Robotically enhanced minimally invasive direct coronary artery bypass surgery: a winning strategy?

AIM: Minimally invasive direct coronary artery bypass (MIDCAB) through a small anterolateral thoracotomy on the beating heart can be considered as the better approach for treating isolated lesions on the left anterior descending (LAD) artery. This original MIDCAB procedure, however, involves a larger and often painful thoracotomy due to rib spreading. We describe our experience with robotically enhanced harvesting of one or both internal mammary arteries (IMAs), and with anastomosis performed under direct vision on a beating heart through a very small thoracotomy without rib retraction. METHODS: Between February 2001 and January 2006, 146 consecutive patients underwent robotically enhanced MIDCAB surgery. Perioperative and early follow-up data were analyzed. RESULTS: In all, 144 left and 13 right IMAs were harvested. The mean extubation time was 11.3 h, the mean intensive care (ICU) stay was 30.3 h, the mean hospital stay 8 days. There were no in-hospital deaths, postoperative myocardial infarctions or renal failures. Systematic control angiograms performed in the first 64 patients showed a 96.3% patency rate of the investigated anastomoses. CONCLUSION: Robotically assisted takedown of the IMA and direct off-pump anastomosis through a small anterolateral thoracotomy with no rib retraction appears to be safe, with minimal morbidity, little blood loss, and a reasonable ventilation time, ICU and hospital stay. It is recommended as the preferred method of revascularization for a growing number of indications and certainly an acceptable alternative to percutaneous transluminal coronary angioplasty.

Minimally invasive aortic root replacement: a bridge too far?

AIM: Minimally invasive aortic valve surgery has been studied widely with outcomes comparable or better than standard sternotomy. We recently reported on decreased blood loss, cross clamp time and length of hospital stay when compared to conventional full sternotomy. We expanded the indication to aortic root surgery and report here our 8 years experience. METHODS: From December 1997 to November 2005, 35 patients (mean age 51.3+/-15 years) underwent aortic root replacement, through a partial upper J-sternotomy. A homograft was implanted in 26 (74.3%) patients; the remainder received a valved (4 bioprosthesis, 5 mechanical) conduit. Mean preoperative euroscore was 7+/-2.7 and mean predicted mortality was 11.5+/-13.8%. Mean and median follow-up time was 51+/-31 and 66 months, respectively. RESULTS: Mean aortic cross clamp and cardiopulmonary bypass time were 126+/-25 and 182+/-61 min respectively. Revision for bleeding was necessary in 1 (2.9%) patient. Mean extubation time was 10.4+/-4.8 hours. No postoperative strokes occurred. Intensive care unit stay ranged from 1 to 42 days (2.7+/-7.4 days, median 1). There were 3 (8.5%) early deaths (sepsis, multi-organ failure and low cardiac output) and 2 late non-cardiac deaths. Hospital morbidity included acute renal failure (n=3), pacemaker implantation (n=3), and prolonged ventilation (n=3). Eleven (31.4%) patients experienced atrial fibrillation. No other reoperations were performed. Actuarial survival at 99 months was 74.4% (n=30). CONCLUSIONS: Our results indicate that minimally invasive aortic root replacement is a challenging but feasible procedure with a lower observed mortality than predicted mortality. We continue to perform this procedure in good risk patients.

Surgical treatment of atrial fibrillation.

Atrial fibrillation is a very common arrhythmia that carries a considerable risk of thromboembolic complications. Surgical treatment is an effective way to convert atrial fibrillation into sinus rhythm and significantly prevents thromboembolism postoperatively. In this review we describe recent advancements in the surgical options and detail our strategy for the surgical treatment of atrial fibrillation.

Hemopump fails as bridge to transplantation in postinfarction ventricular septal defect.

