Robotic totally endoscopic multivessel coronary artery bypass grafting: procedure development, challenges, results

Closed-chest totally endoscopic coronary artery bypass grafting (TECAB) is feasible using robotic technology. During the early phases, TECAB was restricted to single bypass grafts to the left anterior descending artery system. Because most patients referred for coronary artery bypass surgery have multivessel disease, development of endoscopic multiple bypass grafting is mandatory. Experimental work on multivessel TECAB was carried out in the early 2000s, and first clinical cases were already performed. With further technological development of operating robots, double, triple, and quadruple TECAB has become feasible both on the arrested heart and on the beating heart. To date, 161 cases of multivessel TECAB using the da Vinci telemanipulation systems are published in the literature. The main advances enabling multivessel TECAB were the availability of a robotic endostabilizer for beating heart procedures and increased surgeon skills using remote access heart-lung machine perfusion and endo-cardioplegia. Both internal mammary arteries can be harvested and both radial artery and vein graft can be used in multivessel TECAB. Y-grafting and sequential grafting are feasible. Multivessel endoscopic surgical revascularization can be combined with percutaneous coronary interventions in advanced hybrid coronary revascularization. Time requirements for multivessel TECAB are significant, and conversion rates to larger thoracic incisions are higher than those observed for single-vessel TECAB. Clinical short- and long-term outcomes, however, seem to meet the standards of open coronary bypass surgery through sternotomy. The main advantages of multivessel TECAB are a completely preserved sternum, use of double internal mammary artery even in risk groups, and a remarkably short recovery time.     

Economics of coronary artery bypass grafting.

To decide whether the number of operations for coronary artery bypass grafting should be increased, maintained at the present levels, or decreased we need to know how cost effective they are relative to other claimants on the resources of the National Health Service. For this purpose effectiveness is taken to be the effect on life expectancy adjusted for the quality of life. In an assessment of the cost per quality adjusted life year gained coronary artery bypass grafting rates well for cases of severe angina and extensive coronary artery disease. The cost, however, rises sharply for less severe cases. Bypass grafting seems to compare favourably with valve replacement for aortic stenosis and implantation of pacemakers for heart block; it is distinctly better than heart transplantation and the treatment of end stage renal failure but is probably less cost effective than hip replacement. If the number of operations for coronary artery bypass grafting were to increase it would be a fairly strong claimant only if restricted to the most severe cases. The data on which these judgments are based are crude and in need of refinement. The methodology is powerful, far reaching, and open to comment.     

Outcomes in octogenarians undergoing coronary artery bypass grafting

Background

Although octogenarians are being referred for coronary artery bypass grafting (CABG) with increasing frequency, contemporary outcomes have not been well described. We examined data from 4 Canadian centres to determine outcomes of CABG in this age group.

Methods

Data for the years 1996 to 2001 were examined in a comparison of octogenarians with patients less than 80 years of age. Logistic regression analysis was used to adjust for preoperative factors and to generate adjusted rates of mortality and postoperative stroke.

Results

A total of 15 070 consecutive patients underwent isolated CABG during the study period. Overall, 725 (4.8%) were 80 years of age or older, the proportion increasing from 3.8% in 1996 to 6.2% in 2001 (p for linear trend = 0.03). The crude rate of death was higher among the octogenarians (9.2% v. 3.8%; p < 0.001), as was the rate of stroke (4.7% v. 1.6%, p < 0.001). The octogenarians had a significantly greater burden of comorbid conditions and more urgent presentation at surgery. After adjustment, the octogenarians remained at greater risk for in-hospital death (odds ratio [OR] 2.64, 95% confidence interval [CI] 1.95–3.57) and stroke (OR 3.25, 95% CI 2.15–4.93). Mortality declined over time for both age groups (p for linear trend < 0.001 for both groups), but the incidence of postoperative stroke did not change (p for linear trend = 0.61 [age < 80 years] and 0.08 [age ≥ 80 years]). Octogenarians who underwent elective surgery had crude and adjusted rates of death (OR 1.31, 95% CI 0.60–2.90) and stroke (OR 1.59, 95% CI 0.57–4.44) that were higher than but not significantly different from those for non-octogenarians who underwent elective surgery.

Interpretation

In this study, rates of death and stroke were higher among octogenarians, although the adjusted differences in mortality over time were decreasing. The rate of adverse outcomes in association with elective surgery was similar for older and younger patients.The population is rapidly aging, and an increasing number of octogenarians are being referred for coronary artery bypass grafting (CABG).^1,2 Previous single-centre reports from Canada^3,4,5 and from abroad^1,2,6,7,8have concluded that elderly patients undergoing cardiac surgery have worse outcomes than younger patients. In addition, these studies have reported higher costs and slower recovery for octogenarians undergoing CABG, a finding that has generated debate over the appropriate use of health care resources.^1,5,7,9It has become increasingly clear that the results of CABG among octogenarians, although worse than among younger patients, are better than for percutaneous coronary interventions or medical therapy alone when the extent of the patient''s coronary disease is such that revascularization with CABG is indicated.^10,11 Similarly, the superior results of percutaneous coronary intervention relative to medical therapy in elderly patients with coronary disease will likely continue to increase the total number of octogenarians undergoing coronary angiography, which in turn will probably increase the number of patients being referred for CABG.^10,12 Contemporary outcomes for octogenarians undergoing CABG in Canada have not been well described. If we are to have an informed debate and determine appropriate policy, it is important for these outcomes to be known.We aimed to describe the characteristics and outcomes of patients 80 years of age and older undergoing CABG in Canada and to compare their outcomes with those of younger patients. In addition, we examined changes in results over time.     

