Eric Lehr - Academia.edu (original) (raw)

Papers by Eric Lehr

Research paper thumbnail of Robotic mitral valve surgery

European Surgery, 2011

Background: Robotic mitral valve surgery has evolved and matured into a safe and reproducible pro... more Background: Robotic mitral valve surgery has evolved and matured into a safe and reproducible procedure at multiple worldwide centers of excellence.

Research paper thumbnail of Robotic-assisted cryosurgical treatment of atrioventricular node reentrant tachycardia

Innovations (Philadelphia, Pa.), 2011

Atrioventricular nodal reentrant tachycardias typically arise from the existence of variable refr... more Atrioventricular nodal reentrant tachycardias typically arise from the existence of variable refractoriness in fast and slow conduction pathways within the triangle of Koch, which provide input to the atrioventricular node. Standard therapy includes medical management and catheter-based ablation procedures. Robotic-assisted, minimally invasive cryosurgical modification of the atrioventricular node can provide definitive therapy for patients who fail traditional therapy. A 65-year-old man presented with a several-year history of recurrent atrioventricular nodal reentrant tachycardia. Despite medical management and attempted percutaneous ablation, the patient remained symptomatic with weekly episodes. Access was via a 4-cm right anterolateral thoracotomy and peripheral perfusion. The da Vinci S robotic system was used to manipulate the cryoprobe (CryoMaze Probe; ATS Medical, Plymouth, MN USA). A series of spot freezes (tip 60°C) were made along the boundaries of the triangle of Koch u...

Research paper thumbnail of Robotic total endoscopic coronary artery bypass hybrid revascularization procedure in a patient with a preoperative tracheostoma

Interactive cardiovascular and thoracic surgery, 2011

Preoperative tracheostoma presents a significant risk of sternal wound complications, mediastinit... more Preoperative tracheostoma presents a significant risk of sternal wound complications, mediastinitis, stoma necrosis and tracheal injury in patients requiring cardiac surgery. Several approaches have been described to limit these risks. Robotic totally endoscopic coronary artery bypass grafting in patients with a tracheostoma has not been reported. We describe a case of completely endoscopic coronary surgery using the daVinci(®) Si™ system in a patient with a tracheostoma. Single left internal mammary artery grafting to the left coronary artery system was carried out successfully as the first stage of a hybrid revascularization and followed by percutaneous coronary intervention to the circumflex coronary artery. We regard this technique as the most minimally-invasive method of surgical coronary revascularization with a significant potential to reduce the risk of mediastinitis in patients with a tracheostoma.

Research paper thumbnail of Hybrid coronary revascularization – techniques and outcome

European Surgery, 2011

ABSTRACT BACKGROUND: Hybrid coronary revascularization combines minimally invasive coronary arter... more ABSTRACT BACKGROUND: Hybrid coronary revascularization combines minimally invasive coronary artery bypass grafting (CABG) and catheter-based coronary intervention for the treatment of multivessel coronary artery disease. This concept represents an alternative to open multivessel bypass surgery through sternotomy and to multivessel percutaneous intervention (PCI). The former is highly invasive but very effective in the long term; the latter is less invasive but results in more repeat revascularization procedures. METHODS: The surgical part of hybrid coronary intervention can be performed through thoracic mini-incisions and in completely endoscopic fashion. Robotic technology such as the daVinci ® surgical telemanipulation system is increasingly used. Percutaneous interventions in hybrid procedures include implantation of bare metal stents and drug eluting stents. RESULTS: After 15 years of development, the literature reports mortality rates in the one percent range which may be lower than in open bypass surgery. Several studies demonstrate significantly earlier recovery and return to normal activities after hybrid intervention than after heart bypass surgery through sternotomy. Long-term follow-up studies show similar survival compared to survival after multivessel CABG and multivessel PCI. The rate of reinterventions and major adverse events, however, may be lower than after multivessel PCI, and closer to rates after open CABG. CONCLUSIONS: Hybrid revascularization represents a promising concept for treatment of coronary multivessel disease. KeywordsCoronary artery disease–Coronary artery bypass–Surgery–Minimally invasive–Percutaneous coronary intervention–Stenting–Hybrid coronary revascularization

Research paper thumbnail of Robotically assisted minimal invasive and endoscopic coronary bypass surgery

European Surgery, 2011

Background: Minimal invasive coronary surgery as compared with classical coronary artery bypass (... more Background: Minimal invasive coronary surgery as compared with classical coronary artery bypass (CABG) avoids sternotomy. The least invasive procedure is totally endoscopic CABG (TECAB)

Research paper thumbnail of Advanced hybrid closed chest revascularization: an innovative strategy for the treatment of multivessel coronary artery disease†

European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, 2014

Conventional hybrid revascularization (CHR) combines minimally invasive placement of an internal ... more Conventional hybrid revascularization (CHR) combines minimally invasive placement of an internal mammary artery graft to the anterior wall and percutaneous coronary intervention (PCI) of non-anterior wall targets. In this study we assess perioperative and midterm outcomes of advanced hybrid revascularization (AHR) defined as the combination of single or multivessel (MV) totally endoscopic coronary artery bypass grafting (TECAB) with single or multivessel PCI. In total, 90 AHR patients [median age 62 years (35-86)] were compared with 90 CHR patients [median age 60 years (35-85)] in terms of perioperative and mid-term outcomes. The outcomes of the three different AHR options (MV-TECAB + PCI, MV-PCI + TECAB, MV-TECAB + MV-PCI) as well as the sequence of the interventions were further compared. Risk factors for major adverse cardiac and cerebral events (MACCEs) related to the hybrid revascularization strategy were calculated. No perioperative deaths occurred either in the AHR group or i...

Research paper thumbnail of Robotic Totally Endoscopic Multivessel Coronary Artery Bypass Grafting

Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, 2012

Research paper thumbnail of Robotically Assisted Hybrid Coronary Revascularization

Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, 2013

Hybrid coronary revascularization (HCR) is a treatment strategy for the revascularization of mult... more Hybrid coronary revascularization (HCR) is a treatment strategy for the revascularization of multivessel coronary disease that combines the advantages of both minimally invasive surgical techniques and percutaneous coronary intervention (PCI). The optimal sequence by which revascularization should be accomplished has not been determined. We investigated clinical outcomes in a series of patients planned for HCR via robotically assisted totally endoscopic coronary artery bypass (TECAB) and standard PCI based on revascularization sequence. A total of 238 patients planned for HCR between 2001 and 2011 were divided into three groups based on treatment sequence: (a) TECAB before PCI, (b) PCI before TECAB, and (c) same-session procedure. Multiple procedural and clinical end points before discharge and up to 2 years after the procedure were compared between the three groups in an intention-to-treat analysis. Demographic features were reviewed to determine baseline differences between each group. Of the 238 patients, 175 (73.5%) underwent TECAB before PCI, 38 patients (16.0%) underwent PCI before TECAB, and 25 (10.5%) underwent a simultaneous revascularization procedure. At baseline, the patients undergoing TECAB before PCI were significantly older. There was a significantly higher incidence of previous myocardial infarction in the PCI-first group (P < 0.001). There was a significant difference in intensive care unit (ICU) length of stay (LOS), with shorter ICU stays in the simultaneous revascularization group (P = 0.031) and shorter hospital LOS in the PCI before TECAB group (P = 0.021). In conclusion, revascularization sequence did not dramatically impact clinical outcomes in our observational study. The patients undergoing PCI-first and same-session interventions had shorter hospital and ICU LOS compared with the patients undergoing surgery first. Our findings suggest that no revascularization approach is arbitrarily superior and that revascularization sequence should be individualized on the basis of patient presentation and anatomical considerations.

Research paper thumbnail of Robotically Assisted Coronary Endarterectomy

Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, 2011

Robotic assistance has enabled coronary artery bypass surgery to be performed safely in a complet... more Robotic assistance has enabled coronary artery bypass surgery to be performed safely in a completely endoscopic fashion, but diffusely diseased target vessels may pose a technical challenge. We present a case in which coronary endarterectomy was performed on the left anterior descending coronary artery during a two-vessel totally endoscopic coronary artery bypass procedure. A 52-year-old woman presented with intermittent substernal pain. Preoperative studies showed diffuse disease in the left coronary artery system. Bilateral internal mammary arteries were harvested robotically using a skeletonized technique in a completely endoscopic fashion. Cardiopulmonary bypass was achieved via peripheral cannulation, and the heart was arrested with intermittent cold antegrade hyperkalemic blood cardioplegia delivered via an ascending aortic occlusion balloon catheter. The first obtuse marginal anastomosis was performed. The left anterior descending coronary artery was diffusely diseased and heavily calcified. An end-to-side anastomosis was attempted to the right internal mammary artery with unsatisfactory results. A localized coronary endarterectomy was performed, and an extended anastomosis was completed using the right internal mammary artery. The patient recovered uneventfully and was discharged home on postoperative day 6. Diffuse coronary artery disease was once thought to be a prohibitive challenge for minimally invasive coronary bypass procedures. This case demonstrates that local coronary endarterectomy is feasible and safe in robotic totally endoscopic coronary artery bypass surgery.

Research paper thumbnail of Hybrid revascularization with robot and stents: Too much of technology or true close chest surgery for multivessel disease?

The Thoracic and Cardiovascular Surgeon, 2013

Research paper thumbnail of Robotic Totally Endoscopic Triple Coronary Artery Bypass Grafting on the Arrested Heart: Report of the First Successful Clinical Case

The Heart Surgery Forum, 2010

Robotic technology enables &a... more Robotic technology enables "port only" totally endoscopic coronary artery bypass grafting (TECAB). During early procedure development only single bypass grafts were feasible. Because current referral practice for coronary bypass surgery mostly includes multivessel disease, performance of multiple endoscopic bypass grafts is desirable. We report a case in which a patient received a right internal mammary artery bypass graft to the left anterior descending artery and a left internal mammary artery jump graft to 2 obtuse marginal branches. The procedure was performed through 5 ports on the arrested heart using the daVinci S robotic surgical system. This is the first reported triple bypass grafting procedure using an arrested heart approach.

