REVIEW URRENT C OPINION
Totally endoscopic robotic coronary artery bypass surgery Seema P. Deshpande a, Molly Fitzpatrick a, and Eric J. Lehr b
Purpose of review To assess the current status and methods of robotic totally endoscopic coronary artery bypass (TECAB) surgery and discuss important anesthetic considerations. Recent findings Technological and surgical advances in robotics have led to the evolution of TECAB surgery from a single-vessel procedure to quadruple-vessel bypass. TECAB is now a reproducible technique, with a low incidence of mortality and morbidity and superior quality of life. Although early cohorts of patients are still being observed for long-term outcomes, initial and midterm outcomes are comparable to those of conventional coronary artery bypass. TECAB is also associated with specific challenges for the anesthesiologist. Summary TECAB surgery is a feasible alternative to open coronary artery bypass surgery in selected patient populations. Appropriate patient selection, team training, and stepwise application of the procedure are crucial. TECAB is associated with a unique set of challenges, requiring a skilled operative team. As robotic technology and surgical expertise evolve, this technology will find wider application in an increasing high-risk patient population that will require the support of a skilled anesthesiology team. Keywords completely endoscopic coronary artery bypass surgery, minimally invasive, robotic coronary artery surgery, robotics, totally endoscopic coronary artery bypass grafting
INTRODUCTION Totally endoscopic coronary artery bypass (TECAB) surgery represents the most minimally invasive surgical approach to the treatment of coronary artery disease. Although conventional coronary artery bypass (CAB) grafting techniques provide procedural safety and excellent long-term patency, they require a long period of recuperation; whereas robotic technology allows the entire procedure to be performed using only port sites, reducing the recovery times and becoming a feasible alternative to conventional coronary artery bypass grafting (CABG) surgery in selected patients. Results to date show early and midterm outcomes are comparable to the conventional procedures [1–5].
THE DA VINCI SYSTEM Intuitive Surgical’s da Vinci Surgical System is the only commercially available surgical robot suitable for performing TECAB, providing the surgeon with a
three-dimensional, high-definition (1080p) view of the operative field, with up to 15 magnification in three dimensions; the surgeon is virtually immersed in the intrathoracic operative field. The system comprises of a surgeon console, patient cart, and video cart. The dual-console system on the latest model facilitates intraoperative teaching [6]. Seated away from the patient, the surgeon controls three surgical instruments and the endoscope by manipulating ‘masters’ at the surgeon console [7,8].
a Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland and bSwedish Heart and Vascular Institute, Seattle, Washington, USA
Correspondence to Seema P. Deshpande, MBBS, Department of Anesthesiology, University of Maryland School of Medicine, 22 S Greene Street # S8D12, Baltimore, MD 21201, USA. Tel: +1 410 328 9813; fax: +1 410 328 3092; e-mail: [email protected] Curr Opin Anesthesiol 2014, 27:49–56 DOI:10.1097/ACO.0000000000000031
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KEY POINTS TECAB surgery presents a promising, viable alternative to conventional cardiac surgery, with the current data showing comparable early and midterm results. Application of robotic technology presents additional challenges over open CABG for the anesthesiologist – such as one-lung ventilation (OLV), placement of special catheters, limited access to the patient, and induced capnothorax. A dedicated team is integral to the development of a successful robotics program. TECAB is technically demanding, with a steep learning curve – a stepwise approach is necessary for teams to become skilled in this procedure.
METHODS AND TYPES OF TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS Completely endoscopic approaches to coronary revascularization include arrested-heart TECAB, beating-heart TECAB without cardiopulmonary bypass (CPB), and beating-heart TECAB with CPB. First performed in 1998 [9], arrested-heart TECAB provides a still, bloodless field to construct anastomoses as well as the ability to expose the circumflex and right coronary system without hemodynamic instability. Deflation of the lungs on CPB greatly enhances the surgical workspace [10 ]. Many regard TECAB on the beating heart, without the use of extracorporeal circulation, as the ultimate objective of minimally invasive CABG [11]. Familiarity with beating-heart techniques allows the surgeons to provide the benefits of TECAB to patients in whom remote-access perfusion technique of endoaortic occlusion balloon clamp (EAOBC) is contraindicated [10 ]. &
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PREOPERATIVE CONSIDERATIONS Patient selection for TECAB is crucial in order to maximize the benefits and minimize perioperative morbidity and mortality. Patients should have an indication for CABG and be good surgical candidates. Current contraindications include extensive pleural adhesions, a history of pleuritis, radiation, or inflammatory thoracic disease, lung disease that would preclude OLV, previous cardiac surgery, and unfavorable anatomical conditions in the chest such as narrow intercostal spaces (ICSs) or
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significant cardiomegaly with reduced intrathoracic space [12]. Also, a robotic approach is not suitable for patients with acute ongoing myocardial ischemia, hemodynamic instability, or peripheral vascular disease when remote-access perfusion is precluded, as is often the case. Early in the learning curve, when longer operative times are expected, selection of low-risk patients who may better tolerate longer operative times seems prudent [13 ]. TECAB makes unique demands of the pulmonary system, with its challenges of adequate lung separation and prolonged OLV [14]. In addition to functional capacity, pulmonary function testing is a part of the preoperative evaluation to rule out the presence of severe lung disease. Computed tomography (CT) angiogram of the chest, abdomen, and pelvis is mandatory to guide the cannulation strategy. Atherosclerosis may increase the risk of embolic stroke. Pre-existing, asymptomatic arterial dissections could propagate during retrograde CPB flow and tortuous vessels may impede passage of the EAOBC. &
SURGICAL PROCEDURE After left-lung collapse, the camera port is inserted in the left fifth ICS. Carbon dioxide (CO2) is insufflated to target pressures of 10–12 mmHg to develop the intrathoracic surgical working space. Instrument ports are then inserted in the third and seventh ICSs – sometimes a 7-mm assistant port is used in the left fourth ICS and a left subcostal port for an endoscopic stabilizer (Fig. 1). The internal mammary arteries (IMAs) are harvested and heparin is administered. The pericardial fat pad is excised and the pericardium opened. Simultaneously, the bedside surgeon cannulates the femoral vessels. In arrested-heart TECAB, CPB is instituted, the EAOBC inflated, and antegrade cardioplegia is delivered. Target vessels are identified, anastomoses are completed with suture, clips, or a stapling device, and graft patency is assessed. The EAOBC is then deflated, and after a stable rhythm is established, the patient is weaned from CPB. Protamine is administered and decannulation ensues. After careful inspection of port sites, the incisions are closed.