From 1990, six patients were bridged to transplantation with a catheter-mounted axial flow pump (Hemopump). Indications were graft failure (two patients), postinfarction ventricular septal defect (two patients), myocarditis (1 patient), and myocardial infarction (1 patient). The 21F cannula, inserted via the groin, was used as a partial assist in four patients, and the 31F cannula, inserted via the ascending aorta, was used to assist the other two patients completely. Hemodynamic recovery was achieved in all patients (mean cardiac index rose from 2.1 L/gm/m2 to 3.85 L/gm/m2 after 1 hour assist). Sudden pump failure occurred in the two patients with postinfarction ventricular septal defect and a piece of necrotic tissue blocking the catheter was found. Both patients died. The other four patients were successfully bridged to transplantation. One of these patients died during his postoperative hospital stay; the three remaining patients were discharged and were well at follow-up (46, 40, and 3 months). The Hemopump device provides sufficient organ perfusion to be used as a bridge to transplantation. No conclusions can be drawn for the long-term use (longest run in this series was 102 hours). Postinfarction ventricular septal defect is a contraindication for the use of the Hemopump device.

Aneurysm of the left pulmonary artery: surgical allograft repair.

We present a case of left pulmonary artery aneurysm with pulmonary valve stenosis. The aneurysm was excluded and the valve replaced by the implantation of a pulmonary artery allograft. The short-term follow-up (20 months) is promising.

Minimally invasive video-assisted mitral valve surgery: our lessons after a 4-year experience.

BACKGROUND: Right thoracotomy is a well known alternative to median sternotomy to gain access to the left atrium. To avoid the potential drawbacks associated with sternotomy coupled to the desire for a smaller scar and a more rapid rehabilitation in young and active patients, we investigated the purported advantages in patients undergoing video-assisted Port-Access mitral valve surgery. METHODS: Between February 1997 and November 2000, 175 patients (94 men, 81 women) with a mean age of 60 years (range 25 to 84) underwent either Port-Access mitral valve repair (n = 117) or replacement (n = 57) for degenerative disease (n = 112), rheumatic disease (n = 36), chronic endocarditis (n = 15), annular dilatation (n = 8), sclerotic disease (n = 2), and ingrowing myxoma (n = 1). There was one closure of a preexisting paravalvular leak. Standard Carpentier-Edwards repair procedures were used in all patients; in 14 patients polytetrafluoroethylene chordae were inserted for anterior leaflet prolapse. A total of 74 patients (42%) were in New York Heart Association functional class III/IV. RESULTS: Hospital mortality was 1.1% (n = 2). Four patients had conversion to sternotomy and conventional extra corporeal circulation for repair of a dissected aorta (n = 2) or the inabilty to proceed to a safe femoral cannulation (n = 2). Sixteen patients (9%) underwent a revision for bleeding. Mean cross-clamp time and perfusion time was 95 minutes (range 24 to 160) and 135 minutes (range 75 to 215) respectively. Mean intensive care unit and total hospital stay was 1.8 days (1 to 30) and 8.7 days (4 to 36), respectively. Three patients experienced late acute endocarditis: 2 had late mitral valve replacements and 1 patient had medical therapy for late prosthetic valve endocarditis. There were no myocardial infarctions, cerebrovascular events or peripheral ischemia due to thromboembolic phenomena. No wound complications were observed. The degree of patient satisfaction was very high. CONCLUSIONS: The video-assisted Port-Access mitral valve approach is a valid alternative to sternotomy, with the same standards of results and quality.

Video-assisted Port-Access mitral valve surgery: from debut to routine surgery. Will Trocar-Port-Access cardiac surgery ultimately lead to robotic cardiac surgery?

A right thoracotomy is a well-known alternative for midsternotomy to have access to the left atrium. The Port-Access (Heartport, Inc, Redwood City, CA) approach is an invaluable option to avoid cracking of ribs and cartilage. EndoCPB (Heartport, Inc) and Endo-Aortic Clamp (Heartport, Inc) allows installation of the extracorporeal circulation and cardiac arrest from the groin. Videoassistance and shafted instruments help the surgeon to perform the surgery through a 5 x 2-cm port and fulfill the main goals of minimally invasive cardiac surgery, comfort, cosmesis, and fast rehabilitation. From February 1997 to November 1998, 75 patients (40 men/35 women) had either Port-Access mitral valve repair (n = 41) or replacement (n = 33) for a variety of reasons: myxoid degeneration (n = 45), rheumatic disease (n = 21), chronic endocarditis (n = 4), annular dilatation (n = 2), and sclerotic disease (n = 2). One valve was replaced because of an ingrowing myxoma. There was one closure of a paravalvular leak. The mean age was 59.3 years of age (range, 32 to 83 years). Most patients had normal ejection fractions but different grades of mitral valve insufficiency and were in NYHA class II. One 71-year-old patient died after reoperation on postoperative day 1 for failed repair. Two patients had conversion to sternotomy and conventional ECC for repair of a dissected aorta. One patient died, one patient suffered a minor cerebrovascular deficit. Three patients had prolonged intensive care unit (ICU) stays for respiratory insufficiency, 5 patients underwent revision for bleeding. Mean ICU stay was 2.5 days; and mean hospital stay, 9 days (range, 4 to 36). A significant difference between the first 30 and last 38 patients in terms of length of stay in the ICU and the hospital was noticed. Two late mitral valve replacements for chronic endocarditis after repair occurred. One patient had medical therapy for endocarditis after mitral valve replacement. The debut of Port-Access mitral valve surgery may be nerve-racking; the routine is a smooth and sure surgery with maximum comfort, a very discrete scar, and a fast rehabilitation. There were no paravalvular leakages nor myocardial infarctions. Cerebrovascular accidents owing to thromboembolic phenomena, vascular lower limb or wound complications were not seen. Port-Access mitral valve surgery is a very important investment in the future of cardiac surgery. Some learning curve pitfalls were associated with the process of starting this revolutionary technique.

Three years surgical and clinical experience with the Ross procedure in adults.

From January 1991 to October 1994, 20 Ross procedures were performed. Mean age was 39.70 +/- 7.72 years, range 26 to 56 years. Male/female ratio was 14/6. Nineteen operations were elective, one was semiurgent. Predominant valvular lesion was stenosis in seven patients, aortic regurgitation in four, mixed disease in eight and prosthetic dysfunction in one patient. Twelve pulmonary autografts were implanted in the subcoronary (SC) position, eight as an intraaortic cylinder (inclusion technique (INCL)). Early mortality (< 30 days postoperative) was one (5.0%), there was no late mortality. Reoperation for valve failure occurred in two patients (10.0%). Additional CABG was performed in two patients (10.0%) for technical reasons. Major ECG changes were detected in five patients (three RBBB, two ischemia). No thromboembolic events were reported. Mean follow up was 21.2 months. Aortic insufficiency (AI) at one year was similar in the SC and INCL group. AI grade I in SC: 60%, in INCL: 60%; AI grade II in SC 10%, in INCL: 20%. At two years AI grade I occurred in 100% of the SC group. At three years AI grade I occurred in 75% of the SC group and AI grade II in 25%. No patients of the INCL group had two- or three-year follow up. At discharge slight pulmonary regurgitation was traced in only three patients and it remained stable during the follow up.(ABSTRACT TRUNCATED AT 250 WORDS)

Experience with the Edwards Prima stentless aortic bioprosthesis: a 2-year review.

The Edwards Prima stentless aortic valve is an aortic root cylinder which can be used for sub-coronary implantation, as a complete root, or as an inclusion cylinder. We implanted 68 valves in 68 patients: 66 sub-coronary, one complete root and one inclusion. Fourteen patients underwent concomitant CABG, one patient had a left main coronary plasty. There was one non-valve related early death. Patients have been followed for two to 28 months, mean 19 months. Five late deaths occurred, none valve related. Three patients underwent reintervention for endocarditis, two to 14 months after initial valve replacement; in all cases a root replacement with a homograft was done. Transvalvular gradients were acceptable, and effective valve area data were very good. Data did not change during follow up. Mild regurgitation was present in 25% of the cases at two years. The versatility of the Edwards Prima stentless aortic valve is a useful advantage in complex and unexpected conditions. Early clinical and hemodynamic data are good. Further follow up will be needed to evaluate calcification ratio and progress of aortic insufficiency to assess the real benefit of this new generation bioprosthetic valve.

Video-assisted Port-Access combined mitral valve and CABG surgery.

