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Ann Thorac Surg 2005;79:2138-2141
© 2005 The Society of Thoracic Surgeons

Case report

Robotic Totally Endoscopic Coronary Artery Bypass and Catheter Based Coronary Intervention in One Operative Session

Johannes Bonatti, MDa,*, Thomas Schachner, MDa, Nikolaos Bonaros, MDa, Günther Laufer, MDa, Christian Kolbitsch, MDb, Josef Margreiter, MDb, Patrycja Jonetzko, MDc, Otmar Pachinger, MDc, Guy Friedrich, MDc

a Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria
b Department of Cardiac Anesthesiology, Innsbruck Medical University, Innsbruck, Austria
c Department of Cardiology, Innsbruck Medical University, Innsbruck, Austria

Accepted for publication December 10, 2003.

* Address reprint requests to Dr Bonatti, Department of Cardiac Surgery, University of Innsbruck, Anichstrasse 35, A-6020, Innsbruck, Austria (E-mail: johannes.o.bonatti{at}uibk.ac.at).


   Abstract
Top
 Abstract
Introduction
 Comment
 Acknowledgments
 References
 
A 56-year-old male patient underwent robotically assisted totally endoscopic left internal mammary artery (LIMA) to left anterior descending artery (LAD) grafting. After protamine administration complete heart block developed in the patient. On intraoperative angiography the LIMA to LAD graft was perfectly patent but an acute occlusion of the right coronary artery (RCA) was noted. We performed an immediate on table percutaneous coronary angioplasty and stent placement to the RCA. The heart regained sinus rhythm and the wall motion abnormalities on the back wall of the heart resolved. No clinical symptoms indicating ongoing myocardial ischemia were noted postoperatively. This case demonstrates that a hybrid procedure of robotic totally endoscopic coronary artery bypass grafting and catheter based coronary intervention is feasible in one simultaneous session.


   Introduction
Top
 Abstract
 Introduction
Comment
 Acknowledgments
 References
 
Despite advances in interventional cardiology the left internal mammary artery (LIMA) seems to remain the best revascularization strategy for the left anterior descending artery (LAD). For the right coronary artery (RCA) and circumflex artery (Cx) territory, however, catheter based intervention can compete well with surgical strategies. These are reasons why, with the advent of small access or totally endoscopic techniques of LIMA to LAD placement [1–3], combinations of surgery and catheter intervention have been discussed [4–7]. These integrated or so-called hybrid procedures have, in the majority of cases, been carried out in a staged manner but would ideally be performed simultaneously.

A 56-year-old male patient presented with angina Canadian Cardiovascular Society Class III. Echocardiography revealed a left ventricular ejection fraction of 53% without regional wall motion abnormalities or valvular dysfunction. On coronary angiography a complex proximal high grade stenosis of the left anterior descending artery close to the left main stem as well as diffuse arteriosclerosis of the right and circumflex coronary arteries were noted. Figure 1 shows the preoperative findings on the LAD and on the RCA. As a catheter intervention on the LAD lesion was considered as high risk and as no significant comorbidities were present, the patient was scheduled for a totally endoscopic coronary artery bypasss (TECAB) procedure using the daVinci (Intuitive Surgical, Sunnyvale, CA) telemanipulation system.



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  		Fig 1. On preoperative angiography a complex high grade left anterior descending artery stenosis was noted (left panel, arrow). The right coronary artery showed diffuse arteriosclerosis (right panel).

 
Under general anesthesia and left lung collapse a camera port and two working ports were introduced into the left lateral chest. The LIMA was harvested under thoracoscopic vision. After systemic heparinization the right atrium was cannulated with a 25F cannula introduced through the left femoral vein and a 21F ESTECH remote access perfusion (RAP) cannula (ESTECH, Danville, CA) was introduced through the left femoral artery and placed in the ascending aorta. Cardiopulmonary bypass was started and the heart was arrested after inflation of the ascending aortic occlusion balloon of the RAP cannula. The LIMA to LAD anastomosis was carried out endoscopically using a 7 to 0 Pronova suture (Ethicon Inc, Edinburgh, UK). Sinus rhythm was reconstituted after release of the aortic occlusion balloon and the patient was weaned from cardiopulmonary bypass without difficulties. Cardiopulmonary bypass time and aortic cross-clamp time were 140 minutes and 84 minutes, respectively. Total heparin dose was 30,000 IU reaching a maximum activated clotting time level of 1,076 seconds. For reversal of heparin 30,000 IU mg of protamine were administered intravenously.

Shortly after heparin reversal complete heart block developed, which required a short period of cardiopulmonary resuscitation. The patient’s hemodynamics were restored after insertion of a temporary pacemaker. On transesophageal echocardiography (TEE), hypokinesia of the posterior wall of the heart was observed. Electrocardiogram monitoring showed ST segment elevation more than 3 mm in leads II, III, and aVF.

