ROBOTIC CARDIAC SURGERY
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1 ROBOTIC CARDIAC SURGERY N. Bonaros Department of Cardiac Surgery Innsbruck Medical University
2 NEGATIVE PROPHECIES GOOD OMENS N Bonaros ESCVS Regensburg 2013
3 ROBOTIC CORONARY ARTERY BYPASS HAS SURVIVED AND DIFFERENTIATED N Bonaros ESCVS Regensburg 2013
4 DEVELOPMENT OVER TIME AH BH BH Endostabilizer Single Vessel Hybrid DES Double Triple Vessel Hybrid Advanced Multivessel 1998 Hybrid Hybrid 2014 BMS Simultaneous N Bonaros ESCVS Regensburg 2013
5 THE TOOLBOX IS GROWING N Bonaros ESCVS Regensburg 2013
6 ROBOTIC CORONARY SURGERY PROGRAM IN INNSBRUCK Step 1 Basic system training, dry lab animal lab 6/2001 Step 2 Endoscopic LIMA harvesting, completion as MIDCAB, OPCAB, or CABG n=40 Gain more port-access experience ASD Closure Step 3 Robotically performed LIMA LAD anastomosis via median sternotomy on the arrested heart n=35 Step 4 Arrested Heart TECAB procedures 10/2001 4/2009 Totally endoscopic LIMA harvesting and LAD anastomosing N Bonaros ESCVS Regensburg 2013
7 ROBOTIC CORONARY SURGERY PROGRAM IN INNSBRUCK Step 5 Beating Heart TECAB procedures 2/2004 Wet Lab training Endoscopic assisting Step 6 Simultaneous Hybrid AH-TECAB/Cypher-Stent RCA/Cx 5/2004 Step 7 Double Vessel TECAB RIMA-LAD/LIMA OM 1 11/2004 Contact with other robotic Disciplines (MIRA) Step 8/9 Double Vessel TECAB LIMA-LAD/SVG or RIMA RCA 3/2006 Sequential Graft LIMA LAD/DG 5/2007 N Bonaros ESCVS Regensburg 2013
8 Double IMA Sequential grafting Y-Grafts LIMA/RIMA/ Radial Artery Aortocoronary vein grafts Axillocoronary vein grafts Advanced closed chest hybrid revascularization N Bonaros ESCVS Regensburg 2013
9 BEATING HEART ALL-ARTERIAL CABG
10 COMPLEX PROCEDURES
11 ANASTOMOTIC U-CLIPS
12 ANASTOMOTIC CONNECTORS
13 ANASTOMOTIC CONNECTORS
14 ALTERNATIVE INFLOW N Bonaros ESCVS Regensburg 2013
15 PERIOPERATIVE RESULTS MEET CABG STANDARDS N Bonaros ESCVS Regensburg 2013
16 13 YEARS TECAB (N=601)
17 Cumulative freedom from reintervention (PCI or CABG) 96.5% at 5 years Graft failure rate 3.5% at 5 years
18 PEOPLE SAY Conversions Operative times Costs Training Long term results
19 LEARNING CURVE TECAB CONVERSION Conversion % AH LIMA-LAD AH RIMA LIMA BH LIMA LAD AH TECAB x 1 n= 183 AH TECAB x 2 n = 47 BH TECAB x 1 = 62 N Bonaros ESCVS Regensburg 2013
20 CONVERSION Conversion is not a complication! Schachner et al. Ann Thorac Surg. 2011; 91: N Bonaros ESCVS Regensburg 2013
21 OPERATIVE TIMES THE ACHILLES HEEL N Bonaros ESCVS Regensburg 2013
22 OPERATIVE TIMES 500 AH-TECAB LIMA LAD Time (min) 250 OR Time TECAB Time N Bonaros ESCVS Regensburg 2013
23 LEARNING CURVE N Bonaros ESCVS Regensburg 2013
24 FASTEST TIMES Fastest AH-TECAB LIMA LAD Fastest AH-TECAB RIMA LAD LIMA OM Fastest BH-TECAB LIMA LAD Fastest Robotically assisted MIDCAB 1h 51 min 3h 15 min 2h 17 min 1h 35 min Two TECABs / day can be scheduled and performed in one OR N Bonaros ESCVS Regensburg 2013
