Robotically Assisted Totally Endoscopic Coronary Bypass Surgery
2011; Lippincott Williams & Wilkins; Volume: 124; Issue: 2 Linguagem: Inglês
10.1161/circulationaha.110.985267
ISSN1524-4539
AutoresJohannes Bonatti, Thomas Schachner, Nikolaos Bonaros, Eric J. Lehr, David Zimrin, Bartley P. Griffith,
Tópico(s)Aortic Disease and Treatment Approaches
ResumoHomeCirculationVol. 124, No. 2Robotically Assisted Totally Endoscopic Coronary Bypass Surgery Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBRobotically Assisted Totally Endoscopic Coronary Bypass Surgery Johannes Bonatti, MD, Thomas Schachner, MD, Nikolaos Bonaros, MD, PhD, Eric J. Lehr, MD, PhD, David Zimrin, MD and Bartley Griffith, MD Johannes BonattiJohannes Bonatti From the Division of Cardiac Surgery, Department of Surgery (J.B., E.J.L., B.G.), and Division of Cardiology, Department of Medicine (D.Z.), University of Maryland School of Medicine, Baltimore; and Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (T.S., N.B.). , Thomas SchachnerThomas Schachner From the Division of Cardiac Surgery, Department of Surgery (J.B., E.J.L., B.G.), and Division of Cardiology, Department of Medicine (D.Z.), University of Maryland School of Medicine, Baltimore; and Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (T.S., N.B.). , Nikolaos BonarosNikolaos Bonaros From the Division of Cardiac Surgery, Department of Surgery (J.B., E.J.L., B.G.), and Division of Cardiology, Department of Medicine (D.Z.), University of Maryland School of Medicine, Baltimore; and Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (T.S., N.B.). , Eric J. LehrEric J. Lehr From the Division of Cardiac Surgery, Department of Surgery (J.B., E.J.L., B.G.), and Division of Cardiology, Department of Medicine (D.Z.), University of Maryland School of Medicine, Baltimore; and Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (T.S., N.B.). , David ZimrinDavid Zimrin From the Division of Cardiac Surgery, Department of Surgery (J.B., E.J.L., B.G.), and Division of Cardiology, Department of Medicine (D.Z.), University of Maryland School of Medicine, Baltimore; and Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (T.S., N.B.). and Bartley GriffithBartley Griffith From the Division of Cardiac Surgery, Department of Surgery (J.B., E.J.L., B.G.), and Division of Cardiology, Department of Medicine (D.Z.), University of Maryland School of Medicine, Baltimore; and Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria (T.S., N.B.). Originally published12 Jul 2011https://doi.org/10.1161/CIRCULATIONAHA.110.985267Circulation. 2011;124:236–244IntroductionNearly all surgical disciplines have developed endoscopic operations over the last 2 decades that have become the standard of care. In cardiac surgery and specifically for coronary artery bypass grafting (CABG), the adoption of minimally invasive techniques was challenging for the following reasons: First, most procedures are already complex, and endoscopic approaches further increase the degree of complexity; second, the cardiac surgery community had until recently no endoscopic surgical tradition; and finally, early attempts to perform CABG with the use of conventional thoracoscopic instrumentation failed completely.1 Cardiac surgeons have standardized open operations for acquired heart disease, and despite low mortality and excellent results, CABG outcomes are heavily scrutinized. Consequently, the bar has been raised for any new competing technology, which has slowed its adoption.Robotic surgical technology was developed with the idea of performing remote operations and procedures in difficult spaces. These machines allow surgical maneuvers to be performed by instruments on robotic arms that are controlled by the operator from a console situated away from the operating table. This technology is well suited for completely endoscopic suturing inside the chest. In 1998, Loulmet et al2 performed the world's first totally endoscopic coronary artery bypass (TECAB) procedure using robotic assistance. The patient who received a single left internal mammary artery (IMA) to left anterior descending artery graft remains alive and free from angina 12 years postoperatively. During subsequent years, development has been slow but significant. TECAB developed from a single-vessel procedure to complex endoscopic robotic multivessel revascularization (Figure 1). The third generation of surgical telemanipulators is now available, with technological improvements in the areas of high-definition video, robotic arm mobility, instrument reach, surgeon comfort, and capability for intraoperative surgical endoscopic teaching with a dual-console system.3Download figureDownload PowerPointFigure 1. Development of robotic totally endoscopic coronary artery bypass grafting from 1998 to 2010. Note the improvement in performance from single bypass grafting only to complex surgical endoscopic and hybrid interventions. AH indicates arrested heart; BH, beating heart; BMS, bare