INTRODUCTIONThe applicability of off-pump coronary-artery bypass (OPCAB) in patients who present as emergency remains controversial. Herein, we explore the efficacy and safety of OPCAB in patients who were indicated for emergency surgery.

MATERIALS AND METHODSBetween 2002 and 2007, a total of 282 patients underwent OPCAB, of which 68 were presented as emergency. This cohort (group A) was compared to 68 patients who had traditional on-pump coronary artery bypass grafting (CABG, group B) under emergency indications during the same period of time. Baseline demographics, intraoperative data and postoperative outcomes were analysed.

RESULTSPreoperative demographics were comparable in both groups. Mortality during the first 30 days was comparable in both groups and no stroke occurred in the whole series. Patients in group A had significantly less pulmonary complications (4.4% vs 14.7%, P = 0.04), less ventilation time (30.3 ± 33.6 hours vs 41.5 ± 55.4 hours, P = 0.18) and were less likely to have prolonged ventilation, (19.1% vs 35.3%, P = 0.03). Similarly, OPCAB patients had less postoperative renal-failure/dysfunction (5.9% vs 8.8%, P = 0.51) and required less inotropic support (66.2% vs 88.2%, P = 0.002), bloodtransfusions (23% vs 86.8%, P <0.0001), and atrial- (17.6% vs 35.3%, P = 0.02) or ventricular-pacing (17.6% vs 41.2%, P = 0.002). Although the number of diseased vessels was comparable in both groups, patients in group A received less distal anastomoses. (2.78 ± 1.19 vs 3.41 ± 0.89, P = 0.002). Similarly, complete revascularisation was achieved less frequently in group A (76.5% vs 94.1%, P = 0.004).

CONCLUSIONOPCAB strategy is a safe and efficient in emergency patients with reasonable good short-term postoperative outcomes.

Cohort Studies ; Coronary Artery Bypass ; instrumentation ; methods ; Coronary Artery Bypass, Off-Pump ; instrumentation ; methods ; Coronary Artery Disease ; mortality ; surgery ; Emergency Treatment ; Female ; Health Status Indicators ; Humans ; Male ; Middle Aged ; Odds Ratio ; Retrospective Studies ; Safety ; Singapore ; Statistics as Topic ; Time Factors

OBJECTIVETo summarize the experience of minimally invasive robotic coronary bypass on beating heart using da Vinci S in China.

METHODSFifty-six patients underwent selected robotic coronary bypass on beating heart from April 2007 to December 2008. All the patients had history of angina and the coronary arteriography showed severe stenosis in the left anterior descending artery (LAD), of which 10 cases had right coronary artery or left circumflex coronary (LCX) stenosis. The age was 33 to 74 years old, with a mean of (55.8 +/- 9.4) years old. The weight was (71.4 +/- 13.2) kg. All the patients had good lung function and had no medical history of pleurisy and thoracic surgery. CT scan of double internal thoracic artery (ITA) was routinely checked preoperatively. The procedures included: (1) The robotically assisted endoscopic atraumatic coronary artery bypass surgery. The approach was via a small left anterior thoracotomy (6 to 8 cm) after robotic ITA was taken down. The ITA was manually anastomosed to the LAD or LCX on beating heart. (2) Totally endoscopic coronary bypass graft on beating heart. After ITA harvesting, the endo stabilizer was inserted via the fourth port in the xiphoid area under endoscopic vision. The left ITA to the LAD grafting was done using U-clips on beating heart in a totally endoscopic manner using da Vinci S system through 4 ports. For all patients the ITA flow was checked by the Doppler flowmeter after anastomosis was completed. After the surgery was completed, the thoracic port was checked carefully to avoid bleeding. The operating procedures and a variety of clinical parameters were recorded and analyzed. (3) Stent placement after robotic surgery in a hybrid manner. The graft patency rate was evaluated by CT or arteriography.

