Review of Robotic-Assisted, Totally Endoscopic CABG
In total, 26 relevant studies were identified. Four publications were excluded as the investigators reported these results in later papers with accumulating numbers of patients and increased length of follow-up. Four more publications were excluded as the authors focused on specific endpoints in patients included in more comprehensive publications, although they were still considered in the discussion of results. A recent retrospective comparison of their one- and two-vessel patients by Bonatti and coworkers appeared to include patients that were reported in previous publications, so this paper was included in a separate evaluation of multivessel revascularisation (because of the appropriate format of reported endpoints) without patient duplication. Four studies with less than 20 patients were excluded. The study selection process is presented in Figure 1 based on the PRISMA statement. The 14 appraised studies allowed evaluation of 880 BH-TECABG patients, 360 AH-TECABG patients, 633 one-vessel operations and 357 two-vessel operations. A summary of the characteristics of the included studies is reported in Table 1.
(Enlarge Image)
Figure 1.
Search strategy of the systematic review on totally endoscopic coronary artery bypass grafting
Seven studies reported causes and rates of intraoperative exclusion or conversion to CABG through sternotomy or minithoracotomy in BH-TECABG patients, and four studies in AHTECABG patients. Their results are summarized in Table 2. The most common causes for exclusion in both BH-TECABG and AH-TECABG were an intramyocardial left anterior descending (LAD) artery, inadequate working space (commonly reported as <3 cm), a severely calcified LAD and pleural adhesions. The most common causes for conversion in BH-TECABG were haemodynamic instability, intolerance to single-lung ventilation, bleeding and inadequate stabilization of the heart. The majority of conversions in AH-TECABG were due to difficulty with the CPB circuit, including endoaortic balloon rupture or migration and iliofemoral disease.
Almost all studies used arterial grafts exclusively. 'Multivessel' was defined by authors as multiple vessels grafted, not number of conduits used. Two multivessel studies reported specific revascularisation schemes. The most common one-vessel schemes were LIMA-LAD (90%), RIMA-RCA (3%) and LIMA-obtuse marginal artery (OM) (3%). The most common two-vessel schemes were LIMA-diagonal branch (Dx)/OM/circumflex artery (Cx) + RIMA-LAD (49%), LIMA-LAD-LAD jump (18%), LIMA-LAD + RIMA-Dx/OM/Cx (11%). There were only a small number of three and four vessel operations reported.
Seven studies reported short-term outcomes for BH-TECABG and four studies for AH-TECABG. Their results and weighted means of all results are reported in Table 3.
Five studies reported selected endpoints separately for one- and two-vessel operations, though not all of these endpoints were the same, or were not in the same format, and thus meta-analysis was not performed. Five studies that reported operating time all demonstrated significantly increased time for two-vessel operations. Mean times for one-vessel were in the range of 177–252 minutes, and mean times for two-vessel were in the range of 310–378 minutes. The earliest studies also had the longest operating times. Of the three studies that reported mortality, one had no mortality in either group, and the other two found no significant difference. The two studies that reported risk of intraoperative conversion rate both reported increased risk with two-vessel operations.
The short-term postoperative patency of 659 grafts performed in BH-TECABG was 98.3% and for 253 grafts in AH-TECABG was 96.4%. Patency was defined by authors as <50% stenosis and was determined using either computed tomography angiography, angiography performed during a hybrid procedure or stress ECG.
Four studies reported follow-up outcomes for greater than 1 year. Their results are summarized in Table 4. This included a study by Currie and coworkers that determined a graft patency of 92.7% in 12 grafts at 8±1.3 years post operation using cardiac catheterization and stress myocardial perfusion scintigraphy.
Results
Included Trials
In total, 26 relevant studies were identified. Four publications were excluded as the investigators reported these results in later papers with accumulating numbers of patients and increased length of follow-up. Four more publications were excluded as the authors focused on specific endpoints in patients included in more comprehensive publications, although they were still considered in the discussion of results. A recent retrospective comparison of their one- and two-vessel patients by Bonatti and coworkers appeared to include patients that were reported in previous publications, so this paper was included in a separate evaluation of multivessel revascularisation (because of the appropriate format of reported endpoints) without patient duplication. Four studies with less than 20 patients were excluded. The study selection process is presented in Figure 1 based on the PRISMA statement. The 14 appraised studies allowed evaluation of 880 BH-TECABG patients, 360 AH-TECABG patients, 633 one-vessel operations and 357 two-vessel operations. A summary of the characteristics of the included studies is reported in Table 1.
(Enlarge Image)
Figure 1.
Search strategy of the systematic review on totally endoscopic coronary artery bypass grafting
Intraoperative Outcomes
Seven studies reported causes and rates of intraoperative exclusion or conversion to CABG through sternotomy or minithoracotomy in BH-TECABG patients, and four studies in AHTECABG patients. Their results are summarized in Table 2. The most common causes for exclusion in both BH-TECABG and AH-TECABG were an intramyocardial left anterior descending (LAD) artery, inadequate working space (commonly reported as <3 cm), a severely calcified LAD and pleural adhesions. The most common causes for conversion in BH-TECABG were haemodynamic instability, intolerance to single-lung ventilation, bleeding and inadequate stabilization of the heart. The majority of conversions in AH-TECABG were due to difficulty with the CPB circuit, including endoaortic balloon rupture or migration and iliofemoral disease.
Almost all studies used arterial grafts exclusively. 'Multivessel' was defined by authors as multiple vessels grafted, not number of conduits used. Two multivessel studies reported specific revascularisation schemes. The most common one-vessel schemes were LIMA-LAD (90%), RIMA-RCA (3%) and LIMA-obtuse marginal artery (OM) (3%). The most common two-vessel schemes were LIMA-diagonal branch (Dx)/OM/circumflex artery (Cx) + RIMA-LAD (49%), LIMA-LAD-LAD jump (18%), LIMA-LAD + RIMA-Dx/OM/Cx (11%). There were only a small number of three and four vessel operations reported.
Short-term Outcomes
Seven studies reported short-term outcomes for BH-TECABG and four studies for AH-TECABG. Their results and weighted means of all results are reported in Table 3.
Five studies reported selected endpoints separately for one- and two-vessel operations, though not all of these endpoints were the same, or were not in the same format, and thus meta-analysis was not performed. Five studies that reported operating time all demonstrated significantly increased time for two-vessel operations. Mean times for one-vessel were in the range of 177–252 minutes, and mean times for two-vessel were in the range of 310–378 minutes. The earliest studies also had the longest operating times. Of the three studies that reported mortality, one had no mortality in either group, and the other two found no significant difference. The two studies that reported risk of intraoperative conversion rate both reported increased risk with two-vessel operations.
The short-term postoperative patency of 659 grafts performed in BH-TECABG was 98.3% and for 253 grafts in AH-TECABG was 96.4%. Patency was defined by authors as <50% stenosis and was determined using either computed tomography angiography, angiography performed during a hybrid procedure or stress ECG.
Intermediate to Long-term Outcomes
Four studies reported follow-up outcomes for greater than 1 year. Their results are summarized in Table 4. This included a study by Currie and coworkers that determined a graft patency of 92.7% in 12 grafts at 8±1.3 years post operation using cardiac catheterization and stress myocardial perfusion scintigraphy.
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