- Email: [email protected]
Robotic Coronary Artery Bypass Grafting for Transplant Vasculopathy
Accepted Manuscript Robotic Coronary Artery Bypass Grafting for Transplant Vasculopathy Miguel Bravo, MD, Gianluca Torregrossa, MD, Donna Mancini, MD, John Puskas, MD PII:
S0003-4975(19)30127-4
DOI:
https://doi.org/10.1016/j.athoracsur.2018.12.054
Reference:
ATS 32319
To appear in:
The Annals of Thoracic Surgery
Received Date: 3 September 2018 Revised Date:
9 November 2018
Accepted Date: 21 December 2018
Please cite this article as: Bravo M, Torregrossa G, Mancini D, Puskas J, Robotic Coronary Artery Bypass Grafting for Transplant Vasculopathy, The Annals of Thoracic Surgery (2019), doi: https:// doi.org/10.1016/j.athoracsur.2018.12.054. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Robotic Coronary Artery Bypass Grafting for Transplant Vasculopathy
RI PT
Running Head: Treating Transplant Vasculopathy with Hybrid Approach
Miguel Bravo*MD, Gianluca Torregrossa* MD, Donna Mancini+ MD, John Puskas* MD
SC
*Mount Sinai St Luke’s
M AN U
+ Mount Sinai
Gianluca Torregrossa MD
TE D
Corresponding author:
Dpt Cardiac Surgery - Mount Sinai Saint Luke -
EP
Mount Sinai Health System NYC
1111 Amsterdam Avenue #6A-147
AC C
Babcock Building 6th floor 10025 New York City
Email: [email protected]
ACCEPTED MANUSCRIPT
Abstract A 60 year old female developed Cardiac Allograft Vasculopathy (CAV) 9 years after heart transplantation and treated with drug-eluting stent (DES) in the LAD. Recurrence of in stent
RI PT
restenosis (ISR) was treated with another DES. Recurrent IRS was again observed and Robotic Mid-CABG surgery was successfully performed. Mid-CABG is a plausible alternative in patients with CAV and offer the excellent result of LITA to LAD graft despite a sternotomy-spare
SC
approach. This is the first case report of the adoption of this technique in a redo heart transplant
M AN U
patient, opening the scenario for a new tool in the treatment of CAV.
Keywords: Orthotopic heart transplant, Cardiac allograft vasculopathy, Minimally Invasive
AC C
EP
TE D
Coronary Artery Bypass grafting, percutaneous coronary intervention, Robtic MidCAB surgery.
ACCEPTED MANUSCRIPT
The development of cardiac allograft vasculopathy (CAV) remains a common cause of death after heart transplantation.1 Compared to those without CAV, patients with mild forms have a two-fold risk of death, while patients with severe CAV have a 15 times higher mortality2-3.
RI PT
Once diagnosed, the therapy for CAV is limited to modification of risk factors and the use of proliferation signal inhibitors4. For focal disease, drug eluting stents have been more effective in reducing restenosis rates but have not been shown to improve survival.5 Coronary Artery Bypass
SC
Grafting (CABG) has been generally ineffective with most single center studies reporting high perioperative and one-year mortality6-7. Minimally invasive CABG has not yet been reported in
M AN U
these patients. Nonetheless, minimally invasive CABG would decrease the surgical risk of redo sternotomy, limiting the risk of perioperative wound infection. Furthermore, with less intraoperative time there would be less chance for bleeding and the possibilities of pump failure would diminish decreasing intra- and post-operative morbidity and mortality. The possibility of
TE D
performing bypass grafting without a redo-sternotomy represents a potential new tool for treatment of CAV in these patients. We present herein a case of CAV treated with a Robotic
EP
MIDCAB surgery after an in-stent restenosis.
A 63 year old diabetic hypertensive woman underwent orthotopic cardiac transplant in 2006 for
AC C
treatment of hypertrophic cardiomyopathy (HCM). She was diagnosed with HCM at age 30. She was UNOS 1B at the time of transplant. Her transplant surgery was unremarkable and she was discharged within 2 weeks of transplant. There were no episodes of allograft rejection and no donor specific antibody formation. On her first annual catheterization, the arteries were normal. She did well and returned to work as a labor and delivery nurse.