ANESTHETIC CONSIDERATIONS The anesthesiologist has additional challenges with TECAB over open CABG such as OLV, placement of special catheters (pulmonary artery vent and
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FIGURE 1. Standard setup for robot-assisted, arrested-heart totally endoscopic coronary artery bypass (TECAB) surgery, depicting annotation, cannulae/ports for robotic instrument arms: A, 23 French arterial perfusion cannula with a side-arm for endoaortic occlusion balloon catheter (EAOBC) insertion; D, 8 French arterial cannula for distal leg perfusion; V, 25 French venous drainage cannula inserted through the femoral vein; 1, 12-mm subcostal port for stabilizer, if required; 2, 8-mm assistance port in the fourth left intercostal space (ICS); 3, port for left robot arm in seventh left ICS; 4, 12-mm camera port in the fifth left ICS; 5, port for right robot arm in third left ICS. Reproduced with permission from [15].
percutaneous coronary sinus catheter, if required), limited access to the patient, and induced capnothorax, with its attendant consequences, including hemodynamic instability, especially in the hypovolemic patient [16]. Also, remote-perfusion strategies for CPB require significant use of transesophageal echocardiography (TEE) to confirm the placement and positioning of various catheters and surgical cannulae. These procedures demand close communication between the entire team – a dedicated team can reduce the operative time in TECAB [17,18].
PATIENT POSITIONING AND SETUP Intravenous poles and the anesthesia machine are moved further cephalad, away from the operating room table, to avoid collision with the robot. The patient is placed supine with a 308 elevation of the operative hemithorax – special attention must be paid to ensure that the cephalad robot arm is not too close to the patient’s face. As internal defibrillation is not feasible in TECAB, defibrillator pads are applied to the chest in a way that avoids the operative field and allows the chest to be prepped for conversion to sternotomy.
ANESTHETIC TECHNIQUE AND MONITORS A standard general anesthetic technique is used in TECAB, with invasive monitoring and OLV that is
achieved by the usual methods – double-lumen tubes, bronchial blockers, or Univent tubes. Invasive monitoring includes bilateral radial arterial lines to monitor balloon position if an EAOBC is used, pulmonary artery vent, percutaneous coronary sinus catheter on occasion, and TEE. Noninvasive monitoring used is near-infrared spectroscopy (NIRS) cerebral oximetry, which can be a useful adjunct in monitoring the proper placement of the inflated EAOBC. Monitoring the lower extremities with NIRS may guard against leg ischemia that can occur with femoral cannulation [19]. Regional analgesia is an option for postoperative pain relief. In minimally invasive beating-heart procedures, epidural analgesia and paravertebral blocks have been used successfully and could improve lung function and shorten time to extubation [20–22].
TRANSESOPHAGEAL ECHOCARDIOGRAPHY For the safe conduct of TECAB procedures, even during CPB, TEE is important. In addition to monitoring cardiac function and ischemia, TEE is crucial for safe and accurate positioning of guidewires, cannulae, and catheters for CPB [(Supplementary Digital Content 1–3, http://links.lww.com/COAN/A27, http://links.lww. com/COAN/A28, http://links.lww.com/COAN/A29) Supplementary Digital Content 1: Mid-esophageal bicaval view, showing wire for venous cannula (depicted by single arrow) in the right atrium (RA) and superior vena cava (SVC), as well as the pulmonary artery vent (depicted by 2 arrows). LA, left atrium. Supplementary Digital Content 2: Midesophageal bicaval view, showing passage and positioning of venous cannula in the right atrium (RA) and superior venacava (SVC). IVC, inferior venacava; LA, left atrium. Supplementary Digital Content 3: Mid-esophageal bicaval view, showing the venous cannula (VC), pulmonary artery vent (PAV) and coronary sinus catheter (CSC) in the right atrium. Data from Deshpande et al. [15,17]] It also provides early detection of rare, but catastrophic, complications of remote-access perfusion, such as aortic dissection or great vessel injury during cannulation [23]. It is important to note that prior to myocardial revascularization, reversible, significant biventricular segmental wall motion abnormalities, without hemodynamic compromise, have been reported in TECAB procedures [24].
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REMOTE-ACCESS PERFUSION TECHNIQUES Safe, reliable, and reproducible remote-access perfusion techniques are the foundation for effective TECAB. Most commonly, the femoral vessels are cannulated, although the axillary artery can also be used for arterial access in patients with moderate or severe atherosclerotic disease of the aorta, or peripheral arterial disease [25]. A pulmonary artery vent is used to decompress the left ventricle; a percutaneous coronary sinus catheter is inserted when retrograde cardioplegia may be beneficial with aortic insufficiency, when a long cross-clamp time is expected, or when there are multiple ungrafted territories. The EAOBC is a balloon-tipped catheter that is inserted through the sidearm of the femoral arterial cannula into the aortic root under TEE guidance [(Supplementary Digital Content 4–6, http://links.lww.com/COAN/A30, http://links.lww. com/COAN/A31, http://links.lww.com/COAN/A32) Supplementary Digital Content 4: Mid-esophageal aortic valve long axis view showing wire for endoaortic occlusion balloon catheter (EAOBC) advanced too far into the aortic root, abutting the aortic valve; Supplementary Digital Content 5: Midesophageal aortic valve long axis view showing a deflated endoaortic occlusion balloon (EAOBC) in
the ascending aorta, in suboptimal position, abutting the aortic valve; Supplementary Digital Content 6: Mid-esophageal aortic valve long axis view showing inflation of the balloon of the endoaortic occlusion balloon catheter (EAOBC). Data from Deshpande et al. [15]]. It occludes the mid-ascending aorta (Fig. 2), its position monitored by TEE and by comparison of the upper-extremity perfusion pressures. In addition to the delivery of antegrade cardioplegia [(Supplementary Digital Content 7, http://links.lww.com/COAN/A33) Supplementary Digital Content 7: Mid-esophageal aortic valve long axis view showing delivery of antegrade cardioplegia through the endoaortic occlusion balloon (EAOBC) in the ascending aorta. AO, aorta; LA, left atrium; LV, left ventricle. Data from Deshpande et al. [15]], the EAOBC also vents the aortic root and measures aortic root pressure. The reported incidence of aortic dissection with the EAOBC is about three per 1000 patients [26]. Contraindications to insertion of the EAOBC include severe atherosclerosis of the aorta, dilation of the ascending aorta (>38 mm), aortic dissection, peripheral vascular disease, or severe aortic insufficiency. In beating-heart TECAB, prophylactic remoteaccess cannulation can provide a valuable safety net in the event that challenging situations develop
FIGURE 2. Mid-esophageal (ME) aortic valve long axis view, showing the deflated endoaortic occlusion balloon catheter (EAOBC) in the ascending aorta, at the level of the sino-tubular junction, side by side with the inflated EAOBC. Reproduced with permission from [15].
