Totally endoscopic off-pump bilateral internal thoracic artery bypass grafting.

The introduction of robotic assistance has enabled totally endoscopic closed chest procedures, most often by left internal thoracic artery to left (LITA) anterior descending. Endoscopic stabilizers have made off-pump surgery feasible. We report the first case of a totally endoscopic off-pump bilateral ITA grafting in a 58-year-old patient.     

Total endoscopic off-pump coronary artery bypass grafting

Two cases of totally endoscopic off-pump coronary artery bypass grafting (TECAB) of the left internal thoracic artery to the left anterior descending artery using the da Vincitrade mark telemanipulation system (Intuitive Surgical, Mountain View, CA) are described. A new articulating endoscopic stabilizer with cleats was developed to enable endoscopic anchoring of silastic vessel loops for vascular occlusion. Newly created attachments for irrigation and suction, along with active robotic enhanced assistance by a second surgical console, permitted our group to perform for the first time a truly endoscopic bypass grafting without any thoracotomy.     

冠状动脉硬化性心脏病合并左锁骨下动脉严重狭窄非体外循环下同期手术的临床经验

目的探讨非体外循环冠状动脉旁路移植同时主动脉-锁骨下动脉旁路治疗冠状动脉硬化性心脏病(冠心病)合并锁骨下动脉重度狭窄的手术方法及效果.方法2003年1月～2004年5月,我院治疗须行冠状动脉旁路移植术同时合并左锁骨下动脉近端重度狭窄3例,术中先行主动脉-锁骨下动脉旁路,左乳内动脉获得满意的流量后,再行非体外循环冠状动脉旁路移植.结果手术时间210～340 min,平均283 min,出血量570～1 630 ml,平均963 ml.游离左乳内动脉后量杯测流量均＜5 ml/min,主动脉-锁骨下动脉旁路后量杯测流量均＞50 ml/min,乳内动脉远端与前降支吻合后流量仪测流量12～27 ml/min,平均20 ml/min.术后临床症状缓解,未发现冠脉-锁骨下动脉窃血综合征.3例随访3～6个月,平均5个月,无心绞痛发作.结论非体外循环冠状动脉旁路移植同时主动脉-锁骨下动脉旁路手术是治疗冠心病合并锁骨下动脉重度狭窄简单而有效的方法.     

Facilitated endoscopic beating heart coronary artery bypass grafting using a magnetic coupling device

BACKGROUND: Suturing of a coronary anastomosis in totally endoscopic coronary artery bypass grafting on the beating heart is technically demanding. The potential benefits of the endoscopic Magnetic Vascular Positioner device (Ventrica, Inc, Fremont, Calif) to facilitate construction of a coronary anastomosis in a closed chest environment were evaluated. METHODS: Totally endoscopic coronary artery bypass grafting on the beating heart was performed in 8 foxhound-beagle inbred dogs with the da Vinci telemanipulation system (Intuitive Surgical, Mountain View, Calif). A prototype of the endoscopic Magnetic Vascular Positioner device was used to facilitate construction of the coronary anastomosis. One pair of magnets was inserted in the internal thoracic artery and left anterior descending artery using robotic instruments to guide and place the endoscopic delivery platform. All animals underwent angiography; gross inspection of the anastomotic site was performed after excision of the hearts. RESULTS: The procedure was accomplished in all animals in 169 minutes (155-190 minutes). Dissection of the left anterior descending coronary artery (6.5 minutes; 1-20 minutes), positioning of the stabilizer (8.5 minutes; 7-16 minutes), placement of occlusion tapes (6 minutes, 3-10 minutes), and arteriotomy 5.5 minutes (3-30 minutes) was achieved without problems. By use of the Magnetic Vascular Positioner device, the anastomosis at the graft site was performed with the graft still in situ. Except for 1 premature deployment, all other deployments were easily accomplished in 3 minutes (1-28 minutes). The following adverse events were encountered: bleeding from the right ventricle caused by occlusion tape (1), anastomotic leakage on reperfusion requiring repair stitches (2), and anastomotic occlusion as a result of thrombus (1). All except 1 animal with a patent graft and anastomosis survived the procedure. The overall patency was 7 of 8. DISCUSSION: The combination of robotic technology allowing for dexterous manipulation in a closed chest environment and a simple yet effective and timesaving technique for anastomotic coupling may facilitate beating heart totally endoscopic coronary artery bypass grafting.     