metal stent; and DES, drug-eluting stent.This review describes the current techniques that are applied to robotically assisted CABG and reports on overall clinical results of variations on approaches. A slow stepwise approach to learning completely endoscopic techniques is mandatory,4,5 and a stable, dedicated team is vitally important for successful procedure implementation. Some pioneering groups failed and abandoned their programs because such steps were not taken and because a stable team could not be established.Preliminary StepsRobotic Internal Mammary Artery HarvestingThe initial clinical step for programs wishing to develop a robotic coronary surgery program is IMA takedown and completion of CABG through sternotomy or minithoracotomy. Before this step is implemented, IMA harvesting can be practiced in dry laboratory models, in the human cadaver, and in vivo in pigs or dogs. Both pedicled and skeletonized harvesting techniques can be applied, with the latter offering the advantages of better graft length and easier graft handling.Robotic IMA harvesting is performed with the patient under general anesthesia with a double-lumen endotracheal tube to allow single-lung ventilation. With the left lung collapsed, a 12-mm camera port is usually placed into the left fifth intercostal space on the anterior axillary line. Additional 8-mm instrument ports are inserted into the left third and seventh intercostal spaces between the midclavicular line and the anterior axillary line for the instrument arms. Insufflation of CO2 into the chest enhances intrathoracic working space. The IMA is localized, and the endothoracic fascia is removed from the artery to provide adequate exposure of the IMA and its concomitant veins. IMA harvesting is then performed with the use of electrocautery at low energy levels. After systemic heparinization, the graft is clipped distally and detached from the thoracic wall. Distal preparation can be performed elegantly with the use of the robotic instruments. Free flow is assessed, and topical vasodilators can be applied endoscopically. Both the left and the right IMAs can be harvested after port placement from the patient's left side. For access to the right IMA, the retrosternal tissue is dissected, and the right pleura is opened.Table 1 summarizes the operative time and learning curve for robotic IMA harvesting in published articles.2,6–11Table 1. Published Series of Robotic IMA HarvestingAuthor and ReferenceCasesIMA Harvesting Time, minEnd of Steep Part of Learning Curve, CasesLoulmet et al2478±13Falk et al63240–508Dogan et al73765±21Bonatti et al84035–85Reuthebuch et al92666±2220Kiaii et al105066±22Oehlinger et al1110048 (19–180)15IMA indicates internal mammary artery.Robotically Assisted Coronary Artery Bypass Grafting Through MinithoracotomyBefore proceeding to TECAB, some groups feel more comfortable with an additional preliminary step: The IMAs are harvested robotically and followed by graft to coronary artery anastomoses under direct vision through a minithoracotomy.The most commonly used terms for robotically assisted CABG through minithoracotomy are minimally invasive direct coronary artery bypass, single-vessel small thoracotomy, multivessel small thoracotomy, and robotically assisted coronary artery bypass. The IMA harvest is performed as described above, after which the pericardial fat pad is removed, and the pericardium is opened. The robotic endoscope is helpful in localizing the coronary target vessels, and can also assist in identification of the correct intercostal space through which the target vessel is approached for anastomosis, although the minithoracotomy is most commonly performed in the fourth left intercostal space. Small thoracotomy retractors or less traumatic soft tissue retractors enhance exposure of the target vessel and allow use of standard surgical microinstrumentation for direct suturing by hand. Apical suction positioning devices and suction stabilizers are placed through the thoracotomy or through additional small port incisions to enhance exposure of targets on the circumflex and right coronary artery system and for immobilization of the target vessel.Minithoracotomy approaches can be challenging, especially in obese patients, and only a keyhole view of the target vessel is granted rather than the full visual immersion into the chest that is available in robotic TECAB. In addition, minithoracotomies appear to be more painful than a port-only approach, especially if rib spreading is involved. Prolonged rib spreading for minithoracotomy may increase the risk of wound infection, especially in obese and patients with diabetes mellitus.12 In contrast, we have observed an overall rate of deep thoracic wound infection of only 2 in 410 TECAB patients (0.5%), with events occurring only in patients who required conversion to open sternotomy. The outcomes published for robotically assisted minimally invasive direct CABG approaches (Table 2) show no