|Year : 2022 | Volume
| Issue : 4 | Page : 195-200
Robotic coronary revascularization is feasible and safe: 10-year single-center experience
Abdul Wahid Al-Mulla1, Hatem Hemdan Taha Sarhan2, Tamer Abdalghafoor2, Sara Al-Balushi3, Mohamed Ibrahim El Kahlout2, Laith Tbishat2, Dina Fa Alwaheidi2, Maurice Maksoud4, Amr S Omar4, Shady Ashraf1, Ali Kindawi1
1 Department of Cardiothoracic Surgery, Heart Hospital, Doha, Qatar
2 Department of Cardiothoracic Surgery, Heart Hospital; Department of Medical Education, Hamad Medical Corporation, Doha, Qatar
3 Department of Pharmacy, Heart Hospital, Doha, Qatar
4 Department of Cardiothoracic Surgery, Cardiac Anaesthesia and Intensive Care Unit, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
|Date of Submission||15-Jun-2022|
|Date of Acceptance||02-Oct-2022|
|Date of Web Publication||17-Nov-2022|
Dr. Hatem Hemdan Taha Sarhan
Department of Cardiothoracic Surgery, Heart Hospital, Hamad Medical Corporation, PO 3050, Doha
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Objective: The purpose of this study is to investigate the outcomes of patients undergoing robotic surgical coronary revascularization whether total endoscopic coronary artery bypass (TECAB) or robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) in our center.
Methods: This is a retrospective single-center study. It was conducted in the heart hospital at Hamad Medical Corporation, Qatar. We retrospectively studied all cases that had single grafts, left internal mammary artery (LIMA) to left anterior descending (LAD) coronary artery through a minimally invasive approach, either TECAB grafting or RA-MIDCAB grafting operations between February 2009 and December 2020. Both procedures were performed with the assistance of the da Vinci robotic system. In TECAB, the robotic system was used to harvest LIMA and perform the anastomosis with LAD. Whereas in RA-MIDCAB, LIMA was harvested by the robotic system but the anastomosis of LIMA to LAD was performed under direct vision through a small anterior thoracotomy incision. Seventy-one patients' files from the medical records department were reviewed. Preoperative data included age, gender, ethnicity, body mass index (BMI), cardiac risk factors, Euro score, presentation, and the results of the cardiac investigations. The intraoperative data were the type of procedure, operative time, and whether the procedure was completed as planned or converted to thoracotomy or sternotomy. The postoperative data included the length of hospital stay, postoperative complications, 3-month clinic follow-up, and the need for repeat coronary angiography or revascularization.
Results: We found that our patients' ages ranged from 31 to 70 years. The majority were males, with 64 (90.14%) patients. Thirty-one (44.93%) patients were found to have a BMI of 25–29.9 Kg/m2. Forty-seven (66.2%) patients were hypertensive and 37 (52.11%) were diabetic. Dyslipidemia was reported in 35 (50%) patients. TECAB was the primary procedure in 47 (66.2%) patients and the rest underwent RA-MIDCAB. Only 7 (10.14%) patients underwent a planned hybrid procedure. The procedure was completed as planned in 52 (73.2%) patients. The mean operative time was 355.9 ± 95.79 min. Fourteen (19.72%) TECAB procedures were converted to MIDCAB, whereas 5 (7.04%) required sternotomy. Thirteen (18.3%) patients were extubated on the table, 47 (66%) patients were extubated in <24 h, and 7 (9.8%) patients were extubated after 24 h of the procedure. Forty-two (59%) patients stayed only 24 h in ICU and 24 (33.8%) spent more than 24 h. Blood transfusion was required in 8 (11.2%) patients. Only 2 (2.8%) patients experienced bleeding after the surgery. Postoperative infection was observed in 3 (4.29%) patients. No new cerebrovascular accident was detected among the patients after the procedure. Median postoperative hospital stay was 5 days, interquartile range 2, range (2–39). During the 3-month postoperative follow-up, we found that three unplanned coronary angiographies were required for repeat intervention, one of them for LIMA-LAD anastomosis. No redo surgery was performed. Thirty-day mortality was reported in two patients only.
Conclusion: From our experience over more than 10 years in robotic cardiac surgery in Qatar, we believe that robotic coronary revascularization is safe and feasible in selected patients mainly with single vessel coronary artery disease but should be performed in specialized centers and by robotic-trained surgeons.
