title: Is totally endoscopic coronary artery bypass safe, feasible and effective?
abstract: A best evidence topic was written according to a structured protocol. The question addressed was whether totally endoscopic coronary artery bypass (TECAB) is safe, effective and feasible. A total of 171 papers were found, of which eight represented the best evidence. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The da Vinci robotic system was utilized in seven retrospective studies and one multicentre prospective trial, comprising 724 patients undergoing TECAB. Patient-related outcomes, including the incidence of major adverse cardiac events, graft patency and survival, were investigated. From the studies evaluated, TECAB appears to be safe operation with low complication rates and excellent early- and mid-term graft patencies. The incidence of internal thoracic artery injury was documented in four studies and ranged from 0 to 10%. Re-exploration for bleeding was necessary in 1-15% of patients. Conversion to open techniques was performed in 0-24% of cases. There was no in-hospital mortality in the majority of studies, but this reached 2.1% in a large series of 228 patients. Target-vessel reintervention rates varied between 0 and 12.1% according to the institutional experience. Pre- and post-discharge graft patencies were excellent at 93-100 and 92-100%, respectively. Intraoperative variables, such as time taken for internal thoracic artery harvest, anastomosis, cross-clamp, cardiopulmonary bypass (CPB) and the overall operation were as follows: internal thoracic artery harvest time (range 5-187 min), anastomosis time (range 6-82 min), cross-clamp time (range 30-223 min), CPB time (range 41-268 min) and operative time (range 84-600 min). TECAB is a technically demanding and time-consuming procedure associated with a significant learning curve. Proctoring and structured training programmes are currently supported by European and international societies to encourage wider uptake of the procedure. In conclusion, TECAB represents a feasible alternative to conventional coronary artery bypass in selected patients. It is associated with low morbidity and excellent mid-term graft patency. Larger, prospective and multicentre trials are required to assess the long-term and patient-reported outcomes of TECAB.
authors.affiliation: Department of Cardiothoracic Surgery,  Imperial College London, Hammersmith Hospital Campus, London,  UK.
authors.forename: Metesh Nalin
authors.initials: MN
authors.lastname: Acharya
authors.forename: Hutan
authors.initials: H
authors.lastname: Ashrafian
authors.forename: Thanos
authors.initials: T
authors.lastname: Athanasiou
authors.forename: Roberto
authors.initials: R
authors.lastname: Casula
mesh_terms: D000368:Aged; D019985:Benchmarking; D001026:Coronary Artery Bypass / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D003324:Coronary Artery Disease / Q000401:mortality / Q000601:surgery*; D004724:Endoscopy / Q000009:adverse effects / Q000401:mortality; D019317:Evidence-Based Medicine; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000601:surgery; D012086:Reoperation; D012371:Robotics; D025321:Surgery, Computer-Assisted / Q000009:adverse effects / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome