Robotic assisted minimally invasive direct coronary artery bypass grafting (RA-MIDCAB) for revascularization of the left anterior descending (LAD) coronary artery has joined the panoply of advanced cardiac procedures at Penn Cardiac Surgery.
RA-MIDCAB is performed via mini-thoracotomy, and has the advantage of avoiding both sternotomy and cardiopulmonary bypass. At Penn Cardiovascular Surgery, the procedure is offered to patients requiring single-vessel left internal mammary artery (LIMA)-to-LAD intervention as well as to patients at high risk for sternotomy and cardiopulmonary bypass. The LAD provides blood to the entire front wall of the heart muscle and is thus considered the principal target in coronary artery revascularization. The internal mammary arteries are preferred as pedicle grafts for their resistance to atherosclerosis.
RA-MIDCAB is also available at Penn Medicine as a component of staged hybrid procedures involving CABG followed at a later date by percutaneous coronary angioplasty.
Advantages of Robotic Total Arterial MIDCAB
Traditionally, CABG surgery involved harvesting of the saphenous vein — but this practice has been a source of concern in recent years. While the saphenous vein (SV) is easily harvested, lengthy, large in diameter, and technically easy to use, these advantages have been countered over time by evidence of deficiencies in graft longevity and patency. Between 10% to 20% of SV grafts fail within one year, and by 10 years post-CABG surgery, only about half are patent, and of these, only half are free of stenosis.
By comparison, arterial grafts, primarily those employing the mammary arteries, have demonstrated superior patency and durability in CABG, and a minimized need for reintervention. As a result, in part, revascularizations using arteries alone — so called total arterial procedures — are an increasing presence in CABG surgeries, including MIDCAB, and among robotic approaches that, enhanced by advanced instrumentation and visualization, offer simpler and safer access to the source arteries. Using the Robot, both the LIMA and RIMA can be safely harvested from the chest wall to be used as arterial grafts for the RA-MIDCAB procedure. The recognized benefits of robotic surgery (e.g., fewer complications, shorter hospital stay and faster recovery) are realized in robotic MIDCAB.
RA-MIDCAB Outcomes
Outcomes data for RA-MIDCAB are limited to relatively short-term, retrospective single-institution reports. However, most of these suggest generally excellent outcomes and safety for the procedure, particularly at high-volume surgical centers.
RA-MIDCAB Hybrid Procedures at Penn Cardiac Surgery
In patients with blockages of more than one of the major coronary arteries, revascularization of the affected vessels has been shown to improve functional status and outcomes. The treatment of multivessel disease, however, is influenced by the limitations of its interventions, which traditionally include open CABG and percutaneous coronary intervention (PCI). Research indicates that patients with complex multi-vessel coronary disease do better long-term with CABG vs PCI. However, not every patient is candidate for open CABG due to the invasive nature of the operation. Traditional open CABG has limitations, as well, in individuals who cannot have sternotomy. Patients contraindicated for sternotomy with multivessel disease involving the LAD thus have few alternatives for treatment.
A hybrid procedure now available at Penn Medicine offers a beneficial solution for patients with coronary blockages. Combining RA-MIDCAB LIMA-to-LAD with staged PCI, the approach permits early alleviation of the principal blockage in the coronary arteries and addresses both the risk of sternotomy and the concerns of complete revascularization in multivessel disease.
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.
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