Nisivaco Sarah, Bhasin Riya, Kitahara Hiroto, Patel Brooke, Coleman Charocka, Grady Kaitlyn, Oh Won Hee, Balkhy Husam H
Department of Cardiothoracic Surgery, University of Chicago Medicine, Chicago, IL, USA.
Ann Cardiothorac Surg. 2024 Jul 31;13(4):354-363. doi: 10.21037/acs-2024-rcabg-0016. Epub 2024 Jul 18.
Multi-arterial grafting (MAG) with bilateral internal thoracic arteries (BITAs) is superior to single internal thoracic artery (ITA) and veins, however, sternal wound infection (SWI) is a deterrent to using BITA, especially in diabetic and obese patients. Sternal-sparing approaches, including robotic totally endoscopic coronary artery bypass (TECAB), may mitigate this risk. We reviewed outcomes of robotic TECAB with BITA grafting.
A total of 871 patients underwent robotic TECAB at our institution from 7/2013 to 4/2024. Of these, 406 patients received BITA grafts and are the subject of this review. Early and mid-term clinical outcomes were reviewed and angiographic patency in those undergoing hybrid revascularization with percutaneous coronary intervention (PCI) after TECAB. All cases were performed via a beating-heart robotic approach, with standard TECAB port placement.
The mean age of the cohort was 67±9 years and 16% were female. The mean Society of Thoracic Surgeons (STS) risk was 1.47%±2.2%. Thirty-nine percent were diabetic (15% insulin-dependent) and 39% had a body mass index (BMI) ≥30 kg/m. Twenty percent had an ejection fraction (EF) ≤40%. Ninety-eight percent of cases were completed off-pump and there were no conversions to sternotomy. The mean number of grafts per patient was 2.2±0.4. The mean intensive care unit (ICU) and hospital length of stay (LOS) were 1.22±0.62 and 2.44±0.83 days, respectively. Postoperative complications included atrial fibrillation in 13%, acute kidney injury (AKI) in 3.4%, return to theatre for bleeding in 0.7%, postoperative myocardial infarction (MI) in 0.2%, and stroke in 0.2%. Thirty-day mortality was 1.2% [observed/expected (O/E): 0.89]. Return to full activities and work occurred at mean of 14±8.6 and 17±13 days, respectively. Two hundred and two patients (50%) had 'advanced' hybrid revascularization (with at least two arterial grafts and stents). ITA early graft patency in this cohort of patients was 271/278 (98%) with 100% left ITA to left anterior descending artery (LITA-LAD) patency. Mid-term follow-up was complete in all patients at mean of 51±36 months (longest follow-up at 10 years). All-cause mortality was 13% and cardiac-mortality was 2.5%. Freedom from angina was 96%, and freedom from repeat revascularization was 94%.
Use of the beating-heart robotic TECAB approach facilitates BITA grafting to achieve multi-vessel arterial revascularization of the left coronary system, with excellent 10-year outcomes.
双侧胸廓内动脉（BITA）的多动脉移植（MAG）优于单根胸廓内动脉（ITA）和静脉移植，然而，胸骨伤口感染（SWI）是使用BITA的一个阻碍因素，尤其是在糖尿病和肥胖患者中。保留胸骨的手术方法，包括机器人完全内镜冠状动脉搭桥术（TECAB），可能会降低这种风险。我们回顾了机器人BITA移植TECAB的结果。
2013年7月至2024年4月期间，共有871例患者在我院接受了机器人TECAB手术。其中，406例患者接受了BITA移植，为本综述的研究对象。回顾了早期和中期临床结果，以及TECAB术后接受经皮冠状动脉介入治疗（PCI）的混合血运重建患者的血管造影通畅情况。所有病例均采用心脏跳动机器人手术方法，采用标准TECAB端口放置。
该队列患者的平均年龄为67±9岁，16%为女性。胸外科医师协会（STS）平均风险为1.47%±2.2%。39%为糖尿病患者（15%依赖胰岛素），39%的体重指数（BMI）≥30kg/m²。20%的患者射血分数（EF）≤40%。98%的病例在非体外循环下完成，无一例转为胸骨切开术。每位患者的平均移植血管数为2.2±0.4。重症监护病房（ICU）和住院时间（LOS）的平均值分别为1.22±0.62天和2.44±0.83天。术后并发症包括13%的心房颤动、3.4%的急性肾损伤（AKI）、0.7%的因出血返回手术室、0.2%的术后心肌梗死（MI）和0.2%的中风。30天死亡率为1.2%[观察到的/预期的（O/E）：0.89]。恢复完全活动和工作的平均时间分别为14±8.6天和17±13天。202例（50%）患者进行了“高级”混合血运重建（至少有两根动脉移植血管和支架）。该队列患者的ITA早期移植血管通畅率为271/278（98%），左ITA至左前降支动脉（LITA-LAD）通畅率为100%。所有患者均完成了平均51±36个月的中期随访（最长随访10年）。全因死亡率为13%，心脏死亡率为2.5%。无心绞痛发生率为96%，无再次血运重建发生率为94%。
采用心脏跳动机器人TECAB手术方法有助于BITA移植，以实现左冠状动脉系统的多支动脉血运重建，10年结果优异。
