Robotic Coronary Revascularization

Robotic Coronary Artery Bypass (Robotic CABG) and Robotic Totally Endoscopic Coronary Artery Bypass (Robotic TECAB)

Supplying our hearts with blood are 3 main coronary arteries, the left anterior descending (LAD), the circumflex, and the right. As we age we develop narrowing of the arteries which is a condition known as atherosclerosis. Over time, atherosclerosis can cause the coronary arteries to become narrower and narrower (called stenosis) and eventually even become completely blocked. When blood flow to the heart is significantly reduced, the patient experiences this as chest pain. If blood flow is reduced too much, heart muscle can be lost which we call a heart attack. If a heart attack is severe enough, patients can die.

There are 3 main treatments for this condition. Medical therapy which usually includes medications known as beta blockers (which reduce your heart rate and blood pressure hence decreasing the amount of oxygen needed by your heart), ACE inhibitors (which lower your blood pressure), and nitrates (which dilate the coronary arteries helping to bring more blood to the heart muscle). If the blockages are focal and limited, the next line of therapy is usually angioplasty (dilating open the area of narrowing using a small balloon catheter that crosses the atherosclerotic narrowing) and stenting (placing a small hollow metal tube into the artery at the site of narrowing to help prevent recurrent stenosis). Although angioplasty can open areas of blockage without the addition of stenting, data has shown that usually results are improved if a stent is placed as well at the time of angioplasty. Your cardiologist has 2 main choices of stents, BMS (bare metal stents) and DES (drug eluting stents). Data has shown that DES have better long term patency then BMS however improved patency comes at a price. Current best treatment guidelines recommend, usually one year of dual antiplatelet therapy (Aspirin and Plavix) after placement of a DES.  In fact, some physicians recommend lifelong Plavix after placement of a DES to reduce the low but definite risk of late stent thrombosis (clotting of the stent). Taking any drug for life is often less than appealing to most.

Surgery is the third main arm of treatment. In traditional coronary artery bypass surgery, surgeons make a 10 -12 inch incision, and divide the breastbone in the midline. We then have access to all areas of the heart and are able to bring new blood to malnourished areas by sewing either an artery or vein to the diseased coronary arteries beyond their blockages. We almost always use the internal mammary arteries (which normally is a chest wall artery supplying the breastbone with blood) for at least one or two of these grafts, and the greater saphenous veins from the legs or the radial artery for the other bypass grafts.

Successful Robotic TECAB (LIMA to LAD) with postoperative angiogram performed by Dr. Jeffrey D. Lee, MD

 What is Hybrid Coronary Revascularization (HCR)

HCR combines the best of both the worlds of cardiac surgery and cardiology. It’s been well established that internal mammary artery grafts placed to the left anterior descending (LAD) can last a lifetime. In addition, drug eluting stents placed in selected non-LAD arteries have proven to be very durable,   oftentimes rivaling the patency rates of surgically placed saphenous vein grafts. Accordingly, why not combine these two modalities for the benefit of our patients? This combining of the best of the worlds of cardiac surgery and cardiology is called Hybrid Coronary Revascularization. When we perform robotic coronary artery bypass grafting (Robotic CABG), we utilize the Da Vinci Si surgical robot to dissect free the internal mammary artery from the chest wall and to expose the heart and diseased blood vessels. Then using a small 3 inch incision, we can perform a hand sewn anastomosis of the freed up mammary artery to the diseased blood vessel beyond the blockage. When we perform robotic totally endoscopic coronary artery bypass (Robotic TECAB), the entire procedure is completed through tiny “keyhole” port incisions. The patient’s anatomy and medical history primarily determines whether we perform a robotic CABG, robotic TECAB, or a traditional surgical approach. We are highly experienced in all of these approaches. These 2 robotic approaches (robotic CABG and robotic TECAB) bring the mammary arteries directly to your heart muscle in as minimally invasive a fashion as possible and completely avoid sternotomy!  If you have more than one or two arteries blocked, we work closely with our cardiology colleagues who are then able to perform angioplasty and stenting to other diseased coronary arteries in a hybrid coronary revascularization approach (HCR).  8 year angiographic patency of robotic assisted CABG grafts has been reported to be 93.4%.

You can click on these links to download two articles on this topic. Patency and TECAB

One of our patients 3 days after successful Robotic CABG.

Hybrid Coronary Revascularization

double vessel Robotic TECABDr. Johannes Bonatti and I with one of our patients 1 month after successful double vessel Robotic TECAB