Beating Heart Totally Endoscopic Coronary Artery Bypass

Ann Thorac Surg 2010;89:1873-1880. doi:10.1016/j.athoracsur.2010.03.014
© 2010 The Society of Thoracic Surgeons

By Sudhir Srivastava, MD^a,d,*, Suresh Gadasalli, MD^b, Madhava Agusala, MD^b, Ram Kolluru, MD^b, Reyna Barrera, PAC^a,d,Shaune Quismundo, RN, BSN^a,d, Usha Kreaden, MS^c, Valluvan Jeevanandam, MD^d

^a Cardiac Surgical Associates of West Texas, Odessa, Texas
^b Alliance Hospital, Odessa, Texas
^c Intuitive Surgical Inc, Sunnyvale, California
^d University of Chicago Medical Center, Chicago, Illinois

Accepted for publication March 4, 2010.

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008

Abstract

Background: Graft patency and clinical freedom from graft failure remains a subject of investigation in beating-heart totally endoscopic coronary artery bypass.

Methods: A total of 214 patients underwent successful beating-heart totally endoscopic coronary artery bypass from July 2004 to June 2007. Single-, double-, and triple-vessel beating-heart totally endoscopic coronary artery bypass was performed in 139, 68, and 7 patients, respectively. Fifty patients underwent planned hybrid revascularization. Eighty percent of patients (172 of 214) underwent computed tomography angiography or conventional angiography within 3 months from the time of surgery. On computed tomography angiography, the analysis included gross patency, stenosis within the graft,and contrast in the grafted coronary artery. A FitzGibbon score was used to analyze graft patency and anastomosis in patients undergoing conventional angiography. Clinical follow-up was done in all patients for any major adverse cardiac event in relation to the revascularized coronary arteries.

Results: There was no myocardial infarction, operative mortality, or conversion to cardiopulmonary bypass. All patients who had computed tomography angiography were found to have grossly patent graft without stenosis and demonstrated opacification of the grafted coronary artery. Fifty-seven grafts were studied in 39 patients by conventional angiography postoperatively during hybrid revascularization. At the time of study, all grafts except one had FitzGibbon grade A anastomosis and Thrombolysis In Myocardial Infarction grade 3 flow. Three patients (1.4%) required reintervention at 2, 3, and 13 months after initial beating-heart totally endoscopic coronary artery bypass.

Conclusions: The clinical freedom from graft failure noted in 98.6% patients appears to be excellent. Further angiographic and clinical follow-up is required to determine the long-term results.

The complete article is available via The Annals of Thoracic Surgery website (payment required).

Planned Simultaneous Beating-heart Totally Endoscopic Coronary Artery Bypass (TECAB) and Percutaneous Intervention in a Single Operative Setting

Innovations, Volume 1, Number 5, Fall, 2006

Sudhir Srivastava, Suresh Gadasalli, Orlando Tijerina, Reyna Barrera, Shaune Quismundo, and Vishwa Srivastava

Abstract

Background: Staged hybrid revascularization integrated with minimally invasive coronary artery bypass grafting (CABG) and arrested heart totally endoscopic CABG has been reported. We report the first case of planned simultaneous hybrid coronary revascularization, integrating beating-heart TECAB, and percutaneous intervention (PCI) in the same operative setting.

Methods: A 73-year-old woman with symptoms of angina and a history of diabetes was found to have 2-vessel coronary artery disease involving the left anterior descending (LAD) and the right coronary artery (RCA). Left internal thoracic artery (LITA) to the LAD grafting was done on a beating heart in a totally endoscopic manner using the da Vinci robotic system through 4 ports. Immediately after LITA to LAD TECAB, percutaneous angioplasty and stent placement was done through the right femoral artery using the OEC 9800 mobile C-arm in the operating room.

Results: There was no stenosis noted in the RCA after the intervention. LITA angiography showed a completely patent anastomosis. The total operative time for both procedures was 165 minutes. Occlusion and anastomotic times were 14 and 8 minutes, respectively. Total PCI and fluoroscopy times were 10 and 3 minutes, respectively. The patient received clopidogrel (Plavix) and aspirin in the immediate postoperative period and was discharged home on the second postoperative day.

Conclusion: This planned hybrid approach involving a beating heart single-vessel TECAB and simultaneous angioplasty-stent in a single operative setting achieved complete coronary artery revascularization in a less invasive way.

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Enhanced External Counterpulsation and Future Directions
Step Beyond Medical Management for Patients With Angina and Heart Failure

J Am Coll Cardiol, 2007; 50:1523-1531, doi:10.1016/j.jacc.2007.07.024 (Published online 1 October 2007).
© 2007 by the American College of Cardiology Foundation

By: Aarush Manchanda, MD and Ozlem Soran, MD, MPH, FACC, FESC
Washington, DC; and Pittsburgh, Pennsylvania

Abstract

Between 25,000 and 75,000 new cases of angina refractory to maximal medical therapy and standard coronary revascularization procedures are diagnosed each year. In addition, heart failure also places an enormous burden on the U.S. health care system, with an estimated economic impact ranging from $20 billion to more than $50 billion per year. The technique of counterpulsation, studied for almost one-half century now, is considered a safe, highly beneficial, low-cost, noninvasive treatment for these angina patients, and now for heart failure patients as well. Recent evidence suggests that enhanced external counterpulsation (EECP) therapy may improve symptoms and decrease long-term morbidity via more than 1 mechanism, including improvement in endothelial function, promotion of collateralization, enhancement of ventricular function, improvement in oxygen consumption (VO₂), regression of atherosclerosis, and peripheral training effects similar to exercise. Numerous clinical trials in the last 2 decades have shown EECP therapy to be safe and effective for patients with refractory angina with a clinical response rate averaging 70% to 80%, which is sustained up to 5 years. It is not only safe in patients with coexisting heart failure, but also is shown to improve quality of life and exercise capacity and to improve left ventricular function long-term. Interestingly, EECP therapy has been studied for various potential uses other than heart disease, such as restless leg syndrome, sudden deafness, hepatorenal syndrome, erectile dysfunction, and so on. This review summarizes the current evidence for its use in stable angina and heart failure and its future directions.

Click to view page with reference to Dr. Gadasalli's publication

Planned Simultaneous Beating-heart Totally Endoscopic Coronary Artery Bypass (TECAB) and Percutaneous Intervention in a Single Operative Setting

Innovations, Volume 1, Number 5, Fall, 2006

Sudhir Srivastava, Suresh Gadasalli, Orlando Tijerina, Reyna Barrera, Shaune Quismundo, and Vishwa Srivastava

Abstract

Background: Staged hybrid revascularization integrated with minimally invasive coronary artery bypass grafting (CABG) and arrested heart totally endoscopic CABG has been reported. We report the first case of planned simultaneous hybrid coronary revascularization, integrating beating-heart TECAB, and percutaneous intervention (PCI) in the same operative setting.

Methods: A 73-year-old woman with symptoms of angina and a history of diabetes was found to have 2-vessel coronary artery disease involving the left anterior descending (LAD) and the right coronary artery (RCA). Left internal thoracic artery (LITA) to the LAD grafting was done on a beating heart in a totally endoscopic manner using the da Vinci robotic system through 4 ports. Immediately after LITA to LAD TECAB, percutaneous angioplasty and stent placement was done through the right femoral artery using the OEC 9800 mobile C-arm in the operating room.

Results: There was no stenosis noted in the RCA after the intervention. LITA angiography showed a completely patent anastomosis. The total operative time for both procedures was 165 minutes. Occlusion and anastomotic times were 14 and 8 minutes, respectively. Total PCI and fluoroscopy times were 10 and 3 minutes, respectively. The patient received clopidogrel (Plavix) and aspirin in the immediate postoperative period and was discharged home on the second postoperative day.

Conclusion: This planned hybrid approach involving a beating heart single-vessel TECAB and simultaneous angioplasty-stent in a single operative setting achieved complete coronary artery revascularization in a less invasive way.

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Use of Bilateral Internal Thoracic Arteries in CABG Through Lateral Thoracotomy With Robotic Assistance in 150 Patients

Annals of Thoracic Surgery, March, 2006

Sudhir Srivastava, MD, Suresh Gadasalli, MD, Madhava Agusala, MD, Ram Kolluru, MD, Jayaram Naidu, MD, Manish Shroff, MD, Reyna Barrera, PAC, Shaune Quismundo, RN, Vishwa Srivastava, BA

Abstract

BACKGROUND: Internal thoracic arteries (ITA) have been shown to offer longergraft patency. Off-pump coronary artery bypass graft surgery(CABG) through small lateral thoracotomy has been reported. The present study deals with feasibility of using bilateral ITAs (BITA) in CABG through small lateral thoracotomy facilitated by the da Vinci robotic system.

METHODS: Since July 2002, 150 patients underwent CABG through small lateral thoracotomy using robotic assistance for harvesting of BITA. After single lung ventilation, three 1- to 2-cm incisions were made in the third, fifth, and seventh intercostal spaces 2 to 3 cm medial to the anterior axillary line. After insertion of camera and instrument arms, both ITAs were harvested in a completely skeletonized fashion. A small anterolateral thoracotomy was done, enlarging the camera port incision. Distal anastomoses were performed on a beating heart using nitinol surgical clips. Intercostal cryoanalgesia and local anesthetic infusion were used for pain management.

RESULTS: Planned arterial revascularization was completed in 148 patients. Mean number of arterial grafts per patient was 2.6 ± 0.8. All coronary arteries could be reached with BITA as in situ or composite grafts. There was no mortality, stroke, myocardial infarction, or wound infection. Seven patients had new onset atrial fibrillation. Four patients required exploration of postoperative bleeding. Mean postoperative length of stay was 3.6 ± 2.9 days.

CONCLUSIONS: The da Vinci robotic system was found to be safe and feasible for BITA harvesting in multivessel CABG through small lateral thoracotomy. Further follow-up for graft patency is necessary. Postoperative pain may be reduced with aggressive management strategies. The approach offers fast recovery. This sternum-sparing approach may be an evolutionary step toward closed-chest coronary artery bypass graft surgery.

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Successful Treatment of Symptomatic Coronary Endothelial Dysfunction With Enhanced External Counterpulsation

Mayo Clinic Proceedings, May, 2004

PIERO BONETTI, MD; SURESH N. GADASALLI, MD; AMIR LERMAN, MD; GREGORY W. BARSNESS, MD

From the Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic College of Medicine, Rochester, Minn (P.O.B., A.L., G.W.B.); and Healthy Heart Center, Odessa, Tex (S.N.G.). Dr Bonetti is now with University Hospital, Basel, Switzerland.

Abstract

Enhanced external counterpulsation (EECP) is a valuable therapeutic option for patients with coronary artery disease and refractory angina. Although the exact mechanisms by which this technique exerts favorable effects remain unclear, improvement in endothelial function is considered a potential mechanism contributing to the clinical benefit associated with EECP. We describe a young woman with severely symptomatic coronary endothelial dysfunction in the absence of obstructive coronary artery disease who experienced a dramatic and sustained reduction in symptoms in response to a standard 35-hour course of EECP.

Mayo Clin Proc. 2004;79:690-692

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