机器人辅助下房间隔缺损修补术学习曲线与临床结果的相关性

目的 明确单中心的机器人辅助下房间隔缺损修补术的学习曲线及临床结果.方法 回顾性分析2007年1月至2010年12月完成的94例机器人房间隔缺损修补术,按术式不同分成心脏停搏组(54例,Ⅰ组)和心脏搏动组(40例,Ⅱ组).记录每组手术、体外循环、主动脉阻断、术后呼吸机辅助、住ICU和住院时间等指标,采用对数曲线回归分析建立学习曲线,并分析上述指标与临床结果的相关性.结果 两组均无手术死亡或严重并发症发生,术中及术后超声复查未见残余分流.Ⅰ组方法学习曲线为:y(min)=68.741 -8.283(n)(x) (r2 =0.489,P＜0.01);Ⅱ组方法学习曲线为:y(min)=355.51 -56.29(n)(x)(r2 =0.581,P＜0.01).手术、体外循环和主动脉阻断时间与术后呼吸机辅助、住ICU和住院时间无相关性.结论 机器人辅助下房间隔缺损修补术安全、可靠,学习曲线显著,手术时间延长不影响患者恢复.     

全机器人心脏不停跳下房间隔缺损修补术

目的 总结使用"达芬奇S"(da Vinci S)机器人手术系统,心脏不停跳下房间隔缺损修补或房间隔缺损修补+三尖瓣成形术的经验体会.方法 2009年3月至2010年12月,使用da Vinic S机器人系统,心脏不停跳下完成继发孔型房间隔缺损修补或房间隔缺损修补+三尖瓣成形术40例.患者女23例,男17例;年龄平均(38±13)岁.房间隔缺损直径为1.5～3.5 cm,平均(2.8±1.3)cm,无右向左分流,伴有或不伴有三尖瓣重度关闭不全.手术经股动、静脉及右侧颈内静脉插管建立体外循环.于右侧胸壁打直径为0.8 cm的器械臂孔3个,直径为2 cm工作孔1个,术中不阻断升主动脉,经内窥镜套管持续给予二氧化碳,心脏跳动下,术者于操作台前遥控机器人进行房间隔缺损修补,三尖瓣重度关闭不全患者同期行三尖瓣成形术.其中直接缝合房间隔缺损22例,心包补片修补房间隔缺损18例,同期三尖瓣成形9例.术中食管超声评估修补及三尖瓣成形效果.对比不停跳与心脏停跳下全机器人房间隔缺损修补术的手术时间及体外循环时间.结果 所有患者均成功接受全机器人心脏不停跳下房间隔缺损修补术或房间隔缺损修补+三尖瓣成形术,无体循环气体栓子及残余分流等并发症.不停跳组的手术时间、机器人使用时间或体外循环时间少于停跳组.结论 机器人心脏不停跳下房间隔缺损修补术无需阻断升主动脉,简化了全机器人手术过程,手术效果安全可靠.

Abstract：

Objective To Summary the first 40 cases underwent robotic atrial septal defect (ASD) closure or atrial septal defect closure combined bicuspid valve plasty (TVP) using "da Vinci S" surgical System on beating heart. Methods 40 cases of atrial septal defect or combined sever tricuspid valve regurgitation were repaired using "da Vinic S" surgical system on beating heart from March 2009 to December 2010 in cardiovascular department of PLA general hospital. The average age was (38 ± 13) yeas old. 23 cases were female and 17 cases were male. All patients were ostium atrial septal defect with or without pulmonary hypertension. The atrial defect diameter was 1.5 -3.5 cm, and the mean diameter was(2. 8 ±1.3)cm. 9 patients had sever tricuspid valve regurgitation. Without sternotomy, the extracorporeal circulation was established through groin artery,groin vein and internal jugular vein cannulation with the guidance of transeophageal echocardiography. 3 ports of 8 mm and 1 working port of 2 cm were made in the right chest wall. After "da Vinci S" syetem was set up, with the assistant of bed-side surgeon, the surgeon completed the atrial septal defect closure or combined tricuspid valve plasty in the surgeon console with three dimensions visualization. During the operation, without cardioplegia administrated and aortic occlusion, the procedure was completed through right atriotomy. The pleural space was insufflated with carbon dioxide to avoid the air embolism. The direct suturing was used in 22 cases and pericardial patch were used in 18 cases. 9 patients accepted concurrent De Vega tricuspid valve plasty. The transesophageal echocardiography were used to evaluate the result of atrial defect closure or tricuspid valve repair. The operation time, robotic using time and cardiopulmonary time were compared with totally robotic atrial defect repair in arrested heart. Results All cases were accomplished successfully without complication. There was no residual shunt and air embolism. The operation time, robotic using time and cardiopulmonary time were less than the arrested group. Conclusion Robotic atrial septal defect closure or combined tricuspid valve repair on beating heart can avoid aortic ocllusion and can be utilized effectively and safely.     