Clinical and six-month angiographic evaluation of coronary arterial graft interrupted anastomoses by use of a self-closing clip device: a multicenter prospective clinical trial

OBJECTIVES: To evaluate the safety and effectiveness of a self-closing surgical clip with an interrupted technique in left internal thoracic artery to left anterior descending artery bypass grafting. METHODS: Eighty-two patients were enrolled and treated (February 2000 through August 2001) in a prospective, nonrandomized, multicenter trial. Left internal thoracic artery to left anterior descending artery anastomoses were performed in 60 off-pump coronary artery bypasses (73%), 12 conventional coronary artery bypass grafting (15%), and 10 minimally invasive direct coronary artery bypass (12%) procedures. Angiograms (64 to 383 days, mean 200 days) were obtained on 63 patients (77%). Qualitative and quantitative angiographic assessment was performed by an independent core laboratory. RESULTS: The self-closing surgical clip was used for 82 left internal thoracic artery to left anterior descending artery interrupted anastomoses without the requirement for knot tying or primary suture management. Minimum left internal thoracic artery to left anterior descending artery anastomosis time was 3 minutes. There was one perioperative and one late death (both not heart related) and one reexploration for bleeding unrelated to the anastomotic site. FitzGibbon grades were as follows: A (n = 60, 95.2%), B (n = 3, 4.8%) including one kinked left internal thoracic artery, and O (n = 0, 0%). Quantitative analysis (n = 57) showed mean lumen diameters of left internal thoracic artery proximal to the anastomosis of 2.1 mm, at anastomosis of 2.0 mm, and in the left anterior descending artery distal to the anastomosis of 1.9 mm. The average ratio of the anastomosis to the left anterior descending artery diameter was 1.14 (0.45 to 1.93). Anastomotic stenosis as a percentage of average left internal thoracic artery to left anterior descending artery diameter was -2.3%, comparing favorably with results (23% to 24%) reported from the Patency, Outcomes, Economics, Minimally invasive direct coronary artery (POEM) bypass study. CONCLUSIONS: The interrupted technique, facilitated by a self-closing anastomotic clip, yields favorable 6-month angiographic results when compared with other published studies.     

Internal thoracic artery to left anterior descending anastomosis performed on the beating heart by endoscopic robot assistance using a new distal connector.

BACKGROUND: Automated distal connecting devices have been recently introduced to facilitate coronary anastomosis. This could have a large impact on the capacity of robotic systems to perform completely endoscopic off-pump bypass, where the quality of anastomosis and the prolonged operative time for the performance of the anastomosis have until now been cause for concern. Our group tried to determine the feasibility and efficacy of the JoMed distal graft connector using the ZEUS robotic system. METHODS: Six swine, with a mean weight of 25.8 (standard deviation [SD] 2.2) kg, underwent endoscopic off-pump internal thoracic artery-left anterior descending (ITA-LAD) anastomosis with a special stabilizing system using ZEUS robotic assistance. The anastomosis was performed with the JoMed distal connector. RESULTS: The connector was employed successfully in 4 of 6 cases using a special delivery instrument. Two animals fibrillated within 2 minutes after the application of proximal occluding snares and were excluded from the analysis. The total device deployment time was 2 minutes 4 seconds (SD 50 s) in 4 of 6 survivors, which remained hemodynamically stable and in sinus rhythm until euthanasia. Coronary angiography and transonic flow measurements were used to verify patency. CONCLUSION: The JoMed distal graft connector may facilitate the use of robot-assisted endoscopic bypass on a beating heart. Long-term patency issues will need to be assessed.     