Research paper thumbnail of Hybrid Coronary Revascularization: An Overview of Options for Anticoagulation and Platelet Inhibition

The Heart Surgery Forum, 2010

Hybrid coronary revascularization, in which coronary bypass grafting is combined with percutaneou... more Hybrid coronary revascularization, in which coronary bypass grafting is combined with percutaneous coronary intervention, is a promising strategy for optimizing outcomes in the treatment of coronary artery disease. Balancing the risk of surgical bleeding with the risk of percutaneous coronary intervention-related thrombosis is a major challenge inherent in carrying out a successful procedure and requires careful selection of antiplatelet and anticoagulant agents. Advantages and disadvantages of antiplatelet and anticoagulant agents in use today for hybrid coronary revascularization are reviewed. Currently available anticoagulants and platelet inhibitors have been used to provide safe and effective protection from thrombosis while limiting surgical bleeding in hybrid coronary revascularization, but there is no agreement on an optimal strategy, and each patient presents a unique pharmacologic and logistic puzzle. Knowledge of the salient features of the available medications will allow the cardiologist and surgeon to design the optimal strategy for each patient.

Research paper thumbnail of Is an Intraaortic Balloon Pump a Contraindication to Robotic Totally Endoscopic Coronary Artery Bypass?

The Heart Surgery Forum, 2010

The success of robotic totally endoscopic coronary artery bypass (TECAB) in recent years has led ... more The success of robotic totally endoscopic coronary artery bypass (TECAB) in recent years has led to the expansion of the procedure to patients with more severe disease. Outcomes with these patients have not yet been well characterized, and no reports on TECAB performed in patients with a preoperatively placed intraaortic balloon pump (IABP) are available. We present our initial experience with this patient population. We evaluated 5 patients with unstable angina or impaired left ventricular function requiring a preoperatively placed IABP who underwent TECAB using the daVinci telemanipulation system. Procedures were performed either on the beating heart using an endostabilizer (n = 2) or on the arrested heart using remote access perfusion and aortic balloon endoocclusion (n = 3). The median patient age was 67 years (range, 41-73 years), with a median preoperative ejection fraction of 43% (range, 26%-58%) and median EuroSCORE of 5 (range, 3-8). There were no major intraoperative technical issues. The median length of stay in the hospital and intensive care unit was 8 days (range, 5-13 days) and 66 hours (range, 41-142 hours), respectively. There were no intraoperative or 30-day mortalities. This early experience suggests that TECAB is feasible in patients with a preoperatively placed IABP. Both the beating heart and arrested heart versions can be used in this patient population, further broadening the spectrum of applicability of this procedure.

Research paper thumbnail of Robotic total endoscopic double-vessel coronary artery bypass grafting—state of procedure development

The Journal of Thoracic and Cardiovascular Surgery, 2012

Robotic total endoscopic coronary artery bypass grafting (TECAB) has been under development for 1... more Robotic total endoscopic coronary artery bypass grafting (TECAB) has been under development for 10 years. With increasing experience and technological improvement, double-vessel TECAB has become feasible. The aim of the present study was to compare the current outcomes of single- and double-vessel TECAB. Between 2001 and 2011, 484 patients underwent TECAB by 4 surgeons at 2 institutions. The median patient age was 60 years (range, 31-90), and the median European System for Cardiac Operative Risk Evaluation was 2 (range, 0-13). Single-vessel (n = 334) and double-vessel (n = 150) procedures were performed using the da Vinci, da Vinci S, and da Vinci Si robotic systems. Compared with the single-vessel procedure, double-vessel TECAB required a longer operative time (median, 375 minutes; range, 168-795; vs median, 240; range, 112-605; P < .001) and had an increased conversion rate to a larger thoracic incision (31/150 [20.7%] vs 31/334 [9.3%]; P < .001). The median ventilation time was 10 hours (range, 0-288) for double-vessel versus 8 hours (range, 0-278) for single-vessel procedures (P = .006). The hospital stay was comparable, with 6 days (range, 2-27) for double-vessel TECAB and 6 days (range, 2-33) for single-vessel TECAB (P = .794). Perioperative mortality was 0.3% (1/334) with single-vessel TECAB and 2.0% (3/150) with double-vessel TECAB (P = .090). Freedom from major adverse cardiac and cerebral events at 5 years was similar after double- and single-vessel TECAB (73.5% vs 83.1%, P = .150). The 5-year survival was 95.8% and 93.9% (P = .708). Double-vessel TECAB appears feasible and reproducible. The operative times were longer and the conversion rates to a larger thoracic incision were greater than with single-vessel TECAB. Also, the postoperative ventilation time was longer. Other perioperative morbidity and mortality and the recovery time and long-term clinical outcomes, however, were comparable.