On the intraoperative coronary angiography, using a GE OEC 9800 mobile C-arm (General Electric Co), an acute occlusion of the RCA at the distal part was noted, whereas the LIMA to LAD graft was perfectly patent (Fig 2). Percutaneous transluminal coronary angioplasty (PTCA) of the RCA was carried out using a Crossail 2.5/15 mm balloon catheter (Guidant Corp). Additionally a Medtronic driver 3.5/15 mm stent (Medtronics, Minneapolis, MN) was placed due to angiographic haziness and suspected recoil. The stenosis grade was reduced from 100% to 0% and thombolysis in myocardial infarction (TIMI) III flow was present (Fig 3). The heart regained sinus rhythm and the wall motion abnormalities resolved. The patient was transferred to the intensive care unit with stable hemodynamics. Postoperative bleeding was negligible and clopidogrel 150 mg and 100 mg of aspirin were administered 3 hours postoperatively. The patient was extubated and transferred to the regular ward after 6 and 15 hours, respectively. Maximum creatine kinase (CK), MB isoenzyme CK (CK-MB), and troponin I levels were 6,280 U/l, 137 U/l, and 192 µg/L, respectively. No angina or other clinical symptoms indicating ongoing myocardial ischemia were noted. The patient was discharged home on the fourth postoperative day. The predischarge transthoracic echocardiogram showed full recovery of the left and right ventricular wall motion abnormalities.



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  		Fig 2. Intraoperative angiography showed a patent left internal mammary (LIMA) artery graft to the left anterior descending (LAD) artery (left panel). Percutaneous transluminal coronary angioplasty and stent placement were carried out on the intraoperatively occluded right coronary artery (right panel, arrow).

 


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  		Fig 3. The occluded right coronary artery on intraoperative angiography before (left panel, arrow) and after catheter intervention (left panel).

 

   Comment
Top
 Abstract
 Introduction
 Comment
Acknowledgments
 References
 
This case demonstrates that totally endoscopic coronary artery bypass grafting and a catheter based coronary intervention is feasible in one simultaneous session. An acute PTCA and stent placement for evolving myocardial infarction was carried out under fully controlled conditions, having all the requirements needed for surgical intervention should the catheter intervention fail acutely. In our opinion medical (systemic or local fibrinolysis) or surgical revascularization strategies (conventional or minimally invasive) would have delayed the revascularization process and would most probably have caused major irreversible myocardial damage or severe bleeding complications. As potential causes of the RCA occlusion in this case, coagulation disturbances during heparin reversal as well as embolism from the aortic occlusion procedure can be discussed.

Simultaneous hybrid coronary revascularization offers exciting possibilities for minimally invasive treatment of multivessel coronary artery disease. The LIMA to LAD bypass grafting can be performed through small port holes on the left thorax using robotic technology [1–3]. However, long operative times and technical difficulties in reaching the back wall of the heart have so far precluded totally endoscopic multivessel bypass grafting. Combinations between minimally invasive LIMA to LAD grafting and catheter based intervention have only been performed in a staged manner for patients with multivessel disease [4–7]. An integrated teamwork of cardiologists and cardiac surgeons [8] in the same operating room and/or cath lab seems a reasonable approach for the future, combining totally endoscopic surgery and percutaneous coronary intervention for a minimally traumatic revascularization process that offers advantages of both catheter intervention and surgery [9].


   Acknowledgments
Top
 Abstract
 Introduction
 Comment
 Acknowledgments
References
 
The authors have received a research grant from Intuitive Surgical (Sunnyvale, CA).


   References
Top
 Abstract
 Introduction
 Comment
 Acknowledgments
 References
 

  1. 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]
  2. Dogan S, Aybek T, Andressen E, et al. Totally endoscopic coronary artery bypass grafting on cardiopulmonary bypass with robotically enhanced telemanipulationreport of forty-five cases. J Thorac Cardiovasc Surg 2002;123:1125-1131.[Abstract/Free Full Text]
  3. Bonatti J, Schachner T, Bernecker O, et al. Robotic totally endoscopic coronary artery bypassprogram development and learning curve issues. J Thorac Cardiovasc Surg 2004;127:504-510.[Abstract/Free Full Text]
  4. Friedrich GJ, Bonatti J, Dapunt OE. Preliminary experience with minimally invasive coronary-artery bypass surgery combined with coronary angioplasty N Engl J Med 1997;336:1454-1455.[Medline]
  5. Friedrich GJ, Bonatti J, Pachinger O. Minimally invasive coronary bypass surgeryan example for optimal teamwork between cardiologists and cardiac surgeons?. Circulation 1999;99:2967.[Free Full Text]
  6. Riess FC, Bader R, Kremer P, et al. Coronary hybrid revascularization from January 1997 to January 2001a clinical follow-up. Ann Thorac Surg 2002;73:1849-1855.[Abstract/Free Full Text]
  7. Wittwer T, Cremer J, Boonstra P, et al. Myocardial "hybrid" revascularisation with minimally invasive direct coronary artery bypass grafting combined with coronary angioplastypreliminary results of a multicentre study. Heart 2000;83:58-63.[Abstract/Free Full Text]
  8. Fonger JD. Integrated myocardial revascularization Eur J Cardiothorac Surg 1999;16(Suppl 2):S12-S17.[Medline]
  9. Drenth DJ, Veeger NJ, Winter JB, et al. A prospective randomized trial comparing stenting with off-pump coronary surgery for high-grade stenosis in the proximal left anterior descending coronary arterya three-year follow-up. J Am Coll Cardiol 2002;40:1955-1960.[Abstract/Free Full Text]



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This Article
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Günther Laufer
Guy Friedrich
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