Keywords: Coronary artery bypass grafting, MIDCAB, minimally invasive, retrospective, robotic, total endoscopic coronary artery bypass TECAB
|How to cite this article:|
Al-Mulla AW, Sarhan HH, Abdalghafoor T, Al-Balushi S, El Kahlout MI, Tbishat L, Alwaheidi DF, Maksoud M, Omar AS, Ashraf S, Kindawi A. Robotic coronary revascularization is feasible and safe: 10-year single-center experience. Heart Views 2022;23:195-200
|How to cite this URL:|
Al-Mulla AW, Sarhan HH, Abdalghafoor T, Al-Balushi S, El Kahlout MI, Tbishat L, Alwaheidi DF, Maksoud M, Omar AS, Ashraf S, Kindawi A. Robotic coronary revascularization is feasible and safe: 10-year single-center experience. Heart Views [serial online] 2022 [cited 2022 Dec 8];23:195-200. Available from: https://www.heartviews.org/text.asp?2022/23/4/195/361400
| Introduction|| |
Minimally invasive cardiac surgery procedures are growing over the past few years. Median sternotomy for coronary artery bypass grafting (CABG) is the standard incision for patients with coronary artery disease (CAD) requiring surgical revascularization, mainly in patients who have multiple vessel disease. Patients with single vessel disease involving the proximal segment of the left anterior descending (LAD) artery that require surgical revascularization could either be performed through median sternotomy or preferably through a minimally invasive procedure.
MIDCAB and total endoscopic coronary artery bypass (TECAB) grafting are alternatives to conventional sternotomy in such cases. Although the procedure has been proven safe, mid- and long-term results are dependent on the experience of the operating surgeon, mainly due to the challenges and the special skills required for the procedure. These techniques have been developed and established in highly specialized tertiary centers. They were further developed to include multivessel grafting or hybrid revascularization procedure.
| Methods|| |
This is a retrospective single-center study. It was conducted in the heart hospital, Hamad Medical Corporation, Qatar. This center is considered the only tertiary center which provides cardiac surgery services in the country. The study included all patients who had either TECAB or RA-MIDCAB in the past 10 years between February 2009 and December 2020. Seventy-one patients' files were reviewed by the medical record department. The files were in the form of papers and electronic data. We reviewed preoperative, intraoperative, and postoperative data. Preoperative data included age, gender, ethnicity, body mass index (BMI), cardiac risk factors, Euro score, symptoms on presentation, and the results of cardiac investigations. The intraoperative data were the type of procedure, operative time, and whether the procedure was completed as planned or converted to thoracotomy or sternotomy. The postoperative data included length of hospital stay, postoperative complications, 3-month clinic follow-up, and the need for repeat coronary angiography or revascularization.
Categorical variables were presented in counts and percentages, whereas continuous data were presented in mean and standard deviation. The median and interquartile ranges (IQRs) were applied for nonnormally distributed variables. Learning curves for intraoperative surgical outcomes were plotted. Stata/SE 14.2 was used for analysis.
| Results|| |
The preoperative patients' characteristics are summarized in [Figure 1]. Patients' ages ranged from 31 to 70 with 64 (90.14%) identified as males. Thirty-one (43.6%) were found to have a BMI of 25–29.9 kg/m2. Hypertension was reported in 47 (66%) patients. Thirty-seven (52%) patients were found to be diabetic. Dyslipidemia was reported in 35 (49.2%) patients. Chest pain was the main complaint on presentation and was found in 67 (94.37%) patients.
Intraoperative patient data are shown in [Figure 2]. TECAB was planned in 47 (66.2%) patients and the rest underwent RA-MIDCAB. Only 7 (10.14%) patients underwent a planned hybrid procedure. The mean operative time was 355.9 ± 95.79 min. Fourteen (19.72%) TECAB procedures were converted to MIDCAB, whereas 5 (7.04%) required sternotomy.
The outcomes are summarized in [Figure 3]. Thirteen (18.3%) patients were extubated in the table, 47 (66%) patients were extubated in <24 h, and 7 (9.8%) patients were extubated after 24 h of the procedure. Forty-two (59%) patients stayed only 24 h in ICU and 24 (33.8%) spent more than 24 h. Blood transfusion was required in 8 (11.2%) patients. Only 2 (2.8%) patients experienced bleeding after the surgery. Postoperative infection was observed in 3 (4.29%) patients. Arrhythmia in the form of atrial fibrillation was reported in 6 (8.4%) patients. No new cerebrovascular accident (CVA) was detected among the patients after the procedure. Median postoperative hospital stay was 5 days, IQR 2, Range (2–39).
