Long Term Outcomes of Freestyle Stentless Aortic Bioprosthesis: A Single Center Experience.

BACKGROUND: The study is presenting our long-term clinical results after freestyle stentless aortic root bioprosthesis replacement in patients with severe aortic insufficiency with ascending aortic aneurysm. METHODS: Seventy-seven patients with ascending aortic aneurysms and aortic valve insufficiency underwent a total root replacement procedure using a stentless "Freestyle" valve (Medtronic Inc., Minneapolis, Minnesota). There were 50 (64.9%) men and 27 (35.1%) women. Mean age was 68.7 ± 11.1 years. The surgical procedure used a complete root replacement. Concomitant procedures included coronary artery bypass grafting in 15 (19.5%) patients. RESULTS: The mean cardiopulmonary bypass time was 130.3 ± 26.4 minutes and total aortic cross clamp time was 99.5 ± 23.6 minutes. Hospital mortality was 2.6%. The median follow-up time was 11.2 years. The 5- and 10-years freedom from aortic valve reoperation were 97.4 ± 1.2% and 93.4 ± 4.9%, respectively. During 10 years follow up, there were 14 late deaths; 4 deaths were cardiac, and 10 deaths were noncardiac. Valve-related deaths were attributable to thromboembolism in 1 patient, endocarditis in 2 patients, and congestive heart failure in 1 patient. CONCLUSION: The freestyle stentless aortic root bioprosthesis offered good clinical outcomes, in terms of survival and structural valve deterioration. The Freestyle valve is a viable option for use in patients undergoing bioprosthetic aortic valve replacement and expected desire for long-term durability.

Pain and the Quality of Life Following Robotic Assisted Minimally Invasive Surgery.

OBJECTIVE: Minimally invasive bypass grafting is a promising surgical treatment in proximal LAD stenosis procedures. The main goal of this study was to make comparisons between robotically assisted minimally invasive coronary bypass surgery and conventional surgery in isolated proximal LAD lesions in terms of pain and quality of life improvement. METHODS: The study contains patients with proximal LAD lesions who were treated with robotically assisted minimally invasive coronary artery bypass surgery and conventional bypass surgery between June 2005 and November 2012. Fifty patients treated with coronary bypass with cardiopulmonary bypass and complete sternotomy were categorized as Group 1. Fifty patients who applied for robotically assisted minimally invasive bypass surgery were categorized as Group 2. The evaluations of pain and quality of life were done according to the Verbal Rating Scale (VRS) and SF-36 health survey questionnaire, respectively. RESULTS: The conventional bypass group and robotic group had 4.8 ± 1.9 years and 4.3 ± 1.6 years mean follow-up time, respectively. The robotic bypass group had a significantly shorter ICU stay and hospital stay than the conventional bypass group (P < .05). The pain score was higher in the robotic bypass group on the 1st postoperative day (P < .05), but the score on the 4th postoperative day was higher in the conventional bypass group (P < .05). In terms of domains of the SF-36 questionnaire, patient scores were significantly higher in patients who were operated with robotically assisted minimally invasive direct coronary artery bypass (MIDCAB) procedure than in patients who were operated with conventional bypass technique. CONCLUSION: Patients operated with robotically assisted MIDCAB procedure had results with lesser pain, shorter ICU stay, and shorter hospital stay than the other group in isolated proximal LAD stenosis. The same group also had better quality of life results according to the SF-36 questionnaire results.

The Comparison between Minimally Invasive Coronary Bypass Grafting Surgery and Conventional Bypass Grafting Surgery in Proximal LAD Lesion.