Initial prospective multicenter clinical trial of robotically-assisted coronary artery bypass grafting

BACKGROUND: This multicenter prospective trial was designed to assess the safety and efficacy of using a robotically-assisted microsurgical system to create endoscopic coronary anastomoses. METHODS:. Thirty-two patients scheduled for elective primary coronary surgery underwent endoscopic anastomosis of the left internal thoracic artery (LITA) to the left anterior descending (LAD) artery. Three thoracic ports (two for instruments and one for a camera) were placed, and a robotic system was used to perform the LITA-LAD graft. Conventional techniques were used to perform the other grafts. Thirty-one patients underwent median sternotomy and 1 patient underwent a limited anterior thoracotomy. RESULTS:. Graft flow was measured in the operating room and averaged 37 +/- 19 mL/min. Mean anastomosis time was 24 +/- 9 minutes. There were three intraoperative revisions (9%). Two were for inadequate flow and one for an inadvertent injury. Each of these grafts was successfully revised by hand. There were no technical failures of the robotic system. Average postoperative length of stay was 5.5 +/- 2.7 days. There were three reoperations for bleeding, but none of these were related to the LAD anastomosis. Two months following the operation, selective angiography revealed a graft patency of 93%. The patients have been followed for 16 +/- 4 months. CONCLUSIONS: This initial prospective multicenter trial documents the feasibility of robotically-assisted coronary bypass grafting. Further trials are warranted to establish the safety and efficacy of this new technology.     

Initial United States clinical trial of robotically assisted endoscopic coronary artery bypass grafting

OBJECTIVES: With traditional instruments, endoscopic coronary artery bypass grafting has not been possible. This study was designed to determine the clinical feasibility of using a robotically assisted microsurgical system to create endoscopic coronary anastomoses. Methods And Results: Ten patients underwent endoscopic coronary artery bypass grafting of the left internal thoracic artery to the left anterior descending artery. Subxiphoid endoscopic ports (2 for instruments, 1 for a camera) were placed, and a robotic system was used to perform the left internal thoracic artery-left anterior descending artery bypass graft. Conventional techniques were used to perform the other grafts. Blood flow through the left internal thoracic artery graft was measured in the operating room and was adequate in 8 of 10 patients. The 2 inadequate grafts were revised successfully by hand. Six weeks after the operation, selective coronary angiography demonstrated a graft patency of 100% (8/8). There were no technical failures of the robotic system. The only postoperative complication was mediastinal hemorrhage in 1 patient. CONCLUSIONS: This pilot study demonstrates the feasibility of robotically assisted endoscopic coronary artery bypass grafting.     

Early experience of coronary artery bypass grafting with a new self-closing clip device

OBJECTIVE: We are in the midst of development of several new anastomotic devices for use in coronary artery bypass grafting surgery. This study was designed to examine one of these devices (a new self-closing clip) for left internal thoracic artery-left anterior descending coronary artery anastomosis. Its feasibility and the quality of anastomosis were evaluated. METHODS: Fourteen patients who underwent first-time elective coronary artery bypass surgery were enrolled between July and December 2000. The left internal thoracic artery was anastomosed to the left anterior descending coronary artery in an interrupted manner with Coalescent U-clips (Coalescent Surgical, Inc, Sunnyvale, Calif). Immediate patency was checked with a transit-time flowmeter. Selective angiography was performed 6 months after surgical intervention. RESULTS: Five patients underwent on-pump coronary bypass grafting, 9 on the beating heart. One patient was excluded from the study intraoperatively because of a poor target site necessitating a 2-cm-long anastomosis. Left internal thoracic artery-left anterior descending artery anastomoses were created with an average of 11.8 clips in 15.9 minutes. Mean graft flow was 45.6 mL/min. Neither conversion to standard suture technique nor revision of anastomosis was necessary. There tended to be a learning curve in the anastomosis on the beating heart. Postoperative lengths of stay in the intensive care unit and the hospital were 20.7 hours and 3.9 days, respectively. Neither death nor major complication was seen, except for temporary atrial fibrillation in 2 patients. Graft patency at 6 months was 100% (FitzGibbon grade A). CONCLUSION: Left internal thoracic artery-left anterior descending artery anastomoses can be created safely and effectively with new self-closing clips on the beating, as well as the arrested, heart. Midterm patency was shown to be perfect by means of angiography.     

Off-pump coronary bypass using interposed radial artery graft

We describe a patient with severely diseased ascending aorta and small internal mammary arteries, who underwent off-pump coronary artery bypass to the left anterior descending coronary artery and right coronary artery using composite arterial grafts consisting of the pedicled proximal internal mammary artery and interposed radial artery graft. The interposed radial artery graft provides advantages, such as making coronary anastomosis on the beating heart easier and to increasing the flow potentiality of the internal mammary artery.     

