“Factors influencing blood transfusion requirements in robotic totally endoscopic coronary artery bypass grafting on the arrested heart.”
Bonatti, J., T. Schachner, et al. (2011).
European Journal of Cardio-Thoracic Surgery 39(2): 262-267.
Objective: Robotic technology enables totally endoscopic coronary artery bypass grafting (TECAB) procedures. These operations can be performed on either the beating or arrested heart. One challenge of the latter version is a potentially increased need for blood transfusions. We investigated factors associated with transfusion requirements in totally endoscopic coronary artery bypass on the arrested heart (AH-TECAB). Patients and methods: A total of 161 patients, 124 males and 37 females, aged 59 (31-77 years) years, with European System for Cardiac Operative Risk Evaluation (EuroSCORE) 1 (0-7) underwent AH-TECAB using the daVinci telemanipulation system. The Heartport/CardiovationsTM or ESTECH-RAPTM systems were applied for remote access perfusion and aortic endoocclusion. In all cases, the operation was carried out in moderate hypothermia and cardiac arrest using cold crystalloid cardioplegia mixed with blood. Results: After 20 cases, the blood-transfusion rate dropped from 69% to 44%. The overall median number of transfusions was 1 (0-21). The following pre- and intra-operative factors showed a strong association with the application of packed red blood cells (PRBCs): preoperative haemoglobin level (p< 0.001), female gender (p< 0.001), shorter height (p< 0.001), lower weight (p< 0.001), long operative time (p< 0.001) and long cardiopulmonary bypass time (p = 0.001), intra-operative surgical problem (p< 0.001) and conversion to a larger thoracic incision (p< 0.001). Postoperatively, patients with longer ventilation time (p< 0.001) and those needing revision for bleeding (p< 0.001) also received significantly more PRBCs. Conclusion: We conclude that multiple factors are associated with increased blood transfusion requirements in AH-TECAB. However, the transfusion rate can be reduced with experience. Identification of these factors may help in avoiding the application of blood products in the next generation of AH-TECAB procedures. © 2010.
“Early and midterm results of totally endoscopic coronary artery bypass grafting on the beating heart.” Gao, C., M. Yang, et al. (2011).
Journal of Thoracic and Cardiovascular Surgery.
OBJECTIVE: Despite the early introduction of totally endoscopic coronary artery bypass on the beating heart, only a limited number of cases have been performed. The limiting factor has been the concern about safety and graft patency of the anastomosis. This study describes our experience with totally endoscopic coronary artery bypass on the beating heart with robotic assistance and its early and midterm results. METHODS: In 365 cases of robotic cardiac operations, 162 patients underwent robotic coronary artery bypass grafting on the beating heart, of whom 60 patients (46 male, 14 female) underwent totally endoscopic coronary artery bypass on the beating heart. The patients’ mean age was 56.97 +/- 9.7 years (33-77 years). Left internal thoracic artery to left anterior descending anastomosis was performed using the U-Clip device. RESULTS: We completed 58 totally endoscopic coronary artery bypass procedures, in which 16 patients received hybrid procedures. Two patients had conversions to a minithoracotomy. The average left internal thoracic artery harvesting and anastomosis times were 31.3 +/- 10.5 (18 approximately 55) minutes and 11.3 +/- 4.7 (5 approximately 21) minutes, respectively. The mean operating room and operation times were 336.1 +/- 58.5 (210 approximately 580) minutes and 264.8 +/- 65.6 (150 approximately 420) minutes, respectively. The drainage was 164.9 +/- 83.2 (70 approximately 450) mL. Before discharge, 50 patients underwent angiography and 8 patients underwent computed tomography angiography, and the study showed that graft patency was 100%. Unexpectedly, the left internal thoracic artery graft developed a collateral branch in 2 patients. After discharge, all patients were followed up by computed tomography angiography. The average follow-up time was 12.67 +/- 9.43 (1-40) months. One patient had gastric bleeding after surgery. CONCLUSIONS: Totally endoscopic coronary artery bypass on the beating heart is a safe procedure in selected patients and produces excellent early and midterm patency of anastomosis.
“Robotic repair of access-related aortic injuries: Unexpected complication of robot-assisted prostatectomy.”
Gibson, B. and R. Abaza (2011).
Journal of Endourology 25(2): 235-238.
Robot-assisted surgery is becoming more widespread, but despite adoption by most academic institutions, curricula for training residents in robotics have yet to be developed fully. Even after teaching surgeons have mastered robotic techniques, an inherent risk of avoidable injuries may persist as they seek to impart their knowledge of this relatively new surgical modality to trainees. Two cases of aortic injury during access for robot-assisted prostatectomy are described along with their successful robotic repair with root-cause analysis of the events. Robotic surgeons who are involved in training programs should be prepared to handle even major potential complications of robot-assisted surgery regardless of their own expertise or experience. Copyright 2011, Mary Ann Liebert, Inc.
“Is there an optimal minimally invasive technique for left anterior descending coronary artery bypass?” Jegaden, O., F. Wautot, et al. (2011).
Journal of Cardiothoracic Surgery 6(1): 37.
