Early clinical and angiographic outcomes after robotic-assisted coronary artery bypass surgery

Published:October 29, 2013DOI:


      Robotic-assisted coronary artery bypass grafting has emerged as an alternative to traditional coronary artery bypass grafting or percutaneous intervention for patients with coronary artery disease. However, the safety and efficacy of this minimally invasive procedure have not been established in large series.


      From October 2009 to September 2012, 307 consecutive robotic-assisted coronary artery bypass grafting procedures were performed at a single US institution by 2 surgeons. Isolated, off-pump, left internal thoracic artery to left anterior descending coronary artery grafting was planned via a 3- to 4-cm non–rib-spreading minithoracotomy after robotic left internal thoracic artery harvest in all patients. Hybrid coronary revascularization was planned in 159 patients (51.8%). Of the 199 angiograms (64.8%) performed before discharge, 63 were performed as completion angiograms in a hybrid suite immediately after left internal thoracic artery–left anterior descending artery grafting.


      Thirty-day mortality occurred in 4 patients (1.3%), conversion to sternotomy occurred in 16 patients (5.2%), postoperative myocardial infarction occurred in 5 patients (1.6%), and reexploration for bleeding occurred in 7 patients (2.3%). There was 1 (0.3%) postoperative stroke. For the 199 patients with follow-up angiography before discharge, the left internal thoracic artery was confirmed to be patent (<50% stenosis) in 189 patients (95.0%). Among the 10 patients with significant (≥50% stenosis) defects, 5 had graft occlusion or distal left anterior descending occlusion, 2 had poor flow distal to the anastomosis, and 3 had anastomotic lesions (≥50% stenosis). Among the 63 patients with intraoperative completion angiography, 5 patients underwent surgical graft revision, 3 patients underwent minithoracotomy, and 2 patients underwent conversion to sternotomy.


      Robotic-assisted coronary artery bypass grafting is an effective alternative to traditional coronary artery bypass grafting for patients with single or multivessel coronary artery disease, with comparable short-term clinical and angiographic results.

      CTSNet classification

      Abbreviations and Acronyms:

      CAB (coronary artery bypass), CABG (coronary artery bypass grafting), LAD (left anterior descending), LITA (left internal thoracic artery), MIDCAB (minimally invasive direct coronary artery bypass), OR (operating room), PCI (percutaneous coronary intervention), PROM (predicted risk of mortality), TECAB (totally endoscopic coronary artery bypass)
      To read this article in full you will need to make a payment


