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Objectives: Postoperative atrial fibrillation (AFib) is common in patients undergoing coronary artery bypass grafting. Little information is available concerning AFib following minimally invasive cardiac surgery. The aim of our study was to assess the incidence of AFib after totally endoscopic coronary artery bypass (TECAB) grafting and to investigate the factors influencing its occurrence., Methods: Between 2001 and 2010, we performed TECAB in 384 patients, 73% male, aged 60 (37-90) years. Single-vessel bypasses were performed in 280 patients, and 104 received multivessel coronary revascularization. Procedures were performed on the beating heart in 80 cases, and 164 patients underwent a hybrid intervention., Results: A total of 59 patients (15.4%) developed AFib after TECAB. Univariate analysis showed hypertension (P=0.005), increased age (P=0.007), body weight (P=0.006), body mass index (P=0.005), EuroSCORE (P=0.035) and total TECAB operation time (P=0.01) to be significantly associated with AFib. We also found an increased incidence of AFib in patients undergoing hybrid interventions (P=0.036) and beating heart TECAB (P=0.003). Age (P<0.001) and higher body weight (P=0.003) were the only predictors found to be significant in multivariate analysis. Hospital mortality was 1.7% (1 of 59) in the group of patients with AFib and 0.6% (2 of 325) in the group that showed no AFib after operation (P=n.s.). Hospital stay was 7 (4-54) days in patients with AFib and 6 (2-33) days in those without AFib (P=n.s.). There was no significant 5-year survival difference in patients with and without postoperative AFib (94 vs 94%, P=n.s.)., Conclusions: We conclude that the incidence of postoperative AFib in TECAB is relatively low. Age and body weight are the most important predictors of postoperative AFib following TECAB. Short-term clinical outcome and intermediate-term survival are similar in patients with and without postoperative AFib.

Background: According to several studies, women are at higher risk for mortality and experience less relief of angina after coronary artery bypass graft surgery (CABG) than men. Sex-related differences in patients undergoing totally endoscopic coronary bypass grafting (TECABG) have not been investigated thus far. The aim of the present study was to evaluate the impact of sex on the outcome of patients undergoing TECABG., Methods: The data of 500 consecutive patients (364 male, 136 female) undergoing TECABG using the da Vinci telemanipulation system (Intuitive Surgical, Sunnyvale, CA) from 2001 to 2011 at two institutions were investigated regarding sex-related differences in short-term and long-term outcome., Results: In all, 334 single, 150 double, 15 triple, and 1 quadruple TECABG procedures were carried out. Female patients were significantly older (63 years [range, 26 to 90] versus 59 years [range, 31 to 85], p = 0.001) and had higher European System for Cardiac Operative Risk Evaluation score levels (3 [range, 0 to 11] versus 2 [range, 0 to 13], p < 0.001). Male patients received slightly more grafts (1 [range, 1 to 4] versus 1 [range, 1 to 3], p = 0.028), female patients were more likely to undergo beating heart surgery (20% versus 28%, p = 0.042). In-hospital mortality was 3 of 364 men (0.8%) and 2 of 136 women (1.5%; p = 0.513). Comparison of long-term-survival revealed 1-, 3- and 5-year survival rates of 96%, 96%, and 95% in men and 96%, 96%, and 96% in women, respectively, without any significant difference. Analysis of freedom from major adverse cardiac and cerebrovascular events revealed 1-, 3-, and 5-year rates of 86%, 84%, and 82% in men and 85%, 81%, and 81% in women, respectively, without any significant difference., Conclusions: Our data show that women undergoing TECABG have outcomes similar to those of men., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Hybrid coronary revascularization (HCR) is a treatment strategy for the revascularization of multivessel coronary disease that combines the advantages of both minimally invasive surgical techniques and percutaneous coronary intervention (PCI). The optimal sequence by which revascularization should be accomplished has not been determined. We investigated clinical outcomes in a series of patients planned for HCR via robotically assisted totally endoscopic coronary artery bypass (TECAB) and standard PCI based on revascularization sequence., Methods: A total of 238 patients planned for HCR between 2001 and 2011 were divided into three groups based on treatment sequence: (a) TECAB before PCI, (b) PCI before TECAB, and (c) same-session procedure. Multiple procedural and clinical end points before discharge and up to 2 years after the procedure were compared between the three groups in an intention-to-treat analysis. Demographic features were reviewed to determine baseline differences between each group., Results: Of the 238 patients, 175 (73.5%) underwent TECAB before PCI, 38 patients (16.0%) underwent PCI before TECAB, and 25 (10.5%) underwent a simultaneous revascularization procedure. At baseline, the patients undergoing TECAB before PCI were significantly older. There was a significantly higher incidence of previous myocardial infarction in the PCI-first group (P < 0.001). There was a significant difference in intensive care unit (ICU) length of stay (LOS), with shorter ICU stays in the simultaneous revascularization group (P = 0.031) and shorter hospital LOS in the PCI before TECAB group (P = 0.021)., Conclusions: In conclusion, revascularization sequence did not dramatically impact clinical outcomes in our observational study. The patients undergoing PCI-first and same-session interventions had shorter hospital and ICU LOS compared with the patients undergoing surgery first. Our findings suggest that no revascularization approach is arbitrarily superior and that revascularization sequence should be individualized on the basis of patient presentation and anatomical considerations.

Background: Robotic technology has enabled totally endoscopic coronary artery bypass (TECAB) grafting. Little information is available on factors associated with successful and safe performance of TECAB. We report a 10-year multicenter experience with 500 cases, elucidating on predictors of success and safety in TECAB procedures., Methods: Between 2001 and 2011, 500 patients (364 [73%] men; 136 [27%] women; median age [minimum-maximum] 60 years [31-90 years], median EuroSCORE 2 [0-13]), underwent TECAB. Single, double, triple, and quadruple TECAB was performed in 334, 150, 15, and 1 patient, respectively. Univariate analysis and binary regression models were used to identify predictors of success and safety. Success was defined as freedom from any adverse event and conversion procedure, safety was defined as freedom from major adverse cardiac and cerebral events, major vascular injury, and long-term ventilation., Results: Success and safety rates were 80% (400 cases) and 95% (474 cases), respectively. Intraoperative conversions to larger thoracic incisions were required in 49 (10%) patients. The median operative time was 305 minutes (112-1,050 minutes), and the mean lengths of stay in the intensive unit (ICU) and in hospital were 23 hours (11-1,048 hours) and 6 days (2-4 days), respectively. Independent predictors of success were single-vessel TECAB (p = 0.004), arrested-heart (AH)-TECAB (p = 0.027), non-learning curve case (p = 0.049), and transthoracic assistance (p = 0.035). The only independent predictor of safety was EuroSCORE (p = 0.002)., Conclusions: Single-vessel and multivessel TECAB procedures can be safely performed with good reproducible results. Predictors of success include procedure simplicity and non-learning curve cases, whereas predictors of safety are mainly associated with patient selection., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Robotic totally endoscopic coronary artery bypass grafting (TECAB) is an evolving minimally invasive technology with the potential to reduce hospital length of stay (LOS). Little is known about the factors that influence LOS after this procedure. The aim of this study is to define the preoperative, intraoperative, and postoperative variables that predict LOS after TECAB., Methods: From 2001 to 2011, 541 patients, aged 60 years (range, 26 to 90 years), 394 (72.8%) male, 147 (27.1%) female, underwent TECAB using the daVinci telemanipulation system at one European and one American institution. Three hundred forty-six (63.9%) single-, 171 (31.6%) double-, 23 (4.2%) triple-, and 1 (0.2%) quadruple-vessel TECABs were carried out with an overall LOS of 6 days (range, 2 to 54 days) and 30-day mortality of 0.9% (5 of 541); 44.5% of patients (241 of 541) were hybrid intent-to-treat candidates., Results: The following variables showed significant positive correlation with LOS: age, r = 0.188 (p < 0.001); Society of Thoracic Surgeons risk score, r = 0.263 (p < 0.001); EuroSCORE, r = 0.191 (p < 0.001); creatinine, r = 0.135 (p = 0.002); and operative time, r = 0.216 (p < 0.001). Other factors that had significant influence on LOS were hemodialysis (p = 0.037), cerebrovascular disease (p = 0.002), learning curve case (p < 0.001), intraoperative surgical problem (p < 0.001), conversion or on-table revision (p < 0.001), revision for bleeding (p < 0.001), postoperative stroke (p < 0.001), intraaortic balloon pump (p < 0.001), hemodialysis (p < 0.001), and atrial fibrillation (p < 0.001). By multivariate analysis, learning curve case, conversion or on-table revision, and revision for bleeding were independent predictors for prolonged LOS (defined as LOS > 6 days)., Conclusions: Multiple variables affect LOS after TECAB. Older patients, patients on hemodialysis, patients with cerebrovascular disease, and those with higher general risk scores should expect prolonged LOS. Intraoperative surgical difficulties and conversion to open coronary artery bypass grafting also lead to extended LOS. Postoperative events that are known to prolong LOS in open coronary artery bypass grafting also prolong LOS after TECAB., (Copyright © 2013 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Hybrid coronary revascularization combines minimally invasive coronary artery bypass grafting and catheter-based interventions. This treatment option represents a viable alternative to both open multivessel coronary bypass surgery through sternotomy and multivessel percutaneous coronary intervention. The surgical component of hybrid coronary intervention can be offered in a completely endoscopic fashion using robotic technology. We report on one of the largest series to date., Methods: From 2001 to 2011, 226 patients (age, 61 years [range, 31 to 90 years]; 77.0% male; EuroSCORE, 2 [range, 0 to 13]) underwent hybrid coronary interventions on an intention-to-treat basis. Robotically assisted procedures were performed using the daVinci, daVinci S, and daVinci Si surgical telemanipulation systems (Intuitive Surgical, Inc, Sunnyvale, CA) and included 147 single, 72 double, and 7 triple endoscopic coronary artery bypass grafting procedures. Surgery was carried out first in 160 cases (70.8%), percutaneous coronary intervention was carried out first in 38 cases (16.8%), and 28 patients underwent simultaneous operations in a hybrid operating room (12.4%). Drug-eluting stents were used in 70.0% of the patients., Results: Hospital mortality was 3 of 226 patients (1.3%), and hospital stay averaged 6 days (range, 3 to 54 days). Patients walked outside 7 days (range, 3 to 97 days) postoperatively and performed general household work 14 days (range, 7 to 180 days) postoperatively. Full activity was resumed at 42 days (range, 7 to 720 days). Five-year survival was 92.9%, and 5-year freedom from major adverse cardiac and cerebral events was 75.2%. At 5 years, 2.7% of bypass grafts and 14.2% of percutaneous coronary intervention targets needed reintervention., Conclusions: Robotically assisted hybrid coronary intervention enables surgical treatment of multivessel coronary artery disease with minimal trauma. Perioperative results and intermediate-term outcomes meet the standards of open coronary artery bypass grafting. Recovery time is short, and reintervention rates are acceptable., (Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Postoperative cognitive decline is a common complication after coronary artery bypass graft surgery. As robotically assisted totally endoscopic coronary artery bypass grafting (TECAB) has shown several positive impacts on recovery and quality of life, the aim of this study was to assess psychomotor functioning relevant for car-driving abilities before and after this intervention., Methods: A total of 20 patients who underwent TECAB completed a neuropsychological test battery including conventional and computerized assessments [Trail Making Test (TMT A + B), Leeds Psychomotor Tester (LPT), Test System for Attentional Performance (TAP 2.1)] before surgery (T0) and 1 week (T1) and 3 months (T2) after surgery., Results: Data show no significant cognitive decline between T0, T1, and T2 following TECAB. Significant improvements were measured from T0 to T2 for psychomotoric function and visual attention (TMT A; p = 0.038) and for reaction time, which was significantly shorter after 3 months in comparison with T0 and T1; p = 0.001)., Conclusion: Data of our preliminary study show no relevant cognitive decline caused from TECAB and therefore do not contradict the practice of early car driving after this procedure., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: Robotically assisted totally endoscopic coronary artery bypass grafting (TECAB) is a viable option for closed chest coronary surgery, but it requires learning curves and longer operative times. This study evaluated the effect of extended operation times on the outcome of patients undergoing TECAB., Methods: From 2001 to 2009, 325 patients underwent TECAB with the da Vinci telemanipulation system. Correlations between operative times and preoperative, intraoperative, and early postoperative parameters were investigated. Receiver operating characteristic analysis was used to define the threshold of the procedure duration above which intensive care unit stay and ventilation time were prolonged. Demographic data, intraoperative and postoperative parameters, and survival data were compared., Results: Patients with prolonged operative times more often underwent multivessel revascularization (P < .001) and beating-heart TECAB (P =.023). Other preoperative parameters were not associated with longer operative times. Incidences of technical difficulties and conversions (P < .001) were higher among patients with longer operative times. Prolonged intensive care unit stay, mechanical ventilation, hospital stay, and with requirement of blood products were associated with longer operative times. Receiver operating characteristic analysis showed operative times >445 minutes and >478 minutes to predict prolonged (>48 hours) intensive care unit stay and mechanical ventilation, respectively. Patients with procedures >478 minutes had longer hospital stays and higher perioperative morbidity and mortality. Kaplan-Meier analysis revealed decreased survival among patients with operative times >478 minutes., Conclusions: Multivessel revascularization and conversions lead to prolonged operative times in totally endoscopic coronary artery bypass grafting. Longer operative times significantly influence early postoperative and midterm outcomes., (Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Closed-chest totally endoscopic coronary artery bypass grafting (TECAB) is feasible using robotic technology. During the early phases, TECAB was restricted to single bypass grafts to the left anterior descending artery system. Because most patients referred for coronary artery bypass surgery have multivessel disease, development of endoscopic multiple bypass grafting is mandatory. Experimental work on multivessel TECAB was carried out in the early 2000s, and first clinical cases were already performed. With further technological development of operating robots, double, triple, and quadruple TECAB has become feasible both on the arrested heart and on the beating heart. To date, 161 cases of multivessel TECAB using the da Vinci telemanipulation systems are published in the literature. The main advances enabling multivessel TECAB were the availability of a robotic endostabilizer for beating heart procedures and increased surgeon skills using remote access heart-lung machine perfusion and endo-cardioplegia. Both internal mammary arteries can be harvested and both radial artery and vein graft can be used in multivessel TECAB. Y-grafting and sequential grafting are feasible. Multivessel endoscopic surgical revascularization can be combined with percutaneous coronary interventions in advanced hybrid coronary revascularization. Time requirements for multivessel TECAB are significant, and conversion rates to larger thoracic incisions are higher than those observed for single-vessel TECAB. Clinical short- and long-term outcomes, however, seem to meet the standards of open coronary bypass surgery through sternotomy. The main advantages of multivessel TECAB are a completely preserved sternum, use of double internal mammary artery even in risk groups, and a remarkably short recovery time.