A case of left atrial myxoma associated with atrial septal defect

Cardiac myxoma is the most frequent primary tumor of the heart. However, it is rarely associated with congenital cardiac anomalies such as atrial septal defect in the literature. We present a 72-year-old woman referred to the emergency department with loss of consciousness and finally diagnosed as a pedinculated mobile left atrial myxoma and concomitant occurrence of an ostium secundum type atrial septal defect. The mass was successfully excised, and atrial septal defect was safely repaired by primary suture. The patient is currently well after surgery. Atrial myxoma should be considered in the differential diagnosis when patients present with neurological consequences of systemic embolization.     

Right atrial mass after primary repair of an atrial septal defect: thrombus masquerading as a myxoma

Atrial septal defects are among the most common congenital anomalies requiring surgical repair. Thrombus formation after patch-based repair is a recognized complication, usually manifested by an embolic event. However, thromboembolic complications after primary repair of atrial septal defects are exceedingly rare. We present a 38-year-old woman found to have a right atrial mass diagnosed as a myxoma by echocardiography and magnetic resonance imaging 3 years after primary atrial septal defect repair. However, final pathology revealed an organized thrombus. A review of the literature and clinical management of postoperative atrial thrombi are discussed.     

Anesthesia management of totally endoscopic atrial septal defect repair with a robotic surgical system

Study Objective

To investigate anesthetic techniques for robot-assisted endoscopic atrial septal defect (ASD) repair.

Design

Clinical observational study.

Setting

Operating room of a general military hospital.

Patients

56 adult, ASA physical status 1 and 2 patients undergoing elective general anesthesia.

Interventions

After induction of general anesthesia, a left-sided, double-lumen endotracheal tube was positioned to allow single left-lung ventilation and contralateral CO₂ pneumothorax (capnothorax). With ultrasound guidance, peripheral cardiopulmonary bypass (CPB) catheters were placed.

Measurements and Main Results

All patients tolerated single left-lung ventilation before CPB; however, hypoxia (oxygen saturation < 90%) occurred in 11 (19.6%) patients post-CPB, which required treatment with continuous positive airway pressure. Fifteen (26.8%) patients had hypotension secondary to capnothorax, which was treated with transfusion and vasopressors. Aortic cross-clamp time was 43.6 ± 11.2 minutes, and CPB time was 106.7 ± 12.4 minutes. The median intensive care unit stay was 21 hours and postoperative hospital stay was 4 to 7 days.

Conclusions

The key issue for anesthetic management of robot-assisted totally endoscopic ASD repair is maintaining stable hemodynamics and oxygenation, especially during one-lung ventilation and capnothorax.     

Totally endoscopic computer-enhanced atrial septal defect closure in six patients

BACKGROUND: Totally endoscopic procedures have been introduced into cardiac surgery with the application of telemanipulating robotic systems. We report 6 cases of closed-chest atrial septal defect (ASD) closure using a robotic device. METHODS: After deflating the right lung, the endoscopic camera and two robotic arms were inserted into the right hemithorax through 8-mm ports. An accessory port was placed for blood suction and for introduction of ancillary endoscopic instruments. After femoral-femoral cannulation for cardiopulmonary bypass (CPB), aortic occlusion, and cardioplegia delivery, the intracardiac correction was carried out in 5 patients with an ostium secundum ASD and in 1 patient with a patent foramen ovale (PFO) and atrial septal aneurysm (ASA). The ASDs were closed with a continuous braided polyester suture. The PFO closure with septal aneurysm plication was carried out with interrupted stiches. RESULTS: Mean CPB and cross-clamp times were 106 +/- 22 and 67 +/- 13 minutes, respectively. Extubation was carried out within the seventh postoperative hour. All patients returned to normal function within the first postoperative week. CONCLUSIONS: Totally endoscopic ASD closure can be carried out safely using robotic techniques with rapid postoperative recovery and an excellent cosmetic result.     

Coronary embolism following atrial septal defect repair

To our knowledge, coronary embolism following repair of atrial septal defect has not been reported previously. A 29-year-old woman had an angiographically documented embolus to the circumflex coronary artery on the fifth postoperative day after pericardial patch repair of a secundum atrial septal defect. This complication might have been prevented by temporary postoperative anticoagulation.     