Research paper thumbnail of Surgical problems and complex procedures: Issues for operative time in robotic totally endoscopic coronary artery bypass grafting

The Journal of Thoracic and Cardiovascular Surgery, 2012

Objective: Robotically assisted totally endoscopic coronary artery bypass grafting (TECAB) is a v... more Objective: Robotically assisted totally endoscopic coronary artery bypass grafting (TECAB) is a viable option for closed chest coronary surgery, but it requires learning curves and longer operative times. This study evaluated the effect of extended operation times on the outcome of patients undergoing TECAB.

Research paper thumbnail of PREDICTORS OF LONG–TERM OUTCOMES IN HYBRID CORONARY REVASCULARIZATION

Journal of the American College of Cardiology, 2013

Research paper thumbnail of Substrate-Specific Derangements in Mitochondrial Metabolism and Redox Balance in the Atrium of the Type 2 Diabetic Human Heart

Journal of the American College of Cardiology, 2009

Objective-This aim of this study was to determine the impact of diabetes on oxidant balance and m... more Objective-This aim of this study was to determine the impact of diabetes on oxidant balance and mitochondrial metabolism of carbohydrate-and lipid-based substrates in myocardium of type 2 diabetic patients.

Research paper thumbnail of Anesthetic Management of Robotically Assisted Totally Endoscopic Coronary Artery Bypass Surgery (TECAB)

Journal of Cardiothoracic and Vascular Anesthesia, 2013

Over the last decade, TECAB has matured into a reproducible technique associated with low inciden... more Over the last decade, TECAB has matured into a reproducible technique associated with low incidence of both mortality and morbidity, as well as superior quality of life, when compared with open CABG surgery. However, TECAB also is associated with important and specific challenges for the anesthesiology team, particularly with regard to the physiologic stresses of OLV, placement of special catheters, and induced capnothorax. As the technology supporting robotic surgery evolves and familiarity with, and confidence in, TECAB increases, the authors anticipate increasingly widespread use of these procedures in an increasingly fragile and problematic patient population who will require the support of a skilled and vigilant anesthesiology team.

Research paper thumbnail of Is there a role for robotic totally endoscopic coronary artery bypass in HIV positive patients?

The International Journal of Medical Robotics and Computer Assisted Surgery, 2010

Performing cardiac surgery on HIV positive patients represents a significant risk of occupational... more Performing cardiac surgery on HIV positive patients represents a significant risk of occupational exposure to surgeons and their support staff. In addition, the immunocompromized state of these patients may be a factor which could adversely influence the results. Totally endoscopic coronary artery bypass grafting (TECAB) in HIV patients has not been reported. A male patient with HIV and Hepatitis C presented with three vessel coronary artery disease requiring surgical revascularization. Totally endoscopic coronary artery bypass grafting was performed. Using the da Vinci surgical robot, the left and right internal mammary arteries were harvested and sutured to the second obtuse marginal branch and the left anterior descending artery respectively. The patient was discharged home on postoperative day six. At one month following the operation, the patient was asymptomatic and had returned to full activity without the need for sternal precautions. We describe the first case of completely endoscopic coronary surgery using the da Vinci system in an HIV patient. Double internal mammary artery grafting to the left coronary artery system was carried out successfully.

Research paper thumbnail of Closed chest hybrid coronary revascularization for multivessel disease ??? current concepts and techniques from a two-center experience

European Journal of Cardio-Thoracic Surgery, 2011

Hybrid coronary revascularization combining minimally invasive coronary surgery and percutaneous ... more Hybrid coronary revascularization combining minimally invasive coronary surgery and percutaneous coronary intervention (PCI) allows sternal preserving treatment of multivessel coronary disease. The main principle of the technique includes placement of mammary artery graft to the left anterior descending coronary artery (LAD) and performance of PCI in non-LAD target vessels. This principle is based on increasing data showing equivalent results of PCI with coronary revascularization using saphenous vein grafts in selected patients. Providing that perioperative and long-term results are as good as the results of conventional surgical revascularization, this option seems to be quite appealing for patients and referring cardiologists. This concept has been designed to allow rapid rehabilitation and minimize periprocedural pain under concomitant preservation of the patient's body integrity. Robotically assisted endoscopic approaches for hybrid coronary revascularization set the pace for a closed-chest treatment of multivessel coronary disease. The time point of PCI, the use of different anticoagulation protocols as well as the stent selection are some of the variables, which affect outcome. We additionally report on the midterm results of 130 after-closed-chest hybrid-coronary procedures in two institutions. Hybrid procedures using robotic technology and PCI allow closed chest treatment of multivessel coronary artery disease. Single- and double-bypass grafts are feasible and simultaneous interventions can be performed. The overall safety of the procedure seems to be adequate and perioperative clinical results are satisfactory. Intermediate term survival and freedom from angina are excellent.

