Initial experience with a new right ventricular support device for beating heart surgery

OBJECTIVE: Device supported beating heart surgery has been advocated to extend patient selection criteria for off-pump surgery. This article reports the initial experimental and clinical results with a novel paracardial right ventricular support device. METHODS: Preclinical experiments were performed in two pigs. Ten elective patients with triple vessel disease were subjected to beating heart coronary artery bypass grafting surgery during right ventricular support by the paracardial device. Measurements included intraoperative hemodynamics during cardiac tilting, perioperative left ventricular ejection fraction (LVEF), hemolysis parameters, mortality and major morbidity events. RESULTS: A mean of 3.2 +/- 0.2 distal anastomoses per patient were performed. Mean arterial pressure and central venous oxygen saturation remained stable during cardiac tilting. Perioperative LVEF did not vary significantly. Sixty-day mortality and postoperative infarction rate were 0%. Functional Canadian Cardiovascular Society class at 6 days after surgery was 1.2 +/- 0.1 vs. 3.3 +/- 0.2 pre-operatively. CONCLUSION: In this initial clinical experience, application of the novel paracardial right ventricular support device proved to be safe and efficient.     

Coronary endarterectomy on beating heart: Our experience

Introduction Coronary artery bypass grafting (CABG) associated with Endarterectomy is a high risk procedure. After the first report of coronary endarterectomy by Bailey et al in 1951, the preference for this surgical procedure was decreased due to increased morbidity and mortality In patients with total or subtotal large coronary artery obstructions in which there is no possibility to receive a conduit as graft for myocardial revascularisation, endarterectomy remains the procedure of choice. This study was designed to study early and midterm results of off pump coronary artery endarterectomy. Methods Of 172 Consecutive Off Pump CABG done at our institution from Jan 2003 to July 2005, 22 patients underwent supplementary coronary endarterectomy. 16 patients had chronic stable angina 4 had unstable angina two required emergency CABG with endarterectomy following perioperative infarction. The mean ejection fraction was 29.2±4.3 and all of the patients were in New York Heart Association (NYHA) III or IV. All patients were planned for complete total arterial revascularisation using Left Internal Mammary Artery (LIMA). Right Internal Mammary Artery (RIMA), Radial composite “Y” graft, Two patients operated for periop infarct received vein graft. In 16 patients closed endarterectomy was done in five patients double endarterectomy in single vessel was done to chase the plaque distally, in one patient open left anterior descending (LAD) endarterectomy with vein patch reconstruction was performed. Results There were no deaths. None of the procedures were converted to on pump operation. All endarterectomies and bypasses were performed on Beating Heart, all patients were completely revascularised. Peri operative cardiac enzymes studied showed no significant rise in the Creatinine Phoshpokinase (CPK)-Creatinine Phosphokinase myocardial Band (CPK-MB). The mean postoperative Ejection Fraction (EF) was 36.7%±7.2% which was significantly higher than the Preoperative one (p<.05). At the end of four months to one and half year 22 patients were in NYHA class I to II and all were angina free in canadian cardiovascular society class.f Conclusions Coronary End Arterectomy without cardiopulmonary bypass can be performed in patients who are expected to benefit from complete revascularisation. It can be performed with closed as well as open method. However to achieve complete endarterectomy by closed technique in some patients it is essential to chase the plaque. Early and mid term results are encouraging.     

Clinical experience with adaptive support ventilation for fast-track cardiac surgery

OBJECTIVE: To evaluate adaptive support ventilation (ASV), an automatic microprocessor-controlled mode of mechanical ventilation, for the initial ventilatory management in consecutive patients eligible for early extubation after cardiac surgery. DESIGN: Prospective observational study. SETTING: Nonuniversity cardiac center. PARTICIPANTS: One hundred fifty-five consecutive patients eligible for early tracheal extubation after cardiac surgery. INTERVENTIONS: On intensive care unit arrival, patients were ventilated by adaptive support ventilation. This mode provided an automatic selection of initial ventilatory parameters and a continuous adaptation to patient's respiratory activity, guaranteeing that a preset minute ventilation was delivered. Once the patients had recovered sustained spontaneous ventilation, the ventilator was switched manually to pressure support for the terminal part of respiratory weaning followed by extubation. MEASUREMENTS AND MAIN RESULTS: In adaptive support ventilation, all patients could be ventilated satisfactorily except 1; tidal volume was 8.7 +/- 1.4 mL/kg of ideal body weight (mean +/- SD), plateau pressure was 20.3 +/- 3.9 cmH(2)O, and arterial blood gas measurements were satisfactory. One hundred thirty-four patients (86%) were extubated within 6 hours, and intubation time was 3.6 (2.53-4.83) hours (median, [quartiles]). No reintubation because of respiratory failure was required. Adaptive support ventilation was considered easy to use by both the nurses and physicians. CONCLUSIONS: Adaptive support ventilation was used in a group of 155 consecutive patients after fast-track cardiac surgery. This ventilation mode was safe, easy to apply, and allowed rapid extubation in suitable patients. ASV may facilitate postoperative respiratory management.     