BACKGROUND: Minimally invasive bypass grafting surgery has entered the clincal routine in several centers around the world, with an increasing popularity in the last decade. In our study, we aimed to make a comparison between minimally invasive coronary artery bypass grafting surgery and conventional bypass grafting surgery in isolated proximal left anterior descending artery (LAD) lesions. METHODS: Between January 2004 and December 2011, patients with proximal LAD lesions, who were treated with robotically assisted minimally invasive coronary artery bypass surgery and conventional bypass surgery, were included in the study. In Group 1, coronary bypass with cardiopulmonary bypass and complete sternotomy were applied to 35 patients and in Group 2, robotically assisted minimally invasive bypass surgery was applied to 35 patients. The demographic, preoperative, perioperative, and postoperative data were collected retrospectively. RESULTS: The mean follow-up time of the conventional bypass group was 5.7 ± 1.7 years, whereas this ratio was 7.3 ± 1.3 in the robotic group. There was no postoperative transient ischemic attack (TIA), wound infection, mortality, or need for intra-aortic balloon pump (IABP) in any of the patients. In the conventional bypass group, blood transfusion and ventilation time were significantly higher (P < .05) than in the robotic group. The intensive care unit (ICU) stay and hospital stay were remarkably shorter in the robotic group (P < .01). The postoperative pneumonia rate was significantly higher (20%) in the conventional bypass group (P < .01). Postoperative day 1 pain score was higher in the robotic group (P < .05), however, postoperative day 3 pain score in the conventional bypass group was higher (P < .05). Graft patency rate was 88.6% in the conventional bypass group whereas this ratio was 91.4% in the robotic bypass group, which was not clinically significant (P > .05). CONCLUSIONS: In isolated proximal LAD stenosis, robotic assisted minimally invasive coronary artery bypass grafting surgery requires less blood products, is associated with shorter ICU and hospital stay, and lesser pain in the early postoperative period in contrast to conventional surgery. The result of our studies, which showed similarities to the past studies, lead us to recognize the importance of minimally invasive interventions and the need to perform them more frequently in the future.

Left atrial myxoma with neovascularization presenting as a sick sinus syndrome.

Myxoma is benign tumor of the heart. It is mostly located in the left atrium and revascularized by the left and right coronary artery in 30% to 40% of cases. Symptoms of these neovascularized cardiac myxomas are typically quite variable, from obstruction of mitral valve to coronary embolism resulting in acute myocardial infarction. In this case, left atrial myxoma that is revascularized by nodal branches of the right coronary artery presented as a sick sinus syndrome, which is rare in literature.

Comparison of clipping versus ligation of side-branches during saphenous vein graft harvesting: which method is superior?

BACKGROUND: The greater saphenous vein remains the most common conduit used in coronary artery bypass grafting procedures. Surgical trauma during vein harvesting can cause endothelial and smooth muscle injury that has important implications for vein graft longevity. This study was designed to investigate the effect of clipping and ligation of the side-branches during saphenous vein graft harvesting on histologic structures of the saphenous vein. MATERIAL AND METHODS: A total of 50 coronary artery bypass grafting patients (37 men and 13 women, mean age of 59 ± 6 years) were investigated in two groups according to side-branch closing method. In each patient, two side-branches were studied; one of them was ligated using 3/0 silk suture, and the other one was clipped next to the saphenous vein. Each venous sample was studied using hematoxylin and eosin, Masson's trichrome, and elastic tissue fibers-Verhoeff's Van Gieson staining. Histopathologic examination using light microscope was performed to assess intimal, elastic tissue, muscular layer, and adventitial changes. The pathologic alterations were graded on the basis of a scoring system (normal [0], minimal changes [+], mild changes [++], or severe changes [+++]) to assess the degree of damage inflicted by these two different types of branch closing methods. RESULTS: Histologic examination of venous tissue samples with ligated side-branches demonstrated vascular injury in most sections, including denudation and loss of the integrity of the endothelial layer of the vein. An evident disorganization of the subintimal collagen and elastic fibers was also reported. By contrast, histopathologic structure of most sections obtained from the specimens with clipped side-branches remained intact. Intimal, elastic tissue, muscular layer, and adventitial changes were significantly different between the two methods (p = 0.001). CONCLUSIONS: Clipping, rather than ligation, of the side-branches of the saphenous vein conduit during its harvesting for coronary bypass grafting is associated with decreased vein damage. These findings suggest that clipping of the side-branches can be used without major detrimental effects on vascular integrity.

The impact of non-dialysis-dependent renal dysfunction on outcome following cardiac surgery.

