Does Intolerance of Single-Lung Ventilation Preclude Robotic Off-Pump Totally Endoscopic Coronary Bypass Surgery?

Robotic off-pump totally endoscopic coronary artery bypass (TECAB) usually requires isolated single (right) lung ventilation to adequately expose the surgical site. However, in some patients, persistent oxygen desaturation may occur and conversion to cardiopulmonary bypass (CPB) or sternotomy may be necessary. We reviewed the characteristics and clinical outcomes in patients who did not tolerate single-lung ventilation during TECAB surgery.

After Institutional Review Board approval we reviewed 440 patients undergoing robotic TECAB at our institution between July 2013 and April 2019. Patients were separated into 2 groups based on their ability to tolerate single-lung ventilation during the procedure. Group 1 included patients able to tolerate single-lung ventilation and Group 2 were patients who required double-lung ventilation to tolerate the procedure. Early and mid-term outcomes were compared.

Group 2 (121 patients) had higher Society of Thoracic Surgeons scores, higher body mass index, and more triple-vessel disease than Group 1 (319 patients). Group 2 had more bilateral internal mammary artery use, multivessel grafting, and longer operative times. One patient underwent conversion to sternotomy and 5 required CPB (all in Group 1). Intensive care unit and hospital length of stay were longer in Group 2. Observed/expected mortality did not differ between groups (1.06% in Group 2 vs 0.4% in Group 1; P = 0.215). At mid-term follow-up, cardiac-related/overall mortality and freedom from major adverse cardiac events were similar.

In our cohort, intolerance of single-lung ventilation did not preclude robotic off-pump TECAB. Double-lung ventilation is feasible during the procedure and may prevent conversions to sternotomy or use of CPB, resulting in excellent early and mid-term outcomes.