Hybrid Coronary Revascularization by Endoscopic Robotic Coronary Artery Bypass Grafting on Beating Heart and Stent Placement

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1 Hybrid Coronary Revascularization by Endoscopic Robotic Coronary Artery Bypass Grafting on Beating Heart and Stent Placement Changqing Gao, MD, Ming Yang, MD, Yang Wu, MD, Gang Wang, MD, Cangsong Xiao, MD, Hongbin Liu, MD, and Caiyi Lu, MD Departments ofcardiovascular Surgery and Cardiology, and Institute of Geriatric Cardiology, Minimally Invasive and Robotic Cardiac Surgery Center, PLA General Hospital, PLA Institute of Cardiac Surgery, Beijing, China Background. Hybrid revascularization has been used in minimally invasive coronary artery bypass grafting and percutaneous coronary intervention for multivessel coronary artery disease (CAD). Very few endoscopic robotic coronary bypasses on the beating heart have been reported. The aim of this study was to assess hybrid revascularization by endoscopic robotic coronary artery bypass on the beating heart with percutaneous coronary intervention in a staged approach. Methods. Forty-two patients underwent selective robotic coronary artery bypass grafting on the beating heart. Ten patients with right coronary artery or circumflex coronary stenosis underwent stent placement after robotic left internal mammary artery (LIMA) anastomosis to the left anterior descending (LAD) artery surgery in a separate session. The average age of the patients was years old. Coronary arteriography showed significant stenosis or total occlusion of the LAD in all patients and significant stenosis in the right coronary or circumflex arteries. The LIMA was harvested by the da Vinci S robotic surgical system (Intuitive Surgical, Sunnyvale, CA) and manually anastomosed to the LAD off-pump in 6 patients, and by totally endoscopic bypass on the beating heart in 4 patients. Percutaneous coronary intervention with placement of a stent to stenotic non- LAD targets was performed 4 to 5 days after operation. All LIMA-LAD grafts were assessed angiographically. Results. All 10 patients had off-pump robotic bypass surgery and stent placement using a staged approach without complications. Conclusions. Our preliminary study shows that hybrid coronary revascularization by endoscopic robotic coronary artery bypass grafting on a beating heart and subsequent stent placement is a feasible integrated approach for patients with multivessel CAD. (Ann Thorac Surg 2009;87:737 41) 2009 by The Society of Thoracic Surgeons Hybrid revascularization has applied minimally invasive coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for the treatment of multivessel coronary artery diseases. However, only very few endoscopic robotic coronary bypasses on the beating heart has been reported in treatment of multivessel coronary diseases [1]. The ultimate goal of minimally invasive coronary artery bypass grafting is to perform the entire anastomosis in a closed chest. With the advent of robotically enhanced telemanipulation, the latest in minimally invasive techniques is now available and thus enables true closedchest totally endoscopic procedures [2 8]. The concept of hybrid revascularizations was first discussed and applied clinically when left internal mammary artery (LIMA) to the left anterior descending artery (LAD) placement became feasible through minithoracotomies [9 13]. Our Institution initiated the robotic surgery using the da Vinci S (4-arm) surgical system (Intuitive Surgical, Sunnyvale, Accepted for publication Dec 1, Address correspondence to Dr Gao, Department of Cardiovascular Surgery, PLA General Hospital, #28 Fuxing Rd, Beijing, , China; gaochq301@yahoo.com. CA) in China in 2007, and we have completed over 130 cases of robotic cardiac surgeries [14, 15]. In this study, we have assessed hybrid revascularization by endoscopic robotic coronary bypass on the beating heart and PCI in a staged approach. Patients and Methods Patients From April 2007 to August 2008, 42 patients underwent selective robotic coronary bypass grafting on the beating heart, of which 10 patients with right coronary artery or circumflex coronary stenosis received stent placement after robotic LIMA to LAD surgery in separate session, with approval from the Institutional Review Board and informed consent, from June 2007 to August The average age of the patients was years old. Two patients were female and 8 male. All patients had a history of stable angina. The coronary arteriography showed significant stenosis or total occlusion in LAD in all patients and significant stenosis in the right coronary artery or circumflex artery before surgery. No patient had a history of pleurisy. All patients had a preoperative 2009 by The Society of Thoracic Surgeons /09/$36.00 Published by Elsevier Inc doi: /j.athoracsur

