Robotically enhanced coronary artery bypass surgery

Robotically enhanced telemanipulation surgery is a rapidly developing technique which enables totally endoscopic cardiac surgery with utmost precision and perfection on both beating heart and arrested heart. Between December 2002 and September 2006, 268 patients underwent robotically enhanced coronary artery bypass surgery using the da Vinci telemanipulation system. Fourteen patients underwent total endoscopic coronary artery bypass surgery. Of these 12 were performed on a beating heart and 2 on an arrested heart. Two-hundred and fifty-four patients had endoscopic takedown of the internal mammary artery followed by minimally invasive direct coronary artery bypass in 193 patients and left anterolateral thoracotomy in 61 patients. The internal mammary artery mobilization time was 36 min (28–76 min) and the left internal mammary artery to left anterior descending artery anastomosis time ranged from 20 to 36 min for the totally endoscopic coronary artery bypass patients. The right internal mammary artery of one patient was anastomosed to diagonal artery totally endoscopically. The mean internal mammary artery flow by Doppler measurement in patients undergoing minimally invasive direct coronary artery bypass was 58 ml min⁻¹. Seven patients required conversion to median sternotomy and coronary bypass surgery on the beating heart. The mean intensive care unit stay was 1.2 days and the mean hospital stay 4.5 days. There was one in-hospital mortality. All 14 patients who underwent total endoscopic bypass surgery had coronary angiography 3 months later which showed 100% patency in 13 patients. One patient had 50% anastomotic narrowing for which coronary angioplasty was performed in the same sitting. By using telematic technology, a complete endoscopic anastomosis is possible in both single vessels and suitable double vessel disease patients. The use of robotics is now extended to achieve complete myocardial revascularization by harvesting both the internal mammary arteries and making a small thoracotomy for direct anastomosis also.     

Surgical Treatment of a Superior Sulcus Tumor in a Patient with Idiopathic Thrombocytopenic Purpura: Report of a Case

We herein report a resection of a superior sulcus tumor in a patient with idiopathic thrombocytopenic purpura. A resection of the left upper lobe of the lung, left subclavian artery, and left first to third ribs, as well as a reconstruction of the left subclavian artery, were performed. Postoperative hemorrhaging was controlled due to preoperative high-dose intravenous immunoglobulin therapy and a platelet transfusion both during and following surgery. The resected tumor was diagnosed to be a pulmonary pleomorphic carcinoma, which was pathologically determined to be T3N0M0-Stage 2B. The patient remained in good condition for 20 months following the surgery; however, he eventually died due to bone metastases.     

Simultaneous surgery for left lung cancer and the aneurysm of an aberrant left subclavian artery in a patient with right aortic arch

A 69-year-old man with right aortic arch was diagnosed as having left lung cancer (cT2aN1M0, cStage IIA) and an aneurysm of an aberrant left subclavian artery. The aneurysm measured 36 mm in diameter and was located 1 cm peripheral from the origin in the area known as "Kommerell's diverticulu Left carotid artery-to-left subclavian artery bypass graft was placed through a left supraclavicular incision prior to thoracotomy. This bypass graft effectively prevented neurological and ischemic complications of the brain and left upper extremity while we safely and successfully performed resection of the aneurysm along with radical surgery for left lung cancer through left thoracotomy. There have been only 10 case reports, including the present case, that have described surgical resection of lung cancer in a patient with right aortic arch. In addition, this is the 1st report to describe simultaneous surgery for both left lung cancer and an aneurysm of an aberrant left subclavian artery in a patient with right aortic arch.     

不停跳冠状动脉旁路移植术联合同期肺切除术

目的总结不停跳冠状动脉旁路移植术联合同期肺切除术的经验。方法7例不稳定性心绞痛或心肌梗死合并可切除肺部病变患者,实施不停跳冠状动脉旁路移植术联合同期肺切除术。所有患者术前行冠状动脉造影证实不宜行冠状动脉成形术或支架植入术。采用胸骨正中切口,不停跳冠状动脉旁路移植术后行肺切除术。左上肺叶切除2例,右上肺叶切除1例,右上、中叶切除1例,右下肺叶切除1例,左侧肺减容术1例,双侧肺减容术1例。结果本组无住院死亡,但有1例后期死亡。术后并发症包括1例胸骨哆开再次开胸固定、1例房颤。病理检查结果5例肺部恶性肿瘤、2例慢性阻塞性肺气肿。患者随访2～31个月,所有患者术后没有再次出现心肌缺血症状,1例行右肺上、中叶切除患者术后19个月出现局部复发。结论胸骨正中切口不停跳冠状动脉旁路移植术联合同期肺切除术是安全有效的并能降低术后并发症。     