ABSTRACT: . Word count: 263 BACKGROUND: The aim of this retrospective study was to evaluate the clinical outcome of three different minimally invasive surgical techniques for left anterior descending (LAD) coronary artery bypass grafting (CABG): Port-Access surgery (PA-CABG), minimally invasive direct CABG (MIDCAB) and off-pump totally endoscopic CABG (TECAB). METHODS: Over a decade, 160 eligible patients for elective LAD bypass were referred to one of the three techniques: 48 PA-CABG, 53 MIDCAB and 59 TECAB. In MIDCAB group, Euroscore was higher and target vessel quality was worse. In TECAB group, early patency was systematically evaluated using coronary CT scan. During follow-up (mean 2.7+/-0.1 years, cumulated 438 years) symptom-based angiography was performed. RESULTS: There was no conversion from off-pump to on-pump procedure or to sternotomy approach. In TECAB group, there was one hospital cardiac death (1.7%), reoperation for bleeding was higher (8.5% vs 3.7% in MIDCAB and 2% in PA-CABG) and 3-month LAD reintervention was significantly higher (10% vs 1.8% in MIDCAB and 0% in PA-CABG). There was no difference between MIDCAB and PA-CABG groups. During follow-up, symptom-based angiography (n=12) demonstrated a good patency of LAD bypass in all groups and 4 patients underwent a no LAD reintervention. At 3 years, there was no difference in survival; 3-year angina-free survival and reintervention-free survival were significantly lower in TECAB group (TECAB, 85+/-12%, 88+/-8%; MIDCAB, 100%, 98+/-5%; PA-CABG, 94+/-8%, 100%; respectively). CONCLUSIONS: Our study confirmed that minimally invasive LAD grafting was safe and effective. TECAB is associated with a higher rate of early bypass failure and reintervention. MIDCAB is still the most reliable surgical technique for isolated LAD grafting and the least cost effective. KEYWORDS: CABG, arterial grafts, Minimally invasive surgery, Robotics.
“Cost-effectiveness of Clinical Pathway in Coronary Artery Bypass Surgery.”
Lin, Y. K., C. P. Chen, et al. (2011).
Journal of Medical Systems 35(2): 203-213.
Few studies have been devoted to the exploration of the effect of clinical pathways on coronary artery diseases treated with coronary artery bypass (CAB) surgery. This study was aimed to investigate the cost and effectiveness of the clinical pathway on CAB surgery in a medical center. With a retrospective dataset in 2003-2007, 212 CAB surgery patients were included. Data of the costs and postoperative complication occurrence and length of stays were the focus and patient demographics, surgical risk indicator EuroSCORE, surgical conditions were collected. It revealed that there was differentiation across specified cost items in beating heart CAB surgery patients, but not for heart arrest CAB surgery patients with and without clinical pathways enrolled. In addition, there was no difference in postoperative complication occurrence in CAB surgery patients enrolled into clinical pathways. However, robotic beating heart CAB surgery patients enrolled clinical pathways were shown to have less postoperative ordinary ward stay than those not enrolled clinical pathways. CAB surgery patients’ age and surgical risks were related to their postoperative lengths of stay to some extent.
“Predictors, causes, and consequences of conversions in robotically enhanced totally endoscopic coronary artery bypass graft surgery.”
Schachner, T., N. Bonaros, et al. (2011).
Annals of Thoracic Surgery 91(3): 647-653.
Background: Totally endoscopic coronary artery bypass graft surgery (TECAB), using the da Vinci telemanipulator, has become a reproducible operation at dedicated centers. As in every endoscopic operation, conversion is an important and probably inevitable issue. Methods We performed robotic TECAB in 326 patients (age, 60 years; range, 31 to 90 years); 242 were single-vessel and 84 were multivessel TECAB. Results Forty-six of 326 patients (14%) were converted to a larger incision (minithoracotomy, n = 5; sternotomy, n = 41). Left internal mammary artery injury (n = 7), epicardial injury (n = 4), balloon endoocclusion problems (n = 7), and anastomotic problems (n = 18) were common reasons for conversions. Conversion rate was significantly less for single-vessel versus multivessel TECABs (10% versus 25%; p = 0.001). Nonlearning-curve case (7% versus 21%; p < 0.001) and transthoracic assistance (11% versus 22%; p = 0.018) were associated with lower conversion rates. In multivariate analysis, learning-curve case was the only independent predictor of conversion (p = 0.005). Conversion translated into increased packed red blood cell transfusion in the operating room (3 versus 0 units; p < 0.001), longer ventilation time (14 versus 8 hours; p < 0.001), and intensive care unit stay (45 versus 20 hours; p = 0.001). Hospital mortality was 0.6% in this series, with 1 patient in the conversion group (2.2%) and 1 patient in the nonconverted group (0.4%; not significant). Five-year survival was 98% in nonconverted patients and 88% in converted patients (p = 0.018). There was no difference in freedom from angina or freedom from major adverse cardiac and cerebral events. Conclusions Conversion in TECAB is primarily learning curvedependent and associated with increased morbidity, but does not significantly affect hospital mortality. Both nonconverted and converted patients show good long-term survival, which is comparable to patients undergoing open sternotomy coronary artery bypass grafting. Long-term freedom from angina or freedom from major adverse cardiac and cerebral events is not influenced by conversion. © 2011 The Society of Thoracic Surgeons.