2 738 GAO ET AL Ann Thorac Surg HYBRID REVASCULARIZATION BY ENDOSCOPIC ROBOTIC CABG 2009;87: Fig 1. Endoscope and two ports in the third, fifth, and seventh intercostal spaces. computed tomographic scan of the thorax and pulmonary function tests. Acetylsalicylic acid was routinely discontinued 7 days before the operation. Fig 3. The left internal mammary artery to the left anterior descending artery anastomosis using s-18 U-CLIP (Medtronic, Inc). Methods Under single-lung ventilation, the patient was placed in the supine position with the left chest elevated by approximately 30 degrees. External defibrillator patches were placed to subtend the maximum cardiac mass. The da Vinci S surgical system was positioned, and the camera cannula with a CO 2 insufflator port was inserted at the fifth intercostal space (ICS) close to the anterior axillary line. After insertion of the endoscope, two ports were placed in the third and seventh ICS (Fig 1). The LIMA was harvested skeletonized right from the subclavian artery to its bifurcation using a 30 degree-angled endoscope facing upwards (Fig 2) and the pericardium was then opened using the same endoscope with a 30 degree down position for visualization of the LAD and its target site for anastomosis. Three procedures were involved. (1) THE ROBOTICALLY ASSISTED ENDOSCOPIC ATRAUMATIC CORO- NARY ARTERY BYPASS (ENDOACAB) SURGERY. The procedure was performed on the beating heart through a small left anterior thoracotomy (6 to 8 cm) after a robotic LIMA takedown. After heparinization (1 mg/kg), the pericardium was opened and the pericardial retraction sutures helped position the heart for grafting. The LAD was exposed and stabilized with a stabilizer (Octopus IV; Medtronic Inc, Minneapolis, MN). The LIMA was manually anastomosed to LAD using 7-0 prolene sutures. An intraluminal shunt was placed into the vessel when necessary. (2) THE TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS GRAFTING (TECAB) ON THE BEATING HEART. After LIMA was harvested, Fig 2. The left internal mammary artery harvested skeletonized. Fig 4. The left internal mammary artery to the left anterior descending artery anastomosis completed.

3 Ann Thorac Surg GAO ET AL 2009;87: HYBRID REVASCULARIZATION BY ENDOSCOPIC ROBOTIC CABG 739 Fig 5. The left internal mammary artery to the left anterior descending artery graft patency was verified angiographically (case). the endowrist stabilizer (Intuitive Surgical) was inserted through a fourth port in the xiphoid area under endoscopic vision. The patient was heparinized and LIMA was prepared for anastomosis. During the procedure the CO 2 pressure was kept at about 10 to 12 mm Hg depending on the working space and hemodynamics. The saddle loops were placed proximally and distally around the LAD and the anastomosis was performed by using U-CLIP (Medtronic Inc) (Fig 3). After completion of anastomosis (Fig 4), heparin was reversed using protamine, and a single chest tube was placed through the xiphoid port. Fig 7. (A) (B) Successful percutaneous coronary intervention of the right coronary artery. For all patients, blood flow and flow waveform of the LIMA were measured by transit time ultrasound with the flexible flow probe (MediStim Inc, Oslo, Norway), which was inserted through fourth port when the anastomosis was completed. (3) STENT PLACEMENT. Four to 5 days after the surgery, stent placement was carried out in a routine method in the catheter lab. By femoral access, angiographic confirmation of LIMA-LAD graft patency was verified (Figs 5 and 6) and successful PCI of the right coronary or circumflex artery followed (Figs 7A and B). There were no complications. Fig 6. The left internal mammary artery to the left anterior descending artery graft patency was verified angiographically (another case). Patient Selection Inclusion criteria for the endoacab were patients with double-vessel or triple-vessel disease in whom LAD lesions were not suitable for PCI but suitable for surgical bypass and in whom non-lad lesions were amenable to PCI. Inclusion criteria for TECAB on the beating heart