Background: Totally endoscopic coronary artery bypass graft surgery (TECAB), using the da Vinci telemanipulator, has become a reproducible operation at dedicated centers. As in every endoscopic operation, conversion is an important and probably inevitable issue., Methods: We performed robotic TECAB in 326 patients (age, 60 years; range, 31 to 90 years); 242 were single-vessel and 84 were multivessel TECAB., Results: Forty-six of 326 patients (14%) were converted to a larger incision (minithoracotomy, n = 5; sternotomy, n = 41). Left internal mammary artery injury (n = 7), epicardial injury (n = 4), balloon endoocclusion problems (n = 7), and anastomotic problems (n = 18) were common reasons for conversions. Conversion rate was significantly less for single-vessel versus multivessel TECABs (10% versus 25%; p = 0.001). Non-learning-curve case (7% versus 21%; p < 0.001) and transthoracic assistance (11% versus 22%; p = 0.018) were associated with lower conversion rates. In multivariate analysis, learning-curve case was the only independent predictor of conversion (p = 0.005). Conversion translated into increased packed red blood cell transfusion in the operating room (3 versus 0 units; p < 0.001), longer ventilation time (14 versus 8 hours; p < 0.001), and intensive care unit stay (45 versus 20 hours; p = 0.001). Hospital mortality was 0.6% in this series, with 1 patient in the conversion group (2.2%) and 1 patient in the nonconverted group (0.4%; not significant). Five-year survival was 98% in nonconverted patients and 88% in converted patients (p = 0.018). There was no difference in freedom from angina or freedom from major adverse cardiac and cerebral events., Conclusions: Conversion in TECAB is primarily learning curve-dependent and associated with increased morbidity, but does not significantly affect hospital mortality. Both nonconverted and converted patients show good long-term survival, which is comparable to patients undergoing open sternotomy coronary artery bypass grafting. Long-term freedom from angina or freedom from major adverse cardiac and cerebral events is not influenced by conversion., (Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Objective: Robotic technology enables totally endoscopic coronary artery bypass grafting (TECAB) procedures. These operations can be performed on either the beating or arrested heart. One challenge of the latter version is a potentially increased need for blood transfusions. We investigated factors associated with transfusion requirements in totally endoscopic coronary artery bypass on the arrested heart (AH-TECAB)., Patients and Methods: A total of 161 patients, 124 males and 37 females, aged 59 (31-77 years) years, with European System for Cardiac Operative Risk Evaluation (EuroSCORE) 1 (0-7) underwent AH-TECAB using the daVinci telemanipulation system. The Heartport/Cardiovations™ or ESTECH-RAP™ systems were applied for remote access perfusion and aortic endoocclusion. In all cases, the operation was carried out in moderate hypothermia and cardiac arrest using cold crystalloid cardioplegia mixed with blood., Results: After 20 cases, the blood-transfusion rate dropped from 69% to 44%. The overall median number of transfusions was 1 (0-21). The following pre- and intra-operative factors showed a strong association with the application of packed red blood cells (PRBCs): preoperative haemoglobin level (p < 0.001), female gender (p < 0.001), shorter height (p < 0.001), lower weight (p < 0.001), long operative time (p < 0.001) and long cardiopulmonary bypass time (p = 0.001), intra-operative surgical problem (p < 0.001) and conversion to a larger thoracic incision (p < 0.001). Postoperatively, patients with longer ventilation time (p < 0.001) and those needing revision for bleeding (p < 0.001) also received significantly more PRBCs., Conclusion: We conclude that multiple factors are associated with increased blood transfusion requirements in AH-TECAB. However, the transfusion rate can be reduced with experience. Identification of these factors may help in avoiding the application of blood products in the next generation of AH-TECAB procedures., (Copyright © 2010. Published by Elsevier B.V.)

