Eric J. Lehr

Five Hundred Cases of Robotic Totally Endoscopic Coronary Artery Bypass Grafting: Predictors of Success and Safety

BACKGROUND Robotic technology has enabled totally endoscopic coronary artery bypass (TECAB) grafting. Little information is available on factors associated with successful and safe performance of TECAB. We report a 10-year multicenter experience with 500 cases, elucidating on predictors of success and safety in TECAB procedures. METHODS Between 2001 and 2011, 500 patients (364 [73%] men; 136 [27%] women; median age [minimum-maximum] 60 years [31-90 years], median EuroSCORE 2 [0-13]), underwent TECAB. Single, double, triple, and quadruple TECAB was performed in 334, 150, 15, and 1 patient, respectively. Univariate analysis and binary regression models were used to identify predictors of success and safety. Success was defined as freedom from any adverse event and conversion procedure, safety was defined as freedom from major adverse cardiac and cerebral events, major vascular injury, and long-term ventilation. RESULTS Success and safety rates were 80% (400 cases) and 95% (474 cases), respectively. Intraoperative conversions to larger thoracic incisions were required in 49 (10%) patients. The median operative time was 305 minutes (112-1,050 minutes), and the mean lengths of stay in the intensive unit (ICU) and in hospital were 23 hours (11-1,048 hours) and 6 days (2-4 days), respectively. Independent predictors of success were single-vessel TECAB (p = 0.004), arrested-heart (AH)-TECAB (p = 0.027), non-learning curve case (p = 0.049), and transthoracic assistance (p = 0.035). The only independent predictor of safety was EuroSCORE (p = 0.002). CONCLUSIONS Single-vessel and multivessel TECAB procedures can be safely performed with good reproducible results. Predictors of success include procedure simplicity and non-learning curve cases, whereas predictors of safety are mainly associated with patient selection.

Robotically Assisted Totally Endoscopic Coronary Bypass Surgery

Nearly all surgical disciplines have developed endoscopic operations over the last 2 decades that have become the standard of care. In cardiac surgery and specifically for coronary artery bypass grafting (CABG), the adoption of minimally invasive techniques was challenging for the following reasons: First, most procedures are already complex, and endoscopic approaches further increase the degree of complexity; second, the cardiac surgery community had until recently no endoscopic surgical tradition; and finally, early attempts to perform CABG with the use of conventional thoracoscopic instrumentation failed completely.1 Cardiac surgeons have standardized open operations for acquired heart disease, and despite low mortality and excellent results, CABG outcomes are heavily scrutinized. Consequently, the bar has been raised for any new competing technology, which has slowed its adoption. Robotic surgical technology was developed with the idea of performing remote operations and procedures in difficult spaces. These machines allow surgical maneuvers to be performed by instruments on robotic arms that are controlled by the operator from a console situated away from the operating table. This technology is well suited for completely endoscopic suturing inside the chest. In 1998, Loulmet et al2 performed the worlds first totally endoscopic coronary artery bypass (TECAB) procedure using robotic assistance. The patient who received a single left internal mammary artery (IMA) to left anterior descending artery graft remains alive and free from angina 12 years postoperatively. During subsequent years, development has been slow but significant. TECAB developed from a single-vessel procedure to complex endoscopic robotic multivessel revascularization (Figure 1). The third generation of surgical telemanipulators is now available, with technological improvements in the areas of high-definition video, robotic arm mobility, instrument reach, surgeon comfort, and capability for intraoperative surgical endoscopic teaching with a dual-console system.3 Figure 1. Development of robotic totally endoscopic coronary artery bypass grafting from 1998 to …

Decellularization reduces immunogenicity of sheep pulmonary artery vascular patches.

OBJECTIVES Allograft vascular tissue is important in the repair of complex structural lesions of the heart and great vessels, but induces a deleterious immune response that might shorten the effective lifespan of the tissue and sensitize the recipient. We hypothesized that decellularizing allograft vascular tissue reduces the host allogeneic immune response. METHODS Allograft ovine pulmonary artery patches were decellularized, cryopreserved, and implanted into the descending thoracic aorta. The humoral immune response was measured by means of flow cytometry at regular intervals over 6 months. Graft histology, immunohistochemistry, and calcification were assessed after 4 weeks or 6 months. RESULTS Leukocyte infiltration was reduced in decellularized grafts. A trend toward decreased in-patch calcification was observed in the decellularized group (7.6 ± 4.3 vs 40.0 ± 15.9 mg of calcium/mg of protein, P = .107). Decellularization reduced IgG antibody binding to donor splenocytes (9.8% ± 3.3% vs 57.8% ± 13.7% [control value], P = .010), as assessed by means of flow cytometry. All cytokines examined were detected in nondecellularized tissues after 4 weeks but not at 6 months, indicating complete graft rejection at that time. In contrast, transforming growth factor β1 and interleukin 10 were the only prominent cytokines in all decellularized grafts at 4 weeks after transplantation. CONCLUSIONS Decellularization of allograft vascular tissue minimized the recipient cellular immune response and eliminated the production of anti-donor antibodies in recipients.

Hybrid coronary revascularization using robotic totally endoscopic surgery: perioperative outcomes and 5-year results.

BACKGROUND Hybrid coronary revascularization combines minimally invasive coronary artery bypass grafting and catheter-based interventions. This treatment option represents a viable alternative to both open multivessel coronary bypass surgery through sternotomy and multivessel percutaneous coronary intervention. The surgical component of hybrid coronary intervention can be offered in a completely endoscopic fashion using robotic technology. We report on one of the largest series to date. METHODS From 2001 to 2011, 226 patients (age, 61 years [range, 31 to 90 years]; 77.0% male; EuroSCORE, 2 [range, 0 to 13]) underwent hybrid coronary interventions on an intention-to-treat basis. Robotically assisted procedures were performed using the daVinci, daVinci S, and daVinci Si surgical telemanipulation systems (Intuitive Surgical, Inc, Sunnyvale, CA) and included 147 single, 72 double, and 7 triple endoscopic coronary artery bypass grafting procedures. Surgery was carried out first in 160 cases (70.8%), percutaneous coronary intervention was carried out first in 38 cases (16.8%), and 28 patients underwent simultaneous operations in a hybrid operating room (12.4%). Drug-eluting stents were used in 70.0% of the patients. RESULTS Hospital mortality was 3 of 226 patients (1.3%), and hospital stay averaged 6 days (range, 3 to 54 days). Patients walked outside 7 days (range, 3 to 97 days) postoperatively and performed general household work 14 days (range, 7 to 180 days) postoperatively. Full activity was resumed at 42 days (range, 7 to 720 days). Five-year survival was 92.9%, and 5-year freedom from major adverse cardiac and cerebral events was 75.2%. At 5 years, 2.7% of bypass grafts and 14.2% of percutaneous coronary intervention targets needed reintervention. CONCLUSIONS Robotically assisted hybrid coronary intervention enables surgical treatment of multivessel coronary artery disease with minimal trauma. Perioperative results and intermediate-term outcomes meet the standards of open coronary artery bypass grafting. Recovery time is short, and reintervention rates are acceptable.

Robotic cardiac surgery.

Purpose of review To outline current techniques in robotic cardiac surgery and to report the recent results. Recent findings Robot-assisted surgery is the latest iteration toward less-invasive surgical procedures. Cardiac surgeons have slowly adopted robotic techniques into their armamentarium. In particular, robotic mitral valve surgery has evolved over the last decade and become the preferred method of mitral valve repair and replacement at certain specialized centers worldwide because of excellent results. Robotic single-vessel and double-vessel total endoscopic coronary artery bypass grafting procedures have likewise been standardized on the beating and arrested heart. Other cardiac procedures are in various stages of evolution. Results to date have matched the outcomes of major trials for sternotomy-based procedures. In addition, patients may benefit from shorter hospital stays and experience faster return to full activity. Summary Stepwise progression of robotic technology and procedure development will continue to make robotic operations simpler and more efficient, which will encourage more surgeons to take up this technology and extend the benefits of robotic surgery to a larger patient population. Long-term results are needed to determine whether robotic techniques could become the new standard in cardiac surgery.

Predictors, causes, and consequences of conversions in robotically enhanced totally endoscopic coronary artery bypass graft surgery.

BACKGROUND Totally endoscopic coronary artery bypass graft surgery (TECAB), using the da Vinci telemanipulator, has become a reproducible operation at dedicated centers. As in every endoscopic operation, conversion is an important and probably inevitable issue. METHODS We performed robotic TECAB in 326 patients (age, 60 years; range, 31 to 90 years); 242 were single-vessel and 84 were multivessel TECAB. RESULTS Forty-six of 326 patients (14%) were converted to a larger incision (minithoracotomy, n = 5; sternotomy, n = 41). Left internal mammary artery injury (n = 7), epicardial injury (n = 4), balloon endoocclusion problems (n = 7), and anastomotic problems (n = 18) were common reasons for conversions. Conversion rate was significantly less for single-vessel versus multivessel TECABs (10% versus 25%; p = 0.001). Non-learning-curve case (7% versus 21%; p < 0.001) and transthoracic assistance (11% versus 22%; p = 0.018) were associated with lower conversion rates. In multivariate analysis, learning-curve case was the only independent predictor of conversion (p = 0.005). Conversion translated into increased packed red blood cell transfusion in the operating room (3 versus 0 units; p < 0.001), longer ventilation time (14 versus 8 hours; p < 0.001), and intensive care unit stay (45 versus 20 hours; p = 0.001). Hospital mortality was 0.6% in this series, with 1 patient in the conversion group (2.2%) and 1 patient in the nonconverted group (0.4%; not significant). Five-year survival was 98% in nonconverted patients and 88% in converted patients (p = 0.018). There was no difference in freedom from angina or freedom from major adverse cardiac and cerebral events. CONCLUSIONS Conversion in TECAB is primarily learning curve-dependent and associated with increased morbidity, but does not significantly affect hospital mortality. Both nonconverted and converted patients show good long-term survival, which is comparable to patients undergoing open sternotomy coronary artery bypass grafting. Long-term freedom from angina or freedom from major adverse cardiac and cerebral events is not influenced by conversion.

Hybrid coronary revascularization: which patients? When? How?

Purpose of review The aim of this review is to report on current indications and patient selection for hybrid coronary revascularization and to outline current techniques for a hybrid approach. Recent findings Hybrid coronary intervention is a revascularization strategy that combines surgical and catheter-based procedures for treatment of multivessel coronary artery disease. Most published studies report on application of this concept in patients with complex lesions of the left anterior descending artery and nonleft anterior descending lesions suited for percutaneous coronary intervention. Currently, the spectrum of surgical procedures in hybrid coronary revascularization ranges from left internal mammary artery bypass grafting via sternotomy and minithoracotomy to completely endoscopic robotic double vessel coronary artery bypass grafting. Percutaneous coronary intervention in hybrid procedures is performed as single or multiple coronary angioplasty with stenting using either bare metal or drug-eluting stents. Staged and simultaneous approaches can be applied. The latter are increasingly performed in the hybrid operating room. Summary Hybrid coronary intervention is an emerging interdisciplinary approach in the treatment of coronary artery disease and a potential viable alternative to open coronary bypass surgery or multivessel stenting.

