Port-Access cardiac surgery using endovascular cardiopulmonary bypass: theory, practice, and results

BACKGROUND: Reduction of surgical trauma is the aim of minimally invasive cardiac surgery. This can be achieved by reducing the size of the incision or by eliminating or changing the cardiopulmonary bypass system. However, certain cardiac surgical procedures, such as valvular surgery and complex multivessel coronary artery surgery, are not feasible without the use of cardiopulmonary bypass. Therefore endovascular cardiopulmonary bypass may allow reduction of surgical trauma for these patients. METHODS: Since its first application in April 1995, more than 1100 procedures have been performed worldwide using the EndoCPB endovascular cardiopulmonary bypass system. The authors' experience consists of 60 Port-Access coronary artery bypass grafting procedures, 34 Port-Access mitral valve procedures (18 replacements, 16 repairs), 5 atrial septal defect closures, and 3 atrial myxoma removals. RESULTS: The patient survival rate was 99%, the incidence of perioperative stroke was 1%, and the incidence of aortic dissection was 1%. In the Port-Access mitral valve and atrial septal defect patients, the survival rate was 100% with no peri- or postoperative complications. Peri- and postoperative transesophageal echocardiography revealed no perivalvular leak or remaining mitral insufficiency after valve repair. CONCLUSIONS: The EndoCPB endovascular cardiopulmonary bypass system allows the application of true Port-Access minimally invasive cardiac surgery in procedures that require the use of cardiopulmonary bypass and cardioplegic arrest. Sternotomy and its potential complications can be avoided, and the surgical procedures can be performed safely on an empty, arrested heart with adequate myocardial protection.     

70岁以上老年患者冠状动脉旁路移植手术的临床观察

目的：分析我院70岁以上老年患者冠状动脉旁路移植手术的临床特点。方法收集70岁以上老年患者冠状动脉旁路移植手术共232例病例资料进行分析,其中行单纯冠状动脉旁路移植手术208例,加做二尖瓣置换或二尖瓣瓣环成形手术11例,加做主动脉瓣置换手术6例,加做二尖瓣及主动脉瓣双瓣膜置换手术1例,加做纵隔或心包肿物切除手术5例,加做室壁瘤切除手术1例。结果手术后出现呼吸功能衰竭8例、伤口愈合不良6例、手术后出血行二次开胸止血4例,围手术期心肌梗死2例、Ⅲ度房室传导阻滞1例,心包填塞1例。死亡2例。结论70岁以上老年患者行冠状动脉旁路移植手术总体效果满意,手术可提高患者生活质量,延长生存时间。     

The impact of intraoperative transoesophageal echocardiography on an unselected cardiac surgical population: a review of 2343 cases

Although intraoperative transoesophageal echocardiography (TOE) has an established role in the management of some cardiac surgical procedures, there is little data on its impact on coronary artery bypass graft (CABG) cases that are stratified for clinical risk. This is a retrospective review of the surgical impact of intraoperative TOE on 2,343 unselected cardiac cases. The surgical impact of TOE findings were rated E (essential)--resulted in changes to the proposed surgical procedure or V (valuable)--the surgical technique for the planned surgery was altered. The surgical impact that routine TOE had on low-, medium- and high-risk CABG cases was also examined. The surgical impact of TOE for the total study population (E + V) was 4.5%. The impact was greatest in combined CABG + mitral valve procedures (18%). The impact in CABG cases was 3.5% overall, with an estimated impact in low-risk patients of 2.8% (95% CI. 2.7-3.0%) versus 6.7% (95% CI. 5.9-7.7%) in high-risk cases. The commonest E-impact in CABG patients was unscheduled valve surgery (2.6% of high-risk patients). The complication rate attributable to TOE was 0.09%. These findings provide indirect evidence for a potential patient benefit from the routine use of TOE in cardiac surgery.     

Simultaneous operation for cardiac disease and gastrointestinal malignancy

AIM: To investigate the safety of performing simulta-neous cardiac surgery and a resection of a gastrointes-tinal malignancy. METHODS: Among 3664 elective cardiac operations performed in adults at Kagoshima University Hospi-tal from January 1991 to October 2009, this study reviewed the clinical records of the patients who un-derwent concomitant cardiac surgery and a gastroin-testinal resection. Such simultaneous surgeries were performed in 15 patients between January 1991 and October 2009. The cardiac diseases included 8 cases of coronary artery disease and 7 cases with valvular heart disease. Gastrointestinal malignancies included 11 gas-tric and 4 colon cancers. Immediate postoperative andlong-term outcomes were evaluated. RESULTS: Postoperative complications occurred in 5 patients(33.3%), including strokes(n = 1), respiratory failure requiring re-intubation(n = 1), hemorrhage(n = 2), hyperbilirubinemia(n = 1) and aspiration pneu-monia(n = 1). There was 1 hospital death caused by the development of adult respiratory distress syndrome after postoperative surgical bleeding followed aortic valve replacement plus gastrectomy. There was no car-diovascular event in the patients during the follow-up period. The cumulative survival rate for all patients was 69.2% at 5 years. CONCLUSION: Simultaneous procedures are accept-able for the patients who require surgery for both car-diac diseases and gastrointestinal malignancy. In par-ticular, the combination of a standard cardiac operation, such as coronary artery bypass grafting or an isolated valve replacement and simple gastrointestinal resection, such as gastrectomy or colectomy can therefore be safely performed.     

Robotic minimally invasive mitral valve reconstruction yields less blood product transfusion and shorter length of stay

BACKGROUND: Robotic-assisted minimally invasive mitral valve reconstruction has gained popularity recently. Initial reports suggest that this approach can be used with relative safety and efficacy. Direct comparisons with a traditional sternotomy approach have not yet been explored extensively. METHODS: All mitral valve procedures that were performed by a single surgeon during a 3-year period of time were analyzed (n = 142 procedures). Patients whose condition required concomitant coronary artery bypass grafting or aortic valve surgery were excluded subsequently from analysis, because all of these patients were approached obligatorily by sternotomy (n = 71 patients). Six patients underwent right thoracotomy mitral valve procedures without robotic assistance, and 1 patient in cardiogenic shock underwent emergent mitral valve reconstruction by sternotomy. Of the remaining 64 patients who were eligible theoretically for sternotomy or robotic-assisted minimally invasive surgery, 39 patients underwent sternotomy, and 25 patients underwent right chest minimally invasive robotic-assisted surgery. Randomization between these 2 approaches would be almost impossible in the United States. The primary determinant for the choice of approach was request of the referring physician or patient. Multiple perioperative outcomes were then compared. RESULTS: Patients who underwent sternotomy and robotic-assisted surgery exhibited equivalent preoperative characteristics and experienced an equivalent degree of correction of mitral regurgitation in repairs and in need for replacement. Complex mitral valve repairs that entailed leaflet resection and reapproximation, annular plication, sliding annuloplasty, chordal transfer, and GoreTex neochordal construction were accomplished successfully with the robotic system. Cross-clamp and bypass times were longer for patients in the minimally invasive group (110 vs 151 minutes; P = .0015; 162 vs 239 minutes; P < .001, respectively). Mean packed red blood cell transfusion was lower among patients who underwent robotic-assisted surgery (5.0 vs 2.8 units; P = .04). Patients who underwent robotic-assisted surgeries experienced shorter mean duration of postoperative hospitalization (10.6 vs 7.1 days; P = .04). There was 1 death among the patients who underwent sternotomy, and no deaths among the patients who underwent robotic-assisted surgery. CONCLUSION: Patients can undergo mitral valve reconstruction with minimally invasive robotic assistance, avoid a sternotomy, require less blood product transfusion, and experience shorter hospitalization.     

