Robotic totally endoscopic coronary artery bypass grafting (TECAB) of the left anterior descending and right coronary artery system using an arterial Y-graft technique

Abstract

A totally endoscopic version of coronary bypass surgery can on a routine basis only be carried out using robotic technology. Since its introduction in 1998, the procedure has evolved from single to multivessel totally endoscopic coronary artery bypass grafting (TECAB) (1). In most instances of multivessel TECAB, the left and right internal mammary artery (RIMA) are used as in situ bypasses and the left anterior descending artery (LAD) and higher obtuse marginal branches are grafted (2). These targets are readily accessed robotically and can be tackled even on the fully beating heart. For more distant targets, namely the distal circumflex (Cx) coronary artery and the right coronary artery (RCA) system, no specific techniques have been described yet. These coronary branches lie on the diaphragmatic and posterior surface of the heart and require movement of the heart into extreme positions which may compromise hemodynamics significantly if carried out without unloading. In addition, an in situ internal mammary artery bypass may not reach these targets without tension. Y-grafting is an option to achieve better reach. Cardioplegia may facilitate exposure of the RCA and the Cx in the completely endoscopic setting. We describe our technique of completely endoscopic bypass grafting of the posterior descending artery (PDA), a branch of the RCA, using the Y-graft technique. Cardioplegia is achieved by remote access heart lung machine perfusion and endoaortic balloon occlusion. The PDA is exposed on the arrested heart with a special insertion site of the robotic endostabilizer on the left lateral chest wall and lifting up the acute margin of the flaccid, arrested heart.