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Torregrossa G, Amabile A, Nisivaco S, Algoet M, Oosterlinck W, Balkhy HH. The Stradivari Violin of Robotic Heart Surgery: The Robotic EndoWrist Stabilizer. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024; 19:612-615. [PMID: 39311095 DOI: 10.1177/15569845241279259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2024]
Affiliation(s)
- Gianluca Torregrossa
- Department of Cardiac Surgery, Lankenau Heart Center, Main Line Health, Wynnewood, PA, USA
| | - Andrea Amabile
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Sarah Nisivaco
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine and Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Michiel Algoet
- Department of Cardiovascular Sciences, Research Unit of Cardiac Surgery, KU Leuven, Belgium
| | - Wouter Oosterlinck
- Department of Cardiovascular Sciences, Research Unit of Cardiac Surgery, KU Leuven, Belgium
| | - Husam H Balkhy
- Division of Cardiac Surgery, University of Chicago Medicine, IL, USA
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Ashraf SF, Seese L, Hasan IS, Babu AN, Balkhy HH, Kiaii BB, Guy TS, Kaczorowski DJ, Bonatti J. Development and Validation of a Low-Cost, High-Fidelity Simulation Model for Robotic Internal Mammary Artery Harvest Using the da Vinci Xi Robot. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024; 19:633-639. [PMID: 39473044 DOI: 10.1177/15569845241286012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2024]
Abstract
OBJECTIVE We created and validated a low-cost simulation model for robotic internal mammary artery (IMA) takedown. METHODS The simulation model utilized a calf fetus thorax cavity stented open internally and secured to a table. The simulation model was validated at a 2-day robotic cardiac surgery workshop. Each participant harvested one IMA using the da Vinci Xi robot (Intuitive Surgical, Sunnyvale, CA, USA). We compared participant self-reported confidence at robotic IMA harvest before and after using the simulator. RESULTS Our novel thorax-securing strategy resulted in a stable structure and allowed access to both IMAs from the same 3 ports. The cost to set up the first simulation model was $176 and $133 for every subsequent model. Fifty participants used the simulation model: 42 cardiothoracic surgery attendings and 8 fellows or residents. The feedback form response rate was 78% (n = 39). On the Likert scale, participants rated realism of the calf model to simulate robotic IMA harvesting (0 = not realistic, 10 = highly realistic) with a median of 8 out of 10 (interquartile range [IQR] 7 to 9). Participant confidence (0 = not at all confident, 10 = very confident) in robotic IMA harvesting before and after using the simulator increased (P = 0.001) from a median of 5 (IQR 1 to 7) to 9 (IQR 7 to 10). CONCLUSIONS This robotic IMA harvest simulation model is affordable, realistic, and improved participant confidence in robotic IMA harvest. It may provide a valuable training tool for surgeons learning robotic coronary bypass surgery and allows for training frequency necessary to pass basic learning curves.
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Affiliation(s)
- Syed Faaz Ashraf
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, PA, USA
| | - Laura Seese
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, PA, USA
| | - Irsa S Hasan
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, PA, USA
| | - Ashok N Babu
- Department of Cardiovascular Surgery, Saint Thomas West Hospital, Nashville, TN, USA
| | - Husam H Balkhy
- Department of Cardiothoracic Surgery, University of Chicago Medicine, IL, USA
| | - Bob B Kiaii
- Department of Surgery, UC Davis Health, Sacramento, CA, USA
| | - T Sloane Guy
- Georgia Heart Institute at Northeast Georgia Medical Center, Gainesville, GA, USA
| | - David J Kaczorowski
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, PA, USA
| | - Johannes Bonatti
- Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, PA, USA
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Ruel M, Halkos ME. Minimally Invasive Coronary Artery Bypass Grafting is the Future: Pro. Semin Thorac Cardiovasc Surg 2024; 37:34-42. [PMID: 39368527 DOI: 10.1053/j.semtcvs.2024.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Revised: 09/23/2024] [Accepted: 09/27/2024] [Indexed: 10/07/2024]
Abstract
Coronary artery bypass grafting (CABG) remains one of the most commonly performed operations worldwide. However, most CABG operations performed today are as invasive -apart from saphenous vein harvesting- as they were 50 years ago. While heart valve operations have become less invasive, CABG faces formidable challenges in doing so. Valve surgery requires a single surgical exposure to the valve intervened on, but less invasive CABG necessitates multiple surgical exposures to harvest internal thoracic artery conduits, source their inflow plus that of other grafts, and expose each coronary target to be grafted -including anterior, lateral, posterior, and inferior vessels. In this article, we rationalize why we believe that conventional CABG remains unduly invasive, associated with morbidity and prolonged recovery, and why less invasive CABG in its many forms, which we describe, represents a safe, practical, diffusible, and less invasive alternative to sternotomy CABG. Centers of excellence in coronary artery surgery should dedicate resources and expertise to developing high-quality, safe, durable, and advanced forms of lesser invasive CABG.