Totally endoscopic coronary artery bypass grafting (CABG) has become a feasible option using robotic technology and remote access perfusion techniques. The aim of this study was to determine the progression of the procedure's performance in the currently largest single-center series of arrested-heart totally endoscopic CABG. From 2001 to 2007, arrested-heart totally endoscopic CABG was performed in 100 patients (median age 59 years, range 46 to 70; 81 men, 19 women). All patients received left internal mammary artery grafts to the left anterior descending artery using the da Vinci Surgical System. Remote-access femoral perfusion and aortic balloon endo-occlusion were used in all patients. The series was divided into 4 phases: phase 1 (patients 1 to 25), phase 2 (patients 26 to 50), phase 3 (patients 51 to 75), and phase 4 (patients 76 to 100). The conversion rates to larger thoracic incisions were 7 of 25 (28%) in phase 1, 2 of 25 (8%) in phase 2, 1 of 25 (4%) in phase 3, and 1 of 25 (4%) in phase 4 (p = 0.018). Operative times and hospital stays decreased significantly with each subsequent phase, and clinical outcome showed corresponding improvements. There was no perioperative mortality. For the whole patient series, 5-year postoperative survival, freedom from angina, and freedom from major adverse cardiac and cerebral events were 100%, 91%, and 89%, respectively. In conclusion, after an initial steep learning curve, completely endoscopic left internal mammary artery-to-left anterior descending CABG can be performed safely, with low conversion rates. The learning curve for operative times and improvements in clinical outcome continued even at 100 procedures.