Totally endoscopic atrial septal repair in adults with computer-enhanced telemanipulation

OBJECTIVE: Standard surgical closure of an atrial septal defect via sternotomy is a safe and effective procedure with low morbidity and mortality. Considering that young female patients are frequently operated on for atrial septal defects, a minimally invasive procedure avoiding sternotomy is convincingly desirable and led to the approach through a right anterolateral minithoracotomy. The recent clinical introduction of robotically assisted surgery further reduced skin incisions and enabled totally endoscopic procedures through ports. This article reports on a first series of atrial septal defect closures of which the first case was operated on August 24, 1999, in a totally endoscopic closed chest technique using a computer-enhanced telemanipulation system. METHODS: We performed totally endoscopic atrial septal repair using the da Vinci surgical system (Intuitive Surgical, Mountain View, Calif) in 10 consecutive adult patients. Median age was 45.5 +/- 10.0 years, and preoperative New York Heart Association functional class was 1.8 +/- 0.1. Left ventricular ejection fraction was normal in all patients and mean pulmonary artery pressure amounted to 35 +/- 7 mm Hg. Shunt volume ranged from 24% to 70%. All patients displayed a fossa ovalis type of atrial septal defect; 2 of them multiperforated. RESULTS: Neither intraoperative nor postoperative complications occurred. Two patients had to be converted to minithoracotomy due to endoaortic balloon clamp failure. Length of operation was 262 +/- 37 minutes, and cardiopulmonary bypass time was 161 +/- 26 minutes. Intraoperative transesophageal echocardiography certified complete closure of the atrial septal defect in all patients. The totally endoscopic computer-enhanced technique yielded excellent cosmetic results. CONCLUSION: Totally endoscopic atrial septal repair is a feasible and safe procedure with good clinical results and excellent cosmetic outcomes. It may be considered as perfect adjunct to interventional treatment options. Further studies with larger cohorts and randomized trials are necessary to document potential benefits. Evolution in robotic technology and refinement of procedural flow may shorten procedural time and decrease costs.     

Robotic atrial septal defect repair and endoscopic treatment of atrial fibrillation

Computer (robotic) enhancement has emerged as a facilitator of minimally invasive cardiac surgery and has been used to perform portions of intracardiac procedures via thoracotomy incisions. This report describes the use of the da Vinci surgical system in two totally endoscopic ("closed chest") cardiac operations: atrial septal defect closure and pulmonary vein isolation of atrial fibrillation. ASD closure: Fifteen patients underwent repair of a secundum-type atrial septal defect or patent foramen ovale by a totally endoscopic approach, utilizing the da Vinci robotic system. Cardiopulmonary bypass (CPB) was achieved peripherally. Cardioplegia was administered via the distal port of the arterial cannula after endoballoon inflation. Via three port incisions in the right chest, the entire operation including pericardiotomy; bicaval occlusion; atriotomy; atrial septopexy; and atrial closure was performed by a surgeon seated at a computer console. A fourth 15 mm port was utilized for suction and suture passage by a patient-side assistant. In one case, a recurrent shunt was identified and repaired on POD 5. Median ICU length of stay (LOS) was 20 hours, and median hospital LOS was 4 days. Atrial fibrillation surgery: This report also describes the pathway that we have pursued in the development of a totally endoscopic operation for atrial fibrillation. Beginning with animal models, we tested various ablative energy sources; methods of ablation; and minimally invasive approaches. This work has led to the development of a variety of minimally invasive surgical approaches including a totally endoscopic, robotically assisted beating heart procedure for the treatment of atrial fibrillation.     

全胸腔镜房间隔室间隔缺损修补手术学习曲线

目的 总结全胸腔镜下心脏手术的学习曲线.方法 回顾性收集2004年10月至2010年1月由同一术者连续完成的125例全胸腔镜下房间隔缺损、室间隔缺损修补手术病例资料,按手术先后顺序分为A、B、C、D、E5组,每组25例,从各组手术时间、体外循环时间、主动脉阻断时间、中转开胸率及手术并发症等指标比较手术效果.结果 各组病例年龄、性别、体重、病种及手术方式差异无统计学意义(P＞0.05).手术时间、体外循环时间、主动脉阻断时间3项指标A、B组明显长于C、D、E组(P＜0.05),A、B两组间差异无统计学意义(P＞0.05),C、D、E3组之间差异亦无统计学意义(P＞0.05).各组中转开胸率及手术并发症发生率比较差异均无统计学意义(P＞0.05).结论 全胸腔镜房间隔、室间隔缺损修补术的学习曲线约为50例.