perioperative mortality and low complication rates.12–17Table 2. Results of Robotically Assisted Coronary Artery Bypass Grafting on the Beating Heart Through MinithoracotomyAuthor and ReferenceCasesConversionPerioperative MortalityRevision for BleedingStrokeRenal FailureLength of Stay, dKiaii et al105820314.3±1.4Derose et al12371013 (2–14)Subramanian et al133010250% discharged within 1 dTurner et al1470302005.7Srivastava et al15150204003.6±2.9Kon et al16150003.7±1.4Poston et al171000033.8±1.5Total, n (%)4609/3600/46012/3451/3783/325(2.5)(0.0)(3.5)(0.3)(0.9)Open Chest Robotic AnastomosisRobotic surgical devices were designed to enable precise microsurgical maneuvers inside the chest. Robotically assisted coronary microanastomoses are feasible and reproducible with training and practice. We demonstrated previously that suturing coronary anastomoses on inanimate porcine hearts with robotic techniques is an effective training model.18 Such models were required in early Food and Drug Administration studies of robotic surgery4 and should be part of the development process for any clinical program considering robotic CABG. Another early study by our group demonstrated that initial experience with robotic suturing of bypass anastomoses via midline sternotomy as part of a standard CABG procedure is a reasonable step to enable a safe subsequent totally endoscopic approach.5 Bolton and Connally19 described 10 such anastomoses performed on the beating heart through sternotomy or small thoracotomy. Two anastomotic failures were corrected immediately. The authors point out the feasibility and relative safety of this approach. Postoperative hospital stay was 2.8 days, and a stress echocardiogram was normal or improved in 7 of 8 patients restudied at 3 months.Completely Endoscopic ApproachesTotally Endoscopic Coronary Artery Bypass on the Arrested HeartThe world's first TECAB operation was performed with bifemoral cannulation for cardiopulmonary bypass and endoballoon occlusion of the ascending aorta for delivery of cardioplegia.2 A Food and Drug Administration trial for TECAB on the arrested heart (AHTECAB) has been published, confirming the feasibility and safety of this approach.4 Efficiency of AHTECAB is enhanced when endoscopic IMA harvesting and femoral cannulation are performed concurrently by 2 surgeons, 1 at the operating table and 1 at the robotic console. An endoaortic occlusion balloon is advanced into the aortic root under transesophageal echocardiographic guidance. After the IMAs are prepared, the pericardial fat pad is resected, and the pericardium is opened. Cardiopulmonary bypass is initiated; while the patient is systemically cooled, the endo-occlusion balloon is inflated in the ascending aorta, isolating the coronary arteries from the systemic circulation (just as with the application of an aortic cross-clamp in open procedures). Cardioplegic arrest can be induced with antegrade high-potassium, blood cardioplegia solution delivered via the aortic root through a distal channel of the endoballoon catheter. Suturing the CABG anastomosis on the arrested heart is very precise because the heart is still, the surgeon is immersed in the operative field, and the robotic instruments are natural extensions of the surgeons' hands. The current suturing technique does not differ significantly from open CABG. In most cases, however, the robotic surgeon performs the suture in a solo fashion, without countertraction by an assistant.Cardioplegic arrest times are currently prolonged compared with open sternotomy cases, and few data exist on the likelihood of increased myocardial injury arising from these procedures. We have shown previously that for cardiac arrest times of up to 3 hours, myocardial enzyme release is comparable to previous studies on open CABG and that prolonged arrest times in TECAB did not lead to significant reduction of postoperative left ventricular ejection fraction.20The IMA to coronary artery anastomoses are performed with the use of a double-armed 7-cm polypropylene suture, U clips, or anastomotic devices. Single, double,21 and triple AHTECAB are feasible. Our team at the University of Maryland has performed the first triple-vessel AHTECAB worldwide.22 Sequential bypass grafts7 and Y grafts can be constructed in completely endoscopic fashion. Another major advantage of AHTECAB compared with TECAB on the beating heart (BHTECAB) is that the completely flaccid arrested heart can be rotated easily for access to the circumflex coronary artery system without concern for hemodynamic insufficiency. Intrathoracic workspace is enhanced significantly compared with beating heart techniques without extracorporeal circulation because both lungs can be deflated during cardiopulmonary bypass. We have described exposure techniques for the back wall of the heart with the use of suction stabilization.23Table 3 lists available AHTECAB publications with clinical results. No mortality was observed. The conversion