Background: Robotic totally endoscopic coronary bypass (TECAB) surgery was developed during the past decade, and younger surgeons need to be trained in this new modality. This study assessed the learning curves and independent TECAB performance of 2 junior surgeons undergoing TECAB training., Methods: Two surgeons in training performed portions of 44 of 239 robotic TECAB operations, including left (LIMA) and right interior mammary artery (RIMA) harvesting, lipectomy, pericardiotomy, and IMA to left anterior descending coronary artery (LAD) anastomotic suturing., Results: The procedure portions performed faster by the senior surgeon vs trainees were, in minutes (range), lipectomy, 5 (2 to 18) vs 10 (5 to 21; p < 0.001); pericardiotomy, 5 (1 to 21) vs 7 (3 to 16; p = 0.001); RIMA takedown, 35 (25 to 48) vs 49 (40 to 55; p = 0.034); and LIMA to LAD anastomosis, 26 (12 to 100) vs 34 (24 to 67; p = 0.043). After assuming senior roles in the robotic cardiac surgery program, the 2 trained surgeons performed 14 TECABs (LIMA to LAD) without the senior surgeon. Lipectomy took 5 (3 to 8) minutes; pericardiotomy, 5 (2 to 10) minutes; LIMA takedown, 43 (27 to 70) minutes; LIMA to LAD anastomosis, 24 (15 to 60) minutes, cardiopulmonary bypass time, 73 (40 to 126) minutes; and aortic endo-occlusion time, 53 (0 to 83) minutes. No hospital deaths occurred., Conclusions: TECAB can be well taught with a stepwise training program involving portions of the procedure performed by trainees. With such an approach, independent performance after training can be within adequate time limits and yields seemingly acceptable results.

We describe 2 cases of successful conversion from beating-heart (BH) to arrested-heart (AH) totally endoscopic coronary artery bypass surgery (TECAB). The preoperative computed tomographic (CT) scan of the first patient showed significant artherosclerosis of the femoral vessels in both groins. Therefore we tried to avoid inguinal cannulation by performing an off-pump BH-TECAB. But the target vessel was strongly fissured, and bleedings from the surrounding tissue made anastomotic suturing impossible. Therefore we cannulated the groin cautiously and endoclamped the aorta. The preoperative CT scan of the second patient showed a soft plaque in the ascending aorta. Therefore we tried to perform an on-pump BH-TECAB to avoid clamping of the aorta. Even though we snared the target vessel, significant backbbleeding occurred. Therefore we performed endoclamping of the aorta distal to the aortic plaque. In both cases the following AH-TECAB procedure was performed successfully without any problems.

We report 2 cases of minimal invasive revision for postoperative bleeding following totally endoscopic coronary surgery (TECAB). In the first case the revision was performed totally endoscopically without additional incisions. In the second patient revision was performed via enlargement of the camera port to a minithoracotomy. Both revisions were successfully conducted without sternotomy. We demonstrated that the technique of minimal invasive revision can further reduce the rate of conversion to sternotomy in TECAB operations.

Objectives: Coronary artery bypass grafting (CABG) is associated with long rehabilitation periods and slow quality of life (QOL) improvement. Totally endoscopic coronary artery bypass grafting (TECAB) can be performed using robotic technology and remote access perfusion. The aim of this study was to evaluate whether TECAB leads to accelerated QOL improvement as compared to standard CABG., Methods: We included 120 patients who had received robotically assisted CABG, 56 of whom were operated on using standard sternotomy. These patients were compared to 55 patients who underwent the TECAB procedure and to 9 TECAB patients who required conversion to conventional sternotomy. QOL evaluation was performed before the operation and 1, 3 and 6 months after the procedure using the SF-36 health survey and a standardized questionnaire., Results: All quality of life aspects improved significantly in all study patients. At 3 months, TECAB patients showed significantly better QOL scores related to bodily pain and physical health. Hospital stay and time to restoration of daily activities were significantly shorter. Converted patients experienced similar courses to sternotomy patients in terms of QOL., Conclusions: TECAB using robotic technology leads to improved physical health, shorter hospital stay and a more rapid restoration of daily activities. Conversion from TECAB to sternotomy does not lead to QOL impairment as compared to primary sternotomy., (Copyright 2009 S. Karger AG, Basel.)

