Reasons for Conversion and Adverse Intraoperative Events in Robotically Enhanced Minimally Invasive Coronary Artery Revascularization

Abstract

<jats:sec><jats:title>Objective</jats:title><jats:p> The transition from sternotomy access to minimally invasive coronary artery bypass grafting is associated with steep learning curves. This study reports the reasons for sternotomy conversions from robotically enhanced minimally invasive direct coronary artery bypass grafting (RE-MIDCAB) and describes potential risk reduction strategies. </jats:p></jats:sec><jats:sec><jats:title>Methods</jats:title><jats:p> The perioperative data of 759 RE-MIDCAB patients (mean age 65.9 ± 10 years, 25.5% female, 30.2% multivessel disease) operated between July 1, 2002 and November 30, 2018 were reviewed for the reasons of conversion and adverse intraoperative events. Hybrid revascularization was planned in 204 (26.9%) patients. </jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p> Sternotomy conversion occurred in 30 (4.0%) patients. Lung adhesions and unsuccessful single-lung ventilation prohibited safe RE-MIDCAB internal thoracic artery (ITA) harvesting in 11 (36.7%) and 1 (3.3%) patients, respectively. ITA dysfunction ( n = 11, 36.7%) and inadequate target vessel visualization ( n = 3, 10.0%) were among the anatomical reasons for conversions. Adverse intraoperative events included ventricle perforation ( n = 1, 3.3%) and sustained ventricular arrhythmia ( n = 1, 3.3%). The in-hospital mortality and mean length of hospitalization for sternotomy conversion were 3.3% ( n = 1 of 30) and 13.4 ± 14.5 days, respectively. Perioperative morbidities included pneumonia ( n = 4, 13.3%). Premorbid renal dysfunction predicted sternotomy conversion at the 5% level of significance. </jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p> RE-MIDCAB provides an attractive surgical platform for primary- or hybrid coronary artery procedures. The progressive increase in patient risk profiles, strict quality control, and focus on clinical governance require awareness of reasons that potentially contribute RE-MIDCAB to sternotomy conversion to ensure safe and sustainable programs. </jats:p></jats:sec>

Minimally Invasive Coronary Revascularisation Surgery: A Focused Review of the Available Literature

“…When not performed as the primary operation, multiple studies have shown that MIDCAB can be performed in cases of reoperation. [ 94 – 99 ] As opposed to CABG reoperations, MIDCAB has proven to be more effective and not linked to increased mortality and morbidity. [ 100 , 101 ] MIDCAB is also a viable alternative to CABG and can also replace PCI in patients for whom PCI is either risky or impossible.…”

Predictors and outcomes of conversion to sternotomy in minimally invasive coronary artery bypass grafting

“…[ 7 , 9 - 11 ] Similar to the results of Christidis et al,[ 9 ] the most common cause of conversion was intramyocardial LAD in our study. In contrast, van der Merwe et al[ 10 ] showed that the most common causes of conversion were lung adhesions (36.7%) and LIMA dysfunction (36.7%). The main finding of our study is that older age is the only univariate risk factor for conversion.…”

Minimally invasive left internal mammary artery harvesting techniques during the learning curve are safe and achieve similar results as conventional LIMA harvesting techniques

“…A conversion that occurred in the very beginning during the docking period or access to hemithorax was classified as early conversion, while conversion which occurred after safe access was achieved was classified as later conversion. The reasons for conversion were lung adhesion 11 (36.7%), inadequate lung isolation 1 (3.3%), ITA dysfunction 11 (36.7%), poor target vessel visualization 3 (10%), and ventricular perforation, arrhythmia, acute heart failure, and anastomosis dysfunction 1 (3.3%) each [ 26 ]. We also had one LIMA damage in the RACAB group but harvesting in that case was fully completed.…”