Recurrent angina due to high grade re-stenosis of the left subclavian artery after coronary artery bypass grafting in a patient on hemodialysis for chronic renal failure: report of a case

A 49-year-old woman on hemodialysis for chronic renal failure was admitted to our hospital with chest pain. She had undergone quadruple coronary artery bypass grafting (CABG) including a left internal thoracic to left anterior descending coronary artery anastomosis 9 months earlier. The blood flow through the left internal thoracic artery had decreased due to high grade stenosis at the proximal portion of the left subclavian artery, and recurrent angina had developed. She was treated by the placement of Palmaz biliary stents in the left subclavian artery, but re-stenosis occurred after 9 months, causing recurrent angina again. There fore, an operation was proposed and bypass grafting from the descending aorta to the left subclavian artery was successfully performed, resulting in complete resolution of her recurrent angina. This case serves to reinforce that patients on dialysis must be carefully followed up after CABG.     

Off-pump redo coronary artery bypass grafting from descending aorta to the posterolateral area through a left thoracotomy in patients with a patent internal thoracic artery graft

The patients were a 73-year-old man (Case 1) and 56-year-old man (Case 2) who developed angina pectoris and heart failure. Case 2 showed chronic renal failure on hemodialysis. These patients whowed posterolateral myocardial ischemia with a patent internal thoracic artery graft to the left anterior descending artery. Left ventricle ejection fraction was 29% and 33%, respectively. Catheter intervention was unsuccessful, so we performed revascularization from the descending aorta to coronary arteries with saphenous vein grafts via a left thrracotomy using an off-pump technique. In case 2, proximal anastomosis was constructed with the Symmetric aortic connector. This procedure appeared to be a very safe and useful method as an option for redo coronary artery bypass grafting in the posterolateral area in patients with patent old grafts and poor left ventricular function.     

Prospective clinical trial of robotically assisted endoscopic coronary grafting with 1-year follow-up

OBJECTIVE: To follow up in prospective fashion patients with coronary artery anastomoses completed endoscopically with robotic assistance. The robotic system was evaluated for safety and its effectiveness in completing microsurgical coronary anastomoses. SUMMARY BACKGROUND DATA: Recently there has been an interest in using robotics and computers to enhance the surgeon's ability to perform endoscopic cardiac surgery. This interest has stemmed from the rapid advancement of technology and the desire to make cardiac surgery less invasive. Using traditional endoscopic instruments, it has not been possible to perform coronary surgery. METHODS: Nineteen patients underwent robotically assisted endoscopic coronary artery bypass grafting of the left internal thoracic artery (LITA) to the left anterior descending artery (LAD). Two robotic instruments and one endoscopic camera were placed through three 5-mm ports. A robotic system was used to construct the LITA-LAD anastomosis. All other required grafts were completed by conventional techniques. RESULTS: Seventeen LITA-LAD grafts (89%) had adequate intraoperative flow. The mean LITA-LAD graft flow was 38.5 +/- 5 mL/min. At 8 weeks, LITA-LAD grafts were assessed by angiography and showed 100% patency with thrombolysis in myocardial infarction (TIMI) I flow. At a mean follow-up of 17 +/- 4.2 months, all patients were NYHA class I and there were no adverse cardiac events. CONCLUSIONS: The results from the first prospective clinical trial of robotically assisted endoscopic coronary bypass surgery in the United States showed favorable short-term outcomes with no adverse events. Robotic assistance is an enabling technology allowing the performance of endoscopic coronary anastomoses.     