ACCEPTED MANUSCRIPT
In 8/2015, her annual exam showed 80% lesion of the LAD treated with a DES. Cellcept was transitioned to sirolimus. In 6/2016, her angiogram was repeated and showed severe progression with a distal 70% left main stenosis, 70% proximal circumflex stenosis, and a patent LAD stent.
RI PT
Left main and circumflex stents were placed. Her left ventricular function remained normal and she continued to work. Her next cathetherization was on 8/2017 and showed 90% stenosis in the LAD stent. The distal LAD appeared to be of good caliber and free of disease. Graft function
SC
remained normal and she had no signs or symptoms of heart failure. Considering the failure of multiple stents, a complex PCI was not considered to be feasible. Options offered included
M AN U
retransplantation, or coronary artery bypass grafting.
Decision was made to offer a robotically assisted minimally invasive CABG. Surgery was performed using the technique previously described8. Briefly, the patient underwent general anesthesia and single lung ventilation. Three Trocar were placed in 2nd, 5th and 7th intercostal
TE D
spaces and the Da Vinci Xi Robotic System was connected. A camera and two operative branches were used to remove a minimal amount of adhesion from previous surgery. The mammary artery was intact along is course in the left chest and well visualized thought the 3D
EP
high resolution optics of the DaVinci Xi. The left internal mammary artery was harvested from the left chest. After completing a submammary minithoracotomy in the 5th left intercostal space,
AC C
the LITA was anastomosed to the LAD using an automated one-step sutureless distal anastomotic device (Flex-A). The bypass was tested using Trans time Doppler confirming an excellent result. Patient was discharged home in post operative day 4 and continues to do well 6 months after surgery. Minimally invasive CABG represent a new tool to treat CAV or in stent restenosis in CAV avoiding a redo-sternotomy.
ACCEPTED MANUSCRIPT
COMMENT Cardiac allograft vasculopathy (CAV) is the most fatal complication in the first year after orthotopic heart transplant (OHT)3,5. Until now, the most common palliative treatment is
RI PT
Percutaneous Coronary Intervention (PCI)3 and the definitive treatment is heart retransplantation. However, retransplanted patients have worse cardiac outcomes such as the presence of
worsening end-stage heart failure reported by Musci et al.7 Conventional Coronary Artery
SC
Bypass Grafting (CABG) is used in more complicated cases with severe multivessel stenoses6-7. In spite of improvement of heart function, ejection fraction, left ventricular function and
M AN U
sustained graft patency6, conventional CABG using median sternotomy needs to be carefully considered in patients with CAV6. The reason for this is because it is a more invasive procedure and because of its increase in mortality intra- and post-operatively probably secondary to pump failure as Halle et al. stated, in which diffuse disease of the microcirculation5 may play a major
TE D
role in its pathogenesis. Therefore, this case exemplifies a logical and plausible alternative to decrease immunological complications, plaque formation, need for revascularization, and case fatalities by using minimally invasive surgical procedures such as Robotic CABG compared to
EP
conventional open sternotomy CABG and with longer patency and less graft restenosis as in PCI6. Its minimally invasive access makes it a great alternative in patients taking immunotherapy
AC C
because of less risk for bleeding and infections in susceptible patients as well as in less operative time and recovery time.
We hope that this case report opens a window to new possibilities for CAV treatment with successful outcomes such as a decrease in morbidity and mortality and a better quality of life for patients who, otherwise, would perish.
ACCEPTED MANUSCRIPT
FIGURE LEGENDS Figure 1: Pre-operative left heart cath showing the in stent restenosis in the proximal left anterior descending coronary artery and in stent restenosis of the circumflex artery
RI PT
Figures 2 and 3: Post op images of patent left internal thoracic artery to the left anterior
AC C
EP
TE D
M AN U
SC
descending coronary artery
ACCEPTED MANUSCRIPT
References 1.