Postoperative infection was observed in 3 (4.29%) patients. No new CVA was detected among the patients after the procedure. During the 3-month postoperative follow-up, we found that three unplanned coronary angiographies were required for repeat intervention, one of them for left internal mammary artery (LIMA)-LAD anastomosis and the other two for circumflex artery. No redo surgery was performed. Thirty-day mortality was reported in two patients only.
| Discussion|| |
With advances of technology, less invasive procedures were adopted by many medical specialities. In cardiac surgery, surgeons have adopted less invasive procedures for decades that included small incisions and off-pump, the use of video assisted, and finally robotic procedures.
In coronary revascularization, TECAB and MIDCAB were developed as alternatives to the excellent perioperative and long-term results of conventional CABG.,
CABG through median sternotomy is the standard surgical treatment option for patients with CAD, with recent studies underlining its efficacy and durability.,
Placement of the LIMA graft to the LAD artery has been traditionally considered to provide a survival benefit in patients with CAD.
For nonpercutaneous coronary intervention (PCI) candidates with single-vessel CAD, affecting the proximal LAD, minimally invasive CABG seems to be an excellent alternative to median sternotomy.,
For patients with complex multivessel CAD, conventional CABG is the standard of surgical management.
Looking into a 25-year review of minimally invasive coronary bypass surgery; it is mentioned that minithoracotomy on a beating heart is used to be the most common performed approach which was first introduced to be an alternative to PCI with the solid advantages of LIMA as a conduit over stents.
Due to the proximity of the LIMA to the LAD, minimally invasive procedures through anterolateral minithoracotomy without the use of cardiac arrest and aortic cross-clamp have been developed in the late 90s. The procedure called MIDCAB grafting has been performed by dedicated surgeons. Although the procedure has been proven safe, mid- and long-term results are dependent on the experience of the performing surgeon, mainly due to the challenges and the special skills associated with the procedure.,
Minimally invasive cardiac surgery progressed over the decades before evolving into more advanced techniques such as robotically assisted procedures. The first TECAB was reported in 1999. Later on, minimal surgical revascularization was done on an arrested heart utilizing femoral arterial and venous cannulation and intra-aortic balloon occlusion.,
Although robotic-assisted coronary revascularization has never been well evaluated to study its comparability to the conventional CABG, it has been shown, in some instances to be an effective alternative in selected patients.
The first larger series was reported by Mohr et al. in 2001, describing 27 patients who underwent LIMA harvest and LIMA-LAD anastomosis using the da Vinci telemanipulation system.,
The reported mortality in the reported studies ranged from 0% to 2%, perioperative myocardial infarction ranged from 0% to 3.4%, and repeat revascularization is 0%–11.8%., In our study, figures were comparable, 30-day mortality was 2.7%, whereas repeat revascularization was required in 4% of the patients.
A series of 146 consecutive robot-assisted CABG was published without any in-hospital deaths and a 96.3% patency rate.
The availability of endoscopic tools, suction stabilizers, and surgical robots were the mainstays of this evolution. We believe that the shortage of some of the instruments which were needed for our robotic system affected our program learning curve and the number of cases for some time. The learning curve although initially thought to be steep improved dramatically over the years. Despite the complexity of the principle, conversion rates to open are significantly decreasing along with improvement in the operative time.
In a systemic review of about 28 studies that were done in 2018, the reported conversion rate was about 7%. In our study, 14 (19.72%) TECAB procedures were converted to MIDCAB, whereas 5 (7.04%) required sternotomy due to bleeding, poor target, poor LIMA, heart injury, or difficult single-lung ventilation. In the same review which included about 2947 patients who underwent robotic CABG, the overall mean BMI was about 26.9, and diabetes in 40.7% of patients. The cumulative infection rate was about 0.3% reporting a much less occurrence of infection making robotic surgery an ideal option for the above-mentioned high-risk groups. Our postoperative infection was observed in 3 (4.29%) patients. Furthermore, atrial fibrillation which is considered one of the more often complications that have been associated with conventional coronary revascularization was found to occur in only 5% in the same review. In our patients, 43.6% were found to have a BMI of 25–29.9 kg/m2, and 52% were found to be diabetic. Atrial fibrillation was reported in 6 (8.4%) patients.