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(e.g., inadequate working space, graft bleeding, myocardial perforation, ventricular fibrillation, hemodynamic instability, myocardial ischemia, intolerance of OLV, and others), which require rapid conversion to CPB.
INSUFFLATION AND CAPNOTHORAX During insufflation of the chest, a controlled pneumothorax is induced in the operative hemithorax with CO2 to create a surgical working space, which may lead to significant hemodynamic and respiratory consequences. An increase in heart rate, central venous pressure, pulmonary artery pressure, and peak inspiratory pressures, as well as a corresponding decrease in cardiac index and arterial oxygen tension, can be expected with the initiation of capnothorax and OLV, with possibly significant hemodynamic compromise when insufflation pressures exceed 10–12 mmHg. Hemodynamic instability is more likely to occur, and at even lower insufflation pressures, in patients with pre-existing hypovolemia and left ventricular dysfunction [16], possibly requiring fluid bolus, vasopressors, inotropes, and even reduction in insufflation pressure.
MANAGEMENT OF VENTRICULAR FIBRILLATION Internal defibrillation is not feasible in TECAB, and chest compressions are difficult and dangerous to perform with the robot in position. The configuration of the defibrillation pads may not be optimal for conduction across the cardiac axis, possibly making defibrillation less effective. Capnothorax may also insulate the heart from the defibrillation current. Attempting defibrillation with the robot in place risks rib fracture and intrathoracic injury, including cardiac perforation. Hence, prior to attempting external defibrillation, alternative strategies are employed. Antiarrhythmic agents are administered. In arrested-heart TECAB, the EAOBC is reinflated, and the heart rearrested. With asystole, the EAOBC is deflated, and the heart usually returns to a stable rhythm. If ventricular fibrillation persists, external defibrillation is warranted. In that event, all robotic instruments are removed from the thorax, the iatrogenic pneumothorax is evacuated, and twolung ventilation is resumed before attempting defibrillation [27]. While on CPB, ventricular fibrillation is not an emergency as long as the left ventricle is decompressed. With persistent ventricular fibrillation, conversion to sternotomy and further assessment of the cause is indicated.
In beating-heart TECAB, managing ventricular fibrillation can be more difficult. If ventricular fibrillation occurs prior to completion of anastomoses, prophylactic cannulation allows rapid establishment of CPB. If ventricular fibrillation occurs after anastomoses, external defibrillation, pharmacological therapies, and correction of electrolyte abnormalities may help. In refractory ventricular fibrillation, other causes, such as persistent ischemia, must be sought. If all of these measures fail, conversion to open sternotomy and internal defibrillation may be warranted.
CONVERSION TO STERNOTOMY As with all endoscopic procedures, conversion to an open operation may be necessary to complete the procedure safely. In TECAB, conversion rates are reported to range from 5.5 to 15%. Reasons for conversion include technical difficulties with the anastomosis, IMA problems, difficulties with remote perfusion, epicardial lesions, intraoperative ischemia in hybrid procedures, inadequate target exposure, and others. Conversion is often learning curve dependent and is not a failure, rather a safety measure that is not associated with adverse outcomes [23,28,29].
ADVANTAGES OF ROBOTIC SURGERY Bilateral IMA (BIMA) grafts confer an 18% survival advantage over single IMA use at 15 years [30], and results in fewer reinterventions [31–34]. Nevertheless, BIMA use remains at only 3.9% in the USA [35], because of increased technical complexity and fear of sternal wound infections [36–38]. TECAB facilitates multi-IMA grafting [39], while preserving sternal integrity, allowing BIMA to be offered to patients at higher risk for sternal wound infection [40]. Wiedemann et al. [41] demonstrated that TECAB with acceptable operative times could be performed in obese and morbidly obese patients, with no increase in the rate of intraoperative or postoperative complications. Sternal preservation leads to reduced pain, earlier recovery and return to daily activities, and better quality of life [42,43,44 ]. &
OUTCOMES OF TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS SURGERY Results of TECAB, thus far, appear to be comparable with those of open procedures [1–3,9,45–56]; as summarized by JD Lee et al. [13 ].
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The original multicenter, prospective Food and Drug Administration (FDA) study by Argenziano et al. [47] involved 85 patients undergoing singlevessel left anterior descending (LAD) artery revascularization. Five patients (6%) required conversion to sternotomy. There were no deaths or cerebral vascular events reported. Length of stay in hospital was 5.1 3.4 days. At 3 months, re-intervention or angiographic failure occurred in 9% of patients. In 2007, another multicenter study of TECAB by Decanniere et al. [48] reported cumulative rates of freedom from major adverse cardiac and cerebral events at 6 months of 91.2% for patients undergoing arrested-heart TECAB and 94.9% for patients undergoing beating-heart TECAB. The largest series to date for beating-heart TECAB was reported by Srivastava [3] in 2010. The procedure was completed endoscopically in 214 patients – two-thirds of the patients received a single graft, approximately one-third received two grafts, and seven patients underwent triple-vessel bypass. No perioperative myocardial infarctions or operative mortalities were reported. Clinical freedom from graft failure and reintervention was 98.6% in follow-up. In 2011, Gao [1] published findings on 60 patients undergoing single-vessel beating-heart TECAB with impressive results. Two patients underwent conversion intraoperatively to thoracotomy, and one patient was re-explored for bleeding. Mean follow-up at 12.7 months showed no mortalities. Postoperative angiographic graft assessment was performed at 3, 6, and 12 months postoperatively in all patients, with all grafts found patent. Bonatti et al. [10 ] reported their results for 410 patients who underwent TECAB between October 2001 and October 2010. The observed mortality rate was 0.7%. Conversion rate to an open procedure overall was 14.2%, and 7.1% of patients required revision for bleeding, most commonly bleeding from portholes. Cerebral vascular events occurred in seven (1.7%) patients. Long-term results compare favorably with those of major CABG trials; survival and freedom from major adverse cardiac and cerebral event rates, at 5 years, are 95.0 and 80.1%, respectively. Recently, Currie et al. [44 ] reported the results on long-term patency of grafts after robotically assisted CABG. Cardiac catheterization, CT angiography, or both, and stress myocardial perfusion scintigraphy were used to assess graft patency in 82 patients for a mean follow-up of 8 years and 16.3 months. The overall patency rate of all &
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robotically assisted grafts was 92.7%, with a left internal mammary artery (LIMA) to LAD graft patency of 93.4%. The LIMA to LAD patency is comparable to that of reported long-term 10-year patency rates of greater than 90% in conventional CABG [57,58].
