Commentary: Robotic totally endoscopic coronary artery bypass: State of an art

Central MessageTECAB is a demanding endeavor and requires the utmost skilled teamwork, dedication, and leadership. Involved teams should carefully appraise each step toward approaching this expertise.See Article page 153. TECAB is a demanding endeavor and requires the utmost skilled teamwork, dedication, and leadership. Involved teams should carefully appraise each step toward approaching this expertise. See Article page 153. Totally endoscopic coronary artery bypass (TECAB) with robotic assistance can be performed for single left internal thoracic artery–left anterior descending or multivessel grafting, either on the beating or arrested heart, with or without recourse to a small anterolateral thoracotomy. Conventionally, handsewn coronary anastomoses are undertaken via a small left thoracotomy; however, a complete port-based approach can also be used to perform the anastomoses by using endoscopic tools such as nickel-titanium suture clips (U-CLIP; Medtronic Inc, Minneapolis, Minn) or even automated anastomotic devices such as the now-defunct C-Port Flex (Cardica, Redwood City, Calif). TECAB can achieve standalone revascularization or be part of hybrid coronary revascularization, where grafting of the anterior (left anterior descending artery) with or without lateral (circumflex artery) surfaces of the heart is combined with percutaneous coronary intervention to the remaining target vessels.1Toeg H. Al-Atassi T. Labinaz M. Le May M. Ruel M. Hybrid approach for coronary artery revascularization: where do we stand?.Curr Opin Cardiol. 2014; 29: 534-541Crossref PubMed Scopus (5) Google Scholar In this edition of JTCVS Techniques, Dr Balkhy, a leading robotic cardiac surgeon, shares his thoughts on TECAB and his advocacy for the adoption and development of this modality.2Balkhy H.H. Robotic totally endoscopic coronary artery grafting bypass grafting: it's now or never!.J Thorac Cardiovasc Surg Tech. 2021; 10: 153-157Scopus (2) Google Scholar In more than 900 cases, Dr Balkhy has widened the scope of the TECAB approach by incorporating even some high-risk patients. The biggest advantage of a robotic approach to coronary artery bypass grafting (CABG), even if restricted to conduits takedown, is indeed the availability to harvest bilateral internal thoracic arteries while avoiding sternotomy and aortic manipulations, which may improve the functional recovery of the patient.3Gobolos L. Ramahi J. Obeso A. Bartel T. Hogan M. Traina M. et al.Robotic totally endoscopic coronary artery bypass grafting: systematic review of clinical outcomes from the past two decades.Innovations (Phila). 2019; 14: 5-16Crossref PubMed Scopus (16) Google Scholar,4Guo M.H. Wells G.A. Glineur D. Fortier J. Davierwala P.M. Kikuchi K. et al.Minimally Invasive coronary surgery compared to STernotomy coronary artery bypass grafting: the MIST trial.Contemp Clin Trials. 2019; 78: 140-145Abstract Full Text Full Text PDF PubMed Scopus (21) Google Scholar However, there remain concerns regarding a greater incidence of transfusions, rare but eventful conversions to sternotomy or thoracotomy, early graft failure and reinterventions,5Manuel L. Fong L.S. Wolfenden H. Bassin L. Is totally endoscopic coronary artery bypass grafting compared with minimally invasive direct coronary artery bypass grafting associated with superior outcomes in patients with isolated left anterior descending disease?.Ann Med Surg (Lond). 2020; 57: 264-267Crossref PubMed Scopus (1) Google Scholar,6Kofler M. Schachner T. Reinstadler S.J. Stastny L. Dumfarth J. Wiedemann D. et al.Comparative analysis of perioperative and mid-term results of TECAB and MIDCAB for revascularization of anterior wall.Innovations (Phila). 2017; 12: 207-213Crossref PubMed Scopus (10) Google Scholar a similar rate of mortality, stroke, atrial fibrillation, and renal failure compared with conventional CABG.3Gobolos L. Ramahi J. Obeso A. Bartel T. Hogan M. Traina M. et al.Robotic totally endoscopic coronary artery bypass grafting: systematic review of clinical outcomes from the past two decades.Innovations (Phila). 