Other perioperative outcomes including ventilation, intensive care unit stay, and CVA are affected by the operative time, longer operative time increases the risk of CVA. However, in a trial designed to analyze the effect of the operative times on the outcomes of the patients; it was suggested that the main reason for longer operative times was the complexity of the cases. An operative time of >445 min and >478 min is predictive for prolonged ICU stay and mechanical ventilation time, respectively. Our mean operative time was 355.9 ± 95.79 min, and no new CVA was detected.
In other studies, it was found that the significantly longer total operative time, cardiopulmonary bypass time, and aortic cross-clamp time in TECAB is due to the more complex nature of the endoscopic approach and has been mentioned in other series too. We did not use a cross-clamp or bypass machine in our TECAB and RA-MIDCAB procedures.
One of the expectations of minimally invasive surgical strategies is a lower perioperative demand for blood products. However, it was observed a significant need for red blood cells and fresh frozen plasma transfusion in TECAB patients. Eight of our patients (11.2%) received blood transfusions.
In another review, 120 TECAB patients were investigated using the da Vinci robot with the aid of the Flex A distal anastomotic device, they demonstrated a 94.1% overall patency rate with 98.2% patency in the LIMA-LAD grafts, which is comparable to the conventional revascularization technique. In the same review, which was done retrospectively, it was mentioned that most of the cases had single CAD with only 28 patients out of 120 having three-vessel disease, and these patients were candidates for hybrid revascularization; Only 7 of our patients (10.14%) underwent planned hybrid procedure.
Although hybrid revascularization is thought to be a good choice for a certain group of patients. LIMA to LAD and PCI to the rest of the coronary arteries was not adopted widely and only a few centers worldwide perform the procedure.
Moreover, some articles suggested not only equal but also less mortality rates with mean 30-day mortality ranging from 0% to 0.8%, whereas late mortality ranges from 0% to 1%.
Endoscopic coronary artery bypass is feasible for the majority of single-vessel CAD. The key to a successful and safe procedure is meticulous patient selection regarding preoperative risk factors and the complexity of CAD as well as surgeons' experience.
Despite the quicker recovery and better cosmetic results compared with conventional CABG, minimally invasive coronary surgery is still reserved for highly selected patients and is performed in specialized centers.
Current drawbacks of robotically assisted coronary revascularization lie in higher cost, learning curve, and case selection but it should not banish the positive effects and even better outcome in some instances in comparison to the conventional method or even the percutaneous techniques.
In addition, technology is growing and robot science in cardiac surgery is becoming an avenue worth exploring. Encouraging even training programs to incorporate robotic laboratories along with a dedicated program to meet the future surgeons with the needs.
| Conclusion|| |
In conclusion, from our experience of over 10 years in robotic cardiac surgery in Qatar, we believe that robotic-assisted coronary revascularization is safe, less invasive, and effective in selected patients mainly with single-vessel CAD but should be performed on regular basis in specialized centers and by robotic-trained surgeons.
The authors would like to thank all members of the Cardiothoracic Surgery and Medical record department at Heart hospital as well as the Medical Research Center, Hamad Medical Corporation, for supporting this study
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chandrasekharan DP, Taggart DP. Informed consent for interventions in stable coronary artery disease: problems, etiologies, and solutions. Eur J Cardiothorac Surg 2011;39:912-7.
Krapf C, Wohlrab P, Häußinger S, Schachner T, Hangler H, Grimm M, et al
. Remote access perfusion for minimally invasive cardiac surgery: to clamp or to inflate? Eur J Cardiothorac Surg 2013;44:898-904.
Mohr FW, Morice MC, Kappetein AP, Feldman TE, Ståhle E, Colombo A, et al
. Coronary artery bypass graft surgery versus percutaneous coronary intervention in patients with three-vessel disease and left main coronary disease: 5-year follow-up of the randomised, clinical SYNTAX trial. Lancet 2013;381:629-38.
Farkouh ME, Domanski M, Sleeper LA, Siami FS, Dangas G, Mack M, et al
. Strategies for multivessel revascularization in patients with diabetes. N Engl J Med 2012;367:2375-84.
Shahian DM, O'Brien SM, Sheng S, Grover FL, Mayer JE, Jacobs JP, et al
. Predictors of long-term survival after coronary artery bypass grafting surgery: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (the ASCERT study). Circulation 2012;125:1491-500.