rate to larger thoracic incisions dropped from the 25% range in early series2,7,24–26 to a current cumulative total of 16.4%. Revision rates for bleeding are higher than in open CABG and higher than in series on BHTECAB. An impaired coagulation system, as a side effect of cardiopulmonary bypass, is certainly a contributing factor. With increased experience, enhanced prevention and management of port-hole bleeding has greatly reduced this complication. Rates of stroke and renal failure in the published series describing AHTECAB series are very low. Few data are available in the current literature concerning postoperative wound infection, although the Food and Drug Administration AHTECAB trial reported a 6% groin infection rate.4Table 3. Results of Totally Endoscopic Coronary Artery Bypass Grafting Using Cardiopulmonary Bypass and CardioplegiaAuthor and ReferenceCasesConversionPerioperative MortalityRevision for BleedingStrokeRenal FailureLength of Stay, dLoulmet et al22106.5 (mean)Dogan et al73870218.6±2.7Bonatti et al840907007.5 (mean of 2 groups)Falk et al24224017 (5–20)Argenziano et al498503015.1±3.4de Canniere et al2590270Bonatti et al261001108106 (mean of 4 groups)Total, n (%)39064/3900/39021/2982/2761/238(16.4)(0.0)(7.1)(0.7)(0.4)Totally Endoscopic Coronary Artery Bypass on the Beating HeartBHTECAB without any use of extracorporeal circulation is often regarded as the ultimate goal. The appeal of off-pump CABG has lessened, however, because of recent reports questioning its advantage over conventional CABG27 in the open setting. One-year cognitive function is not different between on- and off-pump CABG.28 Nevertheless, even for surgeons who favor AHTECAB, familiarity with BHTECAB techniques is mandatory for managing patients with contraindications to remote access perfusion and balloon endo-occlusion of the ascending aorta (eg, severe peripheral vascular disease, ascending aortic dilatation). Kappert et al29 reported a small series of successful BHTECAB from Dresden, Germany. BHTECAB has become feasible, and was refined with the availability of adequate endoscopic suction stabilizers. The second and third generations of robotic systems (daVinci S and Si) include a suction stabilizer that can be inserted as a robotic instrument and is controlled by the surgeon from the console.After IMA harvesting and exposure of the heart, the endostabilizer is brought into the chest through a subcostal port, which is docked to the fourth arm of the robotic system. The target vessel is immobilized and snared with Silastic tapes. An endoluminal shunt can be inserted. Polypropylene or polytetrafluoroethylene suture, U clips, and anastomotic devices have all been used to construct grafts to coronary artery anastomoses. Technically, the anastomoses in BHTECAB are challenging because the movement of the heart is also magnified.Table 4 lists published clinical results.25,29–33 The conversion rate to larger thoracic incisions has dropped from 32% in the initial series25 to 18%. Perioperative mortality is 0.6% and appears slightly higher than in AHTECAB. Hospital length of stay, however, is slightly shorter. Similar to AHTECAB, the rate of major complications such as stroke and renal failure is ≈0.5%. Prospective randomized trials or retrospective matched comparisons of TECAB with standard on-pump CABG or off-pump CABG are currently unavailable.Table 4. Results of Totally Endoscopic Coronary Artery Bypass Grafting on the Beating Heart Without Heart-Lung Machine UseAuthor and ReferenceCasesConversionPerioperative MortalityRevision for BleedingStrokeRenal FailureLength of Stay, dde Canniere et al25117372Kappert et al293006±1Boyd et al306008.6±2.7Loisance et al3113111Srivastava et al321081501/9301/933.4±2.0Srivastava et al33241270211Total, n (%)48890/4883/4883/3341/3342/334(18.4)(0.6)(0.9)(0.3)(0.6)The authors believe that a comprehensive program for TECAB should offer both beating and arrested heart methods to tailor the procedure to the patient's specific needs. Conversion to open procedures should be regarded primarily as a second option and not as failure.Pump-Supported Beating Heart Totally Endoscopic Coronary Artery BypassEndoscopic placement of coronary bypass grafts to the lateral and back walls of the heart is technically very challenging without cardiopulmonary bypass. Few data, however, are available to assess outcomes of pump-assisted BHTECAB. In 2008, our group began to use cardiopulmonary bypass support for robotic BHTECAB. Both femoral and axillary approaches for arterial cannulation have been used. The primary advantage of axillary artery compared with femoral artery cannulation is antegrade perfusion of the descending and abdominal thoracic aorta and the aortoiliac arterial level, thus lowering the risk of retrograde cerebral embolization and retrograde aortic dissection.34 Cardiopulmonary bypass dramatically reduces the technical difficulty of BHTECAB by unloading the heart and permitting bilateral lung