BACKGROUND: We evaluated the results of different types of cardiovascular surgery in patients with chronic renal failure (CRF) (serum creatinine ≥2 mg/dL) who were not dialysis-dependent. METHODS: Eighty-two patients who presented with non-dialysis-dependent CRF were retrospectively evaluated. Patients in Group 1 (n = 12) underwent valvular surgery, those in Group 2 (n = 58) underwent coronary artery bypass grafting (CABG), and those in Group 3 (n = 12) underwent combined CABG and valvular surgery. RESULTS: The demographics were similar among the groups. Cardiopulmonary bypass and aortic cross-clamping times were shorter (P < .01), the use of blood and blood products was less, and the mechanical ventilation time and hospital stay were shorter in Group 2 in comparison to the other groups (P < .01). There were 4 (6.9%) early mortalities in Group 2. Late mortalities occurred in 4 (33.3%), 16 (27.6%), and 6 (50%) patients from Groups 1, 2, and 3, respectively. Cox regression analysis revealed that age, the presence of a preoperative cerebrovascular accident, the presence of a left main coronary lesion, preoperative blood urea nitrogen level, and the use of blood and blood products were independent risk factors for early mortality. High Euroscore, cerebrovascular accident, the use of platelet suspension, longer ventilation support times, and combined CABG and valvular surgery were independent risk factors for late mortality. CONCLUSIONS: Morbidity and survival seemed to be more dependent on preoperative patient characteristics than the type of surgery in this group of patients. Combined CABG and valvular surgery was a risk factor for late mortality.

Right atrial myxoma associated with portal and splenic vein thrombosis in a patient with Budd-Chiari syndrome.

Budd-Chiari syndrome (BCS) is a rare disorder characterized by hepatic venous obstruction. A 41-year-old male patient presented with right upper quadrant pain, abdominal distension, and dyspnea. He had a history of BCS that was associated with polycythemia vera. Abdominal computed tomography showed hepatomegaly and a hypodense filling defect suggestive of thrombus formation in the hepatic, splenic, and portal veins, and suprahepatic part of the inferior vena cava. Transthoracic echocardiography performed to assess the extension of this pathological process and its relation with intracardiac structures showed a mass lesion in the right atrium, about 4 x 3 cm in diameter. The lesion manifested as an intracardiac thrombus extending from the inferior vena cava. The patient underwent surgical treatment to remove the atrial mass. At surgery, the lesion turned out to be an atrial tumor, which was diagnosed as atrial myxoma in histopathologic examination. The symptoms of the patient resolved after surgery.

Aneurysm and Helicobacter pylori relationship: the seropositivity of CagA, VacA and other antigens of Helicobacter pylori in abdominal and ascending aortic aneurysms.

Helicobacter pylori is thought to be related to atherosclerosis and aneurysm development. We aimed to detect virulance factors of H. pylori and examine the potential etiopathogenetic relationship between aortic aneurysm and H. pylori, 58 abdominal aortic aneurysm (AAA) and 38 ascending aortic aneurysm (AsAA) cases and 57 Healty control group (HCG) were included. We investigated H. pylori IgG by ELISA and virulance factors by Western-Blot (WB) method. No difference was found between AAA (67.24%), AsAA (73.68%) and HCG (57.89%) for H. pylori IgG (p > 0.05). A significant difference was found between AsAA (78.95%) and HCG (57.89%) for H.pylori IgG (p < 0.05) by ELISA and a significant difference was found only between AsAA (100%) and HCG (37.5%) for H. pylori IgG in the 45-55 age group by WB. A statistically significant difference was found between AAA and AsAA for VacA and CagA + VacA and CagA + VacA + UreA antigens and also a significant difference was found between AsAA and HCG for CagA + UreA antigens (p < 0.05). Finally, we suggest that H. pylori VacA has a more important role than CagA in the development of two aneurysms especially in ruptured AAA. New extended studies detecting H. pylori DNA are needed to detect the aetiopathogenesis between aneurysm types and H. pylori.

Comparison of three different surgical methods in aortic root aneurysms: long-term results.