ISHLT Registry report
2.
Gao SZ, Alderman EL, Schroeder JS, Silverman JF and Hunt SA. Accelerated
RI PT
coronary vascular disease in the heart transplant patient: coronary arteriographic findings. J Am Coll Cardiol. 1988;12:334-40. 3.
Agarwal S, Parashar A, Kapadia SR, Tuzcu EM, Modi D, Starling RC and Oliveira
SC
GH. Long-Term Mortality After Cardiac Allograft Vasculopathy Implications of Percutaneous Intervention. JACC: Heart Failure. 2014;2:281-288. Mancini D, Pinney S, Burkhoff D, LaManca J, Itescu S, Burke E, Edwards N, Oz M
M AN U
4.
and Marks AR. Use of rapamycin slows progression of cardiac transplantation vasculopathy. Circulation. 2003;108:48-53. 5.
Halle AA, 3rd, DiSciascio G, Massin EK, Wilson RF, Johnson MR, Sullivan HJ,
TE D
Bourge RC, Kleiman NS, Miller LW, Aversano TR and et al. Coronary angioplasty, atherectomy and bypass surgery in cardiac transplant recipients. J Am Coll Cardiol. 1995;26:120-8.
Patel VS RB, Springer W, Frazier OH, Massin E, Benrey J, Kadipasaoglu K, Cooley
EP
6.
DA. Revascularization procedures in patients with transplant coronary artery disease.
7.
AC C
European Journal of Cardio-Thoracic Surgery. 1997;11:895-901.
Musci M, Loebe M, Wellnhofer E, Meyer R, Pasic M, Hummel M, Bocksch W, Grauhan O, Weng Y and Hetzer R. Coronary angioplasty, bypass surgery, and retransplantation in cardiac transplant patients with graft coronary disease. The Thoracic and cardiovascular surgeon. 1998;46:268-74.
ACCEPTED MANUSCRIPT
Torregrossa G, Kanei Y, Puskas J. Hybrid Robotic Coronary Artery Bypass Grafting:
EP
TE D
M AN U
SC
RI PT
how do we do it. Ann Cardiothorac Surg 2016;5(6):582-585
AC C
8.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0003-4975(19)30127-4
DOI:
https://doi.org/10.1016/j.athoracsur.2018.12.054
Reference:
ATS 32319
To appear in:
The Annals of Thoracic Surgery
Received Date: 3 September 2018 Revised Date:
9 November 2018
Accepted Date: 21 December 2018
Please cite this article as: Bravo M, Torregrossa G, Mancini D, Puskas J, Robotic Coronary Artery Bypass Grafting for Transplant Vasculopathy, The Annals of Thoracic Surgery (2019), doi: https:// doi.org/10.1016/j.athoracsur.2018.12.054. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Robotic Coronary Artery Bypass Grafting for Transplant Vasculopathy
RI PT
Running Head: Treating Transplant Vasculopathy with Hybrid Approach
Miguel Bravo*MD, Gianluca Torregrossa* MD, Donna Mancini+ MD, John Puskas* MD
SC
*Mount Sinai St Luke’s
M AN U
+ Mount Sinai
Gianluca Torregrossa MD
TE D
Corresponding author:
Dpt Cardiac Surgery - Mount Sinai Saint Luke -
EP
Mount Sinai Health System NYC
1111 Amsterdam Avenue #6A-147
AC C
Babcock Building 6th floor 10025 New York City
Email: [email protected]
ACCEPTED MANUSCRIPT
Abstract A 60 year old female developed Cardiac Allograft Vasculopathy (CAV) 9 years after heart transplantation and treated with drug-eluting stent (DES) in the LAD. Recurrence of in stent
RI PT
restenosis (ISR) was treated with another DES. Recurrent IRS was again observed and Robotic Mid-CABG surgery was successfully performed. Mid-CABG is a plausible alternative in patients with CAV and offer the excellent result of LITA to LAD graft despite a sternotomy-spare
SC
approach. This is the first case report of the adoption of this technique in a redo heart transplant
M AN U
patient, opening the scenario for a new tool in the treatment of CAV.