Background: We investigated whether specific surgical measures during the learning curve can influence procedural performance in robotic totally endoscopic coronary artery bypass grafting (TECAB)., Methods: From 2001 to 2006, 70 patients underwent TECAB using the da Vinci telemanipulation system (Intuitive Surgical, Sunnyvale, CA). The following measures were employed with the intent to improve procedure performance: (1) introduction of a fixed team of surgeons at case 14; (2) application of fibrin glue to seal the anastomosis at case 28; and (3) use of a fourth port for transthoracic assistance at case 49., Results: All 3 measures resulted in a reduction of operating room (OR) time (27%, 20%, and 20%). Use of a stable OR team and peri-anastomotic fibrin glue reduced the rate of conversions and on-table revisions from 39% to 9% (P = .006) and from 26% to 7% (P = .038), respectively. Peri-anastomotic fibrin glue significantly reduced postoperative revisions for bleeding. Using transthoracic assistance, anastomotic time was shortened from 35 minutes (range 23-67) to 25 minutes (range 16-100) (P < .001)., Conclusion: The 3 measures can improve intraoperative and clinical results in TECAB.

Objective: Robotic totally endoscopic coronary artery bypass grafting enables coronary artery bypass grafting without sternotomy or thoracotomy. However, longer cardiopulmonary bypass and aortic endo-occlusion times are currently required compared with those of standard coronary artery bypass grafting operations. We investigated whether longer operation times affect the myocardial enzyme release and the postoperative course., Methods: From 2001 through 2006, 85 patients with a median age of 58 years (range, 31-76 years) underwent totally endoscopic coronary artery bypass grafting on the arrested heart by using the da Vinci telemanipulator and remote access perfusion through the femoral vessels (Estech or Heartport). The operations involved the left internal thoracic artery-left anterior descending coronary artery or diagonal branch (n = 74); right internal thoracic artery-right coronary artery (n = 2); double-vessel left internal thoracic artery-obtuse marginal branch/circumflex artery and right internal thoracic artery-left anterior descending coronary artery (n = 8); and double-vessel left internal thoracic artery-left anterior descending coronary artery and saphenous vein graft-right coronary artery (n = 1). Totally endoscopic coronary artery bypass grafting duration was 254 minutes (range, 178-710 minutes), cardiopulmonary bypass time was 114 minutes (range, 57-428 minutes), and aortic endo-occlusion time was 65 minutes (range, 28-230 minutes)., Results: The postoperative ventilation time was 8 hours (range, 0-278 hours), and the intensive care unit stay was 20 hours (range, 11-389 hours). The postoperative stay at our department was 6 days (range, 4-22 days), and we observed no hospital deaths in this series. Forty-five percent of the patients had an increased postoperative peak creatine kinase MB level, and 75% had an increased troponin T level. Postoperative peak creatine kinase MB levels significantly increased with totally endoscopic coronary artery bypass grafting duration (r = 0.588, P < .001), cardiopulmonary bypass time (r = 0.521, P < .001), and aortic endo-occlusion time (r = 0.400, P < .001) and translated into moderately prolonged intensive care unit stay (r = 0.432, P < .001) and ventilation time (r = 0.517, P < .001). Creatine kinase MB levels were not associated with sex, age, or EuroSCORE. The postoperative left ventricular ejection fraction did not differ significantly from the preoperative left ventricular ejection fraction., Conclusions: Myocardial protection can be established in arrested heart totally endoscopic coronary artery bypass grafting operations. An influence of increased myocardial enzyme release on postoperative ventilation time and intensive care unit stay is detectable but does not translate into an early mortality or a decrease in left ventricular ejection fraction.

Background: Robotically assisted totally endoscopic coronary artery bypass graft surgery (TECABG) is an innovative minimally invasive procedure requiring proof of immediate- and short-term patency of grafts to compete with conventional bypass surgery or percutaneous coronary interventions. The purpose of this study was to evaluate the combination of invasive and noninvasive coronary angiography methods in innovative cardiac surgery as an approach to optimal quality control., Methods: In 86 patients after robotic coronary surgery (62 arrested-heart TECABG, 20 through sternotomy with robotically assisted anastomoses, 4 beating-heart TECABG), intraoperative coronary angiography was performed with a mobile C-arm. All patients underwent multislice computed tomography angiography, and invasive coronary angiography was performed in 48 patients within 3 months after surgery., Results: Bypass grafts could be visualized by intraoperative angiography in 84 patients (98%). Spasm of target vessels or bypass grafts, or both (reversible after intraluminal nitroglycerine application), was observed in 47%. In 9 patients, surgical revisions were performed owing to inadequate revascularization results. No angiography-related complications occurred. The sensitivity and specificity of multislice computed tomography for the evaluation of graft patency were 100% and 97%, respectively. The visualization of distal anastomoses and distal target vessels was good in 90% but limited in 10% because of artifacts, limited spatial resolution, and high image noise., Conclusions: The combination of intraoperative angiography and postoperative multislice computed tomography allows safe and high-quality evaluation of immediate- and short-term outcome in innovative robotic coronary surgery. Immediate revisions of bypass grafts are possible, to ensure that all patients leave the operating room with patent bypass grafts.

