Talking Tall Rounds®: Updates on Less Invasive Cardiac Surgery

Announcer:

Welcome to Cardiac Consult, brought to you by the Sydell and Arnold Miller Family Heart, Vascular & Thoracic Institute at Cleveland Clinic. This podcast will explore the latest innovations, medical and surgical treatments, diagnostic testing, research, technology, and practice improvements.

Dr. Eric Roselli:

Good morning, everyone. Welcome to our Wednesday morning Tall Rounds event. As you all know, we typically try to pick a topic that's very focused and disease-based and patient-based and multidisciplinary, but sometimes we just have some things that are just really cool. That's what we're going to be talking about today, an update on a bunch of the different, less invasive cardiac surgical techniques that we use. I suppose we're sticking with sort of the multidisciplinary nature of this as we have a whole bunch of very specialized surgeons talking about some of these unique approaches. But I do want to make sure that I take a moment to give a shout-out to the entire team that's involved with making all these things happen.

We're going to hear from our superstar surgeons, but they all represent an entire team. There's a team of nurses, RNFAs, PAs. The cardiothoracic anesthesia team does an amazing job because they have to make unique changes for these patients as well. And of course, our cardiology colleagues who help us to determine what's the best treatment choices for these patients before they come to the operating room and set these patients up for an appreciation of the complexities of what they're about to go through.

For those of you who aren’t familiar with him, get to know him. Gianluca Torregrossa is our newest surgeon on the team, in the stable. He’s doing a wonderful job so far. He’s going to share with us some of his story about robotic CABG.

Dr. Gianluca Torregrossa:

Thank you so much. Good morning, everyone. For me, it's a pleasure to be here in front of all of you and discuss one of the topics of my preference, which is minimally invasive robotic coronary bypass grafting. What is exactly a robotic CABG? Well, I'll bring you with me in an operating room. You see the patient is lying down, anesthesia has already done its magic, sedated, intubated, and a central line is generally in the right IJ, and an arterial line in the radial, left or right radial. We inserted three trocars in the left chest, second, fourth and sixth intercostal space. We bring in this complex machine, a complex tool that we call the robotic approach. The surgeon sits at the console and controls the instrument from that console itself. A second surgeon or an assistant is at the bedside of the patient in order to help with the management of all of the instruments, changing the instruments, and interchanging the various tools.

We can take two mammary arteries. You see, we are opening now. After opening the pericardium, we are opening the pleura from the left side into the right side. We are seeing the right lung and the right internal thoracic artery. We can take two mammary arteries from three small incisions in the left chest, crossing the midline, being able to bring our camera very close to the mammary itself, to the graft itself, and being able to harvest. This artery looks way bigger than it does when we are taking it from a sternotomy using our loops. You see, we can manage collaterals, cut these collaterals, and control various bleeding and control various elements of the surgery itself.

We go then back to the left side, and we prepare basically the two mammary arteries. This is the proximal right where the vein crosses, and we can prepare two mammary arteries, maintaining the proximity of the two mammary arteries to the final target. When we open the chest of the patients, one of the challenges is how to use the right internal thoracic artery with an open chest, how to pull it, how to push it into the field to reach the final destination on the left heart. Once that is done and you have seen this video before, we start to do the anastomosis.

Anastomosis can be done via a small incision, and we call it, in that case, a robotic MIDCAB, small incision in the chest. We do the anastomosis by hand or sometimes totally robotic, like in this case, where we can basically perform the suture directly with a robot.

What are the advantages? Well, robotic and totally robotic is not always more cosmetically superior and with less pain, no incision, no thoracotomy. Most importantly, reality is that with a total robotic approach, you can avoid pushing the heart into your visualization through the thoracotomy.

And what I mean by that is that the total endoscopic have the opportunity to perform more than one arterial distal target. Generally, robotic MIDCAB has been famous to treat only the LAD with a little to the LAD, but now with this total robotic approach, we can perform two or three bypasses on the left side and have our friends and colleagues, interventional cardiologists complete the revascularization by placing stents in known LAD or non-major target in the right or left system.

And you see the visualization, this is something that becomes the complexity of the surgery is preparing is setting up your table, preparing the patient to get this type of visualization. But the surgery itself and the anastomosis itself becomes, if you want, easy.

