Advanced Hybrid Coronary Revascularization With Bilateral Internal Mammary Arteries: Preventing and Managing
Xander Jacquemyn1, Danny Feike Hoogma2, Wouter Oosterlinck1
1Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
Background:
Robotic-assisted minimally invasive direct coronary artery bypass (MIDCAB) with bilateral internal mammary artery (BIMA) harvesting is an emerging approach for durable revascularization of coronary artery disease (CAD). Intraoperative cardiac luxation is a rare but potentially life-threatening complication during this procedure, yet guidance on recognition and management is limited.
Case Summary:
A 45-year-old woman with familial hypercholesterolemia and diffuse multivessel CAD underwent hybrid revascularization with robotic-assisted MIDCAB using BIMA grafts. Intraoperatively, cardiac luxation occurred but was rapidly resolved through lung inflation counterpressure and robotic pericardial repositioning. The remainder of the procedure proceeded uneventfully. At follow-up, she remained asymptomatic with no signs of graft failure or recurrent ischemia.
Discussion:
This case highlights the importance of prompt recognition and management of cardiac luxation during robotic-assisted MIDCAB. Strategies such as low contralateral lung ventilation pressure, careful pericardial incision placement, and readiness for robotic pericardial repositioning or conversion to sternotomy if hemodynamic compromise persists can prevent complications and optimize outcomes.
Take-Home Messages:
Robotic-assisted BIMA harvesting provides a durable, less invasive revascularization strategy for young patients with familial hypercholesterolemia and diffuse CAD. Intraoperative cardiac luxation is a rare but critical complication during robotic-assisted MIDCAB, requiring immediate bilateral or left-sided lung inflation and robotic repositioning to easily restore hemodynamic stability.
