Bleeding During Robotic CABG Leads
to a Poor Patient Experience
Robert Poston, MD
Chair, Dept. of Cardiothoracic Surgery
St. Francis Medical Center

Bleeding and Transfusions after CABG
• Periop transfusions
• On-pump CABG 63%
• OPCAB 50%
• Robotic CABG 24-44%
NEJM 2012; 366: 1489-97

Therapeutic misconception
• Inaccurate website marketing
• Orthopedics1
• TAVI2
• Robotic cardiac surgery3
• Suboptimal informed consent4
1. RS Labovitch, KJ Bozic, E Hansen. An evaluation of information available on the internet regarding minimally
invasive hip arthroplasty. The Journal of Arthroplasty, 2006
2. Kincaid M, Neuman M Presentation on US Hospital Websites of Risks and Benefits of Transcatheter Aortic
Valve Replacement Procedures. JAMA 2015
3. Poston, et al. Marketing of Low Volume Robotic Cardiac Surgery Programs via the Internet and Public
Reporting Avenues. Abstract, ISMICS 2014
4. S Ryan, V Chirumamilla, RA Bello et al., How informed is “informed consent” for robotic cardiac surgery?
Innovations 2009

Does bleeding and transfusion after
r-CABG increase the risk of unmet
expectations and dissatisfaction?

Methods
Robotic CABG –
hemostat group
(n=62)
Robotic CABG –
control group
(n=131)
Hemostatic into port
sites routinely
Hemostatic into
port sites as needed
Primary OUTCOMES:
• 30 day clinical outcomes
• Patient satisfaction
• HCAHPS score: Items #5-7; 22
• Unmet expectations:
• Size of the incision
• Speed of recovery

Methods: Patient satisfaction
Physician
Communication

Clinical outcomes
Outcome Hemostat
group (n=62)
Control
group (n=131)
p value
RBC transfusion
- % transfused 24.2% 40.8% 0.026
- Units received 0.44 U 1.39 U 0.024
Discharge Hct 32.4±5.7 27.2±6.5 0.001
Chest tube output (cc/24 hr) 529±112 cc 594±133 cc NS
Reoperation 3.2% 3.0% NS
Length of stay (d) 3.5±0.6 3.8±0.9 NS
Composite M&M (O/E) 0.81±0.12 0.95±0.14 NS

Satisfaction outcomes
Outcome Hemostat group
(n=62)
Control group
(n=131)
p value
HCAHPS survey
- Physician communication (percentile) 98% 85% 0.001
- Willing to recommend (% definitely yes) 91% 83% 0.02
Unmet expectations
- Size of the incisions 3 out of 58
respondents (5.2%)
7 out of 125
respondents (5.6%)
NS
- Recovery time 2* out of 58
respondents (3.4%)
17* out of 125
respondents (13.6%)
0.03
*18 out of 19 respondents with unmet expectations about recovery time received ≥1 U PRCs.

Baseline Port
placement
Wound closureSurgeon at robotic console
Baseline
60% of baseline
(severe stress)
HEART RATE
VARIABILITY
SURGICAL STAGE
SURGEON HEART RATE VARIABILITY DURING ROBOTIC SURGERY
Abstract, SRS 2014

Baseline Port
placement
Wound closureSurgeon at robotic console
on bypass
mitral repair
LA closure
repair of
bleeding
remove cardio-
plegia cannula
Baseline
60% of baseline
(severe stress)
HEART RATE
VARIABILITY
SURGICAL STAGE
SURGEON HEART RATE VARIABILITY DURING ROBOTIC SURGERY
Abstract, SRS 2014

Conclusion
Bleeding and
transfusion after
r-CABG
Unmet
expectations about
recovery time
Dissatisfied patient

Conclusion
Bleeding and
transfusion after
r-CABG
Unmet
expectations about
recovery time
Dissatisfied patient
Topical hemostatics Manage expectations