Research paper thumbnail of Robotic mitral valve surgery

European Surgery, 2011

Background: Robotic mitral valve surgery has evolved and matured into a safe and reproducible pro... more Background: Robotic mitral valve surgery has evolved and matured into a safe and reproducible procedure at multiple worldwide centers of excellence.

Research paper thumbnail of Robotic-assisted cryosurgical treatment of atrioventricular node reentrant tachycardia

Innovations (Philadelphia, Pa.), 2011

Atrioventricular nodal reentrant tachycardias typically arise from the existence of variable refr... more Atrioventricular nodal reentrant tachycardias typically arise from the existence of variable refractoriness in fast and slow conduction pathways within the triangle of Koch, which provide input to the atrioventricular node. Standard therapy includes medical management and catheter-based ablation procedures. Robotic-assisted, minimally invasive cryosurgical modification of the atrioventricular node can provide definitive therapy for patients who fail traditional therapy. A 65-year-old man presented with a several-year history of recurrent atrioventricular nodal reentrant tachycardia. Despite medical management and attempted percutaneous ablation, the patient remained symptomatic with weekly episodes. Access was via a 4-cm right anterolateral thoracotomy and peripheral perfusion. The da Vinci S robotic system was used to manipulate the cryoprobe (CryoMaze Probe; ATS Medical, Plymouth, MN USA). A series of spot freezes (tip 60°C) were made along the boundaries of the triangle of Koch u...

Research paper thumbnail of Robotic total endoscopic coronary artery bypass hybrid revascularization procedure in a patient with a preoperative tracheostoma

Interactive cardiovascular and thoracic surgery, 2011

Preoperative tracheostoma presents a significant risk of sternal wound complications, mediastinit... more Preoperative tracheostoma presents a significant risk of sternal wound complications, mediastinitis, stoma necrosis and tracheal injury in patients requiring cardiac surgery. Several approaches have been described to limit these risks. Robotic totally endoscopic coronary artery bypass grafting in patients with a tracheostoma has not been reported. We describe a case of completely endoscopic coronary surgery using the daVinci(®) Si™ system in a patient with a tracheostoma. Single left internal mammary artery grafting to the left coronary artery system was carried out successfully as the first stage of a hybrid revascularization and followed by percutaneous coronary intervention to the circumflex coronary artery. We regard this technique as the most minimally-invasive method of surgical coronary revascularization with a significant potential to reduce the risk of mediastinitis in patients with a tracheostoma.

Research paper thumbnail of Hybrid coronary revascularization – techniques and outcome

European Surgery, 2011

ABSTRACT BACKGROUND: Hybrid coronary revascularization combines minimally invasive coronary arter... more ABSTRACT BACKGROUND: Hybrid coronary revascularization combines minimally invasive coronary artery bypass grafting (CABG) and catheter-based coronary intervention for the treatment of multivessel coronary artery disease. This concept represents an alternative to open multivessel bypass surgery through sternotomy and to multivessel percutaneous intervention (PCI). The former is highly invasive but very effective in the long term; the latter is less invasive but results in more repeat revascularization procedures. METHODS: The surgical part of hybrid coronary intervention can be performed through thoracic mini-incisions and in completely endoscopic fashion. Robotic technology such as the daVinci ® surgical telemanipulation system is increasingly used. Percutaneous interventions in hybrid procedures include implantation of bare metal stents and drug eluting stents. RESULTS: After 15 years of development, the literature reports mortality rates in the one percent range which may be lower than in open bypass surgery. Several studies demonstrate significantly earlier recovery and return to normal activities after hybrid intervention than after heart bypass surgery through sternotomy. Long-term follow-up studies show similar survival compared to survival after multivessel CABG and multivessel PCI. The rate of reinterventions and major adverse events, however, may be lower than after multivessel PCI, and closer to rates after open CABG. CONCLUSIONS: Hybrid revascularization represents a promising concept for treatment of coronary multivessel disease. KeywordsCoronary artery disease–Coronary artery bypass–Surgery–Minimally invasive–Percutaneous coronary intervention–Stenting–Hybrid coronary revascularization

Research paper thumbnail of Robotically assisted minimal invasive and endoscopic coronary bypass surgery

European Surgery, 2011

Background: Minimal invasive coronary surgery as compared with classical coronary artery bypass (... more Background: Minimal invasive coronary surgery as compared with classical coronary artery bypass (CABG) avoids sternotomy. The least invasive procedure is totally endoscopic CABG (TECAB)

Research paper thumbnail of Advanced hybrid closed chest revascularization: an innovative strategy for the treatment of multivessel coronary artery disease†

European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery, 2014

Conventional hybrid revascularization (CHR) combines minimally invasive placement of an internal ... more Conventional hybrid revascularization (CHR) combines minimally invasive placement of an internal mammary artery graft to the anterior wall and percutaneous coronary intervention (PCI) of non-anterior wall targets. In this study we assess perioperative and midterm outcomes of advanced hybrid revascularization (AHR) defined as the combination of single or multivessel (MV) totally endoscopic coronary artery bypass grafting (TECAB) with single or multivessel PCI. In total, 90 AHR patients [median age 62 years (35-86)] were compared with 90 CHR patients [median age 60 years (35-85)] in terms of perioperative and mid-term outcomes. The outcomes of the three different AHR options (MV-TECAB + PCI, MV-PCI + TECAB, MV-TECAB + MV-PCI) as well as the sequence of the interventions were further compared. Risk factors for major adverse cardiac and cerebral events (MACCEs) related to the hybrid revascularization strategy were calculated. No perioperative deaths occurred either in the AHR group or i...