CURRENT STATUS AND CHALLENGES Adoption of TECAB has been limited because of several constraints. TECAB is technically demanding with a steep learning curve [59], so a stepwise approach is necessary for teams to become skilled in this procedure [60]. High capital, maintenance, and case costs may be offset by benefits in reduced hospital length-of-stay and faster recovery [61 ]. &
CONCLUSION Robotic technology presents a novel, viable alternative to the treatment of patients with single-vessel as well as multivessel disease, especially in the context of an increasingly high-risk patient population with diabetes and obesity. As robotic technology continues to evolve, and familiarity as well as surgical skill with the procedure improves, it is anticipated that this technology will have a broader application, although it might be limited to dedicated centers with specialized cardiac surgeons and committed multidisciplinary teams. Acknowledgements This work was internally funded by the authors’ respective departments. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Gao C, Yang M, Wu Y, et al. Early and midterm results of totally endoscopic coronary artery bypass grafting on the beating heart. J Thorac Cardiovasc Surg 2011; 142:843–849. 2. Balkhy HH, Wann LS, Krienbring D, Arnsdorf S. Integrating coronary anastomotic connectors and robotics toward a totally endoscopic beating heart approach: review of 120 cases. Ann Thorac Surg 2011; 92:821– 827. 3. Srivastava S, Gadasalli S, Agusala M, et al. Beating heart totally endoscopic coronary artery bypass. Ann Thorac Surg 2010; 89:1873–1880. 4. Lehr EJ, Rodriguez E, Chitwood WR. Robotic cardiac surgery. Curr Opin Anaesthesiol 2011; 24:77–85.
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Does obesity affect operative times and perioperative outcome of patients undergoing totally endoscopic coronary artery bypass surgery? Interact Cardiovasc Thorac Surg 2009; 9:214–217. 42. Bonaros N, Schachner T, Wiedemann D, et al. Quality of life improvement after robotically assisted coronary artery bypass grafting. Cardiology 2009; 114:59–66. 43. Derose JJ Jr, Balaram SK, Ro C, et al. Mid-term results and patient perceptions of robotically-assisted coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 2005; 4:406–411. 44. Currie ME, Romsa J, Fox SA, et al. Long-term angiographic follow-up of & robotic-assisted coronary artery revascularization. Ann Thorac Surg 2012; 93:1426–1431. This study assessed the long-term patency rates of robotically assisted coronary artery bypass grafts. The long-term patency rates of grafts was 92.7% at a mean follow-up period of 95.8 þ 16.3. The patency rate of LIMA to LAD graft was 93.4%. 45. Dogan S, Aybek T, Andressen E, et al. Totally endoscopic coronary artery bypass grafting on cardiopulmonary bypass with robotically enhanced telemanipulation: report of forty-five cases. J Thorac Cardiovasc Surg 2002; 123:1125–1131. 46. Bonatti J, Schachner T, Bonaros N, et al. Technical challenges in totally endoscopic robotic coronary artery bypass grafting. J Thorac Cardiovasc Surg 2006; 131:146–153. 47. Argenziano M, Katz M, Bonatti J, et al., TECAB Trial Investigators. Results of the prospective multicenter trial of robotically assisted totally endoscopic coronary artery bypass grafting. Ann Thorac Surg 2006; 81:1666–1675. 48. Decanniere D, Wimmergreinecker G, Cichon R, et al. Feasibility, safety, and efficacy of totally endoscopic coronary artery bypass grafting: multicenter European experience. J Thorac Cardiovasc Surg 2007; 134:710–716. 49. Bonatti J, Schachner T, Bonaros N, et al. Effectiveness and safety of total endoscopic left internal mammary artery bypass graft to the left anterior descending artery. Am J Cardiol 2009; 104:1684–1688. 50. Bonatti J, Lee JD, Bonaros N, et al. Robotic totally endoscopic multivessel coronary artery bypass grafting: procedure development, challenges, results. Innovations (Phila) 2012; 7:3–8. 51. Kappert U, Cichon R, Tugtekin SM, Schueler S. Closed chest coronary artery bypass on the beating heart. Heart Surg Forum 2001; 4:89–90. 52. Boyd WD, Rayman R, Desai ND, et al. Closed-chest coronary artery bypass grafting on the beating heart with the use of a computer-enhanced surgical robotic system. J Thorac Cardiovasc Surg 2000; 120:807–809. 53. Loisance DY, Nakashima K, Kirsch M. Computer-assisted coronary surgery: lessons from an initial experience. Interact Cardiovasc Thorac Surg 2005; 4:398–401. 54. Srivastava S, Gadasalli S, Agusala M, et al. Robotically assisted beating heart totally endoscopic coronary artery bypass (TECAB). Is there a future? Innovations (Phila) 2008; 3:52–58. 55. Jegaden O, Wautot F, Sassard T, et al. Is there an optimal minimally invasive technique for left anterior descending coronary artery bypass? J Cardiothorac Surg 2011; 6:37. 56. Dhawan R, Roberts JD, Wroblewski K, et al. Multivessel beating heart robotic myocardial revascularization increases morbidity and mortality. J Thorac Cardiovasc Surg 2012; 143:1056–1061.