4 740 GAO ET AL Ann Thorac Surg HYBRID REVASCULARIZATION BY ENDOSCOPIC ROBOTIC CABG 2009;87: Table 1. Procedures Performed Patient Num. Procedures Surgery Graft PCI No-LAD Targets 1 BH-TECAB LIMA-LAD Bare-stent 2 RCA 2 SVST (beating heart) LIMA-LAD Bare-stent 1 LCX 3 BH-TECAB LIMA-LAD Drug eluting-stent 1 LCX 4 BH-TECAB LIMA-LAD Bare-stent 1 RCA 5 SVST (beating heart) LIMA-LAD Bare-stent 2 RCA 6 SVST (beating heart) LIMA-LAD Bare-stent 1 LCX 7 SVST (beating heart) LIMA-LAD Bare-stent 1 RCA 8 SVST (beating heart) LIMA-LAD Bare-stent 1 LCX 9 BH-TECAB LIMA-LAD Bare-stent 1 LCX 10 SVST (beating heart) LIMA-LAD Drug eluting-stent 2 RCA BH-TECAB totally endoscopic coronary bypass on beating heart; LAD left anterior descending coronary artery; LCX left circumflex coronary artery; LIMA left internal mammary artery; PCI percutaneous coronary intervention; RCA right coronary artery; SVST single-vessel coronary artery bypass grafting through small thoracotomy. were patients with double- or triple-vessel disease in whom LAD involved total or subtotal (high-grade) occlusion judged a suitable surgical target and in whom non-lad lesions were amenable to PCI. We selected a low-risk patient for TECAB in order to keep biologic reserves for tolerance of potentially long operative times. Hemodynamic instability, acute coronary syndromes, or situations in which complete revascularization was not possible served as exclusion criteria. Results In 10 patients, the LIMA was harvested robotically in a skeletonized fashion, of which 6 patients underwent the robotically assisted endoscopic atraumatic CAB (endoacab) on the beating heart and 4 patients underwent totally endoscopic coronary artery bypass (TECAB) on the beating heart. Operating room times for endoacab and TECAB were minutes and minutes, respectively. No conversion for any hemodynamic instability was performed in the patients. The angiographic confirmation of LIMA-LAD patency was verified and successful PCI of the right coronary or circumflex artery followed in separate session without complications (Table 1). Coronary angiography showed that all grafts were patent and all patients were discharged free of angina from the hospital 2 or 3 days after PCI was completed. All 10 patients underwent computed tomography angiography at 6 and 12 months postprocedure. No patient had angina or reintervention for myocardial ischemia. Mean follow-up was 5 months (range, 1 to 14 months) with symptoms absent. Comment The ultimate goal of minimally invasive CABG is to perform the entire anastomosis in a closed chest, to avoid the deleterious effect of cardiopulmonary bypass, and to minimize the incision and surgical trauma. With the advent of robotically enhanced telemanipulation, Loulmet and colleagues performed the first TECAB procedure in 1998 [3]. Despite this successful step, only a limited number of TECAB operations have been performed worldwide [2 8]. We feel that robotic assistance is a significant improvement over minimally invasive direct coronary artery bypass approach [14, 16]. First, visualization within the thoracic cavity and of the LIMA is much better. This reduces the possibility of injuring the LIMA during harvest, and better visualization of the LAD lends to more appropriate placement of thoracotomy for LIMA- LAD anastomosis. For this reason, thoracotomy incisions become smaller. Furthermore, robotic assistance avoids the need for vigorous costal retraction. Second, surgical access is improved with robotic assistance, enabling mobilization of the entire LIMA graft. By increasing the length of the LIMA, a great area of the LAD was available for LIMA-LAD anastomosis. This ensures the target anastomosis occurred with a tension-free LIMA to an optimum location free of disease. With our 42 patient experience, we believe that robotically taking down LIMA and manually anastomosing it to LAD on the beating heart is a standard procedure through a left anterior thoracotomy incision [1, 14]. Totally endoscopic coronary artery bypass grafting on the beating heart with a da Vinci S (4-armed) in selected patients is feasible [14, 17]. However, TECAB on the beating heart is very demanding, especially suturing of the anastomosis; even the slightest movement of the target vessel could impair surgical manipulation due to the 10 magnification and missing tactile feedback. We believe that future development of technology seems to be essential for reproducible anastomosis [17]. Hybrid revascularization combines minimally invasive coronary artery bypass of LIMA to LAD with PCI of other stenosed arteries [9]. Percutaneous coronary intervention is an established technique for coronary revascularization; therefore, hybrid revascularization is an alternative therapy for multivessel coronary artery disease in selected patients in whom PCI is a poor option due to LAD

5 Ann Thorac Surg GAO ET AL 2009;87: HYBRID REVASCULARIZATION BY ENDOSCOPIC ROBOTIC CABG disease location [9]. The survival benefit of the LIMA for ostial or complex lesions of the LAD is well-established [18, 19]. Moreover, the advantage of venous grafts or radial artery grafts over PCI to treat low-grade lesions in other coronary arteries has been questioned [20]. Therefore, hybrid revascularization is an integrated approach for selected patients [1, 9, 21]. The hybrid concept was first discussed and applied clinically when LIMA-LAD placement became feasible through minithoracotomies [9, 10]. Development of the hybrid principle has been generally slow over the last 10 years, mainly due to logistic reasons [21]. Hybrid revascularization can be carried out easily in a staged approach in an operating room and a catheter lab of any Heart Center in order to avoid the complicated logistic issues of a simultaneous approach and longer operative times. In our 42 patients with robotic CABG on the beating heart, 10 patients with RCA or circumflex coronary stenosis underwent stent placement after robotic LIMA to LAD surgery in separate session. The staged approach avoided potentially postoperative bleeding, for patients were not fully loaded with aspirin and clopidogrel preoperatively as in the simultaneous approach although bivalirudin was suggested to be clinically feasible as an anticoagulant in hybrid procedure [1]. By the time of PCI, the angiographic visualization of the LIMA-LAD graft was carried out. From our limited experience, the staged approach is a safer and more effective integrated approach of benefit to both young and elderly patients. Further study is indicated due to the limited number of patients. Our preliminary study shows that hybrid coronary revascularization by endoscopic robotic CABG on the beating heart and stent placement in a staged approach is an integrated approach for the patients with multivessel coronary artery disease. The TECAB on the beating heart for LIMA-LAD is feasible and safe for selected patients; the staged approach avoids the complicated logistics issues and is more feasible for becoming a popular procedure. Further studies are necessary to better determine patient selection and long-term outcomes. This study was sponsored by research grants from the Capital Development Foundation. References 1. Kiaii B, McClure RS, Stewart P, et al. Simultaneous integrated coronary artery revascularization with long-term angiographic follow-up. J Thorac Cardiovasc Surg 2008;136: Dogan S, Aybek T, Andreßen E, et al. Totally endoscopic coronary artery bypass grafting on cardiopulmonary bypass with robotically enhanced telemanipulation: report of fortyfive cases. 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