Research paper thumbnail of Robotic Totally Endoscopic Multivessel Coronary Artery Bypass Grafting

Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, 2012

Research paper thumbnail of Robotically Assisted Hybrid Coronary Revascularization

Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, 2013

Hybrid coronary revascularization (HCR) is a treatment strategy for the revascularization of mult... more Hybrid coronary revascularization (HCR) is a treatment strategy for the revascularization of multivessel coronary disease that combines the advantages of both minimally invasive surgical techniques and percutaneous coronary intervention (PCI). The optimal sequence by which revascularization should be accomplished has not been determined. We investigated clinical outcomes in a series of patients planned for HCR via robotically assisted totally endoscopic coronary artery bypass (TECAB) and standard PCI based on revascularization sequence. A total of 238 patients planned for HCR between 2001 and 2011 were divided into three groups based on treatment sequence: (a) TECAB before PCI, (b) PCI before TECAB, and (c) same-session procedure. Multiple procedural and clinical end points before discharge and up to 2 years after the procedure were compared between the three groups in an intention-to-treat analysis. Demographic features were reviewed to determine baseline differences between each group. Of the 238 patients, 175 (73.5%) underwent TECAB before PCI, 38 patients (16.0%) underwent PCI before TECAB, and 25 (10.5%) underwent a simultaneous revascularization procedure. At baseline, the patients undergoing TECAB before PCI were significantly older. There was a significantly higher incidence of previous myocardial infarction in the PCI-first group (P < 0.001). There was a significant difference in intensive care unit (ICU) length of stay (LOS), with shorter ICU stays in the simultaneous revascularization group (P = 0.031) and shorter hospital LOS in the PCI before TECAB group (P = 0.021). In conclusion, revascularization sequence did not dramatically impact clinical outcomes in our observational study. The patients undergoing PCI-first and same-session interventions had shorter hospital and ICU LOS compared with the patients undergoing surgery first. Our findings suggest that no revascularization approach is arbitrarily superior and that revascularization sequence should be individualized on the basis of patient presentation and anatomical considerations.

Research paper thumbnail of Robotically Assisted Coronary Endarterectomy

Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, 2011

Robotic assistance has enabled coronary artery bypass surgery to be performed safely in a complet... more Robotic assistance has enabled coronary artery bypass surgery to be performed safely in a completely endoscopic fashion, but diffusely diseased target vessels may pose a technical challenge. We present a case in which coronary endarterectomy was performed on the left anterior descending coronary artery during a two-vessel totally endoscopic coronary artery bypass procedure. A 52-year-old woman presented with intermittent substernal pain. Preoperative studies showed diffuse disease in the left coronary artery system. Bilateral internal mammary arteries were harvested robotically using a skeletonized technique in a completely endoscopic fashion. Cardiopulmonary bypass was achieved via peripheral cannulation, and the heart was arrested with intermittent cold antegrade hyperkalemic blood cardioplegia delivered via an ascending aortic occlusion balloon catheter. The first obtuse marginal anastomosis was performed. The left anterior descending coronary artery was diffusely diseased and heavily calcified. An end-to-side anastomosis was attempted to the right internal mammary artery with unsatisfactory results. A localized coronary endarterectomy was performed, and an extended anastomosis was completed using the right internal mammary artery. The patient recovered uneventfully and was discharged home on postoperative day 6. Diffuse coronary artery disease was once thought to be a prohibitive challenge for minimally invasive coronary bypass procedures. This case demonstrates that local coronary endarterectomy is feasible and safe in robotic totally endoscopic coronary artery bypass surgery.

Research paper thumbnail of Hybrid revascularization with robot and stents: Too much of technology or true close chest surgery for multivessel disease?

The Thoracic and Cardiovascular Surgeon, 2013

Research paper thumbnail of Robotic Totally Endoscopic Triple Coronary Artery Bypass Grafting on the Arrested Heart: Report of the First Successful Clinical Case

The Heart Surgery Forum, 2010

Robotic technology enables &a... more Robotic technology enables "port only" totally endoscopic coronary artery bypass grafting (TECAB). During early procedure development only single bypass grafts were feasible. Because current referral practice for coronary bypass surgery mostly includes multivessel disease, performance of multiple endoscopic bypass grafts is desirable. We report a case in which a patient received a right internal mammary artery bypass graft to the left anterior descending artery and a left internal mammary artery jump graft to 2 obtuse marginal branches. The procedure was performed through 5 ports on the arrested heart using the daVinci S robotic surgical system. This is the first reported triple bypass grafting procedure using an arrested heart approach.