Port-access minimally invasive cardiac surgery increases surgical complexity, increases operating room time, and facilitates early postoperative hospital discharge

BACKGROUND: Proposed advantages of port-access cardiac surgery have yet to be substantiated. The authors retrospectively compared patients undergoing port-access cardiac surgery with a matched group undergoing conventional cardiac surgery. METHODS: Forty-six patients who underwent port-access cardiac surgery were matched with 46 who underwent conventional cardiac surgery. Absolute criteria for matching included morning-of-surgery admission, procedure undergone, and care being delivered by one of two surgeons. If possible, matching included care delivered by one of two anesthesiologists. Patients were matched as closely as possible for preoperative demographic and clinical characteristics. RESULTS: All 46 pairs of patients were matched for procedure and admitted the morning of surgery. All 92 operations were performed by one of two surgeons, and 89% were performed by one of two anesthesiologists. Preoperative demographic and clinical characteristics were equivalent between groups. Compared with conventional cardiac surgery, port-access cardiac surgery increased surgical complexity (it almost tripled cardiopulmonary bypass time during coronary artery bypass grafting and increased it almost 40% during mitral valve procedures) and increased total operating room time (P < 0.0001). Port-access cardiac surgery had no beneficial effect on earlier postoperative extubation, decreased incidence of atrial fibrillation, or intensive care unit time, yet it decreased postoperative duration of stay (P = 0.029, all patients), a benefit observed primarily in patients undergoing coronary artery bypass grafting (P = 0.002). CONCLUSIONS: This retrospective analysis revealed that port-access cardiac surgery increases surgical complexity, increases operating room time, has no effect on earlier postoperative extubation or decreased incidence of atrial fibrillation or intensive care unit time, and may facilitate postoperative hospital discharge (primarily in patients undergoing coronary artery bypass grafting). Properly designed prospective investigation is necessary to ascertain whether port-access cardiac surgery truly offers any benefits over conventional cardiac surgery.     

Cardiac surgery in patients with systemic lupus erythematosus

Cardiac surgery was infrequently performed in patients with systemic lupus erythematosus (SLE), and its clinical outcome was reported only in small series. We sought to evaluate the clinical outcome of cardiac operation in patients with SLE. Between January 1996 and March 2005, 9 patients with SLE underwent cardiac surgery at the authors' hospital. Six patients underwent coronary artery bypass grafting (three conventional and three on-pump beating heart), two patients underwent valve replacement and 1 patient underwent simultaneous heart-kidney transplantation. All 6 patients with coronary artery bypass grafting had saphenous venous grafts and two of them had additional left internal mammary artery graft. The overall in-hospital mortality rate was 11% (1/9). Major postoperative complications occurred in 4 patients (44%) including profuse postoperative bleeding, ventricular tachycardia and early graft thrombosis. There were two late deaths including sudden cardiac death and sepsis. The median follow-up duration was 23 months (range, 1-110). In conclusion, although the postoperative complication was common, cardiac operation could be performed in patients with SLE.     

Impact of the opening of a specialized cardiac surgery recovery unit on postoperative outcomes in an academic health sciences centre

PURPOSE: It is controversial as to whether cardiac surgery patients are optimally managed in a mixed medical-surgical intensive care unit (ICU) or in a specialized postoperative unit. We conducted a prospective cohort study in an academic health sciences centre to compare outcomes before and following the opening of a specialized cardiac surgery recovery unit (CSRU) in April 2005. METHODS: The study cohort included 2,599 consecutive patients undergoing coronary artery bypass grafting (CABG), valve and combined CABG-valve procedures from April 2004 to March 2006. From April 2004 to March 2005 (year 1) all patients received postoperative care in mixed medical-surgical ICUs at two different sites staffed by critical care consultants, fellows and residents. From April 2005 until March 2006 (year 2) patients were cared for in a newly-established CSRU on one site staffed by cardiac anesthesiology fellows, a nurse practitioner and consultants in critical care, cardiac anesthesiology and cardiac surgery. The effect of this change on in-hospital mortality, the incidence of ten major postoperative complications, postoperative ventilation hours, readmission rates and case cancellations due to a lack of capacity was assessed using Chi-square or Wilcoxon tests, where appropriate. RESULTS: Coronary artery bypass grafting, valve and combined CABG-valve mortality rates were similar in years 1 and 2. There was a significant reduction in the composite major complication rate (16.3% to 13.0%, P=0.02) and in median postoperative ventilation hours (8.8 vs 8.0 hr, P=0.005) from year 1 to 2. On multivariable logistic regression analysis, the pre-merger interval (year 1) was a significant independent predictor of the occurrence of death or major complications. CONCLUSION: A specialized CSRU with a multi-disciplinary consultant model was associated with stable or improved outcomes postoperatively, when compared to a mixed medical- surgical ICU model of cardiac surgical care.     