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Affiliation(s)
- Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - Michael E Halkos
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
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Lengyel BC, Chinnadurai P, Corr SJ, Lumsden AB, Bavare CS. Robot-assisted vascular surgery: literature review, clinical applications, and future perspectives. J Robot Surg 2024; 18:328. [PMID: 39174843 PMCID: PMC11341614 DOI: 10.1007/s11701-024-02087-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2024] [Accepted: 08/17/2024] [Indexed: 08/24/2024]
Abstract
Although robot-assisted surgical procedures using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) have been performed in more than 13 million procedures worldwide over the last two decades, the vascular surgical community has yet to fully embrace this approach (Intuitive Surgical Investor Presentation Q3 (2023) https://investor.intuitivesurgical.com/static-files/dd0f7e46-db67-4f10-90d9-d826df00554e . Accessed February 22, 2024). In the meantime, endovascular procedures revolutionized vascular care, serving as a minimally invasive alternative to traditional open surgery. In the pursuit of a percutaneous approach, shorter postoperative hospital stay, and fewer perioperative complications, the long-term durability of open surgical vascular reconstruction has been compromised (in Lancet 365:2179-2186, 2005; Patel in Lancet 388:2366-2374, 2016; Wanhainen in Eur J Vasc Endovasc Surg 57:8-93, 2019). The underlying question is whether the robotic-assisted laparoscopic vascular surgical approaches could deliver the robustness and longevity of open vascular surgical reconstruction, but with a minimally invasive delivery system. In the meantime, other surgical specialties have embraced robot-assisted laparoscopic technology and mastered the essential vascular skillsets along with minimally invasive robotic surgery. For example, surgical procedures such as renal transplantation, lung transplantation, and portal vein reconstruction are routinely being performed with robotic assistance that includes major vascular anastomoses (Emerson in J Heart Lung Transplant 43:158-161, 2024; Fei in J Vasc Surg Cases Innov Tech 9, 2023; Tzvetanov in Transplantation 106:479-488, 2022; Slagter in Int J Surg 99, 2022). Handling and dissection of major vascular structures come with the inherent risk of vascular injury, perhaps the most feared complication during such robotic procedures, possibly requiring emergent vascular surgical consultation. In this review article, we describe the impact of a minimally invasive, robotic approach covering the following topics: a brief history of robotic surgery, components and benefits of the robotic system as compared to laparoscopy, current literature on "vascular" applications of the robotic system, evolving training pathways and future perspectives.
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Affiliation(s)
- Balazs C Lengyel
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA.
- Department of Vascular and Endovascular Surgery, Semmelweis University, Budapest, Hungary.
| | - Ponraj Chinnadurai
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
| | - Stuart J Corr
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
| | - Alan B Lumsden
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
| | - Charudatta S Bavare
- Department of Cardiovascular Surgery, Houston Methodist Hospital, 6550 Fannin Street, Houston, TX, 77030, USA
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Nisivaco S, Blair J, Patel A, Kitahara H, Allan T, Patel B, Coleman C, Balkhy HH. Robotic Totally Endoscopic Off-Pump Unroofing of Myocardial Bridge: Early Experience and Midterm Outcomes. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024; 19:409-415. [PMID: 39269034 DOI: 10.1177/15569845241266817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2024]
Abstract
OBJECTIVE Myocardial bridging (MB) occurs when a coronary artery, commonly the left anterior descending (LAD), has an intramyocardial course. In symptomatic patients who fail medical therapy, surgical unroofing can provide symptomatic relief by improving coronary blood flow. We present a series of patients undergoing robotic totally endoscopic beating-heart MB unroofing. METHODS There were 34 patients with an LAD-MB who failed medical therapy and underwent robotic totally endoscopic, off-pump unroofing between January 2017 and October 2023. Patients were evaluated by a multidisciplinary team and underwent provocative coronary angiography to confirm hemodynamic significance. We reviewed perioperative outcomes and contacted patients for midterm follow-up, including completion of a modified Seattle Angina Questionnaire (SAQ). RESULTS The mean age was 48 ± 8 years, and 56% were female patients. One patient had prior septal myectomy via sternotomy. All patients had significant dobutamine Pd/Pa reduction on preoperative coronary angiography. One patient had atrial fibrillation and underwent concomitant ablation with left atrial appendage ligation. The mean procedure time was 140 ± 69 min. All were completed totally endoscopically off-pump without intraoperative conversions. The mean MB length was 4.5 ± 1.4 cm, and the mean depth was 1.6 ± 0.9 cm. Of the patients, 76% were extubated in the operating room. The mean intensive care unit and hospital length of stay were 0.97 ± 0.58 and 1.73 ± 1.1 days, respectively. There were no mortalities or strokes. There was 1 postoperative take-back for bleeding. At midterm follow-up (19 ± 14 months), 28 patients completed the SAQ; 86% reported "much less angina" during activity compared with before surgery, and 93% reported taking no antianginal medication since surgery. CONCLUSIONS In appropriate patients with hemodynamically significant LAD-MB who fail medical therapy, robotic beating-heart unroofing is possible with good outcomes. Further studies are warranted.