Research paper thumbnail of Hybrid Coronary Revascularization: An Overview of Options for Anticoagulation and Platelet Inhibition

The Heart Surgery Forum, 2010

Hybrid coronary revascularization, in which coronary bypass grafting is combined with percutaneou... more Hybrid coronary revascularization, in which coronary bypass grafting is combined with percutaneous coronary intervention, is a promising strategy for optimizing outcomes in the treatment of coronary artery disease. Balancing the risk of surgical bleeding with the risk of percutaneous coronary intervention-related thrombosis is a major challenge inherent in carrying out a successful procedure and requires careful selection of antiplatelet and anticoagulant agents. Advantages and disadvantages of antiplatelet and anticoagulant agents in use today for hybrid coronary revascularization are reviewed. Currently available anticoagulants and platelet inhibitors have been used to provide safe and effective protection from thrombosis while limiting surgical bleeding in hybrid coronary revascularization, but there is no agreement on an optimal strategy, and each patient presents a unique pharmacologic and logistic puzzle. Knowledge of the salient features of the available medications will allow the cardiologist and surgeon to design the optimal strategy for each patient.

Research paper thumbnail of Is an Intraaortic Balloon Pump a Contraindication to Robotic Totally Endoscopic Coronary Artery Bypass?

The Heart Surgery Forum, 2010

The success of robotic totally endoscopic coronary artery bypass (TECAB) in recent years has led ... more The success of robotic totally endoscopic coronary artery bypass (TECAB) in recent years has led to the expansion of the procedure to patients with more severe disease. Outcomes with these patients have not yet been well characterized, and no reports on TECAB performed in patients with a preoperatively placed intraaortic balloon pump (IABP) are available. We present our initial experience with this patient population. We evaluated 5 patients with unstable angina or impaired left ventricular function requiring a preoperatively placed IABP who underwent TECAB using the daVinci telemanipulation system. Procedures were performed either on the beating heart using an endostabilizer (n = 2) or on the arrested heart using remote access perfusion and aortic balloon endoocclusion (n = 3). The median patient age was 67 years (range, 41-73 years), with a median preoperative ejection fraction of 43% (range, 26%-58%) and median EuroSCORE of 5 (range, 3-8). There were no major intraoperative technical issues. The median length of stay in the hospital and intensive care unit was 8 days (range, 5-13 days) and 66 hours (range, 41-142 hours), respectively. There were no intraoperative or 30-day mortalities. This early experience suggests that TECAB is feasible in patients with a preoperatively placed IABP. Both the beating heart and arrested heart versions can be used in this patient population, further broadening the spectrum of applicability of this procedure.

Research paper thumbnail of Robotic total endoscopic double-vessel coronary artery bypass grafting—state of procedure development

The Journal of Thoracic and Cardiovascular Surgery, 2012

Robotic total endoscopic coronary artery bypass grafting (TECAB) has been under development for 1... more Robotic total endoscopic coronary artery bypass grafting (TECAB) has been under development for 10 years. With increasing experience and technological improvement, double-vessel TECAB has become feasible. The aim of the present study was to compare the current outcomes of single- and double-vessel TECAB. Between 2001 and 2011, 484 patients underwent TECAB by 4 surgeons at 2 institutions. The median patient age was 60 years (range, 31-90), and the median European System for Cardiac Operative Risk Evaluation was 2 (range, 0-13). Single-vessel (n = 334) and double-vessel (n = 150) procedures were performed using the da Vinci, da Vinci S, and da Vinci Si robotic systems. Compared with the single-vessel procedure, double-vessel TECAB required a longer operative time (median, 375 minutes; range, 168-795; vs median, 240; range, 112-605; P < .001) and had an increased conversion rate to a larger thoracic incision (31/150 [20.7%] vs 31/334 [9.3%]; P < .001). The median ventilation time was 10 hours (range, 0-288) for double-vessel versus 8 hours (range, 0-278) for single-vessel procedures (P = .006). The hospital stay was comparable, with 6 days (range, 2-27) for double-vessel TECAB and 6 days (range, 2-33) for single-vessel TECAB (P = .794). Perioperative mortality was 0.3% (1/334) with single-vessel TECAB and 2.0% (3/150) with double-vessel TECAB (P = .090). Freedom from major adverse cardiac and cerebral events at 5 years was similar after double- and single-vessel TECAB (73.5% vs 83.1%, P = .150). The 5-year survival was 95.8% and 93.9% (P = .708). Double-vessel TECAB appears feasible and reproducible. The operative times were longer and the conversion rates to a larger thoracic incision were greater than with single-vessel TECAB. Also, the postoperative ventilation time was longer. Other perioperative morbidity and mortality and the recovery time and long-term clinical outcomes, however, were comparable.

