Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments.

OBJECTIVE: The development of endoscopic coronary artery bypass grafting has been limited because of poor visualization and increased technical difficulties in carrying out operations through ports. We investigated whether the use of robotic assisted instruments could minimize these difficulties. METHODS: After a period of technical development and training on cadavers (n = 8) with the Intuitive Surgical system (Intuitive Surgical, Inc, Mountain View, Calif), the first clinical application in coronary artery surgery was performed in 4 male patients (mean age 59 +/- 6 years) with the indication of grafting the left internal thoracic artery to the left anterior descending coronary artery. Robotic assisted 3-dimensional endoscopes and instruments were introduced into the left side of the chest through 3 intercostal ports. The Heartport system (Heartport, Inc, Redwood City, Calif) was used for arresting the heart during the anastomosis. RESULTS: In 2 patients, the harvesting of the left internal thoracic artery was completed endoscopically with robotic assisted instruments and the anastomosis to the left anterior descending artery was performed through a minithoracotomy with conventional instruments. In 2 other patients, the entire operation was completed endoscopically with robotic assisted instruments. Early postoperative coronary angiography demonstrated the patency of the grafts in all cases. At 6-month follow-up, all patients were free of symptoms. CONCLUSIONS: Robotic assisted instruments make endoscopic coronary bypass possible and open a new era in minimally invasive surgery.

Extensive calcification of the mitral valve anulus: pathology and surgical management.

Extensive calcification of the mitral valve anulus is a pathologic entity frequently associated with degenerative valvular disease. The calcification process remains localized to the anulus in 77% of the cases. It may extend, however, to the underlying myocardium. Whenever an operation is necessary for an associated valve insufficiency, the question arises whether it is preferable to repair or to replace the valve and how to manage the calcification. In the first part of this paper the pathology of this disease is studied, and in the discussion a mechanism is proposed to explain the development of the process of calcification. In the second part, a new operation is described, which comprises the temporary detachment of the leaflets, en bloc resection of the calcium deposit, annular reconstruction, and valve repair. For patients in whom the calcification extends to the myocardium a "sliding atrioplasty" of the left atrium is described, which allows the area of exposed muscular fibers to be covered. Between 1986 and 1994, among 68 patients with extensive calcification of the anulus and severe mitral valve insufficiency, 67 benefited from these repair techniques. Ages ranged from 18 to 82 years (mean 62 years). Thirty-two patients had a billowing mitral valve (Barlow), 27 a fibroelastic deficiency, and two Marfan's disease. The calcification involved more than one third of the anulus in 88% of the patients, the posterior anulus in 10.5%, and the whole anulus in 1.5%. The calcification process extended to the myocardial wall in 12% of the patients and to the papillary muscles in 4.5%. In the group of 67 valve repairs, there were two hospital deaths (2.9%), no instances of anulus dehiscence, and no early reoperations. The follow-up period extended from 4 months to 8 years (mean 3 years 8 months). There were two late deaths, 2 and 17 months after the operations, for an actuarial survival of 93% at 7 years. Late reoperation (6 to 62 months) was necessary in four patients (6.4%) for residual mitral valve incompetence (n=2), hemolysis (n=1), or endocarditis (n=1). In one of these patients a new repair was possible, whereas the three other patients required a valve replacement. All patients but one survived the reoperation. Actuarial freedom from reoperation was 87% at 7 years. All 60 patients with valve repair were reviewed for this study by clinical examination and echocardiography. All but one were in functional class I or II. There was no incompetence or trivial residual mitral valve incompetence in 55 patients and moderate incompetence in five. Two thromboembolic events have been recorded for a linearized rate of 1%/pt-yr. This study shows that complete anulus decalcification and valve repair can be done safely in patients with mitral valve insufficiency and extensive calcification of the anulus, even when the calcification process deeply involves the myocardium. It also demonstrates that an initially good result remained stable up to 7 years.

The "physio-ring": an advanced concept in mitral valve annuloplasty.

