Angiographic patency after robotic beating heart totally endoscopic coronary artery bypass grafting facilitated by automated distal anastomotic connectors

Coronary Connector Facilitated Total Endoscopic Coronary Artery Bypass: An Ex Vivo Feasibility Study

OBJECTIVE

Totally endoscopic coronary artery bypass (TECAB) procedures pose significant challenges, motivating the development of Octocon, an automated endoscopic connector designed for coronary anastomoses in off-pump and endoscopic settings. This feasibility study aimed to assess Octocon's functionality and maneuverability in closed-chest conditions during robot-assisted TECAB simulations.

METHODS

The Octocon deployment comprises a 3-step procedure. Initially, delicate self-aligning microstapling technology is used to attach connector halves to individual blood vessels. Subsequently, the connector halves are joined to accomplish the anastomosis process. TECAB conditions were simulated using a dedicated box housing ex vivo porcine hearts. The study, conducted by 3 experienced surgeons, investigated the feasibility and standardization potential of a robot-assisted procedure employing Octocon. It evaluated maneuverability in closed-chest conditions and assessed the effectiveness of grafting internal mammary artery segments to different heart regions using single graft, jump graft, and Y-graft constructions.

RESULTS

The robot-assisted procedure, using 4 standard instruments, successfully completed all 3 steps in 18 anastomotic procedures. In 96% of cases, the procedural steps were accomplished on the first attempt. The feasibility of constructing jump graft and Y-graft geometries on both anterior and posterior heart walls was demonstrated. Furthermore, experiences affirmed the device's endoscopic user-friendliness, ease of teachability, reproducibility, and potential to achieve expedient, leak-free anastomoses.

CONCLUSIONS

This ex vivo study confirmed Octocon's potential suitability and functionality for TECAB. The device can create diverse grafting strategies and achieve wide-open vascular connections on various heart regions, highlighting its potential in advancing minimally invasive, robot-assisted coronary procedures. These promising results justify further exploration for integration into clinical practice.

Hybrid Coronary Revascularization: Early Outcomes and Midterm Follow-Up in Patients Undergoing Single or Multivessel Robotic TECAB and PCI

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.

Robotic Total Endoscopic Coronary Bypass in 570 Patients: Impact of Anastomotic Technique in 2 Eras

BACKGROUND

In coronary bypass grafting, including robotic off-pump totally-endoscopic coronary bypass (TECAB), the anastomotic technique is the most critical part of the procedure. We reviewed results in 570 patients over a 7-year period and compared outcomes between to eras, based on predominant anastomotic technique: connectors versus running suture.

METHODS

Between 7/2013-12/2020, 570 patients underwent off-pump TECAB. Group-1 (378 patients, 7/2013-8/2018) using predominantly the C-Port Flex A^TM distal anastomotic stapler (Aesculap, Tuttlingen Germany), Group-2 (192 patients, 9/2018-12/2020) using predominantly a sutured technique (7-0 Pronova^TM, Johnson and Johnson, USA). Retrospective analysis of clinical outcomes was performed.

RESULTS

Off-pump TECAB was completed in 98.8% (563/570 patients) with an Observed/Expected mortality of 0.6 (6/570 patients). The anastomotic device was used in 89% of 626 grafts in Group-1 and only 11% of 305 grafts in Group-2 (p=0.001). There were no differences in multivessel TECAB (57%vs.53%;p=0.331) or bilateral internal thoracic artery use (50%vs.43%;p=0.127) in Group-1 vs Group-2, respectively. Operative time was shorter in Group-1 (242+84 min vs. 273+88 min;p<0.001). Early clinical outcomes were similar between groups, except for hospital stay which was longer in Group-1 (2.9vs2.3 days;p<0.001). Graft patency was similar (98%vs95%;p=0.295) in Group-1 vs Group-2, respectively.

CONCLUSIONS

Changing the predominant approach from stapled anastomosis to a sutured technique during robotic TECAB resulted in longer operative times. Both approaches led to excellent outcomes, including graft patency. The shorter operative times conferred by using staplers may flatten the learning curve and facilitate broader adoption of TECAB.