Keywords: Orthotopic heart transplant, Cardiac allograft vasculopathy, Minimally Invasive
AC C
EP
TE D
Coronary Artery Bypass grafting, percutaneous coronary intervention, Robtic MidCAB surgery.
ACCEPTED MANUSCRIPT
The development of cardiac allograft vasculopathy (CAV) remains a common cause of death after heart transplantation.1 Compared to those without CAV, patients with mild forms have a two-fold risk of death, while patients with severe CAV have a 15 times higher mortality2-3.
RI PT
Once diagnosed, the therapy for CAV is limited to modification of risk factors and the use of proliferation signal inhibitors4. For focal disease, drug eluting stents have been more effective in reducing restenosis rates but have not been shown to improve survival.5 Coronary Artery Bypass
SC
Grafting (CABG) has been generally ineffective with most single center studies reporting high perioperative and one-year mortality6-7. Minimally invasive CABG has not yet been reported in
M AN U
these patients. Nonetheless, minimally invasive CABG would decrease the surgical risk of redo sternotomy, limiting the risk of perioperative wound infection. Furthermore, with less intraoperative time there would be less chance for bleeding and the possibilities of pump failure would diminish decreasing intra- and post-operative morbidity and mortality. The possibility of
TE D
performing bypass grafting without a redo-sternotomy represents a potential new tool for treatment of CAV in these patients. We present herein a case of CAV treated with a Robotic
EP
MIDCAB surgery after an in-stent restenosis.
A 63 year old diabetic hypertensive woman underwent orthotopic cardiac transplant in 2006 for
AC C
treatment of hypertrophic cardiomyopathy (HCM). She was diagnosed with HCM at age 30. She was UNOS 1B at the time of transplant. Her transplant surgery was unremarkable and she was discharged within 2 weeks of transplant. There were no episodes of allograft rejection and no donor specific antibody formation. On her first annual catheterization, the arteries were normal. She did well and returned to work as a labor and delivery nurse.
ACCEPTED MANUSCRIPT
In 8/2015, her annual exam showed 80% lesion of the LAD treated with a DES. Cellcept was transitioned to sirolimus. In 6/2016, her angiogram was repeated and showed severe progression with a distal 70% left main stenosis, 70% proximal circumflex stenosis, and a patent LAD stent.
RI PT
Left main and circumflex stents were placed. Her left ventricular function remained normal and she continued to work. Her next cathetherization was on 8/2017 and showed 90% stenosis in the LAD stent. The distal LAD appeared to be of good caliber and free of disease. Graft function
SC
remained normal and she had no signs or symptoms of heart failure. Considering the failure of multiple stents, a complex PCI was not considered to be feasible. Options offered included
M AN U
retransplantation, or coronary artery bypass grafting.
Decision was made to offer a robotically assisted minimally invasive CABG. Surgery was performed using the technique previously described8. Briefly, the patient underwent general anesthesia and single lung ventilation. Three Trocar were placed in 2nd, 5th and 7th intercostal
TE D
spaces and the Da Vinci Xi Robotic System was connected. A camera and two operative branches were used to remove a minimal amount of adhesion from previous surgery. The mammary artery was intact along is course in the left chest and well visualized thought the 3D
EP
high resolution optics of the DaVinci Xi. The left internal mammary artery was harvested from the left chest. After completing a submammary minithoracotomy in the 5th left intercostal space,
AC C
the LITA was anastomosed to the LAD using an automated one-step sutureless distal anastomotic device (Flex-A). The bypass was tested using Trans time Doppler confirming an excellent result. Patient was discharged home in post operative day 4 and continues to do well 6 months after surgery. Minimally invasive CABG represent a new tool to treat CAV or in stent restenosis in CAV avoiding a redo-sternotomy.