Research paper thumbnail of Surgical problems and complex procedures: Issues for operative time in robotic totally endoscopic coronary artery bypass grafting

The Journal of Thoracic and Cardiovascular Surgery, 2012

Objective: Robotically assisted totally endoscopic coronary artery bypass grafting (TECAB) is a v... more Objective: Robotically assisted totally endoscopic coronary artery bypass grafting (TECAB) is a viable option for closed chest coronary surgery, but it requires learning curves and longer operative times. This study evaluated the effect of extended operation times on the outcome of patients undergoing TECAB.

Research paper thumbnail of PREDICTORS OF LONG–TERM OUTCOMES IN HYBRID CORONARY REVASCULARIZATION

Journal of the American College of Cardiology, 2013

Research paper thumbnail of Substrate-Specific Derangements in Mitochondrial Metabolism and Redox Balance in the Atrium of the Type 2 Diabetic Human Heart

Journal of the American College of Cardiology, 2009

Objective-This aim of this study was to determine the impact of diabetes on oxidant balance and m... more Objective-This aim of this study was to determine the impact of diabetes on oxidant balance and mitochondrial metabolism of carbohydrate-and lipid-based substrates in myocardium of type 2 diabetic patients.

Research paper thumbnail of Anesthetic Management of Robotically Assisted Totally Endoscopic Coronary Artery Bypass Surgery (TECAB)

Journal of Cardiothoracic and Vascular Anesthesia, 2013

Over the last decade, TECAB has matured into a reproducible technique associated with low inciden... more Over the last decade, TECAB has matured into a reproducible technique associated with low incidence of both mortality and morbidity, as well as superior quality of life, when compared with open CABG surgery. However, TECAB also is associated with important and specific challenges for the anesthesiology team, particularly with regard to the physiologic stresses of OLV, placement of special catheters, and induced capnothorax. As the technology supporting robotic surgery evolves and familiarity with, and confidence in, TECAB increases, the authors anticipate increasingly widespread use of these procedures in an increasingly fragile and problematic patient population who will require the support of a skilled and vigilant anesthesiology team.

Research paper thumbnail of Is there a role for robotic totally endoscopic coronary artery bypass in HIV positive patients?

The International Journal of Medical Robotics and Computer Assisted Surgery, 2010

Performing cardiac surgery on HIV positive patients represents a significant risk of occupational... more Performing cardiac surgery on HIV positive patients represents a significant risk of occupational exposure to surgeons and their support staff. In addition, the immunocompromized state of these patients may be a factor which could adversely influence the results. Totally endoscopic coronary artery bypass grafting (TECAB) in HIV patients has not been reported. A male patient with HIV and Hepatitis C presented with three vessel coronary artery disease requiring surgical revascularization. Totally endoscopic coronary artery bypass grafting was performed. Using the da Vinci surgical robot, the left and right internal mammary arteries were harvested and sutured to the second obtuse marginal branch and the left anterior descending artery respectively. The patient was discharged home on postoperative day six. At one month following the operation, the patient was asymptomatic and had returned to full activity without the need for sternal precautions. We describe the first case of completely endoscopic coronary surgery using the da Vinci system in an HIV patient. Double internal mammary artery grafting to the left coronary artery system was carried out successfully.

Research paper thumbnail of Closed chest hybrid coronary revascularization for multivessel disease ??? current concepts and techniques from a two-center experience

European Journal of Cardio-Thoracic Surgery, 2011

Hybrid coronary revascularization combining minimally invasive coronary surgery and percutaneous ... more Hybrid coronary revascularization combining minimally invasive coronary surgery and percutaneous coronary intervention (PCI) allows sternal preserving treatment of multivessel coronary disease. The main principle of the technique includes placement of mammary artery graft to the left anterior descending coronary artery (LAD) and performance of PCI in non-LAD target vessels. This principle is based on increasing data showing equivalent results of PCI with coronary revascularization using saphenous vein grafts in selected patients. Providing that perioperative and long-term results are as good as the results of conventional surgical revascularization, this option seems to be quite appealing for patients and referring cardiologists. This concept has been designed to allow rapid rehabilitation and minimize periprocedural pain under concomitant preservation of the patient's body integrity. Robotically assisted endoscopic approaches for hybrid coronary revascularization set the pace for a closed-chest treatment of multivessel coronary disease. The time point of PCI, the use of different anticoagulation protocols as well as the stent selection are some of the variables, which affect outcome. We additionally report on the midterm results of 130 after-closed-chest hybrid-coronary procedures in two institutions. Hybrid procedures using robotic technology and PCI allow closed chest treatment of multivessel coronary artery disease. Single- and double-bypass grafts are feasible and simultaneous interventions can be performed. The overall safety of the procedure seems to be adequate and perioperative clinical results are satisfactory. Intermediate term survival and freedom from angina are excellent.