Background: The development of robotic devices has recently offered the possibility of performing coronary artery bypass graft surgery (CABG) in a totally endoscopic way. An important step of this procedure is endoscopic harvesting of the left internal mammary artery (LIMA). It was the aim of our study to find factors influencing LIMA harvesting time and to describe the challenges associated with robotic endoscopic LIMA harvesting., Methods: From June 2001 to December 2005, a total of 100 patients underwent robotically assisted CABG. In all cases, the LIMA was harvested by using the robotic DaVinci device. Coronary artery bypass grafting procedures were completed through sternotomy, minithoracotomy, or in a totally endoscopic fashion., Results: The median LIMA harvesting time was 48 minutes (19 to 180). A significant learning curve was observed: y (min) = 151 - 26 x ln (x), x = LIMA takedown number, p less than 0.001. Takedown time decreased from 140 minutes in the first 10 cases to 34 minutes in the last 10 cases. There was no independent demographic factor that significantly influenced the LIMA harvesting time. The LIMA takedown time also showed no significant correlation with thorax dimensions. Injury to the LIMA occurred in 3 patients (6%) during the first half of the experience and in 1 patient (2%) during the second half (p = not significant)., Conclusions: Robotic-enhanced LIMA takedown is a prerequisite for totally endoscopic CABG. After passing through a significant learning curve, IMA takedown can be performed safely and within an acceptable time frame. Demography and chest size do not seem to influence IMA harvesting time. The rate of LIMA injuries is within the limits of conventional thoracoscopic harvesting.

Background: After the introduction of robotic technology into the heart surgery armamentarium the performance of totally endoscopic coronary artery bypass grafting (TECAB) has become a reality. During the first years of development, the majority of TECAB cases were restricted to single-vessel disease, and the development of multivessel procedures is desirable. We report on a preliminary series of totally endoscopic double-vessel coronary artery bypass grafting., Methods: From 2004 to 2006, 10 patients underwent endoscopic placement of the right internal mammary artery (RIMA) to the left anterior descending artery (LAD) in combination with left internal mammary artery (LIMA) grafting to an obtuse marginal (OM) branch. Indications for the operation were isolated left main disease or left main equivalents. All procedures were performed using the daVinci telemanipulation system, remote-access perfusion, and aortic balloon endo-occlusion., Results: Seven of the 10 interventions were completed endoscopically, and 3 patients were converted to sternotomy. RIMA takedown time was 40 minutes (range, 29-49 minutes); LIMA takedown time was 38 minutes (range, 29-48 minutes). LAD and OM anastomotic times were 23 minutes (range, 14-53 minutes) and 38 minutes (range, 29-48 minutes), respectively. Total TECAB time was 477 minutes (range, 385-545 minutes). Median ventilation time was 15 hours (range, 6-40 hours), median intensive care unit stay was 41 hours (range, 15-141 hours), and patients were discharged after a median of 7 days (range, 5-22 days). No major adverse cardiac or cerebrovascular events occurred during short-term follow-up., Conclusion: Totally endoscopic double-vessel coronary artery bypass grafting on the arrested heart is a reproducible procedure. This intervention offers maximal preservation of patient integrity, but the long operative times need to be investigated.

Background: Remote access perfusion and robotics have enabled totally endoscopic closure of atrial septal defect and patent foramen ovale. The aim of this study was to address learning curve issues of totally endoscopic atrial septal defect repair on the basis of a single-center experience and to investigate whether long cardiopulmonary bypass and aortic occlusion times influence intraoperative and postoperative outcomes., Methods: Seventeen patients (median age, 35 years; range, 16 to 55 years) underwent totally endoscopic atrial septal defect repair using remote access perfusion and robotic technology (da Vinci telemanipulation system). Learning curves were assessed by means of regression analysis with logarithmic curve fit. The effect of operative variables on clinical outcome was analyzed by linear regression using the Spearman's rho coefficient., Results: No operative mortality or serious surgical complications were observed. No residual shunt was detected at intraoperative or postoperative echocardiography. Significant learning curves were noted for total operative time: y(min) = 406 - 49 ln(x) (r2 = 0.725; p = 0.002); cardiopulmonary bypass time: y(min) = 225 - 42 ln(x) (r2 = 0.699; p = 0.003); and aortic occlusion time: y(min) = 117 - 25 ln(x) (r2 = 0.517; p = 0.04), x = number of procedures. Median ventilation time, intensive care unit stay, and hospital length of stay were 7 hours (range, 2 to 19 hours), 26 hours (range, 15 to 120 hours), and 8 days (range, 5 to 14 days), respectively. No correlation was detected between cardiopulmonary bypass time and intubation time (r2 = 0.283; p = 0.326), intensive care unit stay (r2 = -0.138; p = 0.639), or total length of stay (r2 = 0.013; p = 0.962)., Conclusions: Totally endoscopic atrial septal defect repair can be performed safely, and learning curves for operative times are steep. Longer cardiopulmonary bypass times had no negative impact on intraoperative and postoperative outcome.