deflation, which leads to greater working space within the closed chest. Even prophylactic cannulation and cardiopulmonary bypass standby can help in managing the following technical difficulties: myocardial ischemia and arrhythmia during target vessel occlusion, hemodynamic instability during endoscopic exposure of the bypass grafting targets, bleeding from the target vessel, and organ injuries during insertion of robotic instruments. Crash conversions to cardiopulmonary bypass in off-pump CABG through sternotomy have been shown to carry a very high mortality risk, in the 10% range,35 even with full exposure of the heart and direct access for aortic and right atrial cannulation. Resuscitation and emergent groin cannulation are even more difficult in BHTECAB because the robotic arms are docked to the patient. One drawback of a pump run during endoscopic BHTECAB is port-hole bleeding. In our experience, significant diffuse bleeding occurred when a standard heart-lung machine is used. This problem has been controlled with application of minimally invasive extracorporeal circulation. Some of these systems can be run at activated clotting time levels in the 300-second range, thereby dramatically reducing the intraoperative oozing from the portholes.36Time RequirementsTECAB procedures are complex, and consequently, along with other factors, can take longer than open CABG.Table 5 lists published operative times. Note that most of these series include a significant percentage of learning curve cases. In our last 50 cases of totally endoscopic left IMA to left anterior descending artery grafting, the operative time was 225 (112 to 475) minutes, even including fellow training. It is feasible to teach TECAB with adequate safety if the trainee performs distinct portions of the complex procedure (eg, port placement, IMA takedown, pericardial lipectomy, pericardiotomy, suturing of the anastomosis). With increased experience and efficiency with each piece, the trainee can eventually put all of the elements of the procedure together to complete an entire operation. Time requirements for the learning curves of the second generation of robotic coronary bypass surgeons to learn TECAB are lower than for the first generation.37 For the foreseeable future, realistic time requirements for robotic CABG will be in the range of 3 to 5 hours if multivessel CABG is included. With operative times in this range, it is possible to complete 2 procedures in a day in a single operating room.Table 5. Operative Times in Published Series of Robotically Assisted Coronary Artery Bypass GraftingMethod and AuthorCasesLIMA-LAD Anastomosis, minTotal Operating Room Time, minSVST, MVST, RACAB Subramanian1330444±45(multivessel) Turner and Sloan1470356 (first 10 cases)232 (second 10 cases) Srivastava et al15150311±12AHTECAB Argenziano et al48528±11260–400(single vessel) Falk et al63222 (15–34)330 (220–507) Dogan et al73718±4 Bonatti et al84035 (23–66)366(including angiography) Bonatti et al2610010–100178–690(including angiography)BHTECAB Kappert et al29337±13208±42(single vessel) Srivastava et al3210814±4273±130(single and multivessel) Srivastava et al3313913±6177±53(single vessel)LIMA indicates left internal mammary artery; LAD, left anterior descending coronary artery; SVST, single-vessel small thoracotomy; MVST, multivessel small thoracotomy; RACAB, robotically assisted coronary artery bypass grafting; AHTECAB, arrested heart totally endoscopic coronary artery bypass; and BHTECAB, beating heart totally endoscopic coronary artery bypass.Robotic Coronary Artery Bypass Grafting as Part of Hybrid Coronary InterventionCompletely endoscopic placement of a left IMA to the left anterior descending artery or placement of 2 IMA grafts to the left ventricle follows an established long-term therapeutic concept with potentially enhanced survival and is therefore a valuable element of hybrid coronary revascularization procedures. Hybrid coronary interventions combine less invasive surgery and percutaneous intervention as a viable alternative to multivessel percutaneous coronary intervention and multivessel open CABG. Robotic TECAB was combined with percutaneous coronary intervention very early in the conception of hybrid procedures. An international multicenter trial reported the feasibility of robotically assisted TECAB with no mortalities or strokes.38 In this study, early patency rates of robotically sutured left IMA grafts were encouraging, at 96.3%. Our group performed the first simultaneous robotic hybrid coronary interventions in which both TECAB and percutaneous coronary intervention were performed in a single session.39 An increasing number of complex and advanced hybrid coronary interventions, including multivessel TECAB and/or multivessel percutaneous coronary intervention, are being reported.40,41Current Indications and Contraindications for Totally Endoscopic Coronary Artery Bypass GraftingAs multivessel TECAB and advanced hybrid coronary