Noninvasive evaluation of internal thoracic artery and left anterior descending coronary artery anastomotic sites using transthoracic Doppler echocardiography: comparison with coronary arteriography

OBJECTIVES: This study was designed to evaluate anastomotic sites located between the internal thoracic artery and left anterior descending coronary artery using transthoracic Doppler echocardiography, and then to clarify the accuracy of those results by comparison with coronary arteriographic findings. METHODS: We examined 35 consecutive patients who had undergone bypass surgery. The echocardiographic examinations were performed within approximately 1 week of follow-up coronary arteriography, which occurred at 4.3 +/- 2.2 months after bypass surgery. We measured the diameter using intraluminal flow signals, and we also measured flow velocity. RESULTS: Adequate spectral Doppler recordings of coronary flow in the anastomosis were obtained in 31 (89%) of the 35 study patients. In the normal anastomosis group (n = 25), the diameter and the peak blood flow velocity of the internal thoracic artery and left anterior descending coronary artery were 1.5 +/- 0.3 mm and 2.0 +/- 0.4 mm, and 58 +/- 25 cm/s and 47 +/- 20 cm/s, respectively. Stringed internal thoracic artery was found in 4 patients; the echocardiographic findings revealed a greater amount of information regarding the physiologic state in the area of anastomosis compared with angiographic findings. In a stenotic anastomosis found in 2 patients, the blood flow velocity findings at the anastomotic sites (83 +/- 228 cm/s) were higher than those in normal anastomotic patients (59 +/- 28 cm/s). CONCLUSIONS: Transthoracic Doppler echocardiography enabled an effective evaluation of anastomotic sites between the internal thoracic artery and left anterior descending coronary artery in over 80% of our patients. This totally noninvasive method is thought to be reliable and able to provide a greater amount of information, compared with coronary arteriography, regarding the physiologic state of an anastomosis, such as a competitive relationship.     

Off-pump coronary artery bypass via left thoracotomy in patient with infective pancreatic fistula after surgery for bile duct carcinoma; report of a case

A 62-year-old man with infective pancreatic fistula after surgery for bile duct carcinoma underwent off-pump coronary artery bypass (OPCAB) through left thoracotomy to avoid the use of cardiopulmonary bypass and the postoperative mediastinitis, since this patient has infective pancreatic fistula close to the xiphoid process. The coronary arterial revascularizations were performed: left internal thoracic artery to left anterior descending branch and saphenous vein graft to descending thoracic aorta. The aortic mechanical anastomosis device, aortic connector, was utilized the proximal anastomosis of saphenous vein graft so as to avoid aortic clamp, while the distal anastomoses were completed with stabilizer and apical retraction device. Postoperative angiogram showed both grafts were patent. No signs of infection or recurrence of malignant neoplasm was observed. OPCAB via left thoracotomy is one of useful options for patients in whom median sternotomy is not suitable approach for myocardial revascularizations.     

Early experience with robotic technology for coronary artery surgery.

BACKGROUND: To achieve an endoscopic coronary bypass anastomoses we performed a study with endoscopic robotic instrumentation and camera guidance using three-dimensional (3-D) visualization. METHODS: The surgical robotic system ZEUS (Computer Motion Inc, Goleta, CA) consists of three interactive robotic arms and a control unit allowing the surgeon to move the instrument arms in a scaled down mode. The third arm (AESOP, Computer Motion Inc, Goleta, CA) positions the endoscope via voice control. The study had three phases. Phase I: In a phantom model, end-to-side anastomoses between vein grafts and the left anterior descending coronary artery (LAD) of 109 pig hearts were performed. Phase II: In 6 dogs (FBI, 20-25 kg) the left internal mammary artery (LIMA) was harvested endoscopically. During Port-Access (Heartport Inc, Redwood City, CA) cardiopulmonary bypass (CPB), LIMA and LAD were then anastomosed endoscopically with the help of telemetric ZEUS instruments (Computer Motion Inc). Phase III: A total of seven patients were operated on with help of the ZEUS system (Computer Motion Inc). After endoscopic LIMA harvesting and CPB using the Port-Access (Heartport Inc) system, the bypass graft (LIMA to LAD) was anastomosed endoscopically through three thoracic ports in 2 patients. Another 3 patients were operated on off-pump with regional stabilization and 2 patients with sternotomy and routine CPB. RESULTS: The practice with the phantom model and the subsequent animal experiments allowed the surgeons to gain sufficient experience for the clinical setting. In the clinical cases, times for anastomoses ranged from 20 to 42 minutes. Median internal mammary artery flow rate was 74 mL per minute (range 36-110 mL per minute). One patient in the off-pump group was converted to CPB and routine anastomosis. All patients had an uneventful angiographic control and postoperative course. CONCLUSIONS: Using telemetic technology, a completely endoscopic anastomosis of LIMA to LAD is possible on the arrested heart, as well as on the beating heart.     

