Robotic Beating-Heart Totally Endoscopic Coronary Bypass (TECAB): LIMA to LAD

In this new CTSNet President’s Series, Dr. Husam Balkhy, president of ISMICS, showcases cutting-edge, totally endoscopic cardiac procedures from the University of Chicago. Watch for more videos in this series coming soon.    

Introduction 

This video presents a robotic beating-heart totally endoscopic coronary bypass (TECAB) procedure involving a single vessel, specifically, the left internal mammary artery (LIMA) to the left anterior descending (LAD) artery. The patient was a 69-year-old-male who was found to have 90 percent proximal LAD disease initially diagnosed via an abnormal calcium CT scan. He was mildly symptomatic, experiencing dyspnea on exertion. His preoperative Society of Thoracic Surgeons (STS) risk score was 1.8 percent, and his ejection fraction was 35 percent. Left heart catheterization (LHC) confirmed isolated LAD disease. The lesion was not amenable to percutaneous coronary intervention (PCI); therefore, the decision was made to proceed with a robotic beating-heart TECAB, a routine procedure at the authors’ institution. 

Procedure 

The authors’ standard TECAB procedure includes a beating-heart approach, use of the Da Vinci Si robot with the EndoWrist stabilizer, and lung isolation with a single-lumen endotracheal tube with a bronchial blocker. Robotic ports were placed in the left second, fourth, and sixth intercostal spaces. 

To begin, the pericardium was opened to identify all targets. A posterior pericardiotomy was also performed to reduce the incidence of postoperative atrial fibrillation (AF). The authors exclusively use internal mammary artery (IMA) conduits and employ a skeletonized harvesting approach. In this case, the left IMA was utilized, although the authors routinely use bilateral IMA conduits for multiarterial grafting. 

A 12 mm subcostal port was placed and the EndoWrist stabilizer was brought through this. A 5 mm AirSeal working port was placed in the anterior second intercostal space. The target vessel, in this case, the LAD, was exposed using low electrocautery. The stabilizer was controlled by the surgeon at the console and adjusted as needed for optimal visualization. The coronary snare, made for endoscopic procedures, was brought into the chest. Once placed, heparin was administered to achieve an activated clotting time (ACT) goal of 250-300 seconds. 

Intraluminal papaverine was administered into the IMA via a 20-gauge epidural catheter. The bedside assistant drew back on a syringe to ensure intraluminal position of the catheter. The catheter was then withdrawn, and the IMA was clipped, cut from the chest wall, and secured to one limb of the EndoWrist stabilizer. An arteriotomy was made in the target vessel using a snap-fit scalpel, a specialized instrument made for robotic procedures.  
A coronary shunt was utilized for all the authors’ TECAB procedures to increase coronary perfusion and decrease the time the coronary vessel is snared. The shunt is soft and flexible with low risk for intimal injury. Once placed, the target vessel was unsnared. 

The anastomosis was performed using a running suture technique with a double-armed 7-0 Pronova suture. This suture has notable features that help facilitate endoscopic anastomosis, including more memory and slightly less resistance to breakage compared to Prolene. The authors began with one needle to complete the posterior wall and heel of the anastomosis. Once completed, the authors switched to the other needle to complete the remainder of the anastomosis, including the toe. Water was gently squirted through a catheter that was secured to the stabilizer and controlled at the tableside as needed for visualization throughout the anastomosis. A unique advantage of the robotic approach is the enhanced visualization, allowing for every bite to be highly precise. 

Once the anastomosis was nearly complete, the snare was tightened, and the shunt was removed. Throughout the procedure, and particularly during this time when the target was snared, the authors closely monitored the patient’s hemodynamics and EKG tracing. Once the anastomosis was complete, the vessel was unsnared and the stabilizer was carefully removed from the anterior surface of the heart. 

Flow was checked using transit time flowmetry. In this case, the flow probe was brought in through the 12 mm subcostal port rather than the working port, which was only 5 mm. Once flow was checked and found to be satisfactory, the authors administered protamine, ensured hemostasis, closed the anterior mediastinal fat and pericardium, and placed a single 24F Blake drain. 

Conclusion 

The patient underwent a successful beating-heart robotic TECAB with LIMA to LAD via a running sutured technique, with good intraoperative flows. He was extubated in the operating room and discharged on postoperative day one. At the one-month clinic follow-up visit, he had no issues, reported no opioid use after discharge from the hospital, and had returned to normal activities on postoperative day two. 

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