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Ann Thorac Surg 2001;72:610-611
© 2001 The Society of Thoracic Surgeons

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Case report

Computer-enhanced totally endoscopic sequential arterial coronary artery bypass

^a Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany
^b Department of Anesthesia, Intensive Care and Pain Therapy, Johann Wolfgang Goethe University, Frankfurt am Main, Germany

Accepted for publication July 16, 2000.

Address reprint requests to Dr Dogan, Klinik für Thorax-, Herz- und thorakale Gefässchirurgie, Johann Wolfgang Goethe-Universität Frankfurt, Theodor Stern Kai 7, 60590 Frankfurt, Germany
e-mail: s.dogan{at}em.uni-frankfurt.de

	Abstract

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Minimally invasive coronary artery bypass grafting of the anterior wall using a left anterior small thoracotomy became a routine procedure within the last 3 years. The introduction of robotics into the cardiosurgical practice in 1998 has finally enabled totally endoscopic closed chest procedures. We report two patients with totally endoscopic left internal thoracic artery bypass grafting to the left anterior descending artery and the first diagonal branch in sequential arterial revascularization technique using the daVinci surgical system.

	Introduction

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Minimally invasive cardiac surgery follows two different philosophies to achieve increased patient benefit: off-pump techniques to avoid the inflammatory response induced by the heart lung machine [1] or the use of limited approaches avoiding complete median sternotomy [2, 3]. With the introduction of robotics into cardiac surgery, the surgical access was further reduced enabling true port access (totally endoscopic) coronary artery bypass grafting (CABG) [4–6]. About 60 patients worldwide have undergone totally endoscopic left internal thoracic artery (ITA) grafting to the left anterior descending coronary artery (LAD) to date. However, a jump graft using da Vinci surgical system (Intuitive Surgical, Mountain View, CA) has not been reported.

	Case reports

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Patient 1
A 48-year-old man presented with angina on exertion (CCS class II) and signs of ischemia in the anterolateral wall. The coronary angiogram showed a complex lesion of the LAD and a significant stenosis of the right coronary artery (RCA). A percutaneous transluminal coronary angioplasty (PTCA) of the RCA was performed successfully. Four weeks later, a recatheterization showed a progression of his coronary artery disease with multiple severe lesions of the proximal LAD and a severe stenosis of the first diagonal branch. Because of high-risk PTCA conditions, the patient was referred for minimally invasive revascularisation of the LAD and the diagonal branch.

Patient 2
A 53-year-old man with history of angina for more than 12 months (CCS class III) was catheterized and diagnosed with a severe stenosis of the proximal LAD and the first diagonal branch. He underwent PTCA and stent implantation of the LAD, but developed a restenosis within 2 weeks and, therefore, was referred for minimally invasive operative revascularization.

After informed consent was obtained, both patients underwent totally endoscopic double bypass revascularization in sequential revascularization technique at our institution on November 24, 1999, and February 16, 2000.

Anesthesia was induced in a standard fashion except for a double lumen tube for single lung ventilation and invasive blood pressure monitoring in both radial arteries. A pulmonary artery vent catheter (Heartport Inc, Redwood City, CA) was introduced percutaneously for left heart decompression. Complete transesophageal echocardiographic (TEE) monitoring was provided throughout the complex procedure.

The patient was placed on the OR table with the left chest elevated about 40 degrees. Three ports were placed to introduce the stereo endoscope and the robot arms of the daVinci surgical system. The ports for the two robot arms were inserted under endoscopic control in the third and seventh ICS in the anterior axillary line after insufflation of the chest with CO₂. Using a 30-degree videoscope looking up, the left ITA was mobilized from the subclavian artery down to the diaphragmatic branches. The end of the ITA and further two segments were skeletonized and prepared for grafting, respectively, placing the bulldog clamps (Scanlan Int, Saint Paul, MN).

After heparinization, cardiopulmonary bypass (CPB) was established under TEE guidance by way of cannulation of the left femoral vessels using the Port Access EndoCPB system (Heartport Inc). Starting CPB, the heart was decompressed and endoscopic pericardiotomy was performed. Cardioplegic arrest was achieved by antegrade crystalloid cardioplegia delivered to the aortic root by way of the Port Access aortic endoclamp. After a 7-mm arteriotomy of the LAD, the ITA was anastomosed end-to-side with a 7.0 running Prolene suture (Fumedica GmbH, Herne, Germany). Second, the ITA graft was anastomosed side-to-side to the first diagonal branch using a 6-mm length of arteriotomy. After deflation of the aortic endoclamp, the patient was weaned from CPB. Two chest tubes were inserted through the camera and left arm incision.

The total times in the operating room were 5.8 and 7.5 hours, the CPB times were 139 and 168 minutes and the aortic cross clamp times were 100 and 126 minutes, respectively. The patients were weaned from mechanical ventilation and extubated 6.0 and 6.5 hours postoperatively. Total chest tube drainages were 400 and 600 mL. Normal values were found for routine laboratory measures, including cardiac enzymes. The patients were transferred to the normal ward on the first postoperative day. Except for a moderate reperfusion injury of the cannulated right leg in the first patient, which was treated conservatively, the postoperative courses were uneventful. The angiography on the eighth postoperative day showed a patent ITA graft with good perfusion of the LAD and the diagonal branch in both patients (Fig 1).

View larger version (204K): [in this window] [in a new window]   Fig 1. Postoperative control angiography of a sequential left internal thoracic artery bypass to the left anterior descending coronary artery and the first diagonal branch.

	Comment

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	References

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1. Kirklin J.K., Westaby S., Blackstone E.H., Kirklin J.W., Chenoweth Pacifico A.D. Complement and the damaging effects of cardiopulmonary bypass. J Thorac Cardiovasc Surg 1983;86:845-857.[Abstract]
2. Stanbridge R.L., Hadjinikolao L.K. Technical adjuncts in beating heart surgery. Comparison of MIDCAB to off-pump sternotomy: a meta-analysis. Eur J Cardiothorac Surg 1999;16(Suppl 2):24-33.
3. Talwalkar N.G., Cooley D.A. Minimally invasive coronary artery bypass grafting. A review. Cardiol Rev 1998;6:345-349.[Medline]
4. Loulmet D., Carpentier A., d‘Attellis N., et al. Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments. J Thorac Cardiovasc Surg 1999;118:4-10.[Abstract/Free Full Text]
5. Autschbach R., Falk V., Walther T., Diegeler A., Mohr F.W. Robotic techniques. Z Kardiol 1999;88(Suppl 4):42-46.
6. Damiano R.J., Jr, Ehrman W.J., Ducko C.T., et al. Initial United States clinical trial of robotically assisted endoscopic coronary artery bpass grafting. J Thorac Cardiovasc Surg 2000;119:77-82.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Tayfun Aybek Stephan Mierdl Anton Moritz Gerhard Wimmer-Greinecker Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Dogan, S. Articles by Wimmer-Greinecker, G. Search for Related Content PubMed PubMed Citation Articles by Dogan, S. Articles by Wimmer-Greinecker, G. Related Collections Coronary disease