2019; 14: 5-16Crossref PubMed Scopus (16) Google Scholar Costs are also high, with an initial investment exceeding several millions US dollars and additional operational costs between $100,000 and $150,000 per annum. One can only share Dr Balkhy's enthusiasm and admire his expert view of the TECAB approach. However, we must also remember that TECAB has not been deemed superior to other minimally invasive approaches such as minimally invasive coronary surgery (MICS) CABG,7Lapierre H. Chan V. Sohmer B. Mesana T.G. Ruel M. Minimally invasive coronary artery bypass grafting via a small thoracotomy versus off-pump: a case-matched study.Eur J Cardiothorac Surg. 2011; 40: 804-810PubMed Google Scholar,8McGinn Jr., J.T. Usman S. Lapierre H. Pothula V.R. Mesana T.G. Ruel M. Minimally invasive coronary artery bypass grafting: dual-center experience in 450 consecutive patients.Circulation. 2009; 120: S78-S84Crossref PubMed Scopus (126) Google Scholar both in terms of financial implications as well as patient outcomes. As an alternative, conventional MICS CABG allows for revascularization of the entire myocardium, affords the use of bilateral internal thoracic artery or multiple arterial grafts (by way of the radial artery), is associated with very low mortality,7Lapierre H. Chan V. Sohmer B. Mesana T.G. Ruel M. Minimally invasive coronary artery bypass grafting via a small thoracotomy versus off-pump: a case-matched study.Eur J Cardiothorac Surg. 2011; 40: 804-810PubMed Google Scholar and obviates the huge financial implications of TECAB. To achieve best results with TECAB, one needs significant team commitment, talent, resources, and a large-volume practice. It has surgeon-, team-, and institution-specific learning curves that allow best results only in the hands of “skilled enthusiasts.”9Lee J.D. Srivastava M. Bonatti J. History and current status of robotic totally endoscopic coronary artery bypass.Circ J. 2012; 76: 2058-2065Crossref PubMed Scopus (32) Google Scholar, 10Robicsek F. Robotic cardiac surgery: time told!.J Thorac Cardiovasc Surg. 2008; 135: 243-246Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar, 11Une D. Lapierre H. Sohmer B. Rai V. Ruel M. Can minimally invasive coronary artery bypass grafting be initiated and practiced safely? A learning curve analysis.Innovations (Phila). 2013; 8: 403-409Crossref PubMed Scopus (29) Google Scholar While there are signs that the uptake of TECAB may have increased both in North America and in European countries,12Pettinari M. Navarra E. Noirhomme P. Gutermann H. The state of robotic cardiac surgery in Europe.Ann Cardiothorac Surg. 2017; 6: 1-8Crossref PubMed Scopus (26) Google Scholar much of its use is currently restricted to harvesting the left internal thoracic artery, whereas conventional MICS CABG appears to be a much more rapidly developing multivessel platform. Nonetheless, Dr Balkhy demonstrates to us what is possible with robotic technology in the hands of a dedicated robotic surgeon and as a culmination of skilled teamwork, dedication, and leadership. It remains imperative, however, that we carefully anticipate, measure, and prepare for each step when such a demanding endeavor as developing a TECAB program is undertaken. Robotic totally endoscopic coronary artery bypass grafting: It's now or never!JTCVS TechniquesVol. 10PreviewFeature Editor's Introduction—Robotic totally endoscopic coronary artery bypass grafting represents the most advanced form of coronary surgery. After initial enthusiasm, the technique has not been largely adopted by the surgical community and it is currently performed by only a few technical masters. Dr Husam Balkhy presents a superb review of the technique and an important perspective on its possible future. I'm sure readers will enjoy reading it as much as I did. Full-Text PDF Open Access

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