interventions have become feasible, any patient with a clinical indication for CABG can be evaluated for a robotically assisted minimally invasive approach. A multidisciplinary team of cardiologists and heart surgeons should ideally discuss indications on a case-by-case basis.Table 6 lists indications from a coronary anatomic and pathological perspective.Table 6. Indications for Totally Endoscopic Coronary Artery Bypass From a Coronary Anatomic PerspectiveSingle bypass grafts LIMA to LAD■Significant lesions of the proximal LAD■Significant lesions of the proximal LAD associated with significant lesions of non-LAD targets amenable to PCI in hybrid coronary interventions RIMA to RCA■Significant ostial lesions of the RCADouble bypass grafts LIMA to LAD/diagonal branch sequential graft■Significant LAD/diagonal branch bifurcation lesions■Significant LAD/diagonal branch bifurcation lesions associated with significant lesions of non-LAD targets amenable to PCI in hybrid coronary interventions RIMA to LAD combined with LIMA to circumflex coronary system■Significant lesions of the left main coronary artery or left main equivalents■Significant lesions of the proximal LAD and the circumflex coronary artery system■Significant lesions of the left main coronary artery or left main equivalents lesions associated with significant lesions of the RCA system amenable to PCI in hybrid coronary interventions■Significant lesions of the proximal LAD and the circumflex coronary artery system associated with significant lesions of the RCA system amenable to PCI in hybrid coronary interventionsTriple bypass grafts RIMA to LAD combined with LIMA sequential grafts to the obtuse marginal branches■Significant lesions of the left main coronary artery or left main equivalents■Significant lesions of the proximal LAD and the circumflex coronary artery system■Significant lesions of the left main coronary artery or left main equivalents lesions associated with significant lesions of the RCA system amenable to PCI in hybrid coronary interventions■Significant lesions of the proximal LAD and the circumflex coronary artery system associated with significant lesions of the RCA system amenable to PCI in hybrid coronary interventionsLIMA indicates left internal mammary artery; LAD, left anterior descending artery; PCI, percutaneous coronary intervention; RCA, right coronary artery; and RIMA, right internal mammary artery.Contraindications to TECAB are listed in Table 7. Patients with hemodynamic instability are currently unsuited for robotic approaches. Patients with significant pulmonary disease will not tolerate prolonged periods of single-lung ventilation. Endothoracic scarring after previous thoracic surgery, radiation, trauma, or inflammatory disease can be managed with experience but should be carefully evaluated in the patient's preoperative history. Space limitations and distorted thoracic anatomy must be taken into consideration as well as target vessel quality and the grade of systemic atherosclerosis.Table 7. Contraindications for Robotically Assisted Coronary Artery Bypass GraftingAbsolute Cardiogenic shockHemodynamic instabilitySeverely impaired lung functionRelative Pleural adhesions after previous thoracic surgery, trauma, radiation, inflammatory diseaseSignificant space limitations (morbid obesity, significantly enlarged hearts)Chest deformitiesIntramyocardial, heavily calcified, and very small target vessels in beating heart approachesAscending aortic diameter >35 mm and significant aortoiliac atherosclerosis in on-pump arrested heart approachesEffects of Reduced Surgical TraumaAll versions of robotically assisted CABG can lead to a dramatically foreshortened recovery period compared with sternotomy-based CABG. Derose et al,12 in their series on robotically assisted CABG through minithoracotomy, report that 82% of patients returned to normal activities within 10 days postoperatively. Kon and colleagues16 reported a time of 1.8 months for return to all activities for patients undergoing robotically assisted CABG through minithoracotomy. For patients after sternotomy off-pump CABG, this time was 4.4 months. Bonaros et al42 compared Short Form-36 scores for patients after AHTECAB versus patients after conversion to sternotomy and primary sternotomy. At 1 month postoperatively, scores for general health were higher after TECAB. At 3 months, scores for physical function, role of physical function, and bodily pain were significantly better in the patients who had undergone TECAB. In the same study, patients after TECAB resumed outdoor hiking or biking activities within 1 month postoperatively, whereas these activities were resumed ≈2 months after sternotomy.Intermediate and Long-Term ResultsFew articles provide intermediate- and long-term follow-up data. In their 2007 multicenter study on early TECAB experience, de Canniere et al25 report 91.2% freedom from major adverse cardiac and cerebral events at 6 months in AHTECAB pat
Referência(s)