Holzhey DM, Jacobs S, Mochalski M, Walther T, Thiele H, Mohr FW, et al
. Seven-year follow-up after minimally invasive direct coronary artery bypass: experience with more than 1300 patients. Ann Thorac Surg 2007;83:108-14.
Kolh P, Windecker S, Alfonso F, Collet JP, Cremer J, Falk V, et al
. 2014 ESC/EACTS Guidelines on myocardial revascularization: the Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur J Cardiothorac Surg 2014;46:517-92.
Bonatti J, Wallner S, Crailsheim I, Grabenwöger M, Winkler B. “Minimally invasive and robotic coronary artery bypass grafting-a 25-year review.” Journal of thoracic disease 2021:13;1922-44.
Reser D, Hemelrijck MV, Pavicevic J, Tolboom H, Holubec T, Falk V, et al
. Mid-term outcomes of minimally invasive direct coronary artery bypass grafting. Thorac Cardiovasc Surg 2015;63:313-8.
Pompilio G, Alamanni F, Tartara PM, Antona C, Porqueddu M, Veglia F, et al
. Determinants of late outcome after minimally invasive direct coronary artery bypass. J Cardiovasc Surg (Torino). 2007;48:207-14.
Loulmet D, Carpentier A, d'Attellis N, Berrebi A, Cardon C, Ponzio O, et al
. Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments, J. Thorac. Cardiovasc. Surg 1999; 118:4-10.
Loop FD, Lytle BW, Cosgrove DM, Stewart RW, Goormastic M, Williams GW, et al
. Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events. N Engl J Med 1986;314:1-6.
Mohr FW, Falk V, Diegeler A, Mohr FW, Falk V, Diegeler A, et al
. Computer-enhanced “robotic” cardiac surgery: experience in 148 patients. J Thorac Cardiovasc Surg 2001;121:842-53.
Vassiliades TA Jr, Reddy VS, Puskas JD, Guyton RA. Long-term results of the endoscopic atraumatic coronary artery bypass. Ann Thorac Surg 2007;83:979-85.
Srivastava S, Gadasalli S, Agusala M, Kolluru R, Barrera R, Quismundo S, et al
. Beating heart totally endoscopic coronary artery bypass, Ann. Thorac. Surg 2010; 89:1873-80.
de Canniere D, Wimmer-Greinecker G, Cichon R, Gulielmos V, Praef FV, Seshadri-Kreaden U, et al
. Feasiblity, safety, and efficacy of totally endoscopic coronary artery bypass grafting: multicenter European experience, J. Thorac. Cardiovasc. Surg 2007;134:710-6.
Nesher N, Bakir I, Casselman F, Degrieck I, De Geest R, Wellens F, et al
. Robotically enhanced minimally invasive direct coronary artery bypass surgery: A winning strategy? J Cardiovasc Surg (Torino) 2007;48:333-8.
Doulamis IP, Spartalis E, Machairas N, Schizas D, Patsouras D, Spartalis M, et al
. The role of robotics in cardiac surgery: A systematic review. J Robotic Surg 2019;13:41-52.
Wiedemann D, Bonaros N, Schachner T, Weidinger F, Lehr EJ, Vesely M, et al
. Surgical problems and complex procedures: Issues for operative time in robotic totally en- doscopic coronary artery bypass grafting. J Thorac Cardiovasc Surg 2012;143:639'Äê647.
Jegaden O, Wautot F, Sassard T, Szymanik I, Shafy A, Lapeze J, et al
. Is there an optimal minimally invasive technique for left anterior descending coronary artery bypass? J Cardiothorac Surg 2011;6:37.
Balkhy HH, Wann LS, Krienbring D, Arnsdorf SE. Integrating coronary anastomotic connectors and robotics toward a totally endoscopic beating heart approach: review of 120 cases. Ann Thorac Surg. 2011;92:821-7.
Bonaros N, Schachner T, Lehr E, Kofler M, Wiedemann D, Hong P, et al
. Five hundred cases of robotic totally endoscopic coronary artery bypass grafting: predictors of success and safety. Ann Thorac Surg 2013;95:803-12.
Bonaros N, Schachner T, Wiedemann D, Oehlinger A, Ruetzler E, Feuchtner G, et al
. Quality of life improvement after robotically assisted coronary artery bypass grafting. Cardiology 2009;114:59-66.
[Figure 1], [Figure 2], [Figure 3]