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Affiliation(s)
- Sarah Nisivaco
- Department of Cardiothoracic Surgery, University of Chicago Medicine, IL, USA
| | - John Blair
- Department of Cardiology, University of Chicago Medicine, IL, USA
| | - Amit Patel
- Department of Cardiology, University of Chicago Medicine, IL, USA
| | - Hiroto Kitahara
- Department of Cardiothoracic Surgery, University of Chicago Medicine, IL, USA
| | - Tess Allan
- Department of Cardiology, University of Chicago Medicine, IL, USA
| | - Brooke Patel
- Department of Cardiothoracic Surgery, University of Chicago Medicine, IL, USA
| | - Charocka Coleman
- Department of Cardiothoracic Surgery, University of Chicago Medicine, IL, USA
| | - Husam H Balkhy
- Department of Cardiothoracic Surgery, University of Chicago Medicine, IL, USA
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Zacharias J, Glauber M, Pitsis A, Solinas M, Kempfert J, Castillo-Sang M, Balkhy HH, Perier P. The 7 Pillars of Starting an Endoscopic Cardiac Surgery Program. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024; 19:107-117. [PMID: 38619021 DOI: 10.1177/15569845241239448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Affiliation(s)
| | | | | | - Marco Solinas
- Ospedale del Cuore-Fondazione Monasterio, Massa, Italy
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Nisivaco S, Kitahara H, Abutaleb A, Nathan S, Balkhy HH. Robotic Totally Endoscopic Coronary Bypass to the Left Anterior Descending Artery: Left Versus Right Internal Thoracic Artery Grafts. J Surg Res 2023; 291:139-150. [PMID: 37390593 DOI: 10.1016/j.jss.2023.04.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2022] [Revised: 04/04/2023] [Accepted: 04/29/2023] [Indexed: 07/02/2023]
Abstract
INTRODUCTION The left internal thoracic artery (LITA) is most commonly used to bypass the left anterior descending artery (LAD) given its well-established mortality benefit. In some cases, the grafting strategy necessitates placing the right internal thoracic artery (RITA) on the LAD. We compared outcomes in our robotic beating-heart totally endoscopic coronary bypass surgery (TECAB) population between patients receiving LITA versus RITA-LAD grafts. METHODS We retrospectively reviewed patients undergoing robotic TECAB with skeletonized ITA conduits over 9 y. Outcomes were compared between those receiving LITA (Group-1) versus RITA (Group-2) grafts to the LAD (with/without other grafts). End points were early angiographic patency (in patients undergoing hybrid revascularization) and mid-term mortality/major adverse cardiac/cerebrovascular events. A propensity matched subanalysis was performed comparing only patients who received bilateral ITA grafting in each group. RESULTS Society of Thoracic Surgeons predicted mortality risk score was higher in Group-2. Group-1 patients had lower incidence of multivessel disease (75% versus 96%, P ≤ 0.001). Early overall graft patency (97% versus 96%, P = 0.718) and LAD graft patency (98% versus 95%, P = 0.372) were equivalent. At mean 42-mo follow-up (longest 8.5 y), Group-1 had lower all-cause mortality but no difference in cardiac mortality or repeat revascularization. In the propensity matched subanalysis, mid-term outcomes were equivalent. CONCLUSIONS Grafting the LAD with the LITA or RITA during robotic beating-heart TECAB resulted in similar early outcomes and angiographic patency. RITA-LAD patients were more likely to have multivessel disease and higher Society of Thoracic Surgeons risk and had higher all-cause mortality at mid-term analysis but no difference in major adverse cardiac/cerebrovascular events, including cardiac mortality.
