Robotically-assisted, totally endoscopic myocardial bridge unroofing: surgical technique

Myocardial bridging (MB) is a congenital anomaly in which a segment of the coronary artery, most commonly the left anterior descending (LAD) artery, courses intramyocardially. While often asymptomatic, MB can cause myocardial ischemia, arrhythmias, and, in rare cases, sudden cardiac death. Surgical unroofing is the definitive treatment for symptomatic patients who are unresponsive to medical therapy, and it is considered superior to catheter-based interventions. The adoption of robotic techniques has enabled a totally endoscopic approach that minimizes surgical trauma, facilitates faster recovery, and improves cosmetic results. This manuscript details our technique for robotic myocardial bridge unroofing. Preoperative assessment besides standard workup for cardiac surgery, includes coronary computed tomography (CT) angiography, lung function tests, and invasive physiological testing to confirm the significance of MB. Using the da Vinci Xi robotic system, the procedure is performed through four 8-mm robotic ports with femoral cannulation and endoaortic balloon occlusion for endo-cardioplegia, ensuring a motionless field for precise unroofing of the LAD without compromising vessel integrity. Compared to traditional sternotomy-based techniques, the robotic totally endoscopic approach represents a version of the procedure with the least surgical trauma and offers improved visualization as well as enhanced dexterity and precision. Specialized robotic training is required and our experience demonstrates robotic unroofing is a promising evolution in the surgical management of a symptomatic LAD MB.