What Is Minimally Invasive Cardiac Surgery?

Most patient concerns and demands for less invasive surgery are focused on comfort, cosmesis, and rehabilitation that are all related to the degree of invasiveness. The degree of invasiveness of cardiac surgery depends on two factors: the surgical approach--the length of the skin incision, the degree of retraction and aggression to the tissue, and the loss of blood--and the use of cardiopulmonary bypass. Regarding the surgical strategy, four categories of less invasive cardiac surgery can be distinguished: (1) direct coronary artery surgery via sternotomy on the beating heart (without extracorporeal circulation); (2) limited or modified approaches using conventional techniques and instruments with either conventional cardiopulmonary bypass or the EndoCPB endovascular cardiopulmonary bypass system; (3) minimally invasive direct coronary artery bypass on the beating heart via a parasternal or left anterior small thoracotomy; and (4) true Port-Access surgery in which all surgical acts are performed through ports and the heart is arrested with the Endoaortic Clamp catheter. These categories offer different advantages in terms of reducing invasiveness and may have different learning curves. Minimally invasive cardiac surgery is undergoing an explosive evolution, and although the indications and best strategies for the different categories are yet to be determined, the trend cannot be stopped. We try to distinguish between "fashionable" strategies and those that are truly revolutionary and investments in the future.     

What Is a Residency? What Is a Resident?

Residency programs exist to train the next generation of podiatric physicians. A brief review of residency programs and what constitutes a "resident" is offered in a concise format.     

Cardiac Surgery of Premature and Low Birthweight Newborns: Is a Change of Fate Possible?

Low birthweight (LBW) continues to be a high-risk factor in surgery for congenital heart disease. This risk is particularly very high in very low birthweight infants under 1500g and extremely LBW infants under 1000g. From January 2005 to December 2008, 33 consecutive LBW neonates underwent cardiac surgery in our clinic in keeping with the criteria for choice of surgery. Their weight range was between 800 and 1900g. Nine of them were under 1000g. Cardiopulmonary bypass (CPB) was used in 17 patients (39.5%) and pulsatile perfusion mode was applied to patients in the CPB group. The same surgical team operated to achieve palliation (8 patients, 24.2%) or full repair (25 patients, 75.8%). Median gestational age was 36 weeks with 12 (36.4%) premature babies (≤37 weeks). Median age at operation was 5 days. Pathologies were single ventricle (n=3), pulmonary atresia-ventricular septal defect (n=3), aortic coarctation (n=10), aorticopulmonary window and interrupted aortic arch combination (n=6), patent arterial duct (n=11), critical aortic stenosis (n=8), and tetralogy of Fallot with pulmonary atresia (n=2). One infant had VATER syndrome. Selective cerebral perfusion technique was used in complex arch pathologies for cerebral protection. Median follow-up was 14 months. There were four early postoperative deaths. None of the cases showed a need for early reoperation. The acceptable early- and midterm mortality rates in this group suggest that these operations can be successfully performed. There is a need for further multicenter studies to evaluate these high-risk groups.     

Pulsatile Left Ventricular Assist Devices: What Is the Role in the Modern Era?

With the widespread use of continuous-flow ventricular assist devices (VADs), the role of pulsatile VADs remain in question. In acute cardiogenic shock, pulsatile VADs maximize perfusion pressure, restore end organ perfusion, and maximally unload the pulmonary circulation and right heart. In addition, pulsatile left VADs allow for easy conversion to biventricular support using one platform, in the case of acute right ventricular failure. Pulsatile VADs still have a major role in the treatment of acute cardiogenic shock.     

BioGlue? in 2011: What Is Its Role in Cardiac Surgery?

BioGlue surgical adhesive was developed as an adjunct for achieving hemostasis during cardiovascular surgery, and it was approved for use in the United States by the Food and Drug Administration in 2001. When applied to cardiovascular tissues, the glutaraldehyde and bovine serum albumin that comprise BioGlue produce strong crosslinking that bonds tissues and seals defects. These features have made BioGlue particularly well suited for preventing bleeding from fragile cardiovascular anastomoses such as those inherent in the repair of acute aortic dissection. Over the 10-year period since its approval, several studies and clinical reports have illuminated the relative risks and benefits of using BioGlue during cardiovascular operations. Understanding these merits and limitations of BioGlue is essential to ensuring its safe and effective use.     

Cardiac assessment prior to vascular surgery: Is dipyridamole-sestamibi necessary?

Dipyridamole-sestamibi (PMIBI) is recommended prior to vascular surgery in patients with 1 Eagle criteria (Q waves, history of ventricular ectopy, diabetes, advanced age, and/or angina). To review our cardiac morbidity and mortality and the need for preoperative PMIBI, we reviewed 109 consecutive patients with a mean age of 59 years who underwent 145 elective major vascular procedures over a 1-year period. Seventy patients (with a mean of 0.8 Eagle criteria) underwent 92 vascular procedures without preoperative PMIBI and without coronary revascularization. Thirty-one patients (with a mean of 1.1 Eagle criteria) underwent 39 procedures without coronary revascularization following PMIBI, which showed reversible ischemia in seven and a fixed defect in 10; findings were normal in 14. Preoperative coronary bypass or angioplasty was limited to eight patients (14 procedures, mean of 1.6 Eagle criteria) who had unstable angina with (2 patients) or without (6 patients) acute myocardial infarction. There were four perioperative myocardial infarctions (2.8%), seven cardiac events overall (4.8%), and one cardiac death (0.7%). Three (43%) of the seven cardiac events occurred in patients with a normal scan or fixed defect on PMIBI imaging. In the absence of unstable angina, PMIBI had a sensitivity of only 25% and a specificity of 80% of cardiac events. We conclude that among patientswithout severe cardiac symptoms (1) PMIBI has a very limited ability to identify patients at risk for cardiac complications, and (2) preoperative PMIBI is neither necessary nor cost-effective.Supported in part by a grant from the Harbor-UCLA Medical Center Research and Education Institute.Presented at the Fourteenth Annual Meeting of the Southern California Vascular Surgical Society, September 15–17, 1995, La Jolla, Calif.