Diastolic heart failure in patients with aortic valve disease

From March 2002 to August 2005, 53 patients with age between 30 and 86 underwent surgical treatment for aortic valve disease. Preoperative diastolic heart failure was observed in 15 cases (28.3%). Operative procedures consisted of aortic valve replacement (AVR) in 42 cases [AVR and mitral valve replacement (MVR) in 3], aortic valve plasty (AVP) in 2, and aortic root replacement in 4. Concomitant procedures included maze procedure in 2 cases, coronary artery bypass grafting (CABG) in 6, mitral valve surgery in 15, and tricuspid valve annuloplasty (TAP) in 8. There were 7 cases for patient-prosthesis mismatch (PPM) [13.2%]. There were 2 hospital deaths (both were low-output syndrome). Among the surgical survivors, there were 2 late cardiac-related complications (all cases were cardiac failure). There was no recurrence or re-operation. Although all cases had severe diastolic failure, their systolic function was almost normal. Our study suggested that in patients with aortic valve disease, not PPM but diastolic heart failure correlated strongly with postoperative event and survival.     

Capture of particulate emboli during cardiac procedures in which aortic cross-clamp is used. International Council of Emboli Management Study Group

BACKGROUND: Previous studies have shown that atheroemboli are associated with neurologic complications following cardiac operation. Additionally, it has been demonstrated that embolization is closely related to the application and removal of ascending aortic cross-clamps. METHODS: A prospective registry of 304 patients was initiated to describe patient selection, procedures, particulate capture, and clinical outcomes after intraaortic filtration in patients undergoing cardiac surgical procedures with cardiopulmonary bypass and median sternotomy. Prior to the removal of the cross-clamp, the intraaortic filter (EMBOL-X Inc, Mountain View, CA) was deployed and left in place until the patient was weaned from extracorporeal circulation. Upon removal, filters were fixed in formalin and shipped to a core laboratory for examination. RESULTS: Mean patient age was 68 years (range 25 to 88 years), 40% had ascending aortic calcification, 59% of the procedures were coronary artery bypass grafting (CABG), 20% were valve replacement or repair, and 12% were a combination of CABG and valve surgery. Aortic cross-clamps were used in nearly all cases (302 of 304 patients); partial clamps were used in 84% of the CABG procedures. To date, 243 filters have been examined. Sixty-two percent of the filters analyzed revealed fibrous atheroma, 2% grumous atheroma, and 6% epiaortic debris. Platelet and fibrin strands were found in 52% of the filters and 22% contained evidence of thrombus or red blood cells. CONCLUSIONS: These findings from the International Council of Emboli Management Registry confirm that particulates are released during cardiac surgical procedures using the aortic cross-clamp. Continued observational and randomized studies are necessary to confirm the clinical relevance of particulate extraction.     

Port-access Minimally Invasive Cardiac Surgery Increases Surgical Complexity, Increases Operating Room Time, and Facilitates Early Postoperative Hospital Discharge

Background: Proposed advantages of port-access cardiac surgery have yet to be substantiated. The authors retrospectively compared patients undergoing port-access cardiac surgery with a matched group undergoing conventional cardiac surgery.

Methods: Forty-six patients who underwent port-access cardiac surgery were matched with 46 who underwent conventional cardiac surgery. Absolute criteria for matching included morning-of-surgery admission, procedure undergone, and care being delivered by one of two surgeons. If possible, matching included care delivered by one of two anesthesiologists. Patients were matched as closely as possible for preoperative demographic and clinical characteristics.

Results: All 46 pairs of patients were matched for procedure and admitted the morning of surgery. All 92 operations were performed by one of two surgeons, and 89% were performed by one of two anesthesiologists. Preoperative demographic and clinical characteristics were equivalent between groups. Compared with conventional cardiac surgery, port-access cardiac surgery increased surgical complexity (it almost tripled cardiopulmonary bypass time during coronary artery bypass grafting and increased it almost 40% during mitral valve procedures) and increased total operating room time (P < 0.0001). Port-access cardiac surgery had no beneficial effect on earlier postoperative extubation, decreased incidence of atrial fibrillation, or intensive care unit time, yet it decreased postoperative duration of stay (P = 0.029, all patients), a benefit observed primarily in patients undergoing coronary artery bypass grafting (P = 0.002).     