BACKGROUND: Degenerative ascending aortic aneurysms frequently present with aortic valve pathology. If only the noncoronary sinus of Valsalva is dilated, replacement of the noncoronary sinus by tailoring the supracoronary graft with or without aortic valve replacement (AVR) can be a simple operation strategy. We sought to describe our experiences in this kind of operation, and compare them with a relatively homogeneous group of patients who underwent the classical Bentall operation. METHODS: Between January 1997 and June 2007, 99 patients who had dilated ascending aortas with root dilatation and aortic valve pathology underwent operation. Patients were divided into three groups according to the surgical procedure. Classical Bentall operation was applied in 54 patients with dilated sinuses (Group 1). The other patients with dilated noncoronary sinus underwent either ascending aortic replacement with noncoronary sinus replacement (NSR, n = 27) (Group 2), or separate AVR and ascending aortic replacement with NSR (AVR + NSR, n = 18) (Group 3). RESULTS: There were significant reduction of aortic root in Group 2 (Z =-4.560, p < 0.001), and Group 3 (Z =-3.758, p < 0.001). Degree of aortic regurgitation was decreased from 1.56 +/- 0.5 to 0.67 +/- 0.5 postoperatively in Group 2 (Z =-3.874, p < 0.001). Hospital mortality was six (6.1%) (three in Group 1; three in Group 2). Late mortality rate was 6.1% (three in Group 1, three in Group 2). The type of operation was not found to be an independent predictor of overall mortality. No patients in the NSR and AVR-NSR groups had aortic root aneurysm, and there were no reoperations or verified deaths caused by aortic root aneurysm in these patients. CONCLUSIONS: Noncoronary cusp replacement for aortic root remodeling in patients with ascending aortic aneurysm is a technically simple and durable operation. Short- and mid-term results of this method were favorable compared to the Bentall procedure.

Second recurrence of familial atrial myxomas: mother and daughter simultaneously.

Sporadic ca rdiac myxomas rarely recur, however recurrence rates are higher in patients with a familial aggregation or Carney complex. Carney complex is characterised by multiple mucocutaneous lesions and accounts for up to two-thirds of familial cardiac myxomas. A second recurrence is very rare, even in the case of Carney complex. We report on two cases of recurrent cardiac myxoma, a mother and daughter, who concurrently presented with a second recurrence of atrial myxomas. The time interval between the first and second recurrence following surgery was four years in both. The possibility of repeat recurrence of cardiac myxomas demonstrates the importance of regular echocardiography to detect recurrence and to prevent the potential complications associated with cardiac myxomas. Family screening should be recommended for familial myxomas.

Long-term results of monopolar versus bipolar radiofrequency ablation procedure for atrial fibrillation.

BACKGROUND: In this study, we aimed to evaluate the long-term outcomes of monopolar or bipolar radiofrequency ablation concomitant to mitral valve surgery in patients with atrial fibrillation. METHODS: We retrospectively evaluated a total of 167 patients (67 males, 100 females; mean age 56.8±6.9 years; range, 48 to 65 years) with atrial fibrillation who underwent monopolar or bipolar radiofrequency ablation concomitant to mitral valve surgery between September 2001 and January 2015. The patients were divided into two groups according to the procedure applied as those undergoing monopolar ablation (group 1, n=68) and those undergoing bipolar ablation (group 2, n=99). All patients were followed by electrocardiogram and 24-h Holter monitoring. Echocardiography was performed before discharge, at three and 12 months postoperatively, and annually thereafter. Left atrial volume index, left atrial diameter, and left ventricular ejection fraction were recorded. RESULTS: There was no significant correlation between the procedure applied and hypertension, hyperlipidemia, diabetes mellitus, chronic obstructive pulmonary disease, history of the cerebrovascular events (p>0.05). The mean preoperative left atrial diameter decreased from 5.3±0.5 cm to 4.9±0.5 cm postoperatively in all patients (p=0.0001). The mean preoperative left atrial volume index decreased from 53.8±0.4 mL/m2 t o 43.7±6.2 m L/m2 i n t he postoperative period (p=0.0001). During follow-up, 61.8% (n=42) of the patients in group 1 and 62.6% (n=62) of the patients in group 2 remained in sinus rhythm. One patient (1.5%) in group 1 and two patients (2.0%) in group 2 developed early postoperative cerebrovascular accident. CONCLUSION: Monopolar and bipolar ablation methods are safe and effective methods to ensure long-term sinus rhythm. Both procedures do not increase the morbidity risk with very low thromboembolic complication rates.

Comparison of Renoprotective Effect of Dabigatran With Low-Molecular-Weight Heparin.

OBJECTIVE: The susceptibility of tissue to ischemia-reperfusion (I/R) injury is a major obstacle to tissue regeneration and cellular survival. In this study, we investigated the possible renoprotective effect of dabigatran in an experimental renal I/R model. METHOD: A total of 25 rats were randomly divided into 5 equal groups. The control group was used to obtain basal values of oxidant and antioxidant biomarkers. The sham group was used to obtain renal prolidase and malondialdehyde (MDA) levels after renal ischemia (for 45 minutes) and reperfusion (for 1 hour). A standard diet was followed. Oral 15 mg/kg dabigatran etexilate was administrated to group I, intraperitoneal 250 U/kg enoxaparin sodium was administrated to group II, and intraperitoneal 250 U/kg bemiparin sodium was administrated to group III for 1 week before the renal I/R was performed. Renal tissue samples were obtained during the first hour of reperfusion to detect renal prolidase and MDA levels in these groups, after which the rats were euthanized. RESULTS: Renal prolidase levels were significantly higher in the sham group compared with the control group (1834.2 ± 982.3 U/g protein vs 238.8 ± 43.6U/g protein; P = .001). Lower prolidase levels were observed in groups II (838.7 ± 123.8 U/g protein) and III (1012.9 ± 302.3 U/g protein), and the lowest prolidase levels occurred in group I (533.8 ± 96.2 U/g protein; P < .05) when compared with the sham group. The MDA levels were significantly lower (P < .05) in groups I, II, and III (163.9 ± 41.5, 185.4 ± 51.0, and 138.2 ± 22.6 µmol/g protein, respectively) compared with the sham group. CONCLUSION: Dabigatran etexilate, a univalent direct thrombin inhibitor, may protect the renal tissue more effectively when compared to low-molecular-weight heparins.

Does off-pump CABG reduce gastrointestinal complications?

BACKGROUND: The aim of this study was to compare gastrointestinal complications and associated risk factors among patients undergoing cardiac surgery using off- and on-pump revascularization techniques. METHODS: A total of 1146 adult patients who underwent coronary artery surgery during a 6-year period were evaluated retrospectively. Group 1 consisted of 546 patients operated using off-pump techniques and group 2 consisted of 600 cases operated with cardiopulmonary bypass. Patients were compared and evaluated for gastrointestinal complications and possible associated risk factors using univariate and multivariate logistic regression analysis. RESULTS: Overall mortality was 1.6% in group 1 and 2.2% in group 2 (p = 0.523). Mortality due to gastrointestinal complications was 38.5% and 35.7% respectively in group 1 and group 2. The mean EuroSCORE value was 5.1 +/- 2.8 in group 1 and 3.8 +/- 2.4 in group 2 (p < 0.001). The most common gastrointestinal complication in the off-pump group was gastrointestinal bleeding. The leading complication in group 2 was intestinal ischemia. CONCLUSIONS: The incidence rates of gastrointestinal complications were similar in the on- and off-pump coronary artery bypass groups, the type of gastrointestinal complications, however, was different. Mortality rate due to these complications was also similar and remained high, regardless of the type of surgery. Cardiopulmonary bypass did not emerge as a risk factor for gastrointestinal complications, but prolonged cardiopulmonary bypass (longer than 98 minutes) resulted in a high incidence of such complications. Old age and advanced arteriosclerosis emerged as risk factors in both groups resulting in gastrointestinal complications suggesting the ischemic nature of the injury.

Rapid Detection of Acute Kidney Injury by Urinary Neutrophil Gelatinase-Associated Lipocalin in Patients Undergoing Cardiopulmonary Bypass.

OBJECTIVE: Acute kidney injury (AKI) is common following cardiopulmonary bypass (CPB). The aim of this study is to determine the accuracy of urinary neutrophil gelatinase-associated lipocalin (NGAL) levels following cardiac surgery to establish the severity of renal impairment as compared to serum creatinine levels. METHODS: A total number of 28 patients undergoing elective cardiopulmonary bypass were included. Diagnostic criteria of AKI was established in case of a percentage increase in serum creatinine concentration of >50%. Serum creatinine levels were recorded in the preoperative period before induction and in the postoperative period at 24, 48, and 72 hours. Urinary NGAL measurement was performed before induction and in the 4(th) postoperative hour. The duration of CPB surgery, hospital stay, and cross-clamp time were recorded. RESULTS: Based on AKI criteria, subjects were grouped as AKI (n=11) and no AKI (n=19). Postoperative urinary NGAL levels were significantly higher in the group with AKI (11.8 ng mL(-1) vs. 104.0 ng mL(-1), p=0.003). In the AKI group, CPB time bypass (111.9 min vs. 82.7 min) and cross-clamp time (76.9 min vs. 59.1 min) were significantly higher. A cut-off of 25.5 ng mL(-1) yielded a sensitivity of 81.82% and a specificity of 94.12% at the postoperative 4(th) hour with an AUC of 0.947 for predication of AKI. CONCLUSION: Urine NGAL rose significantly much earlier as compared to serum creatinine levels in the early postoperative period. Although larger case series are needed, we are of the opinion that urinary NGAL measurements may be used as an early clinical marker of AKI following CPB.

Angiographic evaluation of graft patency in robotic-assisted coronary artery bypass surgery: 8 year follow-up.

BACKGROUND: Robotic telemanipulation systems have emerged as facilitating tools that enhance minimally invasive cardiac surgery.The purpose of this study was to evaluate graft patency by a combination of invasive and non-invasive coronary angiography methods in robotic-assisted coronary artery surgery(CABG) for optimal quality control. METHODS: Between April 2004 and February 2012, patients who had robotic-assisted CABG were called to have cardiac catheterization or multislice computed tomographic angiography to evaluate graft patency. RESULTS: One hundred patients out of a total 250 cases were followed for graft patency for a mean period of 60.3 ± 23.8 (range 12-94) months. Mean operative time and left internal mammary artery harvest time was 165.96 ± 19.5 and 41.74 ± 5.9 (range 30-55) min. Postoperative graft patency rate was 94% and freedom from target vessel re-interventions was 98%. CONCLUSION: Robotic-assisted CABG can be accomplished with low morbidity, mortality and re-intervention rates. It is a safe procedure in selected patients and produces excellent mid-term graft patency.

Bone cement-enhanced sternal closure technique in cardiac surgery: effects on sternal union, pain and life quality.

BACKGROUND: Median sternotomy provides excellent access to all mediastinal structures in patients undergoing conventional cardiovascular surgery. Although this incision technique is associated with relatively lower complication rates, certain complications such as the sternal dehiscence may pose serious health consequences. In this regard, considerable effort has been paid to develop techniques aiming to improve sternal healing and to enhance postoperative recovery after conventional cardiac surgery. Among these, kryptonite bone cement, a biocompatible polymer with improved mechanical properties when combined with a standard wire cerclage, represents a promising novel approach that may help prevent sternal dehiscence. In this study, the effects of this particular type of bone cement on sternal healing, postoperative pain, and quality of life have been evaluated. METHODS: Kryptonite bone cement enhanced sternal closure was employed in a total of 100 patients undergoing conventional cardiac surgery between November 2009 and June 2012. Of these patients, 50 expressed their willingness to participate in this study. Each participant underwent a computerized tomography imaging for the radiological assessment of sternal healing. Pain and life quality of these patients have been evaluated by Wong-Baker faces pain scale and SF-36 health survey questionnaire, respectively. RESULTS: Mean duration of follow-up was 20.14 ± 7.36 months (range: 10-32). Mean age and body mass index were 71.32 ± 7.23 years (range: 55-85) and 28.34 ± 2.62 (21-34) kg/m2, respectively. Elderly patients (≥70), females and those with chronic obstructive pulmonary disease (COPD) comprised 64%, 26% and 40% of the study population, respectively. No patients had findings suggestive of dehiscence on CT images. No patients reported severe pain (i.e. all patients had a Wong-Baker faces pain scale score <4). Elderly (≥ 70 yr) subjects had better quality of life scores as compared to the remaining group of patients (< 70 yr) according to SF-36 Health Survey results. Vitality and emotional role scores were lower (63.5 ± 25.5, p = 0.018 and 41.7 ± 23.3, p = 0.001, respectively) in female patients. Patients with COPD had lower quality of life scores than those without COPD, particularly with respect to general health scores (73.3 ± 18.5; p = 0.012). CONCLUSIONS: Kryptonite bone cement, when combined with a standard wire cerclage, enhances mechanical strength, prevents sternal dehiscence, reduces postoperative pain and improves quality of life after conventional cardiac surgery. Long-term studies are warranted to better define the role of kryptonite bone cement in the prevention of sternal dehiscence.