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Affiliation(s)
- Sarah Nisivaco
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Illinois
| | - Hiroto Kitahara
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Illinois
| | | | - Sandeep Nathan
- Department of Cardiology, University of Chicago Medicine, Chicago, Illinois
| | - Husam H Balkhy
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Illinois.
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Nisivaco SM, Kitahara H, Abutaleb AR, Nathan S, Balkhy HH. Hybrid Coronary Revascularization: Early Outcomes and Midterm Follow-Up in Patients Undergoing Single or Multivessel Robotic TECAB and PCI. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:513-520. [PMID: 36529976 DOI: 10.1177/15569845221137349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Hybrid coronary revascularization (HCR) is the integration of sternal-sparing coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) in patients with multivessel coronary artery disease (CAD). It is traditionally performed with single-vessel bypass (left internal mammary artery [LIMA] to left anterior descending artery [LAD]) and PCI but can also be accomplished with multiple arterial grafts using bilateral IMA conduits. We sought to review our HCR experience over an 8-year period with robotic totally endoscopic coronary artery bypass (TECAB) and PCI. METHODS Of 694 patients undergoing beating-heart TECAB from August 2013 to June 2022, 306 patients were designated as intention-to-treat HCR candidates. Patients underwent PCI prior to, the same day as, or following TECAB, performed using single or bilateral IMA grafts. We retrospectively reviewed early and midterm outcomes up to 8 years in this cohort of patients. RESULTS The mean Society of Thoracic Surgeons predicted risk of mortality was 1.5% ± 2.5%. There were 44 patients (14%) who had ≥70% left main disease and 218 patients (71%) who had triple-vessel disease. A total of 193 patients (63%) underwent multivessel grafting (advanced HCR), with 83% bilateral IMA use. Mean operative time was 263 ± 80 min, and mean length of stay was 2.6 days. The mean number of vessels bypassed per patient was 1.7 ± 0.6. The mean number of vessels stented was 1.2 ± 0.5. Of the patients, 84% underwent TECAB first, 14% PCI first, and 2% same-day TECAB/PCI. Mortality was 0.6% (observed to expected ratio: 0.42). Early graft patency was 97% (328 of 339 grafts); LIMA-LAD patency was 98%. At 8-year follow-up (mean 37 ± 26 months), all-cause and cardiac-related mortality were 13% and 2.6%, respectively. Freedom from major adverse cardiac and cerebrovascular events was 92%. CONCLUSIONS In patients with multivessel CAD, integrating robotic single and multivessel TECAB with PCI resulted in excellent early and midterm outcomes. In experienced hands, the robotic endoscopic approach allows the routine use of multiple arterial grafting during HCR.
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Affiliation(s)
- Sarah M Nisivaco
- Department of Cardiothoracic Surgery, University of Chicago Medicine, IL USA
| | - Hiroto Kitahara
- Department of Cardiothoracic Surgery, University of Chicago Medicine, IL USA
| | | | - Sandeep Nathan
- Department of Cardiology, University of Chicago Medicine, IL USA
| | - Husam H Balkhy
- Department of Cardiothoracic Surgery, University of Chicago Medicine, IL USA
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Chitwood WR. Historical evolution of robot-assisted cardiac surgery: a 25-year journey. Ann Cardiothorac Surg 2022; 11:564-582. [PMID: 36483613 PMCID: PMC9723535 DOI: 10.21037/acs-2022-rmvs-26] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 11/05/2022] [Indexed: 08/18/2023]
Abstract
Many patients and surgeons today favor the least invasive access to an operative site. The adoption of robot-assisted cardiac surgery has been slow, but now has come to fruition. The development of modern surgical robots took surgeons close collaboration with mechanical, electrical, and optical engineers. Moreover, the necessary project funding required entrepreneurs, federal grants, and venture capital. Non-robotic minimally invasive cardiac surgery paved the way to the application of surgical robots by making changes in operative approaches, instruments, visioning modalities, cardiopulmonary perfusion techniques, and especially surgeons' attitudes. In this article, the serial development of robot-assisted cardiac surgery is detailed from the beginning and through clinical application. Included are references to the historical and most recent clinical series that have given us the evidence that robot-assisted cardiac surgery is safe and provides excellent outcomes. To this end, in many institutions these procedures now have become a new standard of care. This evolution reflects Sir Isaac Newton's famous 1676 quote when referring to Rene Descartes, "If have seen further [sic] than others, it is by standing on the shoulders of giants".