ACCEPTED MANUSCRIPT
COMMENT Cardiac allograft vasculopathy (CAV) is the most fatal complication in the first year after orthotopic heart transplant (OHT)3,5. Until now, the most common palliative treatment is
RI PT
Percutaneous Coronary Intervention (PCI)3 and the definitive treatment is heart retransplantation. However, retransplanted patients have worse cardiac outcomes such as the presence of
worsening end-stage heart failure reported by Musci et al.7 Conventional Coronary Artery
SC
Bypass Grafting (CABG) is used in more complicated cases with severe multivessel stenoses6-7. In spite of improvement of heart function, ejection fraction, left ventricular function and
M AN U
sustained graft patency6, conventional CABG using median sternotomy needs to be carefully considered in patients with CAV6. The reason for this is because it is a more invasive procedure and because of its increase in mortality intra- and post-operatively probably secondary to pump failure as Halle et al. stated, in which diffuse disease of the microcirculation5 may play a major
TE D
role in its pathogenesis. Therefore, this case exemplifies a logical and plausible alternative to decrease immunological complications, plaque formation, need for revascularization, and case fatalities by using minimally invasive surgical procedures such as Robotic CABG compared to
EP
conventional open sternotomy CABG and with longer patency and less graft restenosis as in PCI6. Its minimally invasive access makes it a great alternative in patients taking immunotherapy
AC C
because of less risk for bleeding and infections in susceptible patients as well as in less operative time and recovery time.
We hope that this case report opens a window to new possibilities for CAV treatment with successful outcomes such as a decrease in morbidity and mortality and a better quality of life for patients who, otherwise, would perish.
ACCEPTED MANUSCRIPT
FIGURE LEGENDS Figure 1: Pre-operative left heart cath showing the in stent restenosis in the proximal left anterior descending coronary artery and in stent restenosis of the circumflex artery
RI PT
Figures 2 and 3: Post op images of patent left internal thoracic artery to the left anterior
AC C
EP
TE D
M AN U
SC
descending coronary artery
ACCEPTED MANUSCRIPT
References 1.
ISHLT Registry report
2.
Gao SZ, Alderman EL, Schroeder JS, Silverman JF and Hunt SA. Accelerated
RI PT
coronary vascular disease in the heart transplant patient: coronary arteriographic findings. J Am Coll Cardiol. 1988;12:334-40. 3.
Agarwal S, Parashar A, Kapadia SR, Tuzcu EM, Modi D, Starling RC and Oliveira
SC
GH. Long-Term Mortality After Cardiac Allograft Vasculopathy Implications of Percutaneous Intervention. JACC: Heart Failure. 2014;2:281-288. Mancini D, Pinney S, Burkhoff D, LaManca J, Itescu S, Burke E, Edwards N, Oz M
M AN U
4.
and Marks AR. Use of rapamycin slows progression of cardiac transplantation vasculopathy. Circulation. 2003;108:48-53. 5.
Halle AA, 3rd, DiSciascio G, Massin EK, Wilson RF, Johnson MR, Sullivan HJ,
TE D
Bourge RC, Kleiman NS, Miller LW, Aversano TR and et al. Coronary angioplasty, atherectomy and bypass surgery in cardiac transplant recipients. J Am Coll Cardiol. 1995;26:120-8.
Patel VS RB, Springer W, Frazier OH, Massin E, Benrey J, Kadipasaoglu K, Cooley
EP
6.
DA. Revascularization procedures in patients with transplant coronary artery disease.
7.
AC C
European Journal of Cardio-Thoracic Surgery. 1997;11:895-901.
Musci M, Loebe M, Wellnhofer E, Meyer R, Pasic M, Hummel M, Bocksch W, Grauhan O, Weng Y and Hetzer R. Coronary angioplasty, bypass surgery, and retransplantation in cardiac transplant patients with graft coronary disease. The Thoracic and cardiovascular surgeon. 1998;46:268-74.
ACCEPTED MANUSCRIPT
Torregrossa G, Kanei Y, Puskas J. Hybrid Robotic Coronary Artery Bypass Grafting:
EP
TE D
M AN U
SC
RI PT
how do we do it. Ann Cardiothorac Surg 2016;5(6):582-585
AC C
8.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT