Robotic Coronary Artery Bypass Grafting




Abstract


Totally endoscopic coronary artery bypass grafting (TECAB) represents an advanced form of coronary bypass surgery with a minimum level of surgical trauma involved. It can only be performed in a reproducible manner using a surgical robot. Using five portholes on the chest, the bypass harvesting and grafting processes are carried out endoscopically. The procedure can be performed on the arrested heart using remote access heart-lung machine perfusion and endocardioplegia or on the beating heart using endostabilization and local coronary artery occlusion. To date, all coronary artery territories can be reached, and single- and multivessel TECAB are technically feasible.




Keywords

coronary artery disease, coronary artery bypass grafting, minimally invasive surgery, endoscopic surgery, robotic surgery

 




Introductory Considerations




  • ◆

    The goal of any minimally invasive procedure is to achieve the least surgical trauma possible and to carry out the intervention in a port-only approach. After unsuccessful attempts to perform endoscopic coronary bypass surgery using long-shafted thoracoscopic instrumentation, the first totally endoscopic coronary bypass grafting (TECAB) was carried out in 1998 using a surgical robot. Since then, TECAB has been further developed from single-vessel to multivessel surgical revascularization and is performed in beating heart and stopped heart versions. TECAB can be combined with percutaneous coronary intervention in so-called integrated or hybrid procedures. A second, third, and fourth generation of surgical robots is available, and procedure-specific robotic instrumentation has improved vision, exposure of target vessels, and overall ergonomic features of the procedure.



1


Patient Selection, Indications, and Contraindications




  • ◆

    At the current stage, any patient with a clear indication for surgical coronary revascularization can be considered for TECAB. It is, however, highly important to respect the contraindications listed in Box 7.1 . In general, TECAB is elective surgery, and redo procedures are difficult using open techniques and are long and tedious in the endoscopic setting. Any factor that leads to distortion or reduction of the pleural cavities, such as thoracic deformities, a severely enlarged heart, or reduced lung volume, needs to be respected. Wise judgment needs to be applied as to whether to expose patients to a potentially longer pump time, myocardial ischemic time, and overall procedure time. This is especially true for patients with multiple comorbidities. Because TECAB involves a significant technical learning curve, we strongly recommend to start with simpler versions of the operation in low-risk patients.



    Box 7.1

    Contraindications for Totally Endoscopic Coronary Bypass Grafting (TECAB)


    Absolute Contraindications





    • Cardiogenic shock and hemodynamic instability



    • Severely reduced lung function (VC < 2.5 L; FEV 1 < 70% predicted value)



    • Pulmonary hypertension



    • Chest deformities (e.g., pectus excavatum)



    • Multimorbid patients with generalized vasculopathy



    • Very small, diffusely diseased and calcified target vessels or intramyocardial target vessels in beating heart TECAB



    • Ascending aortic diameter > 3.8 mm and severe aortoiliac atherosclerosis in endoballoon-arrested heart TECAB



    Relative Contraindications





    • Unstable patients on intraaortic balloon pump (IABP)



    • Significantly reduced left ventricular function (left ventricular ejection fraction [LVEF] < 30%)



    • Significantly enlarged hearts (< 25 mm distance between left ventricle and chest wall)



    • Previous cardiac surgery



    • Previous significant chest trauma



    • Previous chest radiation



    FEV 1 , Forced expiratory volume in 1 second; VC, vital capacity.




2


Preoperative Workup




  • ◆

    All patients should receive the same workup as for open coronary artery bypass grafting (CABG). The usual battery of preoperative examinations consists of the clinical history and physical examination, basic blood tests (complete blood count [CBC], basic metabolic panel [BMP], international normalized ratio [INR], type, and screen), carotid Doppler studies, ankle-brachial index (ABI), pulmonary function studies, and echocardiography. To address TECAB-specific questions, computed tomography (CT) angiography of the chest, abdomen, and pelvis is carried out. The parameters that should be assessed for this procedure by the surgeon, surgical team, and radiologist on this CT are listed in Box 7.2 .



    Box 7.2

    Parameters Assessed in Pre–Totally Endoscopic Coronary Bypass Grafting Computed Tomography Angiography of the Chest, Abdomen, and Pelvis


    Heart





    • Size of the heart (cardiothoracic ratio, distance of left ventricular lateral border to chest wall)



    • Distance between internal mammary arteries and target vessels



    • Course of target vessels (intramyocardial vs. epicardial)



    • Size of the pericardial fat pad



    Lung





    • Size of the lung (intrathoracic workspace)



    • Lung pathology



    • Pleural pathology (e.g., clear evidence of adhesions, calcifications)



    Aorta, Iliofemoral Vessels





    • Ascending aortic diameter at the level of right pulmonary artery crossing



    • Grade of aortic atherosclerosis on all levels



    • Iliofemoral atherosclerosis



    • Other aortic pathology (e.g., aneurysms, chronic dissections)





3


Anesthesia



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Jan 26, 2019 | Posted by in CARDIAC SURGERY | Comments Off on Robotic Coronary Artery Bypass Grafting

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