RA-MIDCAB for younger individuals and high-risk patients

Robotic assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) has joined the armamentarium of cardiac surgeries at Penn Cardiac Surgery. Chase Brown, MD, who performs the surgery, discusses this innovative approach in a Penn Medicine Physician Interviews podcast.

The left anterior descending artery (LAD) is the largest of the major coronary branches and a major source of atherosclerotic occlusion. Blockages of the LAD, which supplies much of the blood to the heart muscle, are the target of two innovations in heart surgery—coronary artery bypass grafting (CABG) and coronary angioplasty.

CABG surgery involves harvesting the left internal mammary artery (LIMA) to use as a detour graft for the occluded LAD, the principal coronary artery. Angioplasty comprises placement of drug-eluting stents in the LAD.

In younger patients—those aged 40 to 60—traditional CABG has the disadvantage of requiring sternotomy. This is an impediment in younger patients, Dr. Brown observes, because it involves major surgery with a healing time that may extend to months, and restrictions in lifting, exercise, and daily activity. Stents have no such limitation, though restenosis can be an issue in some patient populations, notes Dr. Brown.

RA-MIDCAB: advancing on CABG

A minimally invasive option, RA-MIDCAB avoids major surgery by introducing the instruments and camera required of surgery through small incisions in the chest wall and extremities. Studies suggest that RA-MIDCAB outcomes for patency and survival are generally comparable to that of traditional CABG.

Because RA-MIDCAB offers an alternative to sternotomy, it is especially well suited to younger, active patients (40 to 60 years) for whom sternotomy would induce extended restrictions on activity. It is also ideal, Dr. Brown notes, for high-risk older patients whose comorbidities preclude sternotomy.

“For patients who are young, who can avoid a sternotomy, we can do a LIMA to LAD to bypass the proximal LAD lesion and avoid this open incision,” Dr. Brown says. “Using the robot, we can harvest the left internal mammary artery off the chest wall. We then remove the robot, and we make a small left thoracotomy. And then through that small incision, while the heart is still beating, we complete an off-pump, off-bypass anastomosis of the left internal mammary artery to the LAD.”

RA-MIDCAB Hybrid Procedures at Penn Cardiac Surgery

High-risk patients contraindicated for sternotomy with multivessel disease involving the LAD have few alternatives for treatment. In this population, combining RA-MIDCAB surgery with staged PCI as a hybrid procedure permits early alleviation of the principal blockage in the coronary arteries and addresses both the risk of sternotomy and the concerns of restenosis and consequent revascularization in multivessel disease.

“This approach allows us to revascularize patients who are not candidates for open sternotomy with a LIMA to LAD,” says Dr. Brown. “And a patient who traditionally would have lots of limitations and many months recovery can usually go home a lot quicker and oftentimes will not need to go to acute rehab.”

About Penn Cardiovascular Surgery

From transplantation to mechanical circulatory support to mitral and aortic valve disease, Penn Medicine’s cardiovascular surgeons are some of the most experienced in the region and the world at treating patients with heart disease. Penn’s continued growth in cardiovascular surgery is driven by tertiary and quaternary referrals for complex surgical procedures. Surgeons perform nearly 3,000 procedures annually with superior outcomes.

Referrals and Consultations

To refer a patient for RA-MIDCAB, please call 215-662-9595 or use our secure online referral form.