Cook Richard C, Fung Anthony Y, Percy Edward D, Mayo John R
From the Division of Cardiovascular Surgery.
Division of Cardiology, and.
Innovations (Phila). 2018 May/Jun;13(3):207-210. doi: 10.1097/IMI.0000000000000499.
Robotically assisted minimally invasive direct coronary artery bypass is an alternative to sternotomy-based surgery in properly selected patients. Identifying the left anterior descending artery when it is deep in the epicardial fat can be particularly challenging through a 5- to 6-cm mini-thoracotomy incision. The objective of this study was to evaluate a technique for predicting conversion to sternotomy or complicated left anterior descending artery anastomosis using preoperative cardiac-gated computed tomography angiograms.
Retrospective review of 75 patients who underwent robotically assisted minimally invasive direct coronary artery bypass for whom a preoperative computed tomography angiogram was available. The distance from the left anterior descending artery to the myocardium was measured on a standardized "5-chamber" axial computed tomography view. The relative risk of sternotomy or complicated anastomosis was compared between patients whose left anterior descending artery was resting directly on the myocardium (left anterior descending artery to the myocardium distance = 0 mm) with those whose left anterior descending artery was resting above (left anterior descending artery to the myocardium distance > 0 mm).
The average left anterior descending artery to the myocardium distance was 3.2 ± 2.6 mm (range = 0-11.5 mm). Fourteen patients (18.7%) had an left anterior descending artery to the myocardium distance of 0 mm. Of the entire group of 75 patients, 6 (8.0%) required conversion to sternotomy. Four others (5.3%) were reported to have a complication with the anastomosis intraoperatively. For patients with left anterior descending artery to the myocardium distance of 0 mm, the relative risk of sternotomy or complicated anastomosis was 18.0 (95% confidence interval = 4.3-75.6, P = 0.0001).
In our experience, patients with left anterior descending artery to the myocardium distance of 0 mm were at significantly higher risk of either conversion to sternotomy or technically challenging anastomosis, with 8 (57.1%) of 14 patients in this group experiencing either end point. This novel measurement may be useful to identify patients who may have anatomy, which is not well suited to the robotically assisted minimally invasive direct coronary artery bypass approach.
对于经过恰当选择的患者，机器人辅助微创直接冠状动脉旁路移植术是基于胸骨切开术的手术的一种替代方案。当左前降支动脉深埋于心外膜脂肪中时，通过5至6厘米的小切口胸廓切开术来识别它可能极具挑战性。本研究的目的是评估一种使用术前心脏门控计算机断层扫描血管造影来预测转为胸骨切开术或复杂的左前降支动脉吻合术的技术。
回顾性分析75例行机器人辅助微创直接冠状动脉旁路移植术且有术前计算机断层扫描血管造影的患者。在标准化的“五腔心”轴向计算机断层扫描视图上测量左前降支动脉到心肌的距离。比较左前降支动脉直接位于心肌上（左前降支动脉到心肌的距离 = 0毫米）的患者与左前降支动脉位于心肌上方（左前降支动脉到心肌的距离>0毫米）的患者转为胸骨切开术或复杂吻合术的相对风险。
左前降支动脉到心肌的平均距离为3.2±2.6毫米（范围 = 0至11.5毫米）。14名患者（18.7%）的左前降支动脉到心肌的距离为0毫米。在75名患者的整个组中，6名（8.0%）需要转为胸骨切开术。另有4名（5.3%）据报道术中吻合出现并发症。对于左前降支动脉到心肌的距离为0毫米的患者，转为胸骨切开术或复杂吻合术的相对风险为18.0（95%置信区间 = 4.3至75.6，P = 0.0001）。
根据我们的经验，左前降支动脉到心肌的距离为0毫米的患者转为胸骨切开术或技术上具有挑战性的吻合术的风险显著更高，该组14名患者中有8名（57.1%）出现了这两种结局中的一种。这种新的测量方法可能有助于识别那些解剖结构可能不太适合机器人辅助微创直接冠状动脉旁路移植术方法的患者。
