Open Heart surgery, but without the open heart and with robots!

         As we have discussed multiple times in class, cardiovascular disease is the leading cause of death in the United States. Not only can the disease itself lead to death, but complications from intervention to treat the disease can put an individual at risk as well. When possible, percutaneous coronary intervention (PCI) or stenting has become the gold standard for treating ischemic heart disease in the coronary vessels. It is minimally invasive and as long as patients continue their medication regimen, can have long lasting benefits. However, sometimes an individual’s disease is so extensive, they require a procedure that’s a little more drastic called Coronary Artery Bypass Grafting (CABG). With this procedure, a new pathway for blood to travel is constructed either using vein grafts (often saphenous vein grafts from the individuals own leg) or arterial grafts from the right or left Internal Mammary Arteries, located on the thoracic cavity wall. CABG has historically been an open-heart procedure, and still is to this day, requiring the sternum to be split and the ribs to be separated to expose the heart (kind of barbaric when you think about it). In 1998, however, the very first totally endoscopic coronary artery bypass (TECAB) was performed with the first generation da Vinci robotic system. No thoracotomy or sternotomy, just a few holes in the chest for those little robot arms to get into!

At first the only coronary artery that was bypassed was the Left Anterior Descending (LAD) artery via the LIMA. It was difficult to find information on why, however there is mention that the LAD is a large target artery which should make it easier on the physician to connect the LIMA to the LAD, and the LAD is located on the anterior portion of the heart, making it easier to access. Eventually, in 2007 the first bilateral IMA TECAB was performed, thus opening the possibility that this procedure can be performed on individuals with multi-vessel disease, not just disease to the LAD. During BL 618 lecture, I wondered if it was possible for this procedure to be done with vein grafts from the legs. I have not been able to find a definitive answer on this however there has been no mention of this in the research. It seems this would not make sense logistically to harvest vessels from the leg when the da Vinci robot has access to IMA through the incisions already made. The article by Canale et al. (2016) also mentioned hybrid procedures, where a surgeon could operate the da Vinci robot for the bypass portion of the procedure meanwhile another cardiologist could attempt stenting of other vessels in the case of multi-vessel disease.

Overall, TECAB seems like a great alternative to traditional open-heart CABG. The healing time is much quicker as patients are not waiting for their sternum to heal after the procedure which improves patient quality of life. When possible, most physicians will opt for less invasive techniques so the ability to do this surgery without cracking open someone’s chest is pretty amazing! Not to mention the graft patency rates after the procedure are comparable if not favorable compared to traditional open-heart CABG (Tinica et al., 2018 and Gong et al., 2016). So why aren’t we doing this at every hospital? Well…robots are expensive, and physicians need to train with this new technology before being able to operate on patients and there are a limited number of surgeons who are trained to perform this procedure. Hopefully with greater access this will become a more standard care option for patients in need.

Sources:

Canale, L., Mick, S., Mihaljevic, T., Nair, R., & Bonatti, J. (2013). Robotically assisted totally endoscopic coronary artery bypass surgery. Journal of Thoracic Disease 5(6), S641-S649. 10.3978/j.issn.2072-1439.2013.10.19

Gong, W., Cai, J., Wang, Z., Chen, A., Ye, X., Li, H., & Zhao, Q. (2016). Robot-assisted coronary artery bypass grafting improves short-term outcomes compared with minimally invasive direct coronary artery bypass grafting. Journal of Thoracic Disease 8(3), 459-468. 10.21037/jtd.2016.02.67

Tinica, G., Chistol, R., Enache, M., Constantin, M., Ciocoiu, M., & Furnica, C. (2018). Long-term graft patency after coronary artery bypass grafting: effects of morphological and pathophysiological factors. Anatolian Journal of Cardiology 20(5), 275-282. 10.14744/AnatolJCardiol.2018.51447