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Cardiovascular anesthesia 57. Shah PJ, Durairah M, Gordon I, et al. Factors affecting patency of internal thoracic artery graft: clinical angiographic study in 1434 symptomatic patients operated between 1982 and 2002. Eur J Cardiothorac Surg 2004; 26:118– 124. 58. Sabik JH, Lytle BW, Blackstone EH, et al. Comparison of saphenous vein and internal thoracic artery graft patency by coronary system. Ann Thorac Surg 2005; 79:544–551. 59. Athanasiou T, Ashrafian H, Rowland SP, Casula R. Robotic cardiac surgery: advanced minimally invasive technology hindered by barriers to adoption. Future Cardiol 2011; 7:511–522.
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60. Schachner T, Bonaros N, Weidemann D, et al. Training surgeons to perform robotically assisted totally endoscopic coronary surgery. Ann Thorac Surg 2009; 88:523–527. 61. Weidemann D, Bonaros N, Schachner T, et al. Surgical problems and & complex procedures: issues for operative time in robotic totally endoscopic coronary artery bypass grafting. J Thorac Cardiovasc Surg 2012; 143:639– 647. An article assessing the factors leading to prolonged operative times in totally endoscopic coronary artery bypass grafting and the effect of the same on early postoperative and midterm outcomes.
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Totally endoscopic robotic coronary artery bypass surgery Seema P. Deshpande a, Molly Fitzpatrick a, and Eric J. Lehr b
Purpose of review To assess the current status and methods of robotic totally endoscopic coronary artery bypass (TECAB) surgery and discuss important anesthetic considerations. Recent findings Technological and surgical advances in robotics have led to the evolution of TECAB surgery from a single-vessel procedure to quadruple-vessel bypass. TECAB is now a reproducible technique, with a low incidence of mortality and morbidity and superior quality of life. Although early cohorts of patients are still being observed for long-term outcomes, initial and midterm outcomes are comparable to those of conventional coronary artery bypass. TECAB is also associated with specific challenges for the anesthesiologist. Summary TECAB surgery is a feasible alternative to open coronary artery bypass surgery in selected patient populations. Appropriate patient selection, team training, and stepwise application of the procedure are crucial. TECAB is associated with a unique set of challenges, requiring a skilled operative team. As robotic technology and surgical expertise evolve, this technology will find wider application in an increasing high-risk patient population that will require the support of a skilled anesthesiology team. Keywords completely endoscopic coronary artery bypass surgery, minimally invasive, robotic coronary artery surgery, robotics, totally endoscopic coronary artery bypass grafting
INTRODUCTION Totally endoscopic coronary artery bypass (TECAB) surgery represents the most minimally invasive surgical approach to the treatment of coronary artery disease. Although conventional coronary artery bypass (CAB) grafting techniques provide procedural safety and excellent long-term patency, they require a long period of recuperation; whereas robotic technology allows the entire procedure to be performed using only port sites, reducing the recovery times and becoming a feasible alternative to conventional coronary artery bypass grafting (CABG) surgery in selected patients. Results to date show early and midterm outcomes are comparable to the conventional procedures [1–5].
THE DA VINCI SYSTEM Intuitive Surgical’s da Vinci Surgical System is the only commercially available surgical robot suitable for performing TECAB, providing the surgeon with a
three-dimensional, high-definition (1080p) view of the operative field, with up to 15 magnification in three dimensions; the surgeon is virtually immersed in the intrathoracic operative field. The system comprises of a surgeon console, patient cart, and video cart. The dual-console system on the latest model facilitates intraoperative teaching [6]. Seated away from the patient, the surgeon controls three surgical instruments and the endoscope by manipulating ‘masters’ at the surgeon console [7,8].
a Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland and bSwedish Heart and Vascular Institute, Seattle, Washington, USA
Correspondence to Seema P. Deshpande, MBBS, Department of Anesthesiology, University of Maryland School of Medicine, 22 S Greene Street # S8D12, Baltimore, MD 21201, USA. Tel: +1 410 328 9813; fax: +1 410 328 3092; e-mail: [email protected] Curr Opin Anesthesiol 2014, 27:49–56 DOI:10.1097/ACO.0000000000000031
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KEY POINTS TECAB surgery presents a promising, viable alternative to conventional cardiac surgery, with the current data showing comparable early and midterm results. Application of robotic technology presents additional challenges over open CABG for the anesthesiologist – such as one-lung ventilation (OLV), placement of special catheters, limited access to the patient, and induced capnothorax. A dedicated team is integral to the development of a successful robotics program. TECAB is technically demanding, with a steep learning curve – a stepwise approach is necessary for teams to become skilled in this procedure.
METHODS AND TYPES OF TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS Completely endoscopic approaches to coronary revascularization include arrested-heart TECAB, beating-heart TECAB without cardiopulmonary bypass (CPB), and beating-heart TECAB with CPB. First performed in 1998 [9], arrested-heart TECAB provides a still, bloodless field to construct anastomoses as well as the ability to expose the circumflex and right coronary system without hemodynamic instability. Deflation of the lungs on CPB greatly enhances the surgical workspace [10 ]. Many regard TECAB on the beating heart, without the use of extracorporeal circulation, as the ultimate objective of minimally invasive CABG [11]. Familiarity with beating-heart techniques allows the surgeons to provide the benefits of TECAB to patients in whom remote-access perfusion technique of endoaortic occlusion balloon clamp (EAOBC) is contraindicated [10 ]. &
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PREOPERATIVE CONSIDERATIONS Patient selection for TECAB is crucial in order to maximize the benefits and minimize perioperative morbidity and mortality. Patients should have an indication for CABG and be good surgical candidates. Current contraindications include extensive pleural adhesions, a history of pleuritis, radiation, or inflammatory thoracic disease, lung disease that would preclude OLV, previous cardiac surgery, and unfavorable anatomical conditions in the chest such as narrow intercostal spaces (ICSs) or
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significant cardiomegaly with reduced intrathoracic space [12]. Also, a robotic approach is not suitable for patients with acute ongoing myocardial ischemia, hemodynamic instability, or peripheral vascular disease when remote-access perfusion is precluded, as is often the case. Early in the learning curve, when longer operative times are expected, selection of low-risk patients who may better tolerate longer operative times seems prudent [13 ]. TECAB makes unique demands of the pulmonary system, with its challenges of adequate lung separation and prolonged OLV [14]. In addition to functional capacity, pulmonary function testing is a part of the preoperative evaluation to rule out the presence of severe lung disease. Computed tomography (CT) angiogram of the chest, abdomen, and pelvis is mandatory to guide the cannulation strategy. Atherosclerosis may increase the risk of embolic stroke. Pre-existing, asymptomatic arterial dissections could propagate during retrograde CPB flow and tortuous vessels may impede passage of the EAOBC. &
SURGICAL PROCEDURE After left-lung collapse, the camera port is inserted in the left fifth ICS. Carbon dioxide (CO2) is insufflated to target pressures of 10–12 mmHg to develop the intrathoracic surgical working space. Instrument ports are then inserted in the third and seventh ICSs – sometimes a 7-mm assistant port is used in the left fourth ICS and a left subcostal port for an endoscopic stabilizer (Fig. 1). The internal mammary arteries (IMAs) are harvested and heparin is administered. The pericardial fat pad is excised and the pericardium opened. Simultaneously, the bedside surgeon cannulates the femoral vessels. In arrested-heart TECAB, CPB is instituted, the EAOBC inflated, and antegrade cardioplegia is delivered. Target vessels are identified, anastomoses are completed with suture, clips, or a stapling device, and graft patency is assessed. The EAOBC is then deflated, and after a stable rhythm is established, the patient is weaned from CPB. Protamine is administered and decannulation ensues. After careful inspection of port sites, the incisions are closed.
ANESTHETIC CONSIDERATIONS The anesthesiologist has additional challenges with TECAB over open CABG such as OLV, placement of special catheters (pulmonary artery vent and
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FIGURE 1. Standard setup for robot-assisted, arrested-heart totally endoscopic coronary artery bypass (TECAB) surgery, depicting annotation, cannulae/ports for robotic instrument arms: A, 23 French arterial perfusion cannula with a side-arm for endoaortic occlusion balloon catheter (EAOBC) insertion; D, 8 French arterial cannula for distal leg perfusion; V, 25 French venous drainage cannula inserted through the femoral vein; 1, 12-mm subcostal port for stabilizer, if required; 2, 8-mm assistance port in the fourth left intercostal space (ICS); 3, port for left robot arm in seventh left ICS; 4, 12-mm camera port in the fifth left ICS; 5, port for right robot arm in third left ICS. Reproduced with permission from [15].
percutaneous coronary sinus catheter, if required), limited access to the patient, and induced capnothorax, with its attendant consequences, including hemodynamic instability, especially in the hypovolemic patient [16]. Also, remote-perfusion strategies for CPB require significant use of transesophageal echocardiography (TEE) to confirm the placement and positioning of various catheters and surgical cannulae. These procedures demand close communication between the entire team – a dedicated team can reduce the operative time in TECAB [17,18].
PATIENT POSITIONING AND SETUP Intravenous poles and the anesthesia machine are moved further cephalad, away from the operating room table, to avoid collision with the robot. The patient is placed supine with a 308 elevation of the operative hemithorax – special attention must be paid to ensure that the cephalad robot arm is not too close to the patient’s face. As internal defibrillation is not feasible in TECAB, defibrillator pads are applied to the chest in a way that avoids the operative field and allows the chest to be prepped for conversion to sternotomy.
ANESTHETIC TECHNIQUE AND MONITORS A standard general anesthetic technique is used in TECAB, with invasive monitoring and OLV that is
achieved by the usual methods – double-lumen tubes, bronchial blockers, or Univent tubes. Invasive monitoring includes bilateral radial arterial lines to monitor balloon position if an EAOBC is used, pulmonary artery vent, percutaneous coronary sinus catheter on occasion, and TEE. Noninvasive monitoring used is near-infrared spectroscopy (NIRS) cerebral oximetry, which can be a useful adjunct in monitoring the proper placement of the inflated EAOBC. Monitoring the lower extremities with NIRS may guard against leg ischemia that can occur with femoral cannulation [19]. Regional analgesia is an option for postoperative pain relief. In minimally invasive beating-heart procedures, epidural analgesia and paravertebral blocks have been used successfully and could improve lung function and shorten time to extubation [20–22].
TRANSESOPHAGEAL ECHOCARDIOGRAPHY For the safe conduct of TECAB procedures, even during CPB, TEE is important. In addition to monitoring cardiac function and ischemia, TEE is crucial for safe and accurate positioning of guidewires, cannulae, and catheters for CPB [(Supplementary Digital Content 1–3, http://links.lww.com/COAN/A27, http://links.lww. com/COAN/A28, http://links.lww.com/COAN/A29) Supplementary Digital Content 1: Mid-esophageal bicaval view, showing wire for venous cannula (depicted by single arrow) in the right atrium (RA) and superior vena cava (SVC), as well as the pulmonary artery vent (depicted by 2 arrows). LA, left atrium. Supplementary Digital Content 2: Midesophageal bicaval view, showing passage and positioning of venous cannula in the right atrium (RA) and superior venacava (SVC). IVC, inferior venacava; LA, left atrium. Supplementary Digital Content 3: Mid-esophageal bicaval view, showing the venous cannula (VC), pulmonary artery vent (PAV) and coronary sinus catheter (CSC) in the right atrium. Data from Deshpande et al. [15,17]] It also provides early detection of rare, but catastrophic, complications of remote-access perfusion, such as aortic dissection or great vessel injury during cannulation [23]. It is important to note that prior to myocardial revascularization, reversible, significant biventricular segmental wall motion abnormalities, without hemodynamic compromise, have been reported in TECAB procedures [24].