A 56-year-old male patient underwent robotically assisted totally endoscopic left internal mammary artery (LIMA) to left anterior descending artery (LAD) grafting. After protamine administration complete heart block developed in the patient. On intraoperative angiography the LIMA to LAD graft was perfectly patent but an acute occlusion of the right coronary artery (RCA) was noted. We performed an immediate on table percutaneous coronary angioplasty and stent placement to the RCA. The heart regained sinus rhythm and the wall motion abnormalities on the back wall of the heart resolved. No clinical symptoms indicating ongoing myocardial ischemia were noted postoperatively. This case demonstrates that a hybrid procedure of robotic totally endoscopic coronary artery bypass grafting and catheter based coronary intervention is feasible in one simultaneous session.

Background: Remote-access perfusion and robotics have enabled totally endoscopic closure of atrial septal defect (ASD) and patent foramen ovale (PFO). We report on a stepwise approach to a totally endoscopic procedure., Methods: Seventeen patients (median age, 39 years; range, 21-55 years) underwent limited-access ASD or PFO closure. As a preparative step, the operation was carried out through minithoracotomy in 11 patients. In parallel, experience with robotic surgery was gained with totally endoscopic coronary artery bypass grafting procedures. After performance of ASD closures in dry-laboratory models using the da Vinci telemanipulation system, 6 patients were operated on in a totally endoscopic fashion., Results: With the endoscopic approach, significant learning curves were noted for cardiopulmonary bypass time y(min) = 226 - 41 * ln(x) (P = .03) and aortic cross-clamp time y(min) = 134 - 42 * ln(x) (P = .01) (x = number of procedures). There was no hospital mortality, and no residual shunts were detected at postoperative echocardiography. Median ventilation time was 9 hours (range, 0-18 hours) for the minithoracotomy group and 6 hours (range, 4-19 hours) for the totally endoscopic group. Median intensive care unit stay was 20 hours (range, 18-24 hours) and 18 hours (range, 18- 120 hours), respectively., Conclusions: The implementation of robotic totally endoscopic closure of ASD or PFO in a heart surgery program seems to be safe. An intermediate step of performing the operations through minithoracotomy, adapting to remote access perfusion systems, and gaining experience in other robotic cardiac surgical procedures seems worthwhile. Learning curves are apparent, and adequate defect closure does not seem to be compromised by the totally endoscopic approach.

OBJECTIVES Conventional hybrid revascularization (CHR) combines minimally invasive placement of an internal mammary artery graft to the anterior wall and percutaneous coronary intervention (PCI) of non-anterior wall targets. In this study we assess perioperative and midterm outcomes of advanced hybrid revascularization (AHR) defined as the combination of single or multivessel (MV) totally endoscopic coronary artery bypass grafting (TECAB) with single or multivessel PCI. METHODS In total, 90 AHR patients [median age 62 years (35–86)] were compared with 90 CHR patients [median age 60 years (35–85)] in terms of perioperative and mid-term outcomes. The outcomes of the three different AHR options (MV-TECAB + PCI, MV-PCI + TECAB, MV-TECAB + MV-PCI) as well as the sequence of the interventions were further compared. Risk factors for major adverse cardiac and cerebral events (MACCEs) related to the hybrid revascularization strategy were calculated. RESULTS No perioperative deaths occurred either in the AHR group or in the CHR group, rates of myocardial infarction (3.3% vs 3.3%, P = 0.196) were similar between CHR and AHR. Operative times were longer in the AHR group [337 (137–794) min vs 272 (148–550) min, P = 0.002] and conversion rates slightly higher (P = 0.060); however, intensive care unit length of stay (P = 0.162) and hospital length of stay (P = 0.238) were similar. There was no difference in the follow-up survival (P = 0.091), freedom from angina (P = 0.844), PCI target vessel revascularization (P = 0.563), TECAB target vessel revascularization (P = 0.135) and MACCEs (P = 0.601) between CHR and AHR at follow-up. No differences were detected between the three variations of AHR in perioperative outcome, mid-term survival, freedom from MACCEs and reintervention. Neither the number nor type of TECAB/PCI targets, nor the sequence of interventions were significant predictors for MACCEs at follow-up. CONCLUSIONS AHR yields comparable results with CHR and can be taken into consideration as a sternum-sparing technique for the treatment of MV-coronary artery disease in selected patients. [ABSTRACT FROM AUTHOR]