Jeffrey D. Lee

Factors Influencing Hospital Length of Stay After Robotic Totally Endoscopic Coronary Artery Bypass Grafting

BACKGROUND Robotic totally endoscopic coronary artery bypass grafting (TECAB) is an evolving minimally invasive technology with the potential to reduce hospital length of stay (LOS). Little is known about the factors that influence LOS after this procedure. The aim of this study is to define the preoperative, intraoperative, and postoperative variables that predict LOS after TECAB. METHODS From 2001 to 2011, 541 patients, aged 60 years (range, 26 to 90 years), 394 (72.8%) male, 147 (27.1%) female, underwent TECAB using the daVinci telemanipulation system at one European and one American institution. Three hundred forty-six (63.9%) single-, 171 (31.6%) double-, 23 (4.2%) triple-, and 1 (0.2%) quadruple-vessel TECABs were carried out with an overall LOS of 6 days (range, 2 to 54 days) and 30-day mortality of 0.9% (5 of 541); 44.5% of patients (241 of 541) were hybrid intent-to-treat candidates. RESULTS The following variables showed significant positive correlation with LOS: age, r = 0.188 (p < 0.001); Society of Thoracic Surgeons risk score, r = 0.263 (p < 0.001); EuroSCORE, r = 0.191 (p < 0.001); creatinine, r = 0.135 (p = 0.002); and operative time, r = 0.216 (p < 0.001). Other factors that had significant influence on LOS were hemodialysis (p = 0.037), cerebrovascular disease (p = 0.002), learning curve case (p < 0.001), intraoperative surgical problem (p < 0.001), conversion or on-table revision (p < 0.001), revision for bleeding (p < 0.001), postoperative stroke (p < 0.001), intraaortic balloon pump (p < 0.001), hemodialysis (p < 0.001), and atrial fibrillation (p < 0.001). By multivariate analysis, learning curve case, conversion or on-table revision, and revision for bleeding were independent predictors for prolonged LOS (defined as LOS > 6 days). CONCLUSIONS Multiple variables affect LOS after TECAB. Older patients, patients on hemodialysis, patients with cerebrovascular disease, and those with higher general risk scores should expect prolonged LOS. Intraoperative surgical difficulties and conversion to open coronary artery bypass grafting also lead to extended LOS. Postoperative events that are known to prolong LOS in open coronary artery bypass grafting also prolong LOS after TECAB.

Advanced hybrid coronary revascularization with robotic totally endoscopic triple bypass surgery and left main percutaneous intervention

CLINICAL SUMMARY The patient, a 57-year-old man with a history of myocardial infarction, left anterior descending coronary artery (LAD) stent, and occluded right coronary artery, automatic implantable cardiac defibrillator implantation, was seen because of ventricular tachycardia, acute non–ST segment elevation myocardial infarction, and automatic implantable cardiac defibrillator discharge. Workup identified anteroapical ischemia, complex 70% stenosis involving the distal left main coronary artery (LMCA) and all 3 major subbranch ostia, and 30% in-stent restenosis of the LAD stent. Hybrid coronary revascularization was planned, including 3-vessel, all-arterial TECAB targeting the LAD, left circumflex coronary artery, and right posterior descending coronary artery systems with staged stenting of the distal LMCA and ramus. In the operating room, left ventricular ejection fraction was 20%; however, this was considered to be reversible because outpatient left ventricular ejection fraction was 45% and implantation of a prophylactic intraaortic balloon pump resulted in significant improvement. With the da Vinci telemanipulation system (Intuitive Surgical, Sunnyvale, Calif), bilateral internal thoracic arteries (ITAs) were harvested with simultaneous harvesting of the left radial artery. An end to side right ITA–radial artery Y anastomosis was created with robotic endoscopic

Robotic Totally Endoscopic Coronary Artery Bypass Grafting in Men and Women: Are There Sex Differences in Outcome?

BACKGROUND According to several studies, women are at higher risk for mortality and experience less relief of angina after coronary artery bypass graft surgery (CABG) than men. Sex-related differences in patients undergoing totally endoscopic coronary bypass grafting (TECABG) have not been investigated thus far. The aim of the present study was to evaluate the impact of sex on the outcome of patients undergoing TECABG. METHODS The data of 500 consecutive patients (364 male, 136 female) undergoing TECABG using the da Vinci telemanipulation system (Intuitive Surgical, Sunnyvale, CA) from 2001 to 2011 at two institutions were investigated regarding sex-related differences in short-term and long-term outcome. RESULTS In all, 334 single, 150 double, 15 triple, and 1 quadruple TECABG procedures were carried out. Female patients were significantly older (63 years [range, 26 to 90] versus 59 years [range, 31 to 85], p = 0.001) and had higher European System for Cardiac Operative Risk Evaluation score levels (3 [range, 0 to 11] versus 2 [range, 0 to 13], p < 0.001). Male patients received slightly more grafts (1 [range, 1 to 4] versus 1 [range, 1 to 3], p = 0.028), female patients were more likely to undergo beating heart surgery (20% versus 28%, p = 0.042). In-hospital mortality was 3 of 364 men (0.8%) and 2 of 136 women (1.5%; p = 0.513). Comparison of long-term-survival revealed 1-, 3- and 5-year survival rates of 96%, 96%, and 95% in men and 96%, 96%, and 96% in women, respectively, without any significant difference. Analysis of freedom from major adverse cardiac and cerebrovascular events revealed 1-, 3-, and 5-year rates of 86%, 84%, and 82% in men and 85%, 81%, and 81% in women, respectively, without any significant difference. CONCLUSIONS Our data show that women undergoing TECABG have outcomes similar to those of men.

Successful Management of Penetrating Injury to the Aortopulmonary Window

previously healthy 35-year-old man presented with Apenetrating injuries to the left hand and anterior chest after an assault with a nail gun. The nails entered along the lateral left palm and left parasternal border (Fig 1). The patient remained hemodynamically stable and demonstrated no respiratory distress, hemoptysis, tachypnea, or hypoxia. Computed tomographic angiography demonstrated a 7.7-cm nail protruding through the left aspect of the manubrium with the nail tip projecting into the aortopulmonary window, under the aortic arch and above the main pulmonary artery, with no evidence of vessel injury. Given the location and length of the nail,