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REMOTE-ACCESS PERFUSION TECHNIQUES Safe, reliable, and reproducible remote-access perfusion techniques are the foundation for effective TECAB. Most commonly, the femoral vessels are cannulated, although the axillary artery can also be used for arterial access in patients with moderate or severe atherosclerotic disease of the aorta, or peripheral arterial disease [25]. A pulmonary artery vent is used to decompress the left ventricle; a percutaneous coronary sinus catheter is inserted when retrograde cardioplegia may be beneficial with aortic insufficiency, when a long cross-clamp time is expected, or when there are multiple ungrafted territories. The EAOBC is a balloon-tipped catheter that is inserted through the sidearm of the femoral arterial cannula into the aortic root under TEE guidance [(Supplementary Digital Content 4–6, http://links.lww.com/COAN/A30, http://links.lww. com/COAN/A31, http://links.lww.com/COAN/A32) Supplementary Digital Content 4: Mid-esophageal aortic valve long axis view showing wire for endoaortic occlusion balloon catheter (EAOBC) advanced too far into the aortic root, abutting the aortic valve; Supplementary Digital Content 5: Midesophageal aortic valve long axis view showing a deflated endoaortic occlusion balloon (EAOBC) in
the ascending aorta, in suboptimal position, abutting the aortic valve; Supplementary Digital Content 6: Mid-esophageal aortic valve long axis view showing inflation of the balloon of the endoaortic occlusion balloon catheter (EAOBC). Data from Deshpande et al. [15]]. It occludes the mid-ascending aorta (Fig. 2), its position monitored by TEE and by comparison of the upper-extremity perfusion pressures. In addition to the delivery of antegrade cardioplegia [(Supplementary Digital Content 7, http://links.lww.com/COAN/A33) Supplementary Digital Content 7: Mid-esophageal aortic valve long axis view showing delivery of antegrade cardioplegia through the endoaortic occlusion balloon (EAOBC) in the ascending aorta. AO, aorta; LA, left atrium; LV, left ventricle. Data from Deshpande et al. [15]], the EAOBC also vents the aortic root and measures aortic root pressure. The reported incidence of aortic dissection with the EAOBC is about three per 1000 patients [26]. Contraindications to insertion of the EAOBC include severe atherosclerosis of the aorta, dilation of the ascending aorta (>38 mm), aortic dissection, peripheral vascular disease, or severe aortic insufficiency. In beating-heart TECAB, prophylactic remoteaccess cannulation can provide a valuable safety net in the event that challenging situations develop
FIGURE 2. Mid-esophageal (ME) aortic valve long axis view, showing the deflated endoaortic occlusion balloon catheter (EAOBC) in the ascending aorta, at the level of the sino-tubular junction, side by side with the inflated EAOBC. Reproduced with permission from [15].
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(e.g., inadequate working space, graft bleeding, myocardial perforation, ventricular fibrillation, hemodynamic instability, myocardial ischemia, intolerance of OLV, and others), which require rapid conversion to CPB.
INSUFFLATION AND CAPNOTHORAX During insufflation of the chest, a controlled pneumothorax is induced in the operative hemithorax with CO2 to create a surgical working space, which may lead to significant hemodynamic and respiratory consequences. An increase in heart rate, central venous pressure, pulmonary artery pressure, and peak inspiratory pressures, as well as a corresponding decrease in cardiac index and arterial oxygen tension, can be expected with the initiation of capnothorax and OLV, with possibly significant hemodynamic compromise when insufflation pressures exceed 10–12 mmHg. Hemodynamic instability is more likely to occur, and at even lower insufflation pressures, in patients with pre-existing hypovolemia and left ventricular dysfunction [16], possibly requiring fluid bolus, vasopressors, inotropes, and even reduction in insufflation pressure.
MANAGEMENT OF VENTRICULAR FIBRILLATION Internal defibrillation is not feasible in TECAB, and chest compressions are difficult and dangerous to perform with the robot in position. The configuration of the defibrillation pads may not be optimal for conduction across the cardiac axis, possibly making defibrillation less effective. Capnothorax may also insulate the heart from the defibrillation current. Attempting defibrillation with the robot in place risks rib fracture and intrathoracic injury, including cardiac perforation. Hence, prior to attempting external defibrillation, alternative strategies are employed. Antiarrhythmic agents are administered. In arrested-heart TECAB, the EAOBC is reinflated, and the heart rearrested. With asystole, the EAOBC is deflated, and the heart usually returns to a stable rhythm. If ventricular fibrillation persists, external defibrillation is warranted. In that event, all robotic instruments are removed from the thorax, the iatrogenic pneumothorax is evacuated, and twolung ventilation is resumed before attempting defibrillation [27]. While on CPB, ventricular fibrillation is not an emergency as long as the left ventricle is decompressed. With persistent ventricular fibrillation, conversion to sternotomy and further assessment of the cause is indicated.
In beating-heart TECAB, managing ventricular fibrillation can be more difficult. If ventricular fibrillation occurs prior to completion of anastomoses, prophylactic cannulation allows rapid establishment of CPB. If ventricular fibrillation occurs after anastomoses, external defibrillation, pharmacological therapies, and correction of electrolyte abnormalities may help. In refractory ventricular fibrillation, other causes, such as persistent ischemia, must be sought. If all of these measures fail, conversion to open sternotomy and internal defibrillation may be warranted.
CONVERSION TO STERNOTOMY As with all endoscopic procedures, conversion to an open operation may be necessary to complete the procedure safely. In TECAB, conversion rates are reported to range from 5.5 to 15%. Reasons for conversion include technical difficulties with the anastomosis, IMA problems, difficulties with remote perfusion, epicardial lesions, intraoperative ischemia in hybrid procedures, inadequate target exposure, and others. Conversion is often learning curve dependent and is not a failure, rather a safety measure that is not associated with adverse outcomes [23,28,29].
ADVANTAGES OF ROBOTIC SURGERY Bilateral IMA (BIMA) grafts confer an 18% survival advantage over single IMA use at 15 years [30], and results in fewer reinterventions [31–34]. Nevertheless, BIMA use remains at only 3.9% in the USA [35], because of increased technical complexity and fear of sternal wound infections [36–38]. TECAB facilitates multi-IMA grafting [39], while preserving sternal integrity, allowing BIMA to be offered to patients at higher risk for sternal wound infection [40]. Wiedemann et al. [41] demonstrated that TECAB with acceptable operative times could be performed in obese and morbidly obese patients, with no increase in the rate of intraoperative or postoperative complications. Sternal preservation leads to reduced pain, earlier recovery and return to daily activities, and better quality of life [42,43,44 ]. &
OUTCOMES OF TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS SURGERY Results of TECAB, thus far, appear to be comparable with those of open procedures [1–3,9,45–56]; as summarized by JD Lee et al. [13 ].
