ROBOTIC CORONARY REVASCULARIZATION

Abstract

Coronary artery bypass grafting (CABG) has been long been established as an effective method of restoring blood flow to the myocardium in the setting of advanced coronary artery disease. Grafting the left internal mammary artery (LIMA) to the left anterior descending coronary artery (LAD) improves long-term survival and multiarterial grafting likely provides additional long-term benefits. Many patients do not receive the benefit of IMA revascularization due to the morbidity associated with CABG. Consequently, cardiac surgeons in the 1990s developed less invasive methods of myocardial revascularization from which spawned the development of robotic coronary artery bypass grafting procedures. Minimally invasive direct coronary artery bypass grafting (MIDCAB) was independently described by Dr. Valavanur Subramanian and Dr. Federico Benetti in 1994 at the International Workshop on Arterial Conduits for Myocardial Revascularization and led to the presentation of a multi-center trial of 168 patients presented at the Annual Meeting of the American Heart Association in 1995. As MIDCAB was adopted by numerous surgeons, its challenges were identified including difficulty harvesting the entire length of the LIMA, limited access to the right internal mammary artery (RIMA), IMA rotation, target vessel identification, suturing through a small incision. Endoscopic techniques for IMA harvesting and anastomotic suturing were also developed, but proved to be very challenging and did not gain widespread adoption. In the late 1990s, robotic technology became available, providing superior visualization of the entire thorax and improved intra-thoracic ergonomic motion for complex intra-thoracic procedures. This technology provided solutions for the challenges associated with endoscopic and limited access coronary artery bypass grafting by allowing ease of access to all intrathoracic regions from single sided ports allowing full dissection of bilateral internal mammary arteries (BIMAs), target vessel identification, access to all regions of the myocardium and more facile anastomoses. Consequently, robotic assisted CABG became a reality and was adopted by a number of highly dedicated centers, where outcomes have been favorable. The procedure has evolved to the point where quadruple vessel CABG has become feasible. Procedures can be performed on the arrested and beating heart. This approach can be extended to approximately one-third of CABG patients when coronary anatomy is carefully assessed, usually in the context of a heart-team, and the treatment of each lesion is considered.