Robotics in cardiac surgery: the Istanbul experience.

BACKGROUND: Robots are sensor-based tools capable of performing precise, accurate and versatile actions. Initially designed to spare humans from risky tasks, robots have progressed into revolutionary tools for surgeons. Tele-operated robots, such as the da Vinci (Intuitive Surgical, Mountain View, CA), have allowed cardiac procedures to start benefiting from robotics as an enhancement to traditional minimally invasive surgery. METHODS: The aim of this text was to discuss our experience with the da Vinci system during a 12 month period in which 61 cardiac patients were operated on. There were 59 coronary bypass patients (CABG) and two atrial septal defect (ASD) closures. RESULTS: Two patients (3.3%) had to be converted to median sternotomy because of pleural adhesions. There were no procedure- or device-related complications. CONCLUSION: Our experience suggests that robotics can be integrated into routine cardiac surgical practice. Systematic training, team dedication and proper patient selection are important factors that determine the success of a robotic surgery programme.

Combined off-pump coronary artery bypass grafting surgery and ablative therapy for atrial fibrillation: early and mid-term results.

BACKGROUND: The aim of this study was to evaluate the feasibility of off-pump coronary artery bypass grafting combined with radiofrequency ablation and to compare outcomes between patients with permanent and paroxysmal atrial fibrillation (AF) in terms of restoring sinus rhythm. METHODS: Thirty-three patients underwent the combined procedure. Mean age was 62.34 +/- 8.20 years; there were 12 female and 21 male patients. Twenty-one patients were diagnosed as permanent AF (group A) and 12 had paroxysmal AF (group B). After the off-pump revascularization patients underwent pulmonary vein ablation. Rhythm was evaluated at discharge and at 6 and 12 months' follow-up. Patients in stable sinus rhythm underwent transthoracic echocardiographic examination to evaluate atrial contractility at 6 and 12 months. RESULTS: There was no operative mortality or major complications. The mean ablation time was 11 +/- 3.4 minutes, including multiple applications. At the end of the procedure 84.5% of patients were free of AF. Sinus rhythm was established in 56% (group A, 52%; group B, 58.3%), 70.5% (group A, 58%; group B, 83.3%), and 71% (group A, 59%; group B, 83.3%) of patients at discharge and at 6 and 12 months, respectively (p = 0.249). Biatrial contractility was detected in 71% of group A and 76% of group B patients at 6 months' follow-up. More patients in group A returned to AF during follow-up when compared with group B (p = 0.016). Female sex (odds ratio, 2.1), chronic lung disease (odds ratio, 1.40), left ventricular disfunction (p = 0.016), and hypertension (odds ratio, 2.57) emerged as risk factors for AF recurrence after ablation. CONCLUSIONS: Concomitant off-pump coronary artery bypass grafting and bipolar radiofrequency ablation was safe and effective. These patients should be considered for adjunctive treatment at the time of off-pump revascularization.

Robotic-enhanced totally endoscopic mitral valve repair and ablative therapy.

PURPOSE: The aim of this article was to assess the feasibility of totally closed robotic mitral valve repair and ablative therapy. DESCRIPTION: Two patients with mitral valve disease and permanent atrial fibrillation underwent the combined procedure using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA). Radiofrequency ablation was performed using the Cardioblate XL unipolar pen (Medtronic Inc, Minneapolis, MN). One patient underwent mitral commissurotomy and the other commissurotomy and Reed annuloplasty. EVALUATION: There were no procedure-related complications. Sinus rhythm was established in both patients after the operation, and transesophageal echocardiography revealed competent mitral valves without residual gradients. CONCLUSIONS: Robotic-enhanced mitral valve repair and ablation proved feasible in both patients with good clinical outcome. The described combined method may find broader application in a selected group of patients with the continuing evolution in technology.