心脏不停跳心内直视手术的临床研究（附1106例报告）

目的　探讨心脏不停跳心内直视手术的方法和意义。方法　总结 110 6例施行心脏不停跳心内直视手术病例。并行循环者 ,阻断上、下腔静脉而不阻断升主动脉 ,不使用心脏停搏液 ;逆行灌注者 ,阻断升主动脉后经冠状静脉窦逆行持续灌注机器氧合血 ,鼻咽温维持在 (33± 1)℃ ,均在心脏空跳条件下完成心内直视手术。结果　心脏手术完毕即可停机 ,术后血流动力学平稳 ,多巴胺用量很少。低心输出量综合征发生率 0 .45 % ,无严重心律失常 ,血尿发生率 1.90 %～ 3.41%。血液生化、心肌超微结构检查结果均显示较传统方法好。无 1例发生空气栓塞。早期死亡率 1.90 % (2 1/ 110 6例 )。结论　心脏不停跳法是一种较接近生理状态的心肌保护方法 ,能最大程度地减少心肌缺血缺氧损伤 ,避免再灌注损伤 ,而获得较理想的心肌保护效果     

心脏不停跳心内直视手术的临床研究

目的探讨心脏不停跳心内直视手术的方法和意义。方法总结1 106例施行心脏不停跳心内直视手术病例。并行循环者,阻断上、下腔静脉而不阻断升主动脉,不使用心脏停搏液;逆行灌注者,阻断升主动脉后经冠状静脉窦逆行持续灌注机器氧合血,鼻咽温维持在(33±1)℃,均在心脏空跳条件下完成心内直视手术。结果心脏手术完毕即可停机,术后血流动力学平稳,多巴胺用量很少。低心输出量综合征发生率0.45%,无严重心律失常,血尿发生率1.90%～3.41%。血液生化、心肌超微结构检查结果均显示较传统方法好。无1例发生空气栓塞。早期死亡率1.90%(21/1 106例)。结论心脏不停跳法是一种较接近生理状态的心肌保护方法,能最大程度地减少心肌缺血缺氧损伤,避免再灌注损伤,而获得较理想的心肌保护效果。     

Redo valve surgery with on-pump beating heart technique

AIM: Reoperations have become of increasing frequency in the last four decades. Redo surgery is more complex than primary surgery and is associated with higher mortality and morbidity. We present our immediate and mid-term results of mitral and aortic prosthetic valve replacement undertaken with beating heart technique. METHODS: The prospective study included 26 consecutive redo valve surgery patients who underwent valve re-replacement. The operation was carried out on a beating heart using normothermic bypass without cross-clamping the aorta for mitral valve surgery and retrograde coronary sinus normothermic noncardioplegic blood perfusion during cross-clamping the aorta for aortic valve procedures. RESULTS: Twenty-six patients (mean age 50+/-15 years) underwent reoperation with beating heart technique. Twenty (76.9%) mitral prosthetic replacements, 4 (15.4%) aortic prosthetic replacements, and 2 (7.7%) double valve replacements were achieved. Fourteen patients (53.8%) were operated for prosthetic valve dysfunction. Eighteen patients (69.2%) were in NYHA class III or IV preoperatively. Mean bypass time was 85+/-30 min. Mean duration of ventilation was 13.6+/-6 h, mean intensive unit stay was 2.8+/-6.4 days, and mean hospital stay was 8.3+/-7.2 days. Two (7.7%) patients required high dose inotropic support and in one patient (3.8%) intra-aortic balloon support was required. Pulmonary complication occurred in 1 patient (3.8%), low cardiac output in 1 patient (3.8%), and re-exploration for bleeding in 2 patients (7.7%). Operative mortality was not observed. CONCLUSION: Normothermic on-pump beating heart valve replacement offers a safe alternative to cardioplegic arrest in high-risk group. Complication rates are low and perioperative mortality is lower than with conventional surgery. Beating heart technique has the advantage of maintaining physiologic condition of the heart throughout the procedure.     

Reversed-J inferior sternotomy for beating heart coronary surgery.

Median sternotomy or combined multiple minimally invasive approaches are currently used to revascularize patients with multivessel coronary artery disease on the beating heart. We present here a new alternative approach for minimally invasive coronary surgery on the beating heart: the reversed-J inferior sternotomy. Through this approach, the left anterior descending, diagonal, and right coronary arteries can be revascularized via a single minimally invasive approach.     

Systematic review of beating heart surgery with the Octopus Tissue Stabilizer.

The safety and efficacy of off-pump coronary artery bypass surgery with the aid of the Octopus Tissue Stabilizer (Octopus OPCAB), in comparison to conventional on-pump coronary artery bypass surgery (CPB-CABG), was examined by a systematic assessment of the peer-reviewed literature. The limited comparative data suggested that there was no difference in safety outcomes between Octopus OPCAB and CPB-CABG. The paucity of efficacy data reported in the higher level comparative studies meant that it was impossible to assess whether Octopus OPCAB was more efficacious than CPB-CABG. The evidence base for the procedure was deemed inadequate and an audit of the procedure was recommended.     

Haemodynamic changes during beating heart coronary surgery with the 'Bristol Technique'.

OBJECTIVES: Optimal exposure and stabilization of the target coronary vessel is essential to allow the construction of a precise coronary anastomosis during off pump coronary surgery. However, this might be achieved at the expense of significant haemodynamic deterioration, particularly while grafting the circumflex and the posterior descending coronary arteries. The present study was designed to assess the haemodynamic changes with the beating heart positioned for grafting the three main coronaries. METHODS: Twenty-nine consecutive patients (21 male, mean age 62.6+/-7.1 years) undergoing off pump coronary surgery were enrolled in the study. Three different surgical settings of exposure and stabilization were used according to the site of anastomosis: left anterior descending (LAD - set-up 1; n=29), posterior descending (PDA - set-up 2; n=15), and circumflex (Cx - set-up 3; n=21) coronary arteries. Haemodynamic measurements were recorded before any cardiac manipulation (baseline) in set-ups 1, 2 and 3, and immediately after the completion of each distal anastomosis with the heart returned to its anatomical position. RESULTS: There were no marked changes in heart rate (HR) and systemic mean arterial pressure during the construction of the anastomoses for any of the three surgical settings. Set-up 1 (LAD) showed a decrease of 15.5% in stroke volume (SV) and an increase of 9% in pulmonary capillary wedge pressure (PCWP) compared to baseline (both P<0.05), with all the other haemodynamic parameters remaining unchanged. Set-up 2 (PDA) showed a marked decrease in SV and cardiac index (CI), and an increase in central venous pressure (CVP) when compared to baseline (all P<0.05). The most extensive changes were observed in set-up 3 (Cx) with a considerable reduction in SV and CI, and an increase in CVP, PCWP, pulmonary arterial pressure, and systemic vascular resistance index (all P<0.05). These haemodynamic changes were transient and totally recovered after the heart was returned to its anatomical position. CONCLUSIONS: Exposure and stabilization of the three main coronary arteries during beating heart surgery does not produce any appreciable change in systemic blood pressure and HR. The haemodynamic deterioration observed during the construction of the circumflex and posterior descending coronary arteries distal anastomoses is transient and well tolerated with no adverse clinical events.     

Retropericardial hematoma: pitfall in beating heart coronary surgery

Beating heart coronary surgery, now an accepted technique of myocardial revascularization, is perceived to have fewer complications than the conventional on-pump approach. However, little attention has been paid to complications that may be specific to the off-pump method. We describe the unusual development of a large retropericardial hematoma following otherwise uneventful beating heart coronary surgery that resulted in global cardiac displacement. This was recognized and investigated promptly, and led ultimately to complete resolution without morbidity with expectant treatment alone. The implication of this observation is discussed along with other reports of perioperative complications following beating heart coronary surgery.     

Laparoscopic nephron sparing surgery. Initial experience

We present our initial experience in laparoscopic nephron sparing surgery. It's a technically advanced procedure requiring considerable minimally invasive expertise. This technique is particularly attractive compared to an open conventional procedure with its larger incision and associated morbidity.     

Feasibility of infrared tracking of beating heart motion for robotic assisted beating heart surgery

Background

Accurate tracking of the heart surface motion is a major requirement for robot assisted beating heart surgery.

Method

The feasibility of a stereo infrared tracking system for measuring the free beating heart motion was investigated by experiments on a heart motion simulator, as well as model surgery on a dog.

Results

Simulator experiments revealed a high tracking accuracy (81 μm root mean square error) when the capturing times were synchronized and the tracker pointed at the target from a 100 cm distance. The animal experiment revealed the applicability of the infrared tracker with passive markers in practical heart surgery conditions.

Conclusion

With the current technology, infrared tracking with passive markers might be the optimal solution for accurate, fast, and reliable tracking of heart motion during robot assisted beating heart surgery.     

A comparison of sufentanil vs. remifentanil in fast-track cardiac surgery patients

We retrospectively compared patients receiving remifentanil with patients receiving sufentanil undergoing fast-track cardiac surgery. After 1:1 propensity score matching there were 609 patients in each group. The sufentanil group had a significantly longer mean (SD) ventilation time compared with the remifentanil group; 122 (59) vs. 80 (44) min, p < 0.001 and longer mean (SD) length of stay in the recovery area; 277 (77) vs. 263 (78) min, p = 0.002. The sufentanil group had a lower mean (SD) visual analogue pain score than the remifentanil group; 1.5 (1.2) vs. 2.4 (1.5), p < 0.001 and consumed less mean (SD) piritramide (an opioid analgesic used in our hospital); 2.6 (4.7) vs. 18.9 (7.3) mg, p < 0.001. The results of our study show that although remifentanil was more effective in reducing time to tracheal extubation and length of stay in the recovery area, there was an increased requirement for postoperative analgesia when remifentanil was used.     

A modified fast-track program for pancreatic surgery: a prospective single-center experience

Objective  

The objective of this study is to evaluate the impact of a fast-track protocol in a high-volume center for patients with pancreatic disorders.