A Reproducible and Effective Technique for Coronary Sinus Injury Repair.

Objective: Coronary sinus injury related to the use of a retrograde cardioplegia catheter is a rare but potentially life-threatening complication with mortality reported as high as 20%. We present a series of iatrogenic coronary sinus injuries as well as an effective method of repair without any ensuing mortality. Methods: There were 3,004 cases that utilized retrograde cardioplegia at our institution from 2007 to 2018. Of these, 15 patients suffered a coronary sinus injury, an incidence of 0.49%. A pericardial roof repair was performed in 14 cases in which autologous pericardium was sutured circumferentially to normal epicardium around the injury with purified bovine serum albumin and glutaraldehyde injected into the newly created space as a sealant. Incidence of perioperative morbidity and mortality, operative time, and length of stay were collected. Results: In our series, there were no intraoperative or perioperative mortalities. Procedure types included coronary artery bypass grafting (CABG), valve replacement and repair, or combined CABG and valve procedures. Median (interquartile range) cross-clamp time was 100 (88 to 131) minutes, cardiopulmonary bypass duration was 133 (114 to 176) minutes, and length of stay was 6 (4 to 8) days. None of the patients returned to the operating room for hemorrhage, and there were no complications associated with the repair of a coronary sinus injury when using the pericardial roof technique. Conclusions: Coronary sinus injuries can result in difficult to manage perioperative bleeding and potentially lethal consequences from cardiac manipulation. Our series supports the pericardial roof technique as an effective solution to a challenging intraoperative complication.

REBOA as a rescue strategy for catastrophic vascular injury during robotic surgery.

Catastrophic bleeding is a feared complication of robotic abdominal procedures that involve dissection in close proximity to major vessels. In the event of uncontrollable hemorrhage, standard practice involves emergency undocking with conversion to laparotomy. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a rapid and life-saving technique gaining acceptance in the trauma setting for the management of catastrophic hemorrhage. The purpose of this study was to evaluate feasibility of REBOA for emergency hemostasis during robotic surgery. The surgical robot was docked to a REBOA mannequin to simulate an upper abdominal surgery. A femoral arterial line was placed in the mannequin. Supplies needed for REBOA insertion were opened and arranged on the surgical back table. The surgeon was seated at the console with an assistant scrubbed. A catastrophic vascular injury was announced. The time it took the surgeon to achieve aortic occlusion by the REBOA was recorded. Four surgeons participated and performed three timed trials each. Each surgeon, irrespective of experience with REBOA or years in surgical practice, was able to obtain aortic occlusion in less than 2 min. The mean time to aortic occlusion for all surgeons was 111 s. No manipulation of the robotic arms was required to perform the procedure. Aortic occlusion was achieved rapidly with REBOA. Ability to achieve prompt aortic control was not associated with surgical experience or prior familiarity with the REBOA device. Prophylactic femoral access and preparation of supplies facilitates prompt placement of the occlusion balloon. REBOA should be considered as a viable alternative to open laparotomy for temporary hemorrhage control during robotic surgery.