Impact of Timing and Surgical Approach on Outcomes After Mitral Valve Regurgitation Operations

BACKGROUND This study investigated whether the timing of mitral valve (MV) repair or surgical approach affects outcomes in patients with MV regurgitation. METHODS Between 1992 and 2009, 2,255 patients underwent MV operations, including 1,305 with isolated MV regurgitation operations (1,054 repairs, 251 replacements). Surgical approaches were sternotomy in 377, video-assisted right minithoracotomy in 481, or robot-assisted in 447. Mean follow-up was 6.4±4.5 years (maximum, 19 years). RESULTS Sternotomy MV repairs decreased during the study while minimally invasive MV repairs increased. Robotic MV repair patients were younger, with fewer women, had better left ventricular ejection fractions, and were more likely to have myxomatous degeneration (all p<0.001). The robotic approach led to a higher MV repair rate and increased use of leaflet/chordal procedures but had longer cardiopulmonary bypass and aortic cross-clamp times (all p<0.001). The 30-day mortality for isolated MV repair was similar for all approaches (p=0.409). Fewer neurological events were observed in the videoscopic and robotic groups (p=0.013). Adjusted survival was similar for all approaches (p=0.357). Survival in patients in New York Heart Association class I to II with myxomatous degeneration or annular dilatation was similar to a matched population but was worse for patients in class III to IV or undergoing MV replacement. CONCLUSIONS MV repair in patients with severe MV regurgitation should be performed before New York Heart Association class III to IV symptoms develop. Minimally invasive MV repair techniques render similar outcomes as the sternotomy approach.

Totally Endoscopic Quadruple Coronary Artery Bypass Grafting Is Feasible Using Robotic Technology

Multivessel robotic totally endoscopic coronary artery bypass grafting is currently under development. Quadruple totally endoscopic coronary artery bypass has so far not been reported. A 75-year-old patient with multivessel coronary artery disease underwent daVinci Si-assisted completely endoscopic placement of a left internal mammary artery bypass to the left anterior descending artery and construction of a right internal mammary artery Y-graft off the left internal mammary artery to the posterior descending artery. The left internal mammary artery was also connected to a diagonal branch as a sequential graft. The obtuse marginal branch was revascularized using an endoscopically harvested vein graft originating from the left axillary artery.

Predictors and consequences of postoperative atrial fibrillation following robotic totally endoscopic coronary bypass surgery

OBJECTIVES Postoperative atrial fibrillation (AFib) is common in patients undergoing coronary artery bypass grafting. Little information is available concerning AFib following minimally invasive cardiac surgery. The aim of our study was to assess the incidence of AFib after totally endoscopic coronary artery bypass (TECAB) grafting and to investigate the factors influencing its occurrence. METHODS Between 2001 and 2010, we performed TECAB in 384 patients, 73% male, aged 60 (37-90) years. Single-vessel bypasses were performed in 280 patients, and 104 received multivessel coronary revascularization. Procedures were performed on the beating heart in 80 cases, and 164 patients underwent a hybrid intervention. RESULTS A total of 59 patients (15.4%) developed AFib after TECAB. Univariate analysis showed hypertension (P=0.005), increased age (P=0.007), body weight (P=0.006), body mass index (P=0.005), EuroSCORE (P=0.035) and total TECAB operation time (P=0.01) to be significantly associated with AFib. We also found an increased incidence of AFib in patients undergoing hybrid interventions (P=0.036) and beating heart TECAB (P=0.003). Age (P<0.001) and higher body weight (P=0.003) were the only predictors found to be significant in multivariate analysis. Hospital mortality was 1.7% (1 of 59) in the group of patients with AFib and 0.6% (2 of 325) in the group that showed no AFib after operation (P=n.s.). Hospital stay was 7 (4-54) days in patients with AFib and 6 (2-33) days in those without AFib (P=n.s.). There was no significant 5-year survival difference in patients with and without postoperative AFib (94 vs 94%, P=n.s.). CONCLUSIONS We conclude that the incidence of postoperative AFib in TECAB is relatively low. Age and body weight are the most important predictors of postoperative AFib following TECAB. Short-term clinical outcome and intermediate-term survival are similar in patients with and without postoperative AFib.