Does the additive risk of mitral valve repair in patients with ischemic cardiomyopathy prohibit surgical intervention?

OBJECTIVE: To assess the surgical risk of additional mitral valve repairs in patients with ischemic cardiomyopathy. SUMMARY BACKGROUND DATA: Severe mitral regurgitation in patients with ischemic cardiomyopathy increases the death rate and symptomatic status. The 1-year survival rate for medical therapy in this subset of patients is less than 20%. Transplantation is usually not feasible because of donor shortage and death while on the waiting list. METHODS: To assess additive risk, a retrospective chart review from 1993 to 1998 was performed comparing patients with ischemic cardiomyopathy (ejection fraction [EF] <25%) and severe mitral regurgitation undergoing mitral valve repair and coronary artery bypass graft operations with patients with an EF of <25% undergoing coronary artery bypass graft alone. These groups were also compared with 140 patients receiving heart transplants since 1993 (group 3). RESULTS: The overall hospital death rate for group 1 was 6.3%. The one death occurred 2 weeks after surgery secondary to sepsis. This was not significantly different from the death rate of 4.1% in group 2. In group 1, there were two deaths at 1 year (87% survival rate), one related to heart failure. One patient was New York Heart Association (NYHA) class IV at 1 year; the remainder of patients were NYHA class I-II. These results were not significantly different than the 8% death rate noted with transplantation. There was no change in EF and minimal residual mitral regurgitation in group 1 based on postoperative transesophageal echocardiography, whereas group 2 had an average 11.7% improvement in EF. CONCLUSIONS: Previously, severe mitral regurgitation in the setting of ischemic cardiomyopathy has been associated with poor survival. In these authors' experience, repairing the mitral valve along with coronary artery bypass grafting does not increase the surgical risk, yields improvement in symptomatic status, and compares favorably to coronary artery bypass grafting alone and cardiac transplantation. However, the lack of change in EF in these patients probably represents an overestimation of the EF before surgery secondary to severe mitral regurgitation.     

Desflurane versus propofol in patients undergoing mitral valve surgery

OBJECTIVE: Myocardial ischemic damage is reduced by volatile anesthetics in patients undergoing coronary artery bypass graft surgery, but it is unknown whether this benefit exists in patients undergoing valvular surgery with ischemia-reperfusion injury related to cardioplegic arrest and cardiopulmonary bypass. This study compared cardiac troponin release in patients receiving either volatile anesthetics or total intravenous anesthesia for mitral valve surgery. DESIGN: Randomized controlled study. SETTING: University hospital. PARTICIPANTS: One hundred twenty patients undergoing mitral valve surgery. Interventions: Fifty-nine patients received the volatile anesthetic desflurane for 30 minutes before cardiopulmonary bypass, whereas 61 patients received a total intravenous anesthetic with propofol. All patients had an opioid-based anesthetic for the mitral valve surgery. MEASUREMENTS AND MAIN RESULTS: Peak postoperative troponin I release was measured as a marker of myocardial necrosis after mitral valve surgery. Patient mean age was 60 years, and 54% were men. There was no significant (p = 0.7) reduction in median (25th-75th percentiles) postoperative peak troponin, 11.0 (7.5-17.4) ng/dL in the desflurane group versus 11.5 (6.9-18.0) ng/dL in the propofol group. A subgroup of patients with concomitant coronary artery disease had the expected reduction (p = 0.02) of peak troponin I in those receiving desflurane, 14.0 (9.7-17.3) ng/dL, when compared with patients receiving total intravenous anesthesia, 31.6 (15.7-52.0) ng/dL. CONCLUSIONS: Myocardial damage measured by cardiac troponin release was not reduced by volatile anesthetics in patients undergoing mitral valve surgery, whereas it was reduced in patients with concomitant coronary artery disease.     

Robot-Assisted Cardiac Surgery

Recognition of the significant advantages of minimizing surgical trauma has resulted in the development of minimally invasive surgical procedures. Endoscopic surgery offers patients the benefits of minimally invasive surgery, and surgical robots have enhanced the ability and precision