Reason and Timing for Conversion to Sternotomy in Robotic-Assisted Coronary Artery Bypass Grafting and Patient Outcomes.

OBJECTIVE: Conversion to sternotomy is a primary bailout method for robotically assisted coronary artery bypass grafting procedures. The aims of this study were to identify the primary reasons for conversion from robotically assisted coronary artery bypass grafting to sternotomy and to evaluate the in-hospital outcomes in such patients. METHODS: Prospectively collected data from February 2004 to April 2017 were reviewed for 72 patients (56 men; mean age = 63.8 years) who required conversion to sternotomy during a robotically assisted coronary artery bypass grafting procedure with planned endoscopic left internal thoracic artery harvest and anastomosis to the left anterior descending on the beating heart. RESULTS: The overall rate of conversion was 12.4% (72/581). Conversions occurred either during attempted endoscopic left internal thoracic artery harvest (31.9%), during endoscopic left anterior descending isolation (40.3%), during manual isolation and anastomosis of the left anterior descending (19.4%), or after anastomosis due to unsatisfactory flow (8.3%). Overall, the most common reason for conversion was an intramyocardial left anterior descending (43.1%). The median stay in the intensive care unit was 1 day (range = 0-20) and the median hospital length of stay was 5 days (range = 3-43). In-hospital complications included new atrial fibrillation (16.7%), need for blood transfusion (20.8%), mediastinitis (4.2%), postoperative myocardial infarction (2.8%), exploration for bleeding (2.8%), and 1 in-hospital death. CONCLUSIONS: The reasons for conversion were primarily related to anatomical factors that created difficulties for endoscopic left internal thoracic artery harvesting and left anterior descending identification. Patients who required conversion to sternotomy from robotically assisted coronary artery bypass grafting demonstrated acceptable outcomes and low complication rates.

Ultrafast Track Robotic-Assisted Minimally Invasive Coronary Artery Surgical Revascularization.

OBJECTIVE: Contemporary anesthetic techniques have enabled shorter sedation and early extubation in off-pump and minimally invasive coronary artery bypass (CABG) surgery. Robotic-assisted CABG represents the optimal surgical approach for ultrafast track anesthesia, with patients able to bypass the cardiac surgical intensive care unit with recovery in the postanesthesia care unit (PACU) and inpatient ward. METHODS: In-hospital postoperative outcomes from ninety patients who underwent either elective or urgent robotically-assisted CABG at our institution were reviewed. These patients were carefully selected by a multidisciplinary team to undergo fast-track anesthesia: extubation in the operating room, 4-hour recovery in the postanesthesia care unit and transfer to the inpatient ward. Intrathecal, paravertebral local, and patient-controlled anesthesia techniques were used to facilitate transition to oral analgesics. RESULTS: Average patient age was 61 ± 9 years. Sixty-six patients (73%) were male. Seventy cases were elective, and 20 patients required urgent revascularization. All patients underwent intraoperative angiography after graft construction, which revealed Fitzgibbon class A grafts. There were no in-hospital mortalities. One patient required re-exploration for bleeding, through the same minimally invasive incision, did not require conversion to sternotomy for bleeding, and was transferred to the intensive care unit postexploration for bleeding for standard postoperative care. Postoperative complications were limited to one superficial wound infection. The mean hospital length of stay was 3.5 ± 1.17 days. CONCLUSIONS: In patients undergoing robotic-assisted CABG, ultrafast-track cardiac surgery with immediate postprocedure extubation and transfer to the inpatient ward has been demonstrated to be safe with no increase in perioperative morbidity or mortality. It requires a dedicated heart team with a carefully selected group of patients. Avoiding cardiac surgical intensive care unit expedites recovery, with possible avoidance of infection and early discharge from hospital.

Is the Future of Coronary Arterial Revascularization a Hybrid Approach?: The Canadian Experience Across Three Centers.

OBJECTIVE: Hybrid coronary revascularization offers and combines the advantages of both surgical and percutaneous revascularization and eliminates at the same time the disadvantages of both procedures. The objective of this study was to assess graft and stent patency at 6 months, rate of bleeding, intensive care unit and hospital stay, rate of reintervention, and long-term clinical follow-up. METHODS: From March 2004 to November 2015, a total of 203 patients underwent robotic-assisted minimally invasive direct coronary artery bypass graft of the left internal thoracic artery to the left anterior descending artery and PCI of a non-left anterior descending vessel in a single or two stage, at three different centers. Patients underwent 6-month angiographic follow-up. The mean ± SD clinical follow-up was 77.82 ± 41.4 months. RESULTS: Successful hybrid coronary revascularization occurred in 196 of the 203 patients. One hundred forty-six patients underwent simultaneous surgical and percutaneous intervention. Nineteen patients underwent PCI before surgery, and 38 patient underwent PCI after surgery. No in-hospital mortality occurred. The mean ± SD ICU stay was 1 ± 1 days and the mean ± SD hospital stay was 5 ± 2 days. Only 13.3% of the patients required a blood transfusion. Six-month angiographic follow-up has been performed in the 95 patients, and it demonstrated a left internal thoracic artery anastomotic patency of 97.9% and stent patency of 92.6%. A total of 77.8 ± 41.4-month clinical follow-up demonstrated 95.1% survival, 92.6% freedom from angina, and 90.7% freedom from any form of coronary revascularization. CONCLUSIONS: Hybrid coronary revascularization seems to be a promising and safe revascularization strategy. It provides selected patients with an alternative, functionally complete revascularization with minimal surgical trauma and good long-term clinical outcomes.