        • Serruys P.W.
        • Morice M.C.
        • Kappetein A.P.
        • Columbo A.
        • Holmes O.R.
        • Mack M.J.
        • et al.
        Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease.
        N Engl J Med. 2009; 360: 961-972
        • Farkouh M.E.
        • Domanski M.
        • Sleeper L.A.
        • Siami F.S.
        • Dangas G.
        • Mack M.
        • et al.
        Strategies for multivessel revascularization in patients with diabetes.
        N Engl J Med. 2012; 367: 2375-2384
        • Holzhey D.M.
        • Cornely J.P.
        • Rastan A.J.
        • Davierwala P.
        • Mohr F.W.
        Review of a 13-year single-center experience with minimally invasive direct coronary artery bypass as the primary surgical treatment of coronary artery disease.
        Heart Surg Forum. 2012; 15: E61-E68
        • McGinn 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-S84
        • Bonatti J.
        • Schachner T.
        • Bonaros N.
        • Lehr E.J.
        • Zimrin D.
        • Griffith B.
        Robotically assisted totally endoscopic coronary bypass surgery.
        Circulation. 2011; 124: 236-244
        • Vassiliades Jr., T.A.
        • Reddy V.S.
        • Puskas J.D.
        • Guyton R.A.
        Long-term results of the endoscopic atraumatic coronary artery bypass.
        Ann Thorac Surg. 2007; 83: 979-985
        • Thiele H.
        • Neumann-Schniedewind P.
        • Jacobs S.
        • Boudriot E.
        • Walther T.
        • Mohr F.W.
        • et al.
        Randomized comparison of minimally invasive direct coronary artery bypass surgery versus sirolimus-eluting stenting in isolated proximal left anterior descending coronary artery stenosis.
        J Am Coll Cardiol. 2009; 53: 2324-2331
        • Kiaii B.
        • McClure R.S.
        • Stewart P.
        • Rayman R.
        • Swinamer S.A.
        • Suematsu Y.
        • et al.
        Simultaneous integrated coronary artery revascularization with long-term angiographic follow-up.
        J Thorac Cardiovasc Surg. 2008; 136: 702-708
        • Vassiliades Jr., T.A.
        • Douglas J.S.
        • Morris D.C.
        • Block P.C.
        • Ghazzal Z.
        • Rab S.T.
        • Cates C.U.
        Integrated coronary revascularization with drug-eluting stents: immediate and seven-month outcome.
        J Thorac Cardiovasc Surg. 2006; 131: 956-962
        • de Canniere D.
        • Wimmer-Greinecker G.
        • Cichon R.
        • Gulielmos V.
        • Van Praet F.
        • Seshadri-Kreaden U.
        • Falk V.
        Feasibility, safety, and efficacy of totally endoscopic coronary artery bypass grafting: multicenter European experience.
        J Thorac Cardiovasc Surg. 2007; 134: 710-716
        • Kon Z.N.
        • Brown E.N.
        • Tran R.
        • Joshi A.
        • Reicher B.
        • Grant M.C.
        • et al.
        Simultaneous hybrid coronary revascularization reduces postoperative morbidity compared with results from conventional off-pump coronary artery bypass.
        J Thorac Cardiovasc Surg. 2008; 135: 367-375
        • Bonaros N.
        • Schachner T.
        • Wiedemann D.
        • Oehlinger A.
        • Ruetzler E.
        • Feuchtner G.
        • et al.
        Quality of life improvement after robotically assisted coronary artery bypass grafting.
        Cardiology. 2009; 114: 59-66
        • Bainbridge D.
        • Cheng D.
        • Martin J.
        • Novick R.
        Does off-pump or minimally invasive coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with percutaneous coronary intervention? A meta-analysis of randomized trials.
        J Thorac Cardiovasc Surg. 2007; 133: 623-631
        • Halkos M.E.
        • Vassiliades T.A.
        • Myung R.J.
        • Kilgo P.
        • Thourani V.H.
        • Cooper W.A.
        • et al.
        Sternotomy versus nonsternotomy LIMA-LAD grafting for single-vessel disease.
        Ann Thorac Surg. 2012; 94: 1469-1477
        • Lamy A.
        • Devereaux P.J.
        • Prabhakaran D.
        • Taggart D.P.
        • Hu S.
        • Paolasso E.
        • et al.
        Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year.
        N Engl J Med. 2013; 368: 1179-1188
        • Zhao D.X.
        • Leacche M.
        • Balaguer J.M.
        • Boudoulas K.D.
        • Damp J.A.
        • Greelish J.P.
        • et al.
        Routine intraoperative completion angiography after coronary artery bypass grafting and 1-stop hybrid revascularization results from a fully integrated hybrid catheterization laboratory/operating room.
        J Am Coll Cardiol. 2009; 53: 232-241
        • Kappert U.
        • Tugtekin S.M.
        • Cichon R.
        • Braun M.
        • Matschke K.
        Robotic totally endoscopic coronary artery bypass: a word of caution implicated by a five-year follow-up.
        J Thorac Cardiovasc Surg. 2008; 135: 857-862
        • Holzhey D.M.
        • Jacobs S.
        • Walther T.
        • Mochalski M.
        • Mohr F.W.
        • Falk V.
        Cumulative sum failure analysis for eight surgeons performing minimally invasive direct coronary artery bypass.
        J Thorac Cardiovasc Surg. 2007; 134: 663-669
        • Wiedemann D.
        • Bonaros N.
        • Schachner T.
        • Weidinger F.
        • Lehr E.J.
        • Vesely M.
        • Bonatti J.
        Surgical problems and complex procedures: Issues for operative time in robotic totally endoscopic coronary artery bypass grafting.
        J Thorac Cardiovasc Surg. 2012; 143: 639-647