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Affiliation(s)
- W Randolph Chitwood
- Department of Cardiovascular Sciences, Brody School of Medicine, East Carolina University, Greenville, NC, USA
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Meta-analysis of survival after extrapleural pneumonectomy (EPP) versus pleurectomy/decortication (P/D) for malignant pleural mesothelioma in the context of macroscopic complete resection (MCR). Updates Surg 2022; 74:1827-1837. [PMID: 36057027 DOI: 10.1007/s13304-022-01369-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 08/20/2022] [Indexed: 10/14/2022]
Abstract
OBJECTIVE We reviewed the available literature on patients with MPM undergoing either extrapleural pneumonectomy (EPP) or pleurectomy/decortication (P/D). METHODS Original research studies that evaluated long-term outcomes of P/D versus EPP were identified, from January 1980 to February 2022. The 30-days and 90-day mortality, along with the 1-, 2-, 3-, 5-year survival, the median overall survival, the macroscopic complete resection (MCR) rate, and the complications were calculated according to both a fixed and a random effect model. The Q and I2 statistic were used to test for heterogeneity among the studies. Sensitivity analysis was performed including only studies that incorporated the MCR concept. RESULTS Eighteen studies were included, incorporating a total of 4,852 patients treated with EPP and P/D. The 30-day mortality was significantly higher in the EPP group (OR: 2.79 [95% CI 1.30, 6.01]; p = 0.009). The median overall survival was higher in the P/D group (WMD:-4.55 [-6.05, -3.04]; p < 0.001). No differences were found regarding the 90-day mortality, MCR rate, and the 1-, 2-,3-, 5-year survival between the EPP and P/D groups. These findings were validated by the sensitivity analysis. The incidence of atrial fibrillation, hemorrhage, pulmonary embolism, air leak, and reoperation was significantly increased in the EPP group (p < 0.05). CONCLUSIONS The present meta-analysis indicates that P/D is associated with enhanced outcomes regarding 30-day mortality, median overall survival, and complications. The P/D approach should be preferred when technically feasible. However, the procedure of choice should be decided based on the goal of MCR in the safest approach for the patient.
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Balkhy HH, Nisivaco S, Kitahara H, AbuTaleb A, Nathan S, Hamzat I. Robotic advanced hybrid coronary revascularization: Outcomes with two internal thoracic artery grafts and stents. JTCVS Tech 2022; 16:76-88. [PMID: 36510526 PMCID: PMC9735326 DOI: 10.1016/j.xjtc.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 07/06/2022] [Accepted: 07/26/2022] [Indexed: 12/15/2022] Open
Abstract
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.
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Key Words
- AHCR, advanced hybrid coronary revascularization
- BITA, bilateral internal thoracic artery
- BMI, body mass index
- CABG, coronary artery bypass grafting
- CAD, coronary artery disease
- DAPT, dual-antiplatelet therapy
- HCR, hybrid coronary revascularization
- LAD, left anterior descending artery
- LITA, left internal thoracic artery
- LOS, length of stay
- MACCE, major adverse cardiac/cerebrovascular events
- MAG, multi-arterial grafting
- MI, myocardial infarction
- MIDCAB, minimally invasive direct coronary artery bypass
- PCI, percutaneous coronary intervention
- RCA, right coronary artery
- RITA, right internal thoracic artery
- SITA, single internal thoracic artery
- TECAB
- TECAB, totally endoscopic coronary artery bypass
- bilateral internal thoracic arteries
- coronary artery bypass
- hybrid revascularization
- off-pump
- percutaneous coronary intervention
- robotic
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Affiliation(s)
- Husam H. Balkhy
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Ill,Address for reprints: Husam H. Balkhy, MD, Department Cardiothoracic Surgery, University of Chicago, 5841 S. Maryland Ave, E-500, Chicago, IL 60637.
| | - Sarah Nisivaco
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Ill
| | - Hiroto Kitahara
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Ill
| | | | - Sandeep Nathan
- Department of Cardiology, University of Chicago Medicine, Chicago, Ill
| | - Ibraheem Hamzat
- Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, Ill
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Chikwe J. Editor's Choice: Papers That May Change Your Practice. Ann Thorac Surg 2022; 114:359-363. [PMID: 35878951 DOI: 10.1016/j.athoracsur.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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13
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Lehr EJ. Avoiding adverse outcomes while changing anastomotic technique in totally endoscopic robotic coronary artery bypass grafting. Ann Thorac Surg 2021; 114:482-483. [PMID: 34922912 DOI: 10.1016/j.athoracsur.2021.11.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 11/22/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Eric J Lehr
- Division of Cardiac Surgery, Swedish Heart and Vascular Institute, 1600 E Jefferson St, Ste 110, Seattle, WA 98122.
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