25 COSTS
26 NOT A PROCEDURE BUT A PROCESS
27 LENGTH OF STAY: A MATTER OF COST Robotic TECAB (n=237) MIDCAB (n=47) CABG (n=66) P (ANOVA) ICU stay (h) 20 (11-480) 20(10-66) 21 (12-264) LOS (d) 7 (2-33) 7 (5-14) 8 (5-25) ndary 104 (44%) 33 (69%) 66 (100%) hospitalization (d) Length of SH (d) 1 (0-12) 5 (0-15) 7 (1-14) Rehabilitation 159 (67%) 29 (62%) 66 (100%) Length of Rehab (d) 21 (0-42) 28 (21-30) 28 (14-39) Length of institutionalization (d) 31 (4-83) 38 (27-48) 44 (10-50) Rippel R et et al. Innovations; 2014; in print
28 OVERALL COSTS Euros Robotic TECAB) (n=237) MIDCAB (n=47) CABG (n=66) P (ANOVA) 1 st Hospitalization ( ) ( ) ( ) nd hospitalization 0 (0-9100) 1300 (0-3900) 1300 ( ) Rehabilitation 3822 (0-7644) 5096 ( ) Total revenues ( ) ( ) 5095 ( ) ( ) Rippel R et et al. Innovations; 2014; in print
29 COST-EFFECTIVENESS ICER = (TECAB cost CABG cost) / (TECAB QALYs CABG QALYs) 6 months Cost /QALY gained Robotic CABG (n=66) P (ANOVA) TECAB) (n=237) 0.380± ± $263,849 $333, ICER $-1,658/QALY gained Rippel R et et al. Innovations; 2014; in print
30 TRAINING
31 TRAINING Increasing case nummber Increasing complexity
32 YOU DON T HAVE TO BE BORN AS A TECAB SURGEON... Schachner et al. Ann Thorac Surg. 2009; 88: N Bonaros ESCVS Regensburg 2013
33 LONG-TERM RESULTS COMPETITIVE TO CONVENTIONAL CABG N Bonaros ESCVS Regensburg 2013
34 LONG-TERM RESULTS Bonaros N, et al. Ann Thorac Surg. 2013; 95: N Bonaros ESCVS Regensburg 2013
35 LONG-TERM RESULTS Bonaros N, et al. Ann Thorac Surg. 2013; 95: N Bonaros ESCVS Regensburg 2013
36 ROBOTIC VS CONVENTIONAL CABG Kofler et et al. Eur J Cardiothorac Surg; 2014; in print
37 ROBOTIC VS CONVENTIONAL CABG Kofler et et al. Eur J Cardiothorac Surg; 2014; in print
38 AT THE END OF THE DAY A minimally invasive procedure with non inferior long-term results is superior compared the conventional one Michael Mack, Cardiac Surgeon, Dallas Tx
39 IT S A MATTER OF PHILOSOPHY... N Bonaros Nikolaos.bonaros@i-med.ac.at
40 SAFETY AND SUCCESS Bonaros N, et al. Ann Thorac Surg. 2013; 95: N Bonaros ESCVS Regensburg 2013
41 REPRODUCIBLE? N Bonaros Nikolaos.bonaros@i-med.ac.at
42 MORE TECHNICAL PROBLEMS CAN BE SOLVED ENDOSCOPICALLY N Bonaros ESCVS Regensburg 2013
43 ZERO TOLERANCE
44 IMPROVING PERIPROCEDURAL OUTCOMES
45 MOST SIGNIFICANT BENEFIT IN THE EARLY REHABILITATION PERIOD N Bonaros ESCVS Regensburg 2013
46 Sternotomy CABG Robotic TECAB Bonaros et al. Cardiology. 2009; 114: Total length of stay (d) Shower (d) 10 4 House keeping (d) Gardening (d) Car driving (d) Public transportati on (d) Hiking (d) Cycling (d) % -60% -40% -60% -55% -40% -30% -60% N Bonaros Nikolaos.bonaros@i-med.ac.at
47
48 PRIMUM NON NOCERE SCRIBONIS LARGUS 50 AC
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