机器人非体外循环冠状动脉旁路移植与支架置入"杂交"手术治疗多支冠状动脉病变

目的 总结达芬奇S机器人系统行非体外循环冠状动脉旁路移植与支架置入"杂交"手术治疗多支冠状动脉病变的技术特点和优势.方法 2007年至2011年,使用da Vinic S全机器人系统完成非体外循环冠状动脉旁路移植术163例,其中12例患者因两支或三支冠状动脉病变,在机器人手术后行分站式支架置入术.男9例,女3例;年龄(56.0±9.7)岁;均有心绞痛症状,冠状动脉造影显示严重的前降支或对角支病变,合并回旋支或右冠状动脉的病变;4例有心肌梗死病史.先对所有患者前降支病变行机器人非体外循环下冠状动脉旁路移植术,术后待患者恢复平稳再行其他病变冠状动脉支架置入术.冠状动脉造影评价在再血管化效果.结果 所有患者均成功接受机器人非体外循环冠状动脉旁路移植术,术后恢复顺利,随后成功接受支架置入术.全组无并发症.结论 机器人非体外循环冠状动脉旁路移植和支架置入"杂交"手术可最大限度的减小手术创伤并实现冠状动脉完全再血管化.

Abstract：

Objective Summary the first group of robotic bypass surgery on the beating heart and stent placement in distinct hybrid session in China. Methods 163 cases patients accepted selective operation of robotic coronary bypass grafting on the beating heart form April 2007 to January 2011. 12 cases had multi coronary vessels stenosis accepted stent placement after robotic surgery in a hybrid manner. The average age of patients was ( 56. 0 ± 9.74 ) years old. 3 case was female and 9 cases were male. All the patients had a medical history of angina. The coronary arterioangiography showed sever left anterior descend ing or diagonal branch stenosis in all patients. And 4 cases had myocardial infarction history. All the patients had good lung function and had no medical history of pleurisy. Without sternotomy, through 3 ports about 1 cm in left thorax, the left internal mammary artery was obtained and simultaneously single vessel coronary artery bypass grafting through small thoracotomy or totally endoscopic coronary bypass (TECAB) was performed on beating heart. The bridge patency and revascularization was accessed by arterioangiography. Results All cases successfully accepted robotic bypass surgery on the beating heart and stent placement in distinct hybrid session without complication. Conclusion Hybrid coronary artery revascularization enable adequate revascularization of patients with multivessel coronary artery disease without sternotomy and with the advantage of the most durable option.     

Concomitant lobectomy by video-assisted thoracic surgery and coronary artery bypass grafting: report of a case

Successful simultaneous operation for cardiac and lung disease was performed in a 71-year-old man with lung carcinoma and ischemic heart disease. Chest CT scan revealed a mass in the right lower lobe and absence of mediastinal lymphadenopathy. Coronary angiography revealed significant stenosis of the left anterior descending artery, circumflex artery and right coronary artery. We performed concomitant video-assisted right lower lobectomy with mediastinal lymph node dissection as a form of less invasive surgery and triple coronary artery bypass grafting under cardiopulmonary bypass. Curative surgery for lung carcinoma and complete revascularization for ischemic heart disease were completed. The postoperative course was uneventful.     

Mitral valve replacement in a patient with a collapsed lung

A 67-year-old man, with a history of pulmonary tuberculosis since 18 years old, presented shortness of breath because of severe mitral regurgitation. Magnetic resonance imaging showed that the heart was displaced into the left thoracic cavity and rotated clockwise around its long axis. The forced expiratory volume per second was 1.06 l (46.7% of the predicted value) and the vital capacity was 2.48 l (72.1% of predicted value). Surgery was performed through a median sternotomy. An internal mammary artery harvest retractor was used to obtain operative exposure. Extensive pericardial suspension was used to push the over-inflated right lung across the midline. Extracorporeal circulation was established. The mitral valve was replaced with a mechanical prosthesis. The patient was weaned easily from extracorporeal circulation and was extubated on the day of surgery. If preoperative respiratory function is adequate, cardiac surgery can be performed safely in a patient with only one functional lung.     