RESULTSAll patients successfully accepted robotic minimally invasive coronary bypass on the beating heart using da Vinci S surgical system without complications. The mean graft flow was (23.2 +/- 16.7) ml/min. And there was no surgical conversion and surgical death. Fifty-three patients received ITA to LAD grafts and 3 patients received double coronary artery bypass grafts as well. Ten cases received stent placement in separate session. The CT scan and angiography revealed patent grafts in all patients. There were no post-operative complications. All patients were discharged from hospital.

CONCLUSIONSAs a new advanced approach of revascularization, robotic ITA harvesting and coronary anastomoses can be safely performed with the da Vinci S system. The procedure is minimally invasive and can offer enhanced ability to control precise and stable operative manipulations.

Adult ; Aged ; Coronary Artery Bypass, Off-Pump ; instrumentation ; methods ; Female ; Humans ; Male ; Middle Aged ; Minimally Invasive Surgical Procedures ; Robotics

OBJECTIVESTo analyze the safety and efficiency of robotically assisted coronary artery bypass grafting (RACABG) on beating heart using da Vinci S system.

METHODSFrom January 2007 to March 2011, 105 patients underwent RACABG on beating heart through minithoracotomy. There were 77 male and 28 female patients, aged from 33 to 77 years with a mean of (59 ± 10) years. After establishment of single left lung ventilation, the 3 trocars of da Vinci system were inserted into the left hemithorax, and robotic system was used to harvest the left internal mammary artery (LIMA) and/or right internal mammary artery (RIMA) from the subclavian vein to the internal mammary artery (IMA) bifurcation with skeletonized technique. After positioning the stabilizer, the LIMA was anastomosed manually to the left anterior descending or diagonal branch sequentially on beating heart through left minithoracotomy. The graft flow was evaluated by the Doppler flow meter after anastomosis was completed, and the graft patency was also evaluated by CT angiography or arteriography after surgery.

RESULTSAll patients had successful RACABG on the beating heart, and the mean graft flow was (21 ± 13) ml/min. One patient suffered from cardiac arrest after the first postoperative day, but he recovered soon and CT angiography showed that graft was patent. One patient with preoperative stroke had postoperative pulmonary infection, and was discharged after treatment. After 4 to 5 days, 4 patients received stent placement in right coronary artery or circumflex coronary in distinct hybrid session. There were no deaths or stroke or reintervention. All patients were discharged without complications and followed up. CTA or angiography revealed patent grafts in all patients, and the mean time of follow-up was (30 ± 12) months.

CONCLUSIONSRobotically assisted coronary artery bypass grafting on beating heart can be performed safely using da Vinci S system. It is a new advanced approach of revascularization not only for patients with single vessel but with multi-vessel lesions as well.

Adult ; Aged ; Coronary Artery Bypass, Off-Pump ; instrumentation ; methods ; Female ; Humans ; Male ; Middle Aged ; Robotics ; Treatment Outcome

The aortic connector system may reduce stroke during proximal venous anastomosis. However, the overall anastomotic patency rate has been generally reported to be low. From October 2002 to March 2004, 68 patients who received proximal anastomosis using the St. Jude Aortic Connector System were included in the study. There were 47 men and 21 women and their mean age was 65.68+/-6.68 yr old (52 to 85 yr). Grafts were evaluated by coronary angiography or multi-slice 16 channel 3-D CT at 6 days and at 6 months postoperatively. In the immediate postoperative period, no stenosis was observed by either angiography (n=22) or 3D CT (n=46). At 6-month postoperatively, we performed either angiography (n=7) or 3-D CT (n=52). Of these patients, 5 patients showed graft stenosis in the midportion, and 3 in the ostium. There were no stroke. Simple, and effective proximal anastomosis with good protection from cerebrovascular accident was achieved especially when calcification or atheromatous plaque was observed at the ascending aorta in the operation room. However, our mid term patency results raise concerns related to venous graft stenosis in the midportion. Therefore, longer follow up is recommended.
Saphenous Vein/*transplantation ; Middle Aged ; Male ; Humans ; Follow-Up Studies ; Female ; Coronary Artery Bypass/*instrumentation ; Aorta/*surgery ; Anastomosis, Surgical/*instrumentation ; Aged, 80 and over ; Aged

OBJECTIVETo investigate the strategies for anesthetic management for totally endoscopic coronary artery bypass grafting with the da Vinci S surgical system.