Robotic skeletonizing of the internal thoracic artery: is it safe?

BACKGROUND: The advantages of internal thoracic artery skeletonization include early high blood flow, a longer conduit, and less bleeding than pedicle internal thoracic artery grafts. Longer conduits are needed for complete endoscopic arterial revascularization. Therefore this study was designed to determine the feasibility and safety of internal thoracic artery skeletonization using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA). METHODS: Nine dogs underwent bilateral robotic internal thoracic artery harvesting through three ports placed in the left chest. One internal thoracic artery was harvested as a pedicle in each dog, and the other was skeletonized. Internal thoracic artery blood flow was measured in each graft, and comparative endothelial histologic studies were performed. Data are mean +/- the standard error of the mean. RESULTS: All 18 internal thoracic arteries were harvested successfully. Skeletonized internal thoracic artery harvests required more time (48.0 minutes +/- 1.8) than pedicle internal thoracic artery harvests (39.0 minutes +/- 1.4; p < 0.05). Internal thoracic artery flows during the final intervals were similar (skeletonized = 30.0 mL/min +/- 2.4 vs pedicle = 31.5 mL/min +/- 1.8; p = 0.9). Free internal thoracic artery bleeding flow was similar in both groups (skeletonized = 162.0 mL/min +/- 3.0 vs pedicle = 189.0 mL/min +/- 2.4; p = 0.4). Histologically, both groups were similar with minimal endothelial damage. CONCLUSIONS: Robotically skeletonized harvesting is safe, but it requires more time (48.0 minutes +/- 1.8) than pedicle internal thoracic artery harvesting. Despite muted tactile feedback with robotics, neither technique was associated with histologic or functional damage. These encouraging results may represent an advantage for complete arterial revascularization in robotic coronary bypass patients.     

Use of the voice-controlled and computer-assisted surgical system ZEUS for endoscopic coronary artery bypass grafting.

OBJECTIVE: With the aim of performing a completely endoscopic coronary bypass anastomosis, we have undertaken an experimental and clinical study using robotic instrumentation and voice-controlled camera guidance. METHODS: The ZEUS Robotic Surgical System (Computer Motion Inc, Goleta, Calif) consists of three interactive robotic arms and a control unit, allowing the surgeon to move the instrument arms in a scaled down mode. The third arm (AESOP, Computer Motion) positions the endoscope via voice control. PHASE I: In a phantom model, vascular grafts were anastomosed to the left anterior descending coronary artery (LAD) of 50 pig hearts with either 2- or 3-dimensional visualization. PHASE II: In 6 dogs (FBI 20-25 kg) the left internal thoracic artery (LITA) was harvested endoscopically. Then the animals were placed on an endovascular cardiopulmonary bypass system (Port-Access, Heartport, Inc, Redwood City, Calif). Anastomosis of the LITA to the LAD was performed endoscopically with the telemetric ZEUS instruments. Flow rates through the LITA were measured by Doppler analysis. PHASE III: Two patients were operated on with the ZEUS system. After endoscopic harvesting of the LITA and cardiopulmonary bypass with the Port-Access system, the bypass graft (LITA-LAD) was anastomosed endoscopically with the ZEUS system through three thoracic ports. RESULTS: In the dry laboratory, the time range required for the robotically assisted coronary anastomosis was 35 to 60 minutes with 2-dimensional visualization and 16 to 32 minutes with 3-dimensional visualization. In the animal experiments, the median time for endoscopic harvesting of the LITA was 86 minutes (range 56-120 minutes) and for the anastomosis, 42 minutes (range 35-105 minutes); flow rates through the LITA ranged between 22 and 45 mL/min. In the clinical cases, preparation times for the LITA were 83 and 110 minutes, respectively, and anastomosis times, 42 and 40 minutes, respectively. Doppler flow rates measured 125 and 85 mL/min, respectively. Both patients had an uneventful follow-up angiogram and postoperative course. CONCLUSIONS: With sophisticated robotic technology, a completely endoscopic anastomosis of the LITA to the LAD is possible, allowing technically precise operations within acceptable time limits.     

