 minutes with a median harvest time of 37min +/- 4 in the first quartile of our series and greatly decreased with experience. Average length of artery extracted was 17.2 cm +/- 1.2 cm through a mean incision length of 2.3 cm +/- 0.7cm. All RA grafts harvested were deemed suitable for grafting. Six patients were converted to open harvest and 15 patients required the addition of a second proximal arm incision. There were 17 ERAH wound infections (1.7%). Neurological impairments were infrequent and mostly consisted of transient numbness over the thenar eminence, index finger and lateral forearm. Five patients manifested clinically significant chronic neuralgias post-operatively. Histological examination of multiple samples of harvested RA’s revealed no signs of intimal trauma or thermal injury. There were no clinically significant hematomas post-operatively and no arm required operative re- intervention. There were 7 postoperative deaths (0.7%), 12 post-op MI’s (1.2%), 22 central neurological complications (2.2%) and no cases of renal failure requiring dialysis. Long-term follow-up on angiography and CT/Angiography revealed a patency rate of 91.3%. ERAH can be effectively and safely adopted as a harvest technique for the RA for CABG. Our results demonstrate ERAH provides adequate length conduits in a timely manner through much smaller incisions, resulting in low rates of infection, neurological impairment, excellent long-term patency and no evidence of histological damage.

Objective The aims of the study were to determine whether endoscopic harvesting of the radial artery (RA) reduces morbidity due to pain, infection, and disability with improvement in satisfaction and cosmesis compared to the conventional technique and (2) to compare the 6-month angiographic patency of the RA harvested conventionally and endoscopically. Methods In a prospective randomized study, 119 patients undergoing coronary artery bypass grafting using the RA were randomized to have RA harvested either conventionally (n = 59) or endoscopically (n = 60). Results Radial artery harvest time (open wound time) was significantly reduced in the endoscopic group (36.5 ± 9.4 vs 57.7 ± 9.4 minutes, P < 0.001). Only one patient developed wound infection (1.6%) in the endoscopic group compared with six patients (10.2%), P = 0.061, in the conventional group. Although this was not statistically significant, clinically this was relevant in terms of reduction in postoperative morbidity. Postoperative pain in the arm incision was significantly lower in the endoscopic group at postoperative day 2 (P < 0.001) and at discharge (P < 0.001) and similar to the conventional open group at 6 weeks’ follow-up (P = 0.103). Overall patient satisfaction and cosmesis were significantly better in the endoscopic group at postoperative day 2 (P < 0.001), at discharge (P < 0.001), and at 6 weeks’ follow-up (P < 0.001). There was no difference in the arm disability postoperatively (P = 0.505) between the two groups. Six-month angiographic assessment of 23 patients (12 endoscopic and 11 open) revealed no difference in the patency rate (10/12 in endoscopic and 9/11 in open group). Conclusions Endoscopic RA harvesting reduced the incidence of postoperative wound infection and wound pain and improved patient satisfaction and cosmesis compared with conventional harvesting technique. There was no difference in the 6-month angiographic patency of the RA harvested conventionally and endoscopically.

OBJECTIVE:From 2005 to 2007, 119 patients were enrolled in a prospective randomized controlled trial comparing open and endoscopically harvested radial arteries for coronary artery bypass grafting. The objective of the current study was to compare graft patency between intervention groups at more than 5 years from the initial trial. We hypothesized that endoscopically harvested radial arteries would show equivalent patency to those conventionally harvested.METHODS:At 5 years or greater from their operation, all consenting patients underwent a single-day anatomic and functional cardiac assessment with coronary computed tomography angiography and sestamibi myocardial perfusion scanning. Medical Outcomes Study 36-Item Short-Form Health Surveys and Seattle Angina Questionnaires were completed to assess the overall quality of life. All patients had received calcium channel blocker therapy for at least 6 months postoperatively.RESULTS:The mean (SD) duration of follow-up was 79.2 (8.6) months for all patients. One death occurred within 30 days of coronary artery bypass grafting in each treatment group, and eight additional noncardiac deaths occurred during the study time frame. Of 119 patients, 66 consented to follow-up. Thirty-two had open radial artery harvest, and 34 had endoscopic radial artery harvest. At more than 5 years, there were 28 patent conventionally harvested radial arteries (87.5%) and 31 patent endoscopically harvested radial arteries (91.2%) (P = 0.705). Measured quality of life was comparable between groups.CONCLUSIONS:Endoscopic radial artery harvest is safe and effective when compared with open radial artery harvest, with excellent graft patency demonstrated at more than 5 years. Patency results are noninferior in endoscopic radial artery harvest.

Redo Coronary artery bypass graft surgery on cardiopulmonary bypass is associated with significant morbidity and mortality in patients with previous heart surgery. In high risk patients like this, minimally invasive robotic-assisted surgical techniques can reduce adverse events, having a faster recovery and return to their normal activities. We evaluate the postoperative evolution of three patients with previous heart surgery that were treated with robotic-assisted coronary artery bypass grafting. We perform single coronary artery bypass graft surgery off pump in three male patients, between 2008 and 2013, using the DaVinci Si System. The three of them had previous aortocoronary bypass surgery without the utilization of Leith internal thoracic artery (LITA). Average age was 72.99 + 5.99 years old. The three procedures were urgent, and the patients were one in CCS Class 4a, other in CCS Class 4b and other in CCS Class 4c. All of them were diabetics, with no renal dysfunction. Surgery was performed using off pump technique, harvesting the LITA with the robot, and performing the anastomosis of IMA to LAD through a small left anterior minithoracotomy. No patient died or had any postoperative complication. The average ICU stay was of 1.3 + 0.58 days with a maximum ICU days of 2. The average hospital stay was of 3.3 + 0.58 days with a maximum hospital days of 4. The immediate postoperative results of robotic assisted single coronary artery bypass surgery in patients with previous heart surgery demonstrate great reproducible and efficacious results. This alternative approach enables possibility of reduce morbidity and mortality, with a faster recovery and return to their daily activities. Though our experience needs to evaluate more patients with this condition, the future results seem promising.

Minimally Invasive coronary artery bypass grafting (CABG) is a rapidly evolving technology that has been shown to increase patient satisfaction and to reduce surgical morbidity and recovery times. Therefore, we present our institutional experience with minimally invasive robotic-assisted CABG with post operative cardiac catheterization.

Objective The aim of this study was to compare the early systemic inflammatory response of the Resting Heart System (RHS; Medtronic, Minneapolis, MN USA), a miniaturized cardiopulmonary bypass (CPB) system, with two groups using a standard extracorporeal circulation system during on-pump coronary artery bypass grafting (CABG) surgery. Methods A total of 60 consecutive patients requiring CABG were prospectively randomized to undergo on-pump CABG using conventional CPB without cardiotomy suction (group A), conventional CPB with cardiotomy suction (group B), or the RHS (group C). Blood samples were collected at five time points: immediately before CPB, 30 minutes into CPB, immediately at the end of CPB, 30 minutes post-CPB, and 1 hour post-CPB. Inflammation was analyzed by changes in (a) levels of plasma proteins, including inflammatory cytokines (interleukin-6 [IL-6], IL-10, and tumor necrosis factor-α), chemokines (IL-8, monokine induced by interferon-γ, monocyte chemotactic protein-1, regulated on activation normal T cell expressed and secreted, and interferon-inducible protein-10), and acute phase proteins (C-reactive protein and complement protein 3); (b) biochemical variables (cardiac troponin I, hematocrit, and immunoglobulin G); and (c) cell numbers (leukocytes, neutrophils, and thrombocytes). Results The RHS showed more delayed secretion of the cytokines tumor necrosis factor-α and IL-10, chemokines monokine induced by interferon-γ (P < 0.001); IL-8, and interferon-inducible protein-10; and complement protein 3 than conventional CPB systems did. Median thrombocyte numbers were higher in the RHS group. Levels of cardiac troponin I, monocyte chemotactic protein-1, and IL-6 were lower in both the RHS and conventional CPB without suction than with suction. Levels of C-reactive protein and regulated on activation normal T cell expressed and secreted, plus leukocyte and neutrophil numbers, were similar in all groups. Conclusions The Medtronic RHS may induce less systemic inflammation than conventional CPB systems, particularly when cardiotomy suction was used, but it did not result in improved clinical benefit.

