Redo Robotic Endoscopic Beating Heart Coronary Bypass (TECAB) After Previous TECAB

Robotic advanced hybrid coronary revascularization: Outcomes with two internal thoracic artery grafts and stents

Objective

Advanced hybrid coronary revascularization is the integration of sternal-sparing multivessel coronary artery bypass grafting and percutaneous coronary intervention in patients with multivessel coronary artery disease. We sought to review our advanced hybrid coronary revascularization experience over an 8.5-year period using robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery grafts and percutaneous coronary intervention.

Methods

From August 2013 to February 2022, 664 patients underwent robotic totally endoscopic coronary artery bypass at our institution. Of the 293 patients who underwent totally endoscopic coronary artery bypass assigned to a hybrid revascularization strategy, 156 patients received bilateral internal thoracic artery grafts and are the subject of this review. Patients underwent percutaneous coronary intervention with drug-eluting stents before or after totally endoscopic coronary artery bypass. We reviewed early and midterm outcomes (up to 8 years) in this cohort of patients with intent-to-treat advanced hybrid coronary revascularization.

Results

The mean age of patients was 65 ± 10 years. The mean Society of Thoracic Surgeons predicted risk of mortality was 1.26 ± 1.56. Triple-vessel disease occurred in 94% of patients, and 17% of patients had 70% or more left-main disease. The mean operative time was 311 ± 54 minutes, and the mean hospital length of stay was 2.7 ± 1.1 days. All patients had bilateral internal thoracic artery grafts; the total number of grafts was 334. Eight seven percentage of patients had totally endoscopic coronary artery bypass ×2, and 13% of patients had totally endoscopic coronary artery bypass ×3. One patient received totally endoscopic coronary artery bypass ×4. The mean number of grafts per patient was 2.14 ± 0.4, and the mean number of vessels stented was 1.23 ± 0.5. There were no conversions, perioperative stroke, or myocardial infarction. Early mortality occurred in 2 patients. Early graft patency was 98% (209/214 grafts); left internal thoracic artery to left anterior descending patency was 100% (66/66 grafts). At 8-year follow-up in 155 patients (mean 39 ± 26 months), all-cause and cardiac-related mortality were 11.6% and 3.9%, respectively. Freedom from major adverse cardiac/cerebrovascular events including repeat revascularization was 94%.

Conclusions

In patients with multivessel coronary artery disease, integrating robotic totally endoscopic coronary artery bypass with bilateral internal thoracic artery and percutaneous coronary intervention resulted in excellent early and midterm outcomes. Further studies are warranted.

Robotic-assisted coronary artery bypass grafting: current knowledge and future perspectives

Minimally invasive direct coronary artery bypass grafting (MIDCAB) and totally endoscopic coronary artery bypass grafting (TECAB) are the two existing strategies for robotic-assisted, surgical myocardial revascularization. In this review, we summarize the wide evidence available in the literature regarding the benefits of these two procedures, and detail the technical skills required to master robotic coronary surgery techniques.

Benefit of Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass in Octogenarians

OBJECTIVE

An important advantage of robotic beating-heart totally endoscopic coronary artery bypass (TECAB) is early functional recovery, in which fragile patients like octogenarians (age >80 years) benefit most. The aim of this study was to investigate the safety and feasibility of TECAB in octogenarians.

METHODS

We retrospectively reviewed patients undergoing TECAB from July 2013 to September 2017 at our institution. Perioperative outcomes of octogenarian patients and that of younger patients were compared.

RESULTS

Of 308 patients who underwent TECAB, 28 patients (9.1%) were octogenarians (mean age 83.8 ± 3.0 years). Octogenarians had a higher rate of hypertension and atrial fibrillation compared to younger patients. TECAB was successfully performed without conversion to any larger incisions in octogenarians. Mean operative time (299 ± 83 minutes vs 281 ± 89 minutes, P = 0.309) and the rate of multivessel bypass (60.7% vs 58.2%, P = 0.798) were similar between octogenarians and younger patients. New atrial fibrillation was observed more frequently in octogenarians compared to younger patients (35.7% vs 18.6%, P = 0.031). Mean length of hospital stay was similar between the 2 groups (octogenarians: 3.9 ± 1.8 days vs younger patients: 3.5 ± 3.0 days, P = 0.475). Twenty-two octogenarians (78.6%) were discharged directly to home. In-hospital mortality was zero in octogenarians.

CONCLUSIONS

Robotic beating-heart TECAB had favorable results in octogenarians with acceptable morbidity and mortality and excellent short length of stay similar to younger patients.