Two cases of reoperative coronary bypass grafting through a small left thoracotomy]

A reoperation by a MIDCAB (minimally invasive direct coronary artery bypass) was performed on 2 patients, including one who had undergone a surgical repair of a left ventricular rupture and another who had undergone a coronary artery bypass operation. In both patients, the left internal thoracic artery was isolated by a left small thoracotomy and then was anastomosed to the LAD (left anterior descending artery). One patient showed stenosis at the site of anastomosis and thus required coronary arterioplasty postoperatively, but was discharged without any further complications. When performing a reoperation by MIDCAB, complications such as injuries to the heart and patent graft during surgery and postoperative complications can be minimized by only performing a bypass to LAD. Such a bypass is usually sufficient in cases in which either marked adhesion is expected in the area of the circumflex artery or if anastomosable branches are not available in the area of the circumflex artery. This surgical technique was found to be an effective modality for a reoperation of the coronary artery, if suitable cases are carefully selected.     

非体外循环下机器人冠状动脉旁路移植手术的麻醉管理

目的 总结非体外循环机器人冠状动脉旁路移植手术中的麻醉技术.方法 2007年1月至2011年3月共完成机器人心脏跳动下冠状动脉旁路移植手术163例,其中62例全机器人冠状动脉旁路移植手术,101例机器人辅助肋间小切口冠状动脉旁路移植手术.麻醉均采用全麻,左侧双腔气管插管.结果 术中单肺通气和CO2气胸引起动脉氧分压(PaO2)和静脉氧饱和度显著降低,163例患者中有17例出现低氧,SpO2降至0.92.使用5～15 cmH2O的持续气道正压后,PaO2从(59±12)mm Hg升至(115±23)mm Hg(P<0.05).CO2气胸开始阶段平均动脉压和心脏指数明显降低,同时伴有平均肺动脉压增高、心率加快,经快速补液和使用血管活性药得以纠正.术后(7.5±3.1)h拔管,ICU停留平均21h.1例因肺部感染在ICU治疗3天;1例行二次手术止血.全部患者术后住院4～7天.结论 非体外循环机器人冠状动脉旁路移植手术中的单肺通气和CO2气胸对患者循环和呼吸功能的影响是麻醉管理的关键.心脏外科医师和麻醉医师要熟练掌握单肺通气和CO2气胸的相关技术知识,恰当处理术中缺氧和血流动力学波动.

Abstract：

Objective Anesthesia for endoscopic robotic coronary artery bypass grafting surgery on beating heart to deal with the hemodynamic compromise, hypoxia and hypercarbia relevant to one lung ventilation ( OLV ) and intrathoracic inflation of CO2 with positive pressure (CO2 pneumothorax) is crucial. Methods Between February 2007 and January 2011, 163 patients underwent robotically assisted coronary artery bypass surgery on beating heart using the da Vinci S Surgical System. Of them, 62 patients underwent totally endoscopic coronary artery bypass grafting ( TECAB). Other 101 patients underwent robotically assisted endoscopic atraumatic coronary artery bypass ( ENDOACAB) in which the left internal mammary artery was harvested robotically and direct anastomosis via a small left anterior thoractomy incision. Results PaO2 and SvO2 after initiate of OLV and CO2 pneumothorax showed a significant decrease. Meanwhile, the SpO2 decreased to 0.92 in 17 of the 163 patients.In these patients, application of CPAP setting 5-15 cmH2O to the collapsed lung resulted in an increase in PaO2 from (59 ±12) mmHg to (115 ±23) mmHg (P < 0.05). At the beginning of CO2 pneumothorax the most dramatic fall in MAP and CI was showed with an increase in MPAP and HR. The hemodynamie compromise was counteracted by transfusion and inotropes/ vasopressors. Postoperatively, the average extubation time was (7. 5 ±3. 1) hours, and median ICU length of stay was 21 hours. One patient remained in the ICU for 3 days for treatment of a postoperative pneumonia. One patient who had underwent ENDOACAB were reexplored for bleeding in the left anterior thoracotomy incision. All patients were discharged home 4 to 7 days after surgery. Conclusion Anesthetic management for the procedures requires detailed knowledge of OLV and CO2 pneumothorax in addition to expertise required in conventional cardiac surgery.     

机器人微创非体外循环冠状动脉旁路移植术

目的 评价da Vincis机器人系统进行胸廓内动脉(IMA)游离、小切口非体外循环下冠状动脉旁路移植术的安全性和手术效果.方法 2007年1月到2011年3月,105例患者接受机器人IMA游离、小切口非体外循环下冠状动脉旁路移植术.其中男性77例,女性28例,年龄33～77岁,平均(59±10)岁.患者术前行64排CT检查评估IMA质量,2例患者左LIMA纤细或走行异常弃用.术者于操作台前、三维成像系统下遥控机器人游离IMA并完成动脉桥与靶血管的徒手吻合.其中4例患者旁路移植后接受了杂交技术于回旋支或右冠状动脉行支架植入术.术中均以超声血流检测仪测量桥血管的波形及血流.术后以冠状动脉造影或64排CT评估桥血管的通畅性,并进行随访.结果 所有患者成功接受上述手术,无手术死亡病例.术中平均IMA血管桥血流量为(21±13) ml/min.1例于术后第1天突发心跳骤停经抢救后痊愈,复查桥血管通畅.1例合并脑梗死患者术后肺部感染,痊愈后出院.其余患者无并发症发生.术中及术后出血少,术后恢复快.随访1～51个月,平均(30±12)个月.术后冠状动脉造影或64排CT复查未见桥血管狭窄或闭塞,心绞痛症状缓解.结论 机器人IMA游离、小切口非体外循环冠状动脉旁路移植术创伤小、疗效确切、安全性好,是微创冠状动脉再血管化的重要方向之一.     

Aortic valve replacement after previous coronary artery bypass grafting: experience with a simplified approach

AIM: Aortic valve replacement (AVR) after previous coronary artery bypass grafting (CABG), particularly in a patent left internal thoracic artery (ITA), is a challenge. Avoidance of injuring the patent graft and ensuring myocardial protection are important issues in the management of these patients. The aim of this study was to evaluate a simplified surgical approach to these reoperations. METHODS: Between January 2003 and June 2005, 19 of 287 AVRs performed at our institution were in a patient subset (mean age 70 years, range: 62-82) who received AVR after previous CABG surgery. The aortic valve gradients were between 50 and 107 mm Hg. Our operation strategy followed the KIS-principle (keep it simple): both femoral vessels were cannulated using the Seldinger technique. Only the area around the ascending aorta and the right atrium was dissected to permit x-clamping, aortotomy, and catheterization for retrograde cardioplegia and a left ventricular vent. The anterior aspect of the heart and the left side, where the ITA was embedded and patent, were left untouched and not clamped. RESULTS: The mean interval between the first and second operation was 6.5 years. Fourteen patients received biological prostheses. Four patients received an additional surgery at the time of AVR. The mean operating time was 267 min; the mean AoX-clamp time was 63 min. One patient died because of severe heart failure. In all others the postoperative course was uneventful. CONCLUSIONS: We believe that the indication for AVR in patients scheduled for CABG should be re-evaluated. In those in which Redo-surgery for new or increased valve stenosis is indicated, a simple and safe surgical option is presented.     

Beating heart coronary artery bypass surgery after orthotopic heart transplantation

Beating-heart coronary artery bypass surgery was performed in a 52-year-old man with accelerated transplant coronary artery disease 10 years after orthotopic heart transplantation. Transplant coronary artery disease was first detected in the left circumflex coronary artery 9 years after transplantation. Rapid progression to triple vessel disease occurred within 1 year, and the patient developed worsening symptoms of shortness of breath and chest pain. He underwent off-pump "beating heart" left internal mammary artery to left anterior descending coronary artery bypass surgery. The circumflex coronary artery was not graftable due to diffuse and truncated small vessel disease. His postoperative course was uneventful and he was discharged on the fifth postoperative day. Coronary angiography 3 months after the surgery revealed a widely patent left internal mammary artery to left anterior descending artery bypass. He is alive and symptom free more than 1 year after his surgery.     

Left ventricular pseudo-false aneurysm after a myocardial infarction; application of heart positioner

We herein present the case of a pseudo-false aneurysm which developed in a patient after a myocardial infarction in the posterior left ventricular wall. A 71-year-old man experienced an acute myocardial infarction due to occlusion in the left circumflex artery. Five weeks after the myocardial infarction, echocardiography and magnetic resonance imaging (MRI) disclosed a pseudo-false aneurysm at the posterior left ventricular wall. A patch closure of the aneurysm and coronary artery bypass grafting (CABG) to both the left anterior descending artery and the left circumflex arteries were successfully performed. At surgery, the Starfish Heart Positioner, a commercially available device that is designed to lift the heart during off-pump CABG, was found to be very useful for exposing the posterior left ventricular wall by lifting and fixing the apex of the left ventricle.     

Technique of successful clinical double-lung transplantation

Lung transplantation has become a successful method in the therapy for end-stage pulmonary disease. While single-lung transplantation provides benefit to patients with pulmonary fibrosis, bilateral lung transplants are required for septic or emphysematous lung disease. We describe the technique employed in 6 patients to transplant en bloc both lungs with the recipient heart left in place. The lungs are connected by a left atrial cuff, main pulmonary artery, and trachea. The completed implantation has a tracheal anastomosis securely wrapped in omentum, a left atrial anastomosis posterior to the heart, and a pulmonary artery anastomosis anteriorly. Airway ischemia resulted in the death of 1 patient. This procedure allows complete excision of all diseased pulmonary tissue, retention of the recipient's own heart, and separate excision of the donor heart for use in another recipient, thereby markedly increasing the supply of donor lungs for transplantation.     

Two patients of left lung cancer with right aortic arch: review of eight patients

We report two cases of left lung cancer in patients with variant right aortic arches. Preoperative heart examination ascertained that neither patient had congenital heart disease. Patient 1 exhibited a right aortic arch with mirror-image branching of the major arteries. The patient's clinical stage was T1aN0M0 stage IA. Patient 2 exhibited a right aortic arch with an aberrant left subclavian artery. The patient received induction chemotherapy for cT2aN2M0 stage IIIA adenocarcinoma of the lung. In patients with a right aortic arch undergoing surgery, especially mediastinal lymph node dissection, it is important to consider the anatomical displacement of the vagus and recurrent laryngeal nerves in addition to the vascular abnormalities. In this study, we found that preoperative identification of anomalous structures using three-dimensional computed tomography was particularly useful in evaluating the anatomical location and position of the left recurrent laryngeal nerve from an embryological point of view.     

Reoperations with the Right Gastroepiploic Artery without Cardiopulmonary Bypass

A bstract The right gastroepiploic artery (RGEA) has been utilized as the bypass conduit on the inferior surface of the heart with a minimally invasive approach. Fourteen patients had reoperative coronary bypass surgery for severely symptomatic single-vessel disease of the right coronary artery. All surgeries were performed since May 1996. A small mid-line incision including splitting of the lower sternum gave excellent exposure. The inferior surface of the heart was dissected to expose and stabilize the target vessel. The heart rate was controlled with a diltiazem drip. Cardiopulmonary bypass was not necessary in any case. The right coronary artery was bypassed in three patients, the posterior descending artery branch in ten patients, and the terminal circumflex of the left coronary artery in one. After grafting, patency of the anastomosis was demonstrated by Doppler echocardiogram. Two patients had left anterior descending artery (LAD) grafts with LIMA (left mammary artery) and RGEA grafts performed simultaneously with two port access incisions. No patient had perioperative mortality or complications. No patient had recurrent angina. Doppler color echocardiographic imaging studies before discharge confirmed patency of the graft in 13 of 14 cases. In one case, the gastroepiploic artery could not be visualized. Angiographic visualization was positive in seven cases; seven patients were not studied yet. The gastroepiploic artery is an excellent conduit for vascularization of the inferior aspect of the heart. The operation can be done with a minimally invasive technique and without the use of cardiopulmonary bypass. This approach seems especially applicable in selective reoperative cases.     

Intralobar pulmonary sequestration supplied by multiple anomalous arteries: report of a case

Pulmonary sequestration is abnormal pulmonary tissue that has separated from the normal pulmonary parenchyma, is not connected to the tracheobronchial tree, and is supplied by a systemic artery. We describe herein a case of intralobar pulmonary sequestration found in a 66-year-old man who was admitted to our hospital with hemoptysis, coughing, and fever. Angiography showed that the branches of the 11th left intercostal artery and a bronchial artery had formed a hypervascular area in the lower part of the left lung. Bronchial artery embolization and subsequent embolization of the left 11th intercostal artery were performed in an attempt to control the recurrent hemoptysis. These treatments were unsuccessful, and he was transferred to our department of surgery after coughing up about 400 ml of fresh blood. A left lower lobectomy was performed. The resected lung contained a large feeding artery, some acute and partly organizing inflammatory lesions within collapsed lung parenchyma, and massive intra-alveolar hemorrhage in the peripheral area. The patient had an uneventful recovery and was discharged 22 days after his operation. Received: March 24, 2000 / Accepted: January 9, 2001     

Unilateral high-frequency jet ventilation supporting one-lung ventilation during thoracic surgical procedures

We report two cases where surgery on the right lung had to be performed for resection of a malignoma. In both cases, function of the left lung was severely restricted. In the first patient, the volume on this side was reduced by around 50% as the result of a recently performed upper lobe resection. In the second patient, perfusion of the left lung accounted for only 18% of the total lung perfusion. On the basis of these changes we considered conventional one-lung ventilation impracticable and performed surgery using differential lung ventilation. The dependent (left) lung was ventilated by intermittent positive pressure ventilation (IPPV), where the tidal volume in the first patient had to be reduced to 200 ml because of high airway pressures. Ventilation of the non-dependent (right) side was performed simultaneously in both patients by means of high frequency jet ventilation (HFJV). Under this procedure arterial O2 saturation ranged from 96 to 100%, and arterial CO2 partial pressure was 45 mmHg. Surgery was not hindered by ventilation, the postoperative progress was also without complications. The case reports show that with the help of the ventilation regime described (operated side: HFJV, non-operated side: IPPV) lung surgery can be successfully performed on patients who are unsuitable for conventional one-lung ventilation for functional reasons.     

Reoperative Coronary Artery Bypass Grafting Via a Left Thoracotomy and a Small Laparotomy Without Cardiopulmonary Bypass: Report of a Case

A 66-year-old woman with aortic stenosis underwent an aortic root replacement with a composite graft and coronary artery reconstruction 2 years before presentation. On coronary angiography performed 2 years after operation, saphenous vein graft (SVG) to right coronary artery and SVG to first diagonal branch had both become totally occluded. SVG to left anterior descending artery showed 75% stenosis on the heel side of the distal anastomosis. The patient underwent a second coronary artery bypass via a left thoracotomy (the left internal thoracic artery was anastomosed to the first diagonal branch by interposing it with the left radial artery) and a small laparotomy (the right gastroepiploic artery was anastomosed to the right coronary artery) without a cardiopulmonary bypass. This approach is preferable to avoiding both a resternotomy and cardiopulmonary bypass in patients requiring repeat surgery. Received: September 29, 2000 / Accepted: May 15, 2001     

Mitral valve re-replacement in a patient with occlusion of the left internal carotid artery

An 83-year-old female patient, who had previously undergone mitral valve replacement using bioprosthesis at 15 years ago, presented symptoms of congestive heart failure. Mitral valve regurgitation was caused by structural deterioration of the bioprosthetic valve, and replacement of the bioprosthesis was indicated. Digital subtraction angiography revealed occlusion of the left internal carotid artery, which put this patient at high risk to cerebral complications during heart valve surgery. Administration of acetazolamide induced a marked decrease in the blood flow in the left cerebral hemisphere. Re-replacement of the mitral valve was successfully performed under high-flow cardiopulmonary bypass. Intra-aortic balloon pumping produced pulsatile blood flow with a peak pressure of 90-100 mmHg during the cardiopulmonary bypass. She recovered after surgery with no neurological complication. We believe the pulsatile cerebral perfusion produced by the intra-aortic balloon pumping with high-flow cardiopulmonary bypass was effective for preventing cerebral complications in this patient with internal carotid artery occlusion.