The advantages of minimally invasive coronary artery bypass grafting (CABG) surgery over conventional CABG include shorter recovery time, overall reduction in morbidity, blood transfusion, greater patient satisfaction, shorter hospital stay, and earlier return to work. In order to explore the opportunities within our practice to improve patient care while at the same time protecting our patients from harm and reducing costs to our financially challenged hospitals, we identified an opportunity to explore the option of bypassing the intensive care unit (ICU) in a highly selected group of patients undergoing minimally invasive coronary artery bypass surgery. This was accomplished through an extensive collaboration between nurses, administrators and physicians alike. A collaborative pathway was constructed for selection of suitable patients by the surgeon and anaesthesiologists based on the grounds of compatible coronary anatomy for minimally invasive coronary artery revascularization. Secondary factors included minimal systemic co-morbidity. A total of 14 patients underwent successful fast track cardiac surgery. There were 12 males and 2 females. They all received preoperative spinal injection of 15 mg of bupivacaine and 3 to 5 mcg/kg of preservative free morphine prior to their general anaesthesia. Using single lung ventilation they underwent Robotic-assisted CABG. Immediately after the revascularization they underwent cardiac catheterization to confirm patency of their graft and simultaneous percutaneous coronary intervention in 2 patients in the hybrid operating suite. Simultaneously, their anaesthetic and neuromuscular blockade was reversed achieving spontaneous respiration. Following clinical confirmation of return of spontaneous respiration, wakefulness and protective airway reflexes, the endotracheal tube was removed, and the patients were transferred to the post anaesthetic care unit (PACU). All patients were monitored in the PACU for 4 to 6 hours before being transferred to the postoperative ward. One patient had to return to the operating room for increase bleeding after 3 hours. He underwent uncomplicated exploration for chest wall bleeding. All patients had patent grafts, no post-operative complications and were extremely satisfied on discharge. Average length of stay in hospital was 3.1 ± 0.78 days. We believe Ultra fast track cardiac surgery is a safe and efficient way to conduct cardiac surgery in a highly selected group of patients. The importance of collaboration and a team based approach cannot be emphasized enough. We anticipate expanding this program within our own institution and look forward to evaluating the cost effectiveness of avoiding the ICU.

BACKGROUND: Simultaneous integrated coronary artery revascularization combines coronary artery bypass surgery and percutaneous coronary intervention into a single procedure. This approach provides immediate, complete and optimal myocardial revascularization in it less invasive manner. Because simultaneous integrated coronary revascularization necessitates two distinct anticoagulation protocols for the surgical and percutaneous aspects of the procedure, combining these anticoagulation protocols carries it bleeding risk. Using a single anticoagulant to facilitate the necessities of both aspects Of the integrated approach may alleviate this risk.CASE PRESENTATION: A 45-year-old man With an Occluded left anterior descending artery and a moderately stenotic circumflex artery underwent simultaneous integrated coronary revascularization. Bivalirudin was Used to achieve anticoagulation for the duration of the procedure. The patient. was asymptomatic with excellent patency of both the bypass graft: and the stented circumflex artery via angiography at 10 months.CONCLUSION: Bivalirudin Call be used to effectively achieve a unified anticoagulation protocol for simultaneous integrated revascularization.