METHODSBetween January 2007 and May 2009, 16 patients underwent off-pump coronary artery bypass grafting via a totally endoscopic approach. After anesthetic induction, a left-sided double-lumen endotracheal tube was positioned to allow single right-lung ventilation during intra-operative procedure. The left internal mammary artery graft was harvested and anastomosed with the anterior descending branch with robotic assistance. The hemodynamic status and left ventricular function of each patient were recorded immediately after the induction (T1), after single right-lung ventilation (T2), after dissecting the left internal mammary artery (T3), after using the heart stabilizator (T4) and after the completion of the anastomosis (T5).

RESULTSThe mean arterial blood pressure at T2, T3, and T4 were significantly reduced as compared with that at T1 (P<0.05), and the mean pulmonary artery pressure at T2, T3 and T4, the heart rate (HR) at T2, T3 and T5, the pulmonary capillary wedge pressure at T4 and the central venous pressure at T5 all increased significantly in comparison with those at T1 (P<0.05).

CONCLUSIONAlthough the hemodynamics and the respiratory function in totally endoscopic coronary artery bypass grafting are both extremely unstable as a result of single right-lung ventilation and surgical procedure, the appropriate administration of vasopressors and adjustment of respiratory function in anesthesia can allow the completion of the procedure with acceptable hemodynamics.

Aged ; Anesthesia, Intravenous ; methods ; Coronary Artery Bypass, Off-Pump ; instrumentation ; methods ; Coronary Vessels ; surgery ; Endoscopy ; Female ; Humans ; Male ; Mammary Arteries ; surgery ; Middle Aged ; Minimally Invasive Surgical Procedures ; Robotics

BACKGROUND/AIMS: In the bare-metal stent era, routine follow-up coronary angiography (RFU CAG) was used to ensure stent patency. With the advent of drug-eluting stents (DESs) with better safety and efficacy profiles, RFU CAG has been performed less often. There are few data on the clinical impact of RFU CAG after second- or third-generation DES implantation in clinically stable patients with coronary artery disease; the aim of this study was to examine this issue. METHODS: We analyzed clinical outcomes retrospectively of 259 patients who were event-free at 12-month after stent implantation and did not undergo RFU CAG (clinical follow-up group) and 364 patients who were event-free prior to RFU CAG (angiographic follow-up group). Baseline characteristics were compared between the groups. RESULTS: The Kaplan-Meier estimated total survival and major adverse cardiac event (MACE)-free survival did not differ between the groups (p = 0.100 and p = 0.461, respectively). The cumulative MACE rate was also not different between the groups (hazard ratio, 0.85; 95% confidence interval, 0.35 to 2.02). In the angiographic follow-up group, 8.8% revascularization was seen at RFU CAG. CONCLUSIONS: RFU CAG did not affect long-term clinical outcome after second- or third-generation DES implantation in clinically stable patients.
Aged ; *Coronary Angiography ; Coronary Artery Bypass ; Coronary Artery Disease/radiography/*therapy ; Coronary Restenosis/etiology/radiography/surgery ; Coronary Vessels/*radiography ; Disease Progression ; Disease-Free Survival ; *Drug-Eluting Stents ; Female ; Humans ; Kaplan-Meier Estimate ; Male ; Middle Aged ; Myocardial Infarction/etiology/radiography/surgery ; Patient Selection ; Percutaneous Coronary Intervention/adverse effects/*instrumentation ; Predictive Value of Tests ; Proportional Hazards Models ; Prosthesis Design ; Retrospective Studies ; Risk Factors ; Time Factors ; Treatment Outcome