BACKGROUND: A new annuloplasty ring has been developed with the aim of adding flexibility to the remodeling annuloplasty concept. Here we report its clinical use with special emphasis on segmental valve analysis and valve sizing. METHODS: From October 1992 through June 1994, 137 patients aged 4 to 76 years (mean age, 49.1 years) were operated on. The main causes of mitral valve insufficiency were degenerative, 90; bacterial endocarditis, 15; and rheumatic, 13. The indication for operation was based on the severity of the mitral valve insufficiency (90 patients were in grade III or IV) rather than on functional class (60 patients were in class III or IV). At echocardiography 6 patients had normal leaflet motion (type I), 119 leaflet prolapse (type II), and 12 restricted leaflet motion (type III). Surgical repair was carried out using Carpentier techniques of valve reconstruction. In 3 patients, inadequate ring sizing was responsible for systolic anterior motion of the anterior leaflet diagnosed by intraoperative echo. The valve was replaced in 2 patients. There were three hospital deaths, no late deaths, one reoperation for recurrent mitral valve insufficiency due to chordal rupture 1 month after repair, one reoperation for atrial thrombus formation 5 months after repair, one anticoagulant-related hemorrhage, and one thromboembolic episode. RESULTS: Mid-term follow-up between 6 and 18 months was available in 94 patients. Echocardiography showed trivial or no regurgitation in 93.2% of the patients and minimal regurgitation in 6.8%. The average transmitral diastolic gradient was 3.55 +/- 1.93 mm Hg. Left ventricular end-systolic diameter and volume decreased postoperatively, demonstrating an improved left ventricular function. CONCLUSIONS: This preliminary experience has provided promising results and allowed us to define the indications of the Physio-Ring versus the classic ring. It has also shown that valve sizing and proper ring selection are of primary importance.

Carpentier-Edwards pericardial bioprosthesis in aortic position: long-term follow-up 1980 to 1994.

Aortic valve replacement with Carpentier-Edwards pericardial bioprosthesis was associated with excellent midterm clinical results. Long-term evaluation, however, remained to be determined. We reviewed the first 124 patients who underwent aortic valve replacement with a Carpentier-Edwards bioprosthesis at the Hôpital Broussais between 1980 and 1985. There were 67 males (54%) and 57 females (46%). The mean age at operation was 65 years (range, 18-83 years). The operative mortality (30 days) was 4%. All but 2 patients were followed up for an average of 7.7 years and a total of 973 patient years. There were 45 late deaths (4.7%/patient-year) of which 16 were valve-related (1.7%/patient-year). The actuarial survival rate was 49.9% at 12 years. The actuarial rate for freedom from valve-related mortality was 78.3% at 12 years. There were 7 thromboembolic events in 5 patients and 3 anticoagulation-related hemorrhages. Freedom from structural valve deterioration was 100% at 12 years and 83.3% at 13 years. We conclude that implantation of Carpentier-Edwards pericardial bioprosthesis in aortic position is associated with an excellent long-term clinical outcome. It is believed that the improved results of this valve result from the following original features: fully flexible stent, distensible struts, infrastent tissue mounting, optimal tissue orientation, and improved preservation.

Heparin-induced thrombocytopenia and thrombosis following open heart surgery.

We recently observed five cases of early thrombus formation in patients undergoing anticoagulation with subcutaneous heparin following open heart surgery. The reasons prompting surgery were as follows: one mitral valve replacement, one double valve replacement, one mitral valve reconstruction, one aortic valve replacement associated with coronary bypass. In all cases, intravenous heparin was begun on the day of surgery and replaced by subcutaneous (SC) heparin on postoperative day 1. Acute thrombocytopenia was observed between the 6th and 11th postoperative day. This was interpreted as denoting an idiosyncratic reaction to heparin which was replaced by low molecular weight heparin (LMWH) in two cases and by acenocoumarol in the other cases. Massive thrombosis of the aortic valve resulted in the death of one patient. Thrombosis of the left atrium occurred in three patients (two of whom had a transient ischemic attack (TIA)). One patient had aorto-iliac thrombosis. Successful reoperation was carried out in four of the five patients. Although heparin-induced thrombocytopenia and thrombosis [HITT] is a rare complication of heparin therapy, serial platelet count monitoring and in vitro platelet aggregation tests are mandatory in the diagnosis of this syndrome. Discontinuation of heparin is indicated as soon as the syndrome is recognized and the institution of aspirin is recommended if the thromboembolic complication requires reoperation and reexposure to heparin.

Infrarenal aortic stents: initial clinical experience and angiographic follow-up.

From March 1990 to May 1991, arterial stents were placed in seven patients because of a tight stenosis (five patients) or a total chronic occlusion (two patients) located in the infrarenal aorta. In one case, the aortic occlusion extended to both common iliac arteries. After balloon dilatation, aortic stents were successfully positioned in all cases. Bilateral common iliac recanalization and stent placement were performed in one case. No complications occurred in any of the patients. No complications occurred in any of the patients. Follow-up data were derived from clinical assessments and angiographic results. After a 15.1-month mean follow-up period (range 12-24 months), the seven aortic stents remained patent. Three iliac artery procedures were performed in two of the patients as well. Claudication recurred in three of the seven patients which was related to a common iliac occlusion (one case) or distal progression of atherosclerosis (two cases). Aortic stents seem to be suitable for treating failed angioplasty of aortic lesions but the procedure remains technically difficult when there is associated severe atherosclerosis of the proximal common iliac arteries. Nevertheless, considering the morbidity rate (0%) and the patency rate in this series, this technique could become an alternative to surgical treatment for infrarenal aortic occlusive lesions.

Percutaneous iliac artery stent: angiographic long-term follow-up.

The authors conducted a prospective study of 49 consecutive patients with 53 lesions in 52 iliac arteries. All were treated between October 1987 and April 1990 with percutaneous transluminal angioplasty (PTA) and insertion of either a self-expandable or balloon-expandable stent. Lesions included total occlusion (28%), dissection (42%), post-PTA restenosis (21%), and unsatisfactory PTA (9%). Complications included one aortic protrusion, one acute thrombosis of the stent (resolved with urokinase), and three distal embolizations (5.7%) (resolved with urokinase and aspiration). During 15 months of follow-up, two patients died (one after occlusion). Three other occlusions occurred; one of these was resolved with local thrombolysis. Hyperplasia occurred in seven cases (13.5%), and stenosis occurred at the end of the stent because of incomplete covering of the lesion in three (5.8%); a complementary procedure was performed in six of these cases. Primary patency was 85.3% at 12 months and 80.9% at 18 months; secondary patency rate was 96.1% at 12 and at 18 months. At the end of the study, excluding data for the two patients who died, 27 limbs (54%) were asymptomatic and improvement was achieved in 19 (38%); the clinical success rate was 92%. No amputations were required.

Valve repair with Carpentier techniques. The second decade.

Among 206 consecutive patients having undergone mitral valve repair with a prosthetic ring between 1972 and 1979 in our institution, the 195 patients (94.5%) who survived the operation were studied to assess the long-term function of this method of repair. Patients' ages ranged from 18 to 79 years (mean age 48.7 years). Mitral valve insufficiency was due to degenerative disease in 113 patients (58%), rheumatic disease in 74 (38%), ischemia and other causes in eight patients (4%). A total of 188 patients (9.7%) were in New York Heart Association class III or IV preoperatively and 94 (48%) had atrial fibrillation. The patients were divided into three functional groups: type I (normal leaflet motion), 35 patients (18%); type II (leaflet prolapse), 147 patients (75%); and type III (restricted leaflet motion), 13 patients (7%). The techniques included prosthetic ring annuloplasty (185 patients), leaflet resection (158 patients), chordal shortening (89 patients), leaflet mobilization (10 patients) and papillary muscle reimplantation (2 patients). Long-term follow-up was available in 189 patients (96.8%), for a rate of 2316 patients per year. The 15-year actuarial and valve-related survival rates were 72.4% and 82.8%, respectively. At 15 years, 93.9% of the patients were free from thromboembolism, 96.6% free from endocarditis, 95.6% free from anticoagulant-related hemorrhage, and 87.38% free from reoperation. Actuarial rate of freedom from reoperation was higher in the group with degenerative disease (92.7%) than in the group with rheumatic disease (76.12%). Among the 157 survivors, 117 (74%) were in New York Heart Association class I and class II and 105 (66%) were in sinus rhythm. Doppler echocardiographic studies showed normal ventricular contractility in 134 patients (84.5%), absence of mitral regurgitation in 112 (74%), trivial regurgitation in 27 (17%), and significant regurgitation in 4 patients (2.5%).

Surgery for aortic dissection: 53 operated cases with 32 in the acute phase.

53 cases of aortic dissections were operated on between 1961 and 1975 in the Service of Cardiovascular Surgery at the Broussais Hospital, Paris (Prof. Ch. Dubost). The present study deals with 32 cases operated on in the acute phase. 31 originated in the ascending aorta and 1 in the descending aorta. Operative mortality was 50% (16/32), 4 patients died immediately following sternotomy. Operation consisted in replacement of the ascending aorta for the majority of type I and II dissections. When aortic insufficiency was present, a simple resuspension procedure was effective in 50% of cases. The authors prefer early operative intervention in type I and II dissections and medical treatment in type III dissections.