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The original multicenter, prospective Food and Drug Administration (FDA) study by Argenziano et al. [47] involved 85 patients undergoing singlevessel left anterior descending (LAD) artery revascularization. Five patients (6%) required conversion to sternotomy. There were no deaths or cerebral vascular events reported. Length of stay in hospital was 5.1 3.4 days. At 3 months, re-intervention or angiographic failure occurred in 9% of patients. In 2007, another multicenter study of TECAB by Decanniere et al. [48] reported cumulative rates of freedom from major adverse cardiac and cerebral events at 6 months of 91.2% for patients undergoing arrested-heart TECAB and 94.9% for patients undergoing beating-heart TECAB. The largest series to date for beating-heart TECAB was reported by Srivastava [3] in 2010. The procedure was completed endoscopically in 214 patients – two-thirds of the patients received a single graft, approximately one-third received two grafts, and seven patients underwent triple-vessel bypass. No perioperative myocardial infarctions or operative mortalities were reported. Clinical freedom from graft failure and reintervention was 98.6% in follow-up. In 2011, Gao [1] published findings on 60 patients undergoing single-vessel beating-heart TECAB with impressive results. Two patients underwent conversion intraoperatively to thoracotomy, and one patient was re-explored for bleeding. Mean follow-up at 12.7 months showed no mortalities. Postoperative angiographic graft assessment was performed at 3, 6, and 12 months postoperatively in all patients, with all grafts found patent. Bonatti et al. [10 ] reported their results for 410 patients who underwent TECAB between October 2001 and October 2010. The observed mortality rate was 0.7%. Conversion rate to an open procedure overall was 14.2%, and 7.1% of patients required revision for bleeding, most commonly bleeding from portholes. Cerebral vascular events occurred in seven (1.7%) patients. Long-term results compare favorably with those of major CABG trials; survival and freedom from major adverse cardiac and cerebral event rates, at 5 years, are 95.0 and 80.1%, respectively. Recently, Currie et al. [44 ] reported the results on long-term patency of grafts after robotically assisted CABG. Cardiac catheterization, CT angiography, or both, and stress myocardial perfusion scintigraphy were used to assess graft patency in 82 patients for a mean follow-up of 8 years and 16.3 months. The overall patency rate of all &
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robotically assisted grafts was 92.7%, with a left internal mammary artery (LIMA) to LAD graft patency of 93.4%. The LIMA to LAD patency is comparable to that of reported long-term 10-year patency rates of greater than 90% in conventional CABG [57,58].
CURRENT STATUS AND CHALLENGES Adoption of TECAB has been limited because of several constraints. TECAB is technically demanding with a steep learning curve [59], so a stepwise approach is necessary for teams to become skilled in this procedure [60]. High capital, maintenance, and case costs may be offset by benefits in reduced hospital length-of-stay and faster recovery [61 ]. &
CONCLUSION Robotic technology presents a novel, viable alternative to the treatment of patients with single-vessel as well as multivessel disease, especially in the context of an increasingly high-risk patient population with diabetes and obesity. As robotic technology continues to evolve, and familiarity as well as surgical skill with the procedure improves, it is anticipated that this technology will have a broader application, although it might be limited to dedicated centers with specialized cardiac surgeons and committed multidisciplinary teams. Acknowledgements This work was internally funded by the authors’ respective departments. Conflicts of interest There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Gao C, Yang M, Wu Y, et al. Early and midterm results of totally endoscopic coronary artery bypass grafting on the beating heart. J Thorac Cardiovasc Surg 2011; 142:843–849. 2. Balkhy HH, Wann LS, Krienbring D, Arnsdorf S. Integrating coronary anastomotic connectors and robotics toward a totally endoscopic beating heart approach: review of 120 cases. Ann Thorac Surg 2011; 92:821– 827. 3. Srivastava S, Gadasalli S, Agusala M, et al. Beating heart totally endoscopic coronary artery bypass. Ann Thorac Surg 2010; 89:1873–1880. 4. Lehr EJ, Rodriguez E, Chitwood WR. Robotic cardiac surgery. Curr Opin Anaesthesiol 2011; 24:77–85.
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Totally endoscopic coronary artery bypass Deshpande et al. 5. Bonatti J, Schachner T, Wiedemann D, et al. Factors influencing blood transfusion requirements in robotic totally endoscopic coronary artery bypass grafting on the arrested heart. Eur J Cardiothorac Surg 2011; 2:39262– 39267. 6. Lehr EJ, Grigore A, Reicher B, et al. Dual console robotic system to teach beating heart total endoscopic coronary artery bypass grafting: a video presentation. Interact Cardiovasc Thorac Surg 2010; 8:S113– S114. 7. Ballantyne GH, Moll F. The da Vinci telerobotic surgical system: the virtual operative field and telepresence surgery. Surg Clin North Am 2003; 83:1293–1304; vii.. 8. Trimlett RHJ, De Souza AC, Coonar AS, et al. Toward totally endoscopic coronary artery surgery. Surg Endosc 2004; 18:319–322. 9. Loulmet D, Carpentier A, d’Attellis N, et al. Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments. J Thorac Cardiovasc Surg 1999; 118:4–10. 10. Bonatti J, Schachner T, Bonaros N, et al. Robotically assisted totally & endoscopic coronary bypass surgery. Circulation 2011; 124:236–244. This article describes the types and technique of robotically assisted coronary artery bypass surgery and the overall clinical results of various approaches. 11. Anderson CA, Rodriguez E, Chitwood WR Jr. Robotically assisted coronary surgery: what is the future? Curr Opin Cardiol 2007; 22:541–544. 12. Kiaii B, Bainbridge D, Fernandes P. Surgical, anesthetic, perfusion-related advances in minimal access surgery. Semin Cardiothorac Vasc Anesth 2007; 11:282–287. 13. Lee JD, Srivastava M, Bonatti J. History and current status of robotic totally & endoscopic coronary artery bypass. Circ J 2012; 76:2058–2065. An overview of the history, development, and current results of both beating-heart and arrested-heart TECAB. 14. Ceballos A, Chaney MA, LeVan PT, et al. Case 3 – 2009. Robotically assisted cardiac surgery. 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60. Schachner T, Bonaros N, Weidemann D, et al. Training surgeons to perform robotically assisted totally endoscopic coronary surgery. Ann Thorac Surg 2009; 88:523–527. 61. Weidemann D, Bonaros N, Schachner T, et al. Surgical problems and & complex procedures: issues for operative time in robotic totally endoscopic coronary artery bypass grafting. J Thorac Cardiovasc Surg 2012; 143:639– 647. An article assessing the factors leading to prolonged operative times in totally endoscopic coronary artery bypass grafting and the effect of the same on early postoperative and midterm outcomes.
Volume 27 Number 1 February 2014
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