Automated distal coronary bypass with a novel magnetic coupler (MVP system)

OBJECTIVE: We sought to assess the feasibility of performing sutureless distal coronary artery bypass anastomoses with a novel magnetic coupling device. METHODS: From May 2000 to April 2001, single-vessel side-to-side coronary artery bypass grafting on a beating heart was performed in 39 domestic white pigs (35-60 kg) without the use of mechanical stabilization, shunts, or perfusion bridges. Animals were divided into 2 groups. Seventeen pigs underwent right internal thoracic artery to right coronary artery bypass grafting through a median sternotomy (group 1) with a novel magnetic vascular positioning system (MVP system; Ventrica, Inc, Fremont, Calif). Twenty-two pigs underwent left internal thoracic artery to left anterior descending artery grafting with the MVP anastomotic device through a left anterior minithoracotomy (group 2). This system consists of 2 pairs of elliptical magnetic implants and a deployment device. One pair of magnets forms the anastomotic docking port within the graft; the other pair forms an identical anastomotic docking port within the target vessel. The anastomosis is created when the 2 docking ports magnetically couple. Anastomotic patency was evaluated by means of angiography during the first postoperative week and at 1 month. Histologic studies were performed at different time points as late as 6 months. RESULTS: Right internal thoracic artery to right coronary artery anastomoses and left internal thoracic artery to left anterior descending artery anastomoses were successfully performed with the system in all animals. The self-adherent and self-aligning properties of the implants allowed for immediate and secure approximation of the arteries (total anastomotic time between 2-3 minutes). Anastomoses were constructed without a stabilization platform. Five nondevice-related deaths occurred postoperatively. One-week angiography, performed in 35 surviving animals, showed a patent graft and anastomosis in all cases. The patency rate at 1 month was 97% (33/34). Histologic studies as late as 6 months demonstrated neointimal coverage of the magnets without any significant luminal obstruction. Histology also confirmed the presence of viable tissue between magnets. CONCLUSION: The MVP anastomotic system uses magnetic force to create rapid and secure distal coronary artery anastomoses, which might facilitate minimally invasive and totally endoscopic coronary artery bypass surgery.     

Robotic totally endoscopic coronary artery bypass: program development and learning curve issues

BACKGROUND: The introduction of new procedures in heart surgery is a critical phase that includes learning curves and the risk of increased mortality or morbidity. Totally endoscopic coronary artery bypass grafting using robotic techniques represents such an innovative procedure. The aim of this report is to demonstrate the safe introduction of totally endoscopic coronary artery bypass grafting using a stepwise and modular approach. METHODS: From June 2001 until December 2002, 50 procedures were performed using the da Vinci telemanipulator system. After baseline training the following procedure modules were carried out in a stepwise manner: robotically assisted endoscopic left internal thoracic artery harvesting and completion of the procedure as conventional coronary artery bypass grafting, minimally invasive direct coronary artery bypass, or off-pump coronary artery bypass (n = 19), robotically assisted suturing of left internal thoracic artery to left anterior descending anastomoses during conventional coronary artery bypass grafting (n = 15), totally endoscopic coronary artery bypass grafting on the arrested heart using remote access perfusion and aortic endocclusion coronary bypass grafting (n = 15). One patient was excluded intraoperatively from a robotic procedure due to pleural adhesions. RESULTS: A significant learning curve was observed for left internal thoracic artery takedown time, y(min) = 181 - 39 x ln(x) (x = procedure number) (P <.001), and total operative time in totally endoscopic coronary artery bypass grafting, y(min) = 595 - 87 x ln(x) x = (procedure number) (P =.028). The conversion rate in totally endoscopic coronary artery bypass grafting was 2/15. Intensive care unit stay correlated significantly with total operative time (r =.427, P =.002). There was no hospital mortality. CONCLUSION: Totally endoscopic coronary artery bypass grafting can be safely implemented into a heart surgery program. Learning curves are steep for robotic left internal thoracic artery takedown and for performance of totally endoscopic coronary artery bypass grafting. Long operative times translate into prolonged intensive care unit stay in specific cases but not into increased mortality.