Although conventional right thoracotomy is a well-known alternative for mid-sternotomy to access the left atrium, a combined video-assisted mitral and left anterior descending (LAD) approach via Port-Access has not yet been described. We report the case of a 68-year-old patient with severe mitral valve regurgitation due to myxoid degeneration associated with a critical LAD coronary artery stenosis. A totally video-assisted 'true' Port-Access (i.e. no costal retraction) mitral valve repair and direct coronary artery bypass were performed in combination, without complications.

Cardioscopy and robotic assistance for the diagnosis of intraventricular endocarditis.

A 44-year-old male patient with an undefined mass in the left ventricular endocardium was scheduled for minimally invasive cardiac surgery. Ventricular investigation and tissue biopsies were completed with the help of a voice-controlled robotic arm. Pathologic examination revealed non-bacterial thrombotic endocarditis. In addition to videoscopy, robotic assistance allows an easier diagnostic and therapeutic approach of intraventricular pathologies.

Minimally invasive video-assisted mitral valve repair: short and mid-term results.

BACKGROUND AND AIM OF THE STUDY: Port-Access video-assisted surgery for mitral valve repair has become an alternative for mid-sternotomy. However, mid-term results are not yet available. METHODS: Between February 1997 and December 1999, 121 patients underwent mitral valve surgery through a 4- to 5-cm right anterolateral thoracotomy using the Heartport endovascular cardiopulmonary bypass system; among these patients, 77 (57 males, 20 females; mean age 59 years; range 31-84 years) underwent mitral valve repair. Severe (4+) mitral regurgitation (MR) was seen in 63 patients (82%). Mean NYHA class was 2.5+/-0.4. Standard Carpentier mitral valve repair procedures were used in all patients; 11 received PTFE chordae for anterior leaflet prolapse. RESULTS: Pathologies were degenerative (n = 69), chronic endocarditis (n = 4), annular dilatation (n = 3) and rheumatic (n = 1). Hospital mortality was 1.3% (n = 1). Two patients (2.6%) had conversion to sternotomy for aortic dissection caused by the Endo-Aortic Clamp. Nine patients (11%) underwent revision for bleeding. Mean cross-clamp and perfusion times were 103 min (range: 24-160 min) and 140 min (range: 75-215 min), respectively. Mean hospital stay was eight days (range: 4-36 days). During follow up (mean 31 months; range: 17-51 months) all patients improved their NYHA class; eight (11%) remained in class II. Left ventricular (LV) end-diastolic and LV end-systolic diameters decreased from 61+/-7.3 mm to 53+/-6.9 mm (p <0.01) and from 37+/-6.8 mm to 34+/-6.9 mm (p <0.05), respectively. Sixty-two patients (88%) had no or trivial MR, and nine (12%) had moderate MR (2+). There were two late valve replacements for endocarditis, and no late deaths. CONCLUSION: Port-Access mitral valve repair constitutes a valid alternative to the standard procedure, and has good mid-term results. Video-assisted mitral valve repair appears to be safe and reproducible.

Adequate global myocardial perfusion provided by a left internal mammary artery. A case report.

We report a 57-year-old patient who developed a significant stenosis in a proximal anastomosis after CABG. Reconstruction was carried out with the left internal mammary artery which provided the global myocardial perfusion with an excellent longterm functional result.

The implantable cardioverter defibrillator: the end of the thoracotomy approach.

Internal cardioverter defibrillator (ICD) implantation has become a standard therapy for life-threatening arrhythmias. A simple and safe surgical implantation technique is therefore mandatory in this high risk population. In a 30-month period 86 patients received 87 ICD devices. An endocavitary lead system was used as first choice in 62 patients and defibrillation thresholds (DFT) of 25 joules (J) or less were obtained in 57 patients. A thoracotomy approach was avoided using a biphasic shock wave form in 17 patients and the addition of a subcutaneous (sc) patch in 11 patients or wire array lead in 9 patients. There was one early non-technique related death (1.7%) after the transvenous approach. Reoperation was necessary in three patients with lead complications and in two patients for local device problems (one migration, one infection). With the recent progress in ICD technology, a thoracotomy approach could be avoided for the last 52 patients. For comfort and cosmetic reasons left subcostal insertion of the device has been successfully used in the last 50 patients. We conclude that the nonthoracotomy approach can now be offered to all patients in need for an ICD as a consequence of the technological progress made in the field of electric treatment of malignant ventricular arrhythmias. A stepwise approach with a minimum of implanted hardware and the use of biphasic shock systems now offers a simple and efficient treatment alternative with very low perioperative risk. Internal cardioverter defibrillator implantation in combination with open heart procedures can easily be avoided.

Free-hand sewn allografts, stentless (Prima Edwards) and stented (CESA) porcine bioprostheses. A comparative hemodynamic study.

In a retrospective, non-randomized study, the clinical and hemodynamic properties of 50 consecutively implanted hand-sewn allografts (group I), 50 stentless bioprostheses (group II) and 50 stented bioprostheses (group III) were compared. Preoperative hemodynamic and clinical data were identical in the three groups, except for age (group I: 54.4 +/- 8.7, group II: 67.0 +/- 5.1, group III: 70.0 +/- 5.1). Peak and mean gradients and flow characteristics with echo Doppler were performed at 1 week, 6 and 12 months. For the 21, 23 and 25 diameter prostheses, group differences between groups II and III in peak and mean gradients were not significant after 1 week and 1 year. In all groups, allografts had significantly lower gradients. Regurgitation (I-II) was present after 1 week and 1 year in group I: in 17/48 and 22/42 patients respectively, in group II 7/49 and 11/44 patients and in group III: in 1/49 and 2/44 patients. Early mortality and morbidity were comparable in all groups. Allografts have superior hemodynamic properties. Differences in gradients in groups II and III were not significant, though differences in technique allowed the implantation of a larger bioprostheses in group II. Regurgitation was most prominent in the allograft group. Immediate postoperative results were not influenced by the type of prosthesis.

Aggressive primary treatment for poststernotomy acute mediastinitis: our experience with omental- and muscle flaps surgery.

OBJECTIVE: The surgical treatment of poststernotomy acute mediastinitis remains challenging. After disappointing results with a conservative management of post coronary artery bypass grafting (CABG) mediastinitis, we shifted towards a more aggressive surgical management. METHODS: From March 1993 until December 1999, 32 patients (6 female/26 male), 0.5% of the total sternotomy population, were operated for mediastinitis, defined as wound and sternal dehiscence with medistinal pus and positive culture. Mean age was 66 years (32-79 years). Twenty-two patients (75%) underwent CABG and 16 patients were in New York Heart Association (NYHA) class III/IV. RESULTS: We performed an omentoplasty in 11 patients, a pectoralis muscle flap associated with an omentoplasty in 20 patients. One patient had a bilateral pectoralis myoplasty. The reconstruction surgery occurred at an average of 11 days (6-26) after primary surgery. Twelve patients had a previous surgical drainage (1-3 surgical procedures) of the mediastinum. Hospital mortality was nine patients (28%). Seven of these patients (77%) were in NYHA IV with inotropic support. Five patients had to be reoperated on: four patients had a bilateral myoplasty after omentoplasty, one patient had an omentoplasty after a unilateral myoplasty. Late epigastric hernia was seen in three patients, two patients had wound revision and one had a retroperitoneal drainage for pancreatitis. There were no early or late flap failures. CONCLUSION: In our experience, omental and pectoralis flaps for poststernotomy acute mediastinitis provides good outcome of our stable patients. We would be reluctant to use it as standard therapy in our unstable patients.

An alternative route for sequential venous grafts of the lateral aspect of the heart.

An alternative route, using the oblique pericardial sinus, is described for single and sequential vein grafts of the lateral aspect of the heart. This technique prevents kinking of the graft, reduces the need for excess vein length, and is an elegant way of protecting the graft in case a resternotomy is necessary. When the route was used in 63 patients, no technique-related morbidity or mortality was encountered.

Sternitis and mediastinitis after coronary artery bypass grafting. Analysis of risk factors.

As part of a quality control program, we analyzed possible risk factors in the development of sternitis and mediastinitis after coronary artery bypass grafting. From 1 January 1990 through 31 December 1991, 1,368 consecutive coronary artery bypass grafting procedures were performed at our institution, either alone or in combination with other procedures. Twenty-three patients (1.7%) developed sternitis and/or mediastinitis; 7 (30.4%) of these patients died in an early postoperative phase. Univariate analysis revealed the following statistically significant (p < or = 0.05) risk factors: perfusion time, length of stay in operating room of longer than 5 hours 30 minutes, presence at the operation of a certain surgical resident, revision for bleeding, and postoperative mechanical ventilation lasting longer than 72 hours. After multivariate analysis, statistically significant independent risk factors were: diabetes mellitus, recent cigarette-smoking, reoperation, presence of a certain surgical resident at the operation, revision for bleeding, and length of mechanical ventilation of longer than 72 hours. The use of both internal thoracic arteries was not, in this study, shown to be an independent risk factor. We conclude that although the technique of using both internal thoracic arteries for myocardial revascularization carries no extra risk by itself in the development of sternitis or mediastinitis, associated factors such as prolonged stay in the operating room and reoperation could be responsible for a higher frequency of sternitis-mediastinitis in patients who have undergone this procedure. Therefore, it is advisable to use this technique selectively in high-risk patients. Close surveillance and reporting of wound infections is mandatory to detect risk factor related to the surgical staff (such as Staphylococcus aureus dissemination).

Repair of atrial septal defects via limited right anterolateral thoracotomy.

INTRODUCTION: Right thoracotomy is a well known alternative for median sternotomy to gain access to the right atrium. The Port-Access technique is a surgical option to reduce the skin incision to 5 cm and have a considerable gain in cosmesis and post-operative rehabilitation. PATIENTS AND METHODS: From February 1997 to May 2000, 50 patients (19M/31F) had Port-Access atrial septal defect repair (ASD) with the Heartport Endo-CPB and Endo-aortic clamp system. Mean age was 46 years (range 10.5-74 years). Forty-nine patients had a type II ASD. Most of the patients were asymptomatic (48 were NYHA class I-II). Five patients underwent combined procedures: two mitral valve repairs, one mitral valve replacement, one plasty of the superior vena cava and one mini Cox-Maze. Direct closure was obtained in 34 patients (68%). Mean aortic cross clamp time was 56 minutes (range 24-134 min) and mean perfusion time was 102 minutes (range 32-196 min). RESULTS: There were no conversions to sternotomy. The procedure was complicated in six patients: revision for bleeding (n = 1), stenting of the iliac vein (n = 1), enlargement plasty of the femoral artery (n = 1), transient renal failure (n = 1), sick sinus syndrome requiring pacemaker implantation (n = 1) and one lymphocoele. No thromboembolic or peripheral ischaemic complications were noted. Per- and postoperative echocardiography showed no leakage in any patients. There was no hospital mortality. Mean ICU and hospital stay were 1.14 days (range 1-3 days) and 6.41 days (range 4-10 days) respectively. CONCLUSION: The Port-Access approach of ASD closure constitutes a valid alternative to sternotomy with the same standards of results and quality.

Abdominal aortic aneurysm, an absolute surgical indication?

In a retrospective study, 155 patients operated for infrarenal abdominal aortic aneurysm during a 5.5-year period (jan. 1986-->oct. 1991) were reviewed. In our series, 111 patients underwent elective (EL) surgery, 44 patients had an emergency (EM) operation. Male/female ratio was 10/1. Mean age in the EL group and EM was 68.1 years and 71.82 years respectively (p < 0.05). In the EL group, 68 (= 61%) patients were asymptomatic. All patients in the EM group had symptoms: shock + syncope in 28 patients, acute back pain in 4 patients, acute abdominal pain in 12 patients. Aneurysm diameter > or = 8 cm was present in 33% of the EL group, but in 57% of the EM group. Early mortality for the EL and EM group was 3.6% and 23% respectively (p < 0.001). Major postoperative complications were present in 13% in the EL group, in 55% in the EM group (p < 0.001). During a 5-year follow-up of 135 patients (= 96%), 22 patients died. Cardiac problems (7/22) and cancer (5/22) were most prominent. 5-year survival for the entire group was 83%; EL (85%) and EM (76%) were not significant. None of the patients subsequently underwent an operation related to the abdominal aortic intervention.