Management of dyslipidemia after coronary artery bypass grafting

The results of serial angiographic studies and intervention trials in patients after coronary artery bypass artery grafting have provided ample evidence that abnormalities of the plasma lipoprotein system are one of the most significant risk factors for a rapid atherosclerotic attrition of saphenous vein grafts. In addition to confirming the well recognized role and contribution of cholesterol-rich LDL or lipoprotein B particles to the progression of atherosclerotic lesions, intervention trials have also provided strong evidence for the atherogenic capacity of some intact and partly delipidized triglyceride-rich very low density lipoprotein and intermediate density lipoprotein (lipoprotein B complex) particles, and the protective effect of some (high density lipoprotein 3) but not all high density lipoprotein particles. Most importantly, those studies have emphasized the need for an early, aggressive treatment of dyslipoproteinemias with pharmacological agents as the most efficient therapeutic approach to delaying, if not preventing, the detrimental effect of atherosclerosis on saphenous vein grafts.     

Simultaneous endoscopic radial artery and great saphenous vein harvesting for redo coronary artery bypass grafting. A report of two cases

Aim: An ageing population and increase in patient co-morbidities are forcing cardiac surgeons to meticulously consider the benefits and risks of respective conduits and their harvesting techniques. Case reports: Two cases of simultaneous endoscopic radial artery and great saphenous vein harvesting, for redo coronary artery bypass grafting, are presented. A shortage of venous conduits after previous bypass grafting, as well as the presentation of several risk factors of wound-healing complications, favoured simultaneous utilisation of both endoscopic techniques. Conclusion: Endoscopic vessel harvesting together with the pre-harvesting duplex study is able to gain not only high-quality conduits but also minimize the risk of wound-healing and neurological disturbances associated the saphenous vein and radial artery harvesting.     

Arterial end-to-side grafting in coronary artery bypass grafting: the Tector procedure

Background. The current treatment of choice in patients with three-vessel coronary disease is coronary artery bypass grafting. The use of the left internal mammary artery in bypass grafting has shown superior long-term outcomes compared with venous grafting. In our study we assess the safety and feasibility of all-arterial coronary artery bypass graft surgery using the procedure as described by Tector et al. in 2001.Methods. Between June 2001 and February 2007, we studied 133 patients eligible for non-emergency surgical revascularisation. Primary endpoints were death or re-infarction within a 30-day period. Secondary endpoints were the need for emergency coronary surgery, angioplasty and mediastinitis. Long-term follow-up had a mean duration of 33 months postoperatively.Results. All 133 patients were successfully revascularised, 98% with the off-pump technique. In 93% of the patients (n=124) full arterial grafting was achieved using both internal mammary arteries. Thirty-day mortality was 1.5% (n=2), ten re-thoracotomies were performed, one myocardial infarction and one case of mediastinitis were reported. In the next four years six additional patients died. Most of these deaths were due to non-cardiovascular causes. Two patients required angioplasty because of distal bypass graft failure and one for new native coronary artery disease. Conclusion. All-arterial bypass grafting using both internal mammary arteries with the technique as described by Tector is safe and feasible without excess deep sternal wound infections. Late major adverse cardiac events are rare and due to distal graft dysfunction, which can be treated by percutaneous coronary intervention. (Neth Heart J 2010;18:7-11.)     

Epicardial coronary spasm due to endothelial dysfunction after spontaneous coronary artery dissection

Netherlands Heart Journal -     

Biomechanical rationale of coronary artery bypass grafting of multivessel disease

The biomechanical model of human coronary arteries was modified for improving the quality of diagnosis and surgical treatment for coronary heart disease. The problem of hemodynamics in the left coronary artery with multivessel bed disease – 45% stenosis of the anterior descending branch and 75% stenosis of the circumflex branch – was particularly considered. Numerical simulation of the coronary arterial bypass of the main trunk was carried out to estimate the functional condition of the coronary arteries after restoring myocardial blood supply by surgery.     

Inflammatory cytokines and soluble receptors after coronary artery bypass grafting

Much interest has been focused on the overexpression of proinflammatory cytokines, but studies on their soluble receptors are rare. For a comprehensive picture of cytokine activation in cardiac surgery, a combination of cytokines and the corresponding soluble receptor concentration should be determined. Blood samples were collected from the radial artery and coronary sinus perioperatively in ten patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. TNF-alpha, IL-6, sTNFRI, sTNFRII, and sIL-6R levels in the plasma were determined. Systemic TNFRI, TNFRII and IL-6 increased significantly after reperfusion to the myocardium, while perioperative systemic sIL-6r levels were similar. Arterial and sinus levels of TNFRI, TNFRII and sIL-6r were similar before cardiopulmonary bypass. Five minutes after reperfusion to the myocardium, higher sinus TNFRI and TNFRII and lower sinus sIL-6R levels were observed as compared to the arterial levels. The myocardium release of sTNFRI (r=0.57, P=0.089) and sTNFRII (r=0.64, P=0.047) positively correlated with the change of cardiac index after cardiopulmonary bypass. Myocardium releases sTNFRI and sTNFRII after ischaemic-reperfusion injury, and this may be of benefit to cardiac performance. sIL-6R is constantly being produced in areas other than the myocardium, while sIL-6R levels are reduced by consumption in the myocardium after ischaemic-reperfusion injury.