Information on atherosclerosis and CAD

How is Coronary Artery Disease Diagnosed?

Alternatives to bypass surgery

Methods to perform bypass surgery

Methods to perform bypass surgery

Methods to perform bypass surgeryAscending aortic disease

Methods to perform bypass surgery: Beating Heart Surgery

Evolution of Minimally Invasive Bypass1990s 2000s PresentOn-pump bypass Off-pump bypass Minimally Invasive (OPCAB)

Results for Robotic Bypass

Results for Robotic Bypass

Two IMAs are better than one5Liberal use of BIMAR Poston: 45% useSrivastava: 150 cases1National average2: 6%Boston average3: 4%EndoACAB4: 5.3%Srivastava, Ann Thorac Surg. 2006;81(3):800-6 Circulation 2009;120(11):935-40MASS-DAC report, 10/14/09Vassiliades, Ann Thor Surg 2007; 83:979-84Lytle BW et al. JTCVS 1999;117:855-72Long-term Results for Robotic Bypass

Possible ComplicationsFailure of the bypass graftsConversion to an open procedure (1-2% risk)Unable to tolerate breathing with one lungPoor access to the arteries that need to be bypassedBleeding that can not be controlledIncisional painLearning Curve

Candidates for Robotic BypassSuitable coronary arteries for bypassAble to tolerate breathing with one lungNo evidence of unstable symptoms or blood pressure

How to reach Dr. PostonOffice phone: 773-702-2500Cell phone: 617-610-0126Email: rposton@surgery.bsd.uchicago.eduAddress: Robert Poston, MD Professor of Surgery Division of Cardiothoracic Surgery University of Chicago Medical Center 5841 S. Maryland Ave, MC 5040 Chicago, IL 60637 Fax 773-702-4187

What Happens During a Consultation?Review of Coronary Angiographic ImagesDiscrete blockage, good targets Multiple blockages, poor targets

What Happens During a Consultation?Review of Medical HistoryNo contraindications for surgery and general anesthesiaAppropriate need for bypass surgery (vs. stenting or medical therapy)Appropriate candidate for less invasive approachStable symptomsAdequate lung function

What Happens During a Consultation?Review of Pros and Cons of Robotic BypassQuicker recoveryLess complicationsSternal infectionStrokeReduced loss of blood, fluid, heat during surgeryLong-term results not yet confirmedSafety compromised in certain patientsUnexpected events occur during the learning curve

What Happens During a Consultation?Why wasnt this option brought up before?1) For many patients, robotic bypass as an appropriate option for the treatment of CAD 2) Traditional bypass surgery is not clearly more effective in all respects that matter to patients. 3) The choice between available options is sensitive to the preferences of individuals4) Clinicians often make assumptions about patients preferences and provide recommendations without explaining all options.

Testing required before surgeryLung function (if necessary)Other organ function (liver, kidneys, brain)Clotting testsAny prior problem with surgery?Is there a pacemaker? EP consultConsultation with anesthesiologists

Day of SurgeryArrive at the Admitting Department for check-in (6am for first case, 10am for second case)Will be escorted from Admitting to Preop Holding Area.Dr. Poston will visit you and family in Preop Area at 6:45amTaken to OR at 7:00amAfter the case is complete (typically 12noon to 2pm)Patient will go to CTICU Dr. Poston will immediately contact family to discuss caseIf case extends beyond 3pm, nurse on team will contact family to provide updateIf no update provided or any other concern, call Dr. Postons cell phone 617-610-0126For interested family, best means for information from Dr. Poston is via email: rposton@surgery.bsd.uchicago.edu (allow 4-6 hour timeframe for response)Dr. Poston will contact your primary care provider and cardiologist within 24 hours via telephone to provide update

Events After SurgeryTypical length of stay in the CTICU is 12 to 36 hours, which depends mainly on:Stable blood pressureAdequate urine outputNo bleeding or need for transfusionsBreathing comfortably without the need for assistance other than nasal cannula Adequate pain controlOnce cleared, will be transferred to a step-down unit until ready for discharge to home which depends mainly on:Able to walk steady without assistanceNo requirement for nasal cannula to maintain oxygen levelsNo other outstanding medical issuesDr. Poston will the patient in the CTICU twice a day at 6:45am and 4-5pm and when in the step-down unit once a day at 7-8am.For primary contact person, if no update provided prior to discharge or any other concern, call Dr. Postons cell phone 617-610-0126For interested family, best means for information from Dr. Poston is via email: rposton@surgery.bsd.uchicago.edu (allow 4-6 hour timeframe for response)Dr. Poston will provide your primary care provider and cardiologist with a copy of the discharge summary and operative note via fax and letter

Events After DischargeTypical length of recovery (i.e. time to return to work or normal activity) is 3 weeks, which depends mainly on:Physical functioning that was possible prior to surgery Degree of activity that is required for your jobPresence of surgical complications that would delay your recoveryWhether your pain is well controlledAt 3 weeks, outpatient clinic visit will be scheduled. Purpose of this visit is to check the healing of the wounds and assess for any complications.If any problems arise before clinic visit, call Dr. Postons cell phone 617-610-0126 or contact via email: rposton@surgery.bsd.uchicago.edu (allow 4-6 hour timeframe for response)Dr. Poston will provide your primary care provider and cardiologist with a copy of the clinic note describing your status at the follow-up visit.

Follow-up test after bypass surgery

RIMALIMALAD OM1Predischarge CT angiographyFollow-up test after bypass surgery

Concerning Symptoms After DischargeChest painNot concerning if located near incision and pain is made worse by coughing or putting pressure on incisionConcerning if similar to symptoms that were present prior to undergoing bypass surgeryWound problemsRedness, worsening pain, swellingExcessive drainageBreathing difficulties that get progressively worse rather than betterIf any problems arise before clinic visit, call Dr. Postons cell phone 617-610-0126 or contact via email: rposton@surgery.bsd.uchicago.edu (allow 4-6 hour timeframe for response)

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