Years ago I prepared these slides, but with years and experience, I understood that these slides is actually wrong. I thought that there is an evolution of coronary artery bypass grafting, but as you heard before from Faisal Bakaeen, MD, reality is that robotic coronary bypass grafting is part of a dedicated coronary team. It is a tool that a coronary expert is capable of using in select type of patients based on the anatomy, based on the characteristics. These are complex patients and that can be discussed together with interventional cardiologists to understand when is appropriate to put a stent or when is not.

And I think that all of this conversation over the last 20 years of CABG versus PCI, both in literature and in the hallway of clinical activity is coming to an end. It's not anymore us against them. It's actually the opportunity to better understand which patients are better treated with a coronary bypass grafting, which patients are better treated with stents. And in certain occasions when the combination of both, one or two mammary artery to the best grafting plus a stent is the right decision. This is what we call hybrid or advanced hybrid when we use multiple arteries in different configurations and complete revascularization.

There are two major trials that have been published. What we are doing is actually supported by science. Five years published on JACC, 10 years published on Circulation. This randomized trial compares multi-vessel coronary artery disease patients receiving hybrid revascularization, robotic LIMA to LAD plus stent versus sternotomy off-pump or on pump CABG, LIMA and vein. The long term 10 years were excellent. In this meta-analysis, we actually provided support of the fact that hybrid one or two mammary artery plus stents perform better than multiple stents. Patients that are refusing surgery, they don't want to have a sternotomy, they tend to have multiple layers of stent placed in their coronary artery, but they do actually better when couple of mammary artery are deployed in their coronary.

This is the opportunity. The opportunity is to both grow business and treating more patients both for CABG and for PCI and bring interventional cardiologists and cardiac surgeons more together rather than apart.

And which are the patients? Electively, these are numerous patients. We have a stable coronary artery disease with moderate syntax involvement of the proximal LAD, CTO of the LAD that cannot be successfully reopened with a percutaneous intervention, or we want a better long-term outcome for them. STEMI, for example, a right patient that comes in with a STEMI in the right and then has coronary artery disease on the left. The patient is still young and active and there is a discussion of offering two mammary artery for the left system. Patients that have non-ischemic cardiomyopathy, but we saw very low ejection fraction, but present coronary artery disease in which we want to temporize the LVAD or the transplant and we can deploy one or two mammary artery avoiding and sparing a sternotomy.

Here is when we perform the MIDCAB, so the incision on the side. Again, this is instead when TECAB becomes superior, the opportunity to perform more than one single vessel. These are patients that leave the hospital in one day, go back to normal activities within one or two weeks. There is no limitation. They go back and driving basically directly from the hospital back home. This one is the revolutionary change that we want to embrace together with our team. You see the robot offers you also more modalities, more technology.

You see here, this is a bypass perform. You see this strange black and white color is a special option that we have, a special view that we have by using the robot. We can inject, anesthesia can inject from the right IJ, contrast that in this view modality becomes green. You can see the flow of your blood passing and becoming green. You will see now the backflow through the mammary artery and the anastomosis of the blood coming back into the left internal thoracic artery.

And then when I open the bulldog, the blood that comes down from the subclavian is now coming down through the anastomosis into your LAD. During the surgery we can do, if you want, angiographic control, visually angiographic control of the artery itself, making sure that you have a good pulsatility, you have a good opening of the coronary and all of your bypass are open in adjunct to other system of measuring the flow through the bypass, making sure that the results of what we are doing, despite they are minimally invasive, are still the excellent long-term results that made the clinic at the forefront of coronary revolution and coronary innovation in the last 40 or 50 years.

With this, I remark again the concept of a team, and I leave with the last two slides that are about a story. I think a story always wakes you up from the 7:00 morning meeting.

This is the first man who closed a marathon in less than two hours. There were professors in physiology who became full professors, proving that it was impossible for every man based on the VO2 max to complete a 42-kilometer run in less than two hours. This man did it. How he did it, he had 42 professional runners working with him. Each one of them was pacing him for each one of the kilometers. There was a laser that was giving the pace to tell the front runner how to do it. You see, he was running with a white shirt that was studied to eliminate any type of wind effect against him. The reality is that with a team, you can achieve results that you would never have been able or meant to be impossible by a single human being.

And with this, I want to say thank you so much for having me here and looking forward to working with all of you. Thank you.

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