Objective: Traditionally integrated coronary artery revascularization has been described as a 2-stage procedure. We evaluated the safety and feasibility of 1-stage, simultaneous, hybrid, robotically assisted coronary artery bypass grafting surgery and percutaneous coronary intervention.Methods: Fifty-eight patients underwent simultaneous, integrated coronary artery revascularization in an operating theater equipped with angiographic equipment. Forty-five patients were men. The mean age was 59 years. All internal thoracic arteries were harvested with robotic assistance. All anastomoses were manually constructed through a small anterior non-rib-spreading incision without cardiopulmonary bypass on the beating heart. Immediately after and within the same operative suite, both angiographic confirmation of graft patency and percutaneous coronary intervention were performed. In 52 patients therapeutic anticoagulation was achieved with the direct thrombin inhibitor bivalirudin.Results: There were no deaths or wound infections. There was 1 perioperative myocardial infarction. One patient had a stroke, and 3 patients required re-exploration for bleeding. The median lengths of intensive care and hospital stay were 1 and 4 days, respectively. All patients were alive and symptom free at follow-up (mean, 20.2 months; range, 1.1-40.8 months). Long-term angiographic follow-up in 54 patients showed 49 (91%) patent grafts (mean, 9.0 months; range, 4.3-40.8 months). There were 7 in-stent restenoses and 2 occluded stents.Conclusion: For multivessel coronary artery disease, simultaneous integrated coronary artery revascularization with bivalirudin is safe and feasible. This approach enables complete multivessel revascularization with decreased surgical trauma and postoperative morbidity. Further studies are necessary to better determine patient selection and long-term outcomes.

Saito, A; Quantz, M; McKenzie, N; Kiaii, B; Swinamer, S; Fisher, G; Novick, R Author Information

Patients with atrial fibrillation are at significant risk for sustaining a thromboembolic stroke. More than 90% of thromboemboli form in the left atrial appendage. Ligation of the left atrial appendage to reduce the risk of stroke is often performed in connection with other cardiac surgical procedures. As a stand-alone procedure, however, left atrial ligation has generally been deemed too invasive and has gained little support as an alternative therapeutic option. We report a case of port-access robotic-assisted left atrial ligation as a stand-alone procedure in a patient with chronic atrial fibrillation in whom anticoagulation was a contraindication. To our knowledge, this is the first reported case of stand-alone robotic-assisted left atrial ligation in the literature.

Background: Investigation into the surgical application of robot technology continues to expand. We report on the first case series of robotic-assisted mitral valve (RAMV) repair in Canada with use of the da Vinci telemanipulation system (Intuitive Surgical, Sunnyvale, Calif.). Methods: Between February 2004 and August 2004, 10 patients with normal left ventricular function and severe mitral valve regurgitation underwent RAMV repair with use of the da Vinci system. Peripheral cardiopulmonary bypass, transthoracic aortic cross-clamping and antegrade cardioplegia were used in all cases. A minithoracotomy in the fourth intercostal space and 2 ports in the third and fifth intercostal spaces allowed surgical access. All mitral valve valvuloplasties and band annuloplasties were done endoscopically with robotic assistance. Results: Nine of 10 patients had successful valve repair, and 1 had conversion to mitral valve replacement due to persistent regurgitation. There were no deaths, strokes or need for sternotomy. One patient required re-exploration for bleeding. Conclusion: Minimally invasive RAMV repair is feasible and safe with promising early postoperative results when performed by experienced surgical personnel accomplished in both mitral valve procedures and robotic techniques.

Hybrid myocardial revascularization combines coronary surgery with percutaneous intervention as an alternative therapy for ischemic heart disease. The order and sequence of the hybrid approach is not yet clearly defined. We report on the benefits of an enhanced surgical suite equipped with a carbon fiber operating table and digital C-arm for robotic-assisted hybrid revascularization in a single operative sequence. To our knowledge, this is the first reported case of concurrent robotic-assisted hybrid revascularization utilizing an enhanced operative suite.