Magnetic Resonance Imaging-Guided Transurethral Ultrasound Ablation of Prostate Tissue in Patients with Localized Prostate Cancer: A Prospective Phase 1 Clinical Trial.

BACKGROUND: Magnetic resonance imaging-guided transurethral ultrasound ablation (MRI-TULSA) is a novel minimally invasive technology for ablating prostate tissue, potentially offering good disease control of localized cancer and low morbidity. OBJECTIVE: To determine the clinical safety and feasibility of MRI-TULSA for whole-gland prostate ablation in a primary treatment setting of localized prostate cancer (PCa). DESIGN, SETTING, AND PARTICIPANTS: A single-arm prospective phase 1 study was performed at three tertiary referral centers in Canada, Germany, and the United States. Thirty patients (median age: 69 yr; interquartile range [IQR]: 67-71 yr) with biopsy-proven low-risk (80%) and intermediate-risk (20%) PCa were treated and followed for 12 mo. INTERVENTION: MRI-TULSA treatment was delivered with the therapeutic intent of conservative whole-gland ablation including 3-mm safety margins and 10% residual viable prostate expected around the capsule. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Primary end points were safety (adverse events) and feasibility (technical accuracy and precision of conformal thermal ablation). Exploratory outcomes included quality of life, prostate-specific antigen (PSA), and biopsy at 12 mo. RESULTS AND LIMITATIONS: Median treatment time was 36min (IQR: 26-44) and prostate volume was 44ml (IQR: 38-48). Spatial control of thermal ablation was ±1.3mm on MRI thermometry. Common Terminology Criteria for Adverse Events included hematuria (43% grade [G] 1; 6.7% G2), urinary tract infections (33% G2), acute urinary retention (10% G1; 17% G2), and epididymitis (3.3% G3). There were no rectal injuries. Median pretreatment International Prostate Symptom Score 8 (IQR: 5-13) returned to 6 (IQR: 4-10) at 3 mo (mean change: -2; 95% confidence interval [CI], -4 to 1). Median pretreatment International Index of Erectile Function 13 (IQR: 6-28) recovered to 13 (IQR: 5-25) at 12 mo (mean change: -1; 95% CI, -5 to 3). Median PSA decreased 87% at 1 mo and was stable at 0.8 ng/ml (IQR: 0.6-1.1) to 12 mo. Positive biopsies showed 61% reduction in total cancer length, clinically significant disease in 9 of 29 patients (31%; 95% CI, 15-51), and any disease in 16 of 29 patients (55%; 95% CI, 36-74). CONCLUSIONS: MRI-TULSA was feasible, safe, and technically precise for whole-gland prostate ablation in patients with localized PCa. Phase 1 data are sufficiently compelling to study MRI-TULSA further in a larger prospective trial with reduced safety margins. PATIENT SUMMARY: We used magnetic resonance imaging-guided transurethral ultrasound to heat and ablate the prostate in men with prostate cancer. We showed that the treatment can be targeted within a narrow range (1mm) and has a well-tolerated side effect profile. A larger study is under way. TRIAL REGISTRATION: NCT01686958, DRKS00005311.

Coagulation assessment in children with diabetic ketoacidosis.

OBJECTIVES: To assess potential hypercoagulability during diabetic ketoacidosis in children. DESIGN: A prospective, controlled pilot study. SETTING: University-affiliated pediatric critical care unit and emergency department in a tertiary care children's hospital. PATIENTS: Children (1-18 years) admitted with an episode of diabetic ketoacidosis and healthy children as controls. All patients with diabetic ketoacidosis managed according to a preestablished protocol. INTERVENTIONS: Thromboelastography was performed using citrated whole-blood samples drawn at the time of admission and upon biochemical and clinical resolution of diabetic ketoacidosis. Citrated whole-blood samples drawn from healthy nondiabetic children acted as control samples. MEASUREMENTS AND MAIN RESULTS: Fifteen patients (11.7 ± 4.1 years) in the diabetic ketoacidosis group and 20 patients (8.9 ± 4.5 years; p = 0.06) in the control group completed the study. Values for standard thromboelastography parameters (R and K time, α angle, maximum amplitude, coagulation index, and Ly30) in the diabetic ketoacidosis group, both on admission and resolution, were within the control range; thromboelastography profiles of diabetic ketoacidosis patients on admission were not significantly different from profiles obtained upon diabetic ketoacidosis resolution. The mean α-angle was significantly higher in known diabetic patients compared with newly diagnosed diabetics on admission; however, it still remained within the control normal range. CONCLUSIONS: Thromboelastographic assay results do not reflect a hypercoagulable state in this group of children with diabetic ketoacidosis. Further investigation is required to examine the potential role of injured endothelium in the suspected hypercoagulability during diabetic ketoacidosis.

