Robotic Heart Bypass Surgery in India and UAE | Complete Patient Guide

• IDEAL CANDIDATES:

• Patients with single-vessel or two-vessel CAD, particularly isolated LAD disease, who are not suitable for PCI due to vessel anatomy, lesion complexity (high SYNTAX score), or prior stent failure

• Patients with two-to-three vessel disease where at least one graft (typically LIMA-to-LAD) can be placed robotically, with a hybrid approach using PCI for additional vessels

• Patients with preserved or mildly reduced left ventricular ejection fraction (LVEF ≥ 35%) on echocardiography

• Patients with a low-to-moderate EuroSCORE II or STS Mortality Risk Score who are deemed high-risk for conventional open sternotomy (e.g., porcelain aorta, severe COPD, prior chest surgery)

• Non-obese patients (BMI < 35) with no severe chest wall deformity, as adequate working space is required for port placement

• Patients who prioritize faster return to work, lower infection risk, and improved cosmesis

• REQUIRED PRE-OPERATIVE DIAGNOSTICS:

• Coronary CT Angiography (CCTA) or invasive diagnostic coronary angiography with SYNTAX score calculation

• Transthoracic Echocardiography (TTE/ECHO) to assess LVEF, regional wall motion abnormalities, and valvular function

• Cardiac MRI (CMR) or PET Myocardial Perfusion Imaging (MPI) — essential for assessing myocardial viability in patients with suspected hibernating myocardium and reduced LVEF

• Pulmonary function tests (PFTs/Spirometry) — critical for robotic cases, as single-lung ventilation is required intraoperatively

• Full blood panel: CBC, CMP, coagulation profile (PT/INR/aPTT), HbA1c, lipid panel, renal function (eGFR), thyroid function

• 12-lead ECG and 24-hour Holter monitoring if arrhythmia is suspected

• Carotid Doppler ultrasound in patients over 65 or with history of TIA/stroke

• RELATIVE OR ABSOLUTE CONTRAINDICATIONS:

• Severely reduced LVEF (< 25%) without evidence of viable myocardium on PET or CMR

• Diffuse three-vessel disease requiring more than 3 distal anastomoses that cannot be safely completed robotically

• Severe obstructive lung disease (FEV1 < 50% predicted) precluding safe single-lung ventilation

• Prior left-sided thoracic surgery with significant pleural adhesions

• Active endocarditis, hemodynamic instability, or cardiogenic shock requiring urgent open intervention

• Severe coagulopathy unresponsive to correction

• Significant aortic stenosis or mitral regurgitation requiring concomitant valve surgery (unless a combined robotic/open hybrid approach is planned)

TECHNIQUE 1 — TOTALLY ENDOSCOPIC CORONARY ARTERY BYPASS (TECAB, OFF-PUMP):

This is the most advanced iteration of robotic CABG. Using the da Vinci Xi system, the surgeon performs the entire operation endoscopically — LIMA harvest and coronary anastomosis — on the beating heart, with no cardiopulmonary bypass ('off-pump'). This eliminates bypass-related systemic inflammation, reduces aortic manipulation (lowering stroke risk), and is ideal for single-vessel LAD disease. Anastomosis is secured using a specialized endoscopic stabilizer (e.g., the Octopus Nuvo system) to immobilize the target vessel segment. TECAB off-pump is technically demanding and is performed at only a small number of high-volume centers globally, several of which are in India and the UAE.

TECHNIQUE 2 — TECAB ON-PUMP (Endoscopic, Arrested Heart):

The robotic dissection and anastomosis are performed endoscopically, but the heart is arrested using cardioplegia solution via peripheral cardiopulmonary bypass (femoral cannulation). This allows the surgeon to work in a still, bloodless field, making it suitable for patients with more complex coronary anatomy. It extends the applicability of TECAB to multivessel disease and cases where the coronary target is deep or heavily calcified.

TECHNIQUE 3 — ROBOTIC-ASSISTED HYBRID REVASCULARIZATION:

In patients with multivessel CAD, a hybrid strategy is increasingly preferred at advanced centers. The surgeon robotically performs a LIMA-to-LAD anastomosis (the most critical and durable graft), followed by PCI with drug-eluting stents (DES) to the remaining diseased vessels, either in the same session in a hybrid operating suite or in a staged procedure within 24–72 hours. This approach combines the proven 20-year durability of the LIMA-LAD graft with the minimal invasiveness of PCI, avoiding the risk of harvesting and anastomosing multiple arterial grafts robotically.

TECHNIQUE 4 — ROBOTIC-ASSISTED CABG (Port-Access, Mini-Thoracotomy Hybrid):

The robotic system is used for LIMA harvest through port incisions, after which a small (4–5 cm) left anterior mini-thoracotomy is made for direct-vision anastomosis under stabilization. This is a widely practiced intermediate technique that offers robotic precision for LIMA harvest (associated with fewer harvesting injuries versus conventional endoscopic or open harvesting) while allowing the surgeon more familiar open-anastomosis technique. It is particularly popular in India's high-volume cardiac centers.

COMPARISON — ROBOTIC vs. CONVENTIONAL OPEN CABG:

• Incision: 3–4 ports (8–12 mm) vs. 20–25 cm sternotomy

• ICU Stay: 1–2 days vs. 3–5 days

• Total Hospital Stay: 5–8 days vs. 8–12 days

• Return to Normal Activity: 3–5 weeks vs. 8–12 weeks

• Blood Transfusion Rate: ~10–15% vs. 40–60%

• Sternal Wound Infection Risk: Near-zero (no sternotomy) vs. 1–5%

• Graft Patency (LIMA-LAD at 10 years): >90% (equivalent to open)

• Cost: Comparable or slightly higher for robotic; offset by shorter hospitalization

ANESTHESIA & PERFUSION CONSIDERATIONS:

All robotic CABG procedures require general anesthesia with a double-lumen endotracheal tube for selective single-lung ventilation of the right lung, allowing the left thoracic cavity to be insufflated with CO2 for workspace. Transesophageal echocardiography (TEE) is used intraoperatively to monitor cardiac function and confirm graft flow in real time.

PHASE 1 — PRE-TRAVEL CONSULTATION WITH GAF HEALTHCARE (2–4 weeks before travel): The patient submits existing cardiac investigation reports (coronary angiogram, ECHO, ECG, blood reports) to GAF Healthcare's medical coordination team. A GAF-assigned cardiac surgery specialist reviews the case and issues a formal Opinion Letter confirming robotic candidacy, estimated costs, and recommended hospital. GAF assists with e-Medical Visa application (India) or advance registration with the receiving facility (UAE). Current antiplatelet therapy (aspirin, clopidogrel, ticagrelor) and anticoagulants are reviewed — P2Y12 inhibitors are typically withheld 5–7 days pre-operatively.

PHASE 2 — ARRIVAL & PRE-OPERATIVE WORKUP (Days 1–3 in country): Upon arrival, the patient is admitted or assessed at the partner hospital's dedicated international patient lounge. A full pre-operative workup is completed within 24–48 hours: repeat ECHO, coronary CT or review of angiogram, PFTs, and a complete blood panel. The cardiac surgery team — including the robotic surgeon, cardiac anesthesiologist, and perfusionist — conducts a formal pre-operative consultation and consent process. A dedicated GAF patient coordinator assists with translation, family communication, and administrative formalities.

PHASE 3 — SURGICAL DAY (Day 3 or 4): The patient is taken to the Hybrid/Robotic Operating Suite. Anesthesia induction is followed by placement of a double-lumen endobronchial tube (for single-lung ventilation), a pulmonary artery catheter or PiCCO monitor, and intraoperative TEE probe. The da Vinci robotic system is docked. Operative time for TECAB single-vessel (LIMA-LAD) is approximately 2.5–4 hours; multi-vessel or hybrid procedures may take 4–6 hours. Vasopressors (norepinephrine, vasopressin) and inotropes (milrinone, dobutamine) are titrated in real time by the anesthesia team. On completion, intraoperative graft flow is assessed using transit-time flow measurement (TTFM) to confirm anastomotic patency before closure.

PHASE 4 — ICU & CARDIAC STEP-DOWN UNIT (Days 1–3 post-op): The patient is extubated in the ICU within 4–8 hours of surgery in uncomplicated cases. Hemodynamic monitoring continues via arterial line, central venous catheter, and continuous telemetry. Chest tubes (typically 1–2 small-bore drains) are removed within 24–36 hours. Antiplatelet therapy (aspirin 100 mg daily, plus clopidogrel for hybrid PCI cases) is restarted within 12–24 hours. Beta-blockers (metoprolol succinate or bisoprolol) are initiated to reduce the risk of post-operative atrial fibrillation (POAF), which occurs in approximately 15–30% of post-CABG patients. Statin therapy (high-intensity: rosuvastatin 40 mg or atorvastatin 80 mg) is initiated or continued.

PHASE 5 — WARD RECOVERY & MOBILIZATION (Days 3–8): Patients are stepped down to a monitored cardiac ward. A structured cardiac physiotherapy protocol begins on Day 1 post-extubation — initially in-bed breathing exercises and incentive spirometry, progressing to sitting, standing, and supervised ambulation by Day 2–3. Pain management is multimodal: intercostal nerve blocks or epidural analgesia (placed pre-operatively at many centers), supplemented by scheduled acetaminophen, NSAIDs (if renal function permits), and judicious opioid use. Wound sites (3–4 small port sites, each < 1.5 cm) are assessed daily. Discharge planning, medication reconciliation, and a GAF-arranged post-discharge accommodation plan are finalized.

PHASE 6 — POST-DISCHARGE RECOVERY IN COUNTRY (Weeks 2–5): GAF Healthcare arranges serviced apartment or hotel accommodation for the patient and one attendant within proximity to the hospital. Outpatient follow-up visits are scheduled at Day 7, Day 14, and Day 28 post-discharge for wound check, ECG, echocardiography, and blood tests (CBC, lipids, renal function, HbA1c). The patient is advised to walk progressively — targeting 20–30 minutes of low-intensity walking daily by Week 3. Driving, lifting > 5 kg, and sexual activity are deferred until Week 4–6 post-operatively, per surgeon guidance.

PHASE 7 — FIT-TO-FLY CLEARANCE & RETURN HOME (Weeks 4–5): A formal Fit-to-Fly assessment is conducted by the treating cardiac surgeon, typically at the Day 28 outpatient visit. Requirements for clearance: stable hemodynamics, no active pleural effusion or pericardial effusion on ECHO, no uncontrolled arrhythmia, surgical wounds fully healed, ambulating independently. The patient receives a detailed discharge summary (in English and, if required, their native language), a medication list, a 3-month follow-up plan, and emergency contact protocols from GAF Healthcare. For long-haul flights, prophylactic low-molecular-weight heparin (e.g., enoxaparin) and compression stockings are prescribed to mitigate DVT risk.