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Right Internal Mammary Artery Use in 140 Robotic Totally Endoscopic Coronary Bypass Cases: Toward Multiarterial Grafting

Balkhy, Husam H. MD; Nathan, Sandeep MD; Arnsdorf, Susan E. MS; Krienbring, Dorothy J. BSN

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: January/February 2017 - Volume 12 - Issue 1 - p 9–14
doi: 10.1097/IMI.0000000000000341
Original Articles

Objective Benefits of adding a second arterial graft in coronary bypass are well documented. In patients requiring mulitvessel grafting robotic totally endoscopic coronary bypass (TECAB) has allowed for routine harvesting and use of the right internal mammary artery (RIMA). We retrospectively reviewed the technical considerations and target choice in 140 cases of beating heart TECAB where a RIMA graft was used.

Methods In 2008, we introduced beating heart TECAB with anastomotic connectors into our practice, first with single IMA and then with bilateral internal mammary artery. A robotic stabilizer was used not only to facilitate exposure of the coronary targets but also to aid the RIMA harvest using a skeletonized approach. Flow measurements were obtained routinely. We reviewed the technical aspects, target choice, and intraoperative flows in our TECAB patients who underwent grafting with RIMA grafts.

Results From February 2008 to January 2015, a total of 404 patients underwent beating heart TECAB with anastomotic connectors, of which 194 (48%) were mulitvessel procedures. One hundred forty patients (35%) had a RIMA graft and constitute the patient population for this review. One hundred thirty-one RIMA grafts were harvested via left-sided ports and grafted to left coronary targets, and nine RIMA grafts were harvested via right-sided ports and grafted to the right coronary artery. Flow was greater than 25 mL/min (pulsatility index < 2) in 95% of grafts. Perioperative mortality was 0.7% and mean ± standard deviation length of hospital stay was 3.1 (1.5) days. The RIMA was used as an in situ graft in 124 cases (84%) and as a free T-graft in 24 cases (16%) cases. Right internal mammary artery graft use in all TECABS increased from 23% in the first 5 years to 53% in the last 2 years.

Conclusions Robotic TECAB allows the routine harvesting and use of the RIMA graft in a safe and reproducible manner. Skeletonization and sternal sparing allow the RIMA to reach various coronary targets. Further studies are needed for this approach to impact the adaption of multiarterial grafting.

From the Departments of *Cardiothoracic Surgery and †Cardiology, University of Chicago Medicine, Chicago, IL USA.

Accepted for publication December 1, 2016.

Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, June 3–6, 2015, Berlin, Germany.

Disclosure: The authors declare no conflicts of interest.

Address correspondence and reprint requests to Husam H. Balkhy, MD, Department of Cardiothoracic Surgery, University of Chicago Medicine, 5841 S Maryland Ave, Rm E500, MC 5040, Chicago, IL 60637 USA. E-mail:

©2017 by the International Society for Minimally Invasive Cardiothoracic Surgery