Comparison of MAX-ACT and K-ACT values when using bivalirudin anticoagulation during minimally invasive hybrid off-pump coronary artery bypass graft surgery.

OBJECTIVE: To compare the kaolin-activated coagulation time (K-ACT) to the MAX-ACT for monitoring anticoagulation with bivalirudin in patients undergoing hybrid off-pump coronary artery revascularization procedures. DESIGN: A prospective, observational study. SETTING: A cardiac surgical operating room of a university-affiliated hospital. PARTICIPANTS: Twelve patients undergoing off-pump coronary artery bypass graft surgery and percutaneous coronary intervention during the same procedure anticoagulated with bivalirudin to a target K-ACT of >300 seconds. INTERVENTION: At baseline and at frequent intervals during anticoagulation, K-ACT and MAX-ACT assays were run contemporaneously, and the pairs of results were analyzed with descriptive statistics, by correlation analysis, and with Bland-Altman analysis. MEASUREMENTS AND MAIN RESULTS: The MAX-ACT and K-ACT assays were highly correlated, but the MAX-ACT assay consistently reported significantly lower ACT values compared with the K-ACT. The mean bias (K-ACT minus MAX-ACT) was 94 seconds (limits of agreement, 51-138 seconds). CONCLUSION: To maximize patient safety, centers using bivalirudin for anticoagulation during cardiac surgical procedures need to be aware of the different performance characteristics of ACT assay subtypes.

Comparison of a single-use GlideScope Cobalt videolaryngoscope with a conventional GlideScope for orotracheal intubation.

BACKGROUND: This study was conceived to compare the single-use GlideScope Cobalt videolaryngoscope with the conventional GlideScope videolaryngoscope for orotracheal intubation, as judged by time to intubation (TTI) and ease of intubation. METHODS: One hundred patients with normal-appearing airways requiring orotracheal intubation for elective surgery were randomly allocated to have their tracheas intubated by a heterogeneous group of operators with the Cobalt GlideScope or the conventional GlideScope. TTI was assessed by a blinded observer. Operators were blinded until the start of laryngoscopy. A visual analogue scale (VAS) assessed the ease of intubation. The number of intubation attempts, number of failures, glottic grades, and fogging of the video screen were recorded. RESULTS: There was no difference between the median TTI of the GlideScope Cobalt and the conventional GlideScope (40.1 sec, interquartile range [IQR] 34.1, 51.3 vs 39 sec, IQR 32.6, 48.1, respectively; P = 0.75). The ease of intubation was similar between the two devices (median Cobalt VAS: 16 mm, IQR 10.8, 27.3, vs median conventional VAS: 12.5 mm, IQR 10, 20.5, respectively; P = 0.12). There were no significant differences between the two devices with respect to glottic exposure, intubation attempts, failures, or video screen fogging. CONCLUSIONS: The GlideScope Cobalt has similar performance characteristics compared with the conventional GlideScope videolaryngoscope when used for orotracheal intubation. The two devices can likely be used interchangeably. (ClinicalTrials.gov number, NCT00459797.).

A comparison of glidescope videolaryngoscopy to direct laryngoscopy for nasotracheal intubation.

BACKGROUND: In this study, we compared the effectiveness of direct laryngoscopy (DL) and the GlideScope videolaryngoscope (GVL) for nasotracheal intubation, as judged by the time to intubation (TTI-the primary outcome) and the ease of intubation. METHODS: Seventy patients requiring nasotracheal intubation for elective surgery were randomly allocated to intubation with the GVL or DL. TTI was assessed by a blinded observer. Operators were blinded until the start of laryngoscopy. A Visual Analog Scale assessed the ease of intubation. The number of intubation attempts, number of failures, glottic grades, amount of bleeding, usage of Magill forceps, and the severity of postoperative sore throat were recorded. RESULTS: The median TTI was 23.2 s faster with the GVL (43.5 s, interquartile range [IQR]: 39.8-67.3) than with DL (66.7 s, IQR: 53.8-89.9), P = 0.0023. Nasotracheal intubation was easier with the GVL than with DL (Visual Analog Scale 10 mm, IQR: 5.5-18, vs 20 mm, IQR: 10-32, P = 0.0041). The incidence of postoperative moderate or severe sore throat was significantly reduced in the GVL group (9% vs 34%, P = 0.018). Glottic exposure was significantly better with the GVL. Magill forceps were not used in the GVL group, but were used 49% of the time in the DL group, P < 0.0001. The incidence and severity of bleeding were similar between groups. CONCLUSIONS: Compared with DL, the GVL has superior performance characteristics when used for nasotracheal intubation and demonstrates an important reduction of postoperative sore throat. The GVL has a clear role in routine nasotracheal intubation.

The GlideScope-specific rigid stylet and standard malleable stylet are equally effective for GlideScope use.

PURPOSE: The GlideScope videolaryngoscope usually provides excellent glottic visualization, but directing an endotracheal tube (ETT) through the vocal cords can be challenging. The goal of the study was to compare the dedicated GlideScope-specific rigid stylet to the standard malleable stylet, assessed by time to intubation (TTI). METHODS: Eighty patients requiring orotracheal intubation for elective surgery were randomly allocated to either the GlideScope rigid stylet (GRS) or a standard malleable stylet to facilitate intubation using the GlideScope. Time to intubation was recorded by blinded assessors; operators were blinded until after laryngoscopy. The operator assessed the ease of intubation using a visual analogue scale (VAS). The number of intubation attempts, number of failures, glottic grades, and use of external laryngeal manipulation were documented. RESULTS: The median TTI was 42.7 sec (inter-quartile range (IQR) 38.9-56.7) for the GRS group compared to 39.9 sec (IQR 34.1-48.2) for the control group (P=0.07). The median VAS score for ease of intubation was 20 (IQR 12.0-33.0) for the GRS group compared to 18 (IQR 9.5-29.5) for the control group (P=0.21). There was no significant difference in TTI or VAS between stylets. The overall incidence of a Cormack-Lehane grade I or II glottic view was 98%. CONCLUSIONS: In a group of experienced operators using the GlideScope, the dedicated GRS and the standard malleable ETT stylet are equally effective in facilitating endotracheal intubation.

Effect of stylet angulation and endotracheal tube camber on time to intubation with the GlideScope.

PURPOSE: The GlideScope videolaryngoscope usually provides excellent glottic visualization, but directing an endotracheal tube (ETT) through the vocal cords is sometimes difficult. The goal of the study was to determine which of two ETT angles (60 degrees vs 90 degrees ) and cambers (forward vs reverse) was better, as determined by time to intubation (TTI). METHODS: Two hundred patients requiring orotracheal intubation for elective surgery were randomly allocated to one of four groups: A) 90 degrees angle, forward camber; B) 90 degrees angle, reverse camber; C) 60 degrees angle, forward camber; D) 60 degrees angle, reverse camber. Time to intubation was assessed by a blinded observer. Operators were blinded until the point of intubation. A visual analogue scale (VAS) assessed the ease of intubation. The number of intubation attempts, number of failures, glottic grades, and use of external laryngeal manipulation were recorded. RESULTS: The angle of the ETT had an impact on TTI but camber did not. The 90 degrees angle demonstrated a 13% faster TTI than the 60 degrees angle (47.1 +/- 21.2 sec vs 54.4 +/- 28.2 sec, P=0.042), and it resulted in easier intubation (VAS 16.4 +/- 14.2 mm vs 27.3 +/- 23.5 mm, P=0.0001). The overall incidence of a grade 1 or 2 Cormack-Lehane glottic view was 99%. CONCLUSIONS: In a heterogeneous group of operators and patients intubated with the GlideScope, a 90 degrees ETT angle provided the best result and should be the initial configuration. The camber of the ETT does not affect the time to intubation.

Point-of-care platelet function testing.

Cardiopulmonary bypass has unpredictably deleterious effects on platelet function. Patients with cardiovascular disease have treatments aimed at reducing platelet aggregation and are at risk of excessive bleeding during surgery. Transfusion of blood products, particularly platelets, probably causes increased morbidity and mortality. Conversely, patients with excessive platelet aggregation are at risk of thrombotic complications--undesirable outcomes in the context of myocardial revascularization and prevention of stroke. Platelet function is difficult to monitor. Laboratory tests take time, and the results are not immediately available. Point-of-care (POC) testing of platelet function should facilitate the clinical management of bleeding patients by rationalizing platelet transfusion and avoiding unnecessary transfusion. Furthermore, POC platelet function could alert the clinician to risks of excessive platelet activation and measure the efficacy of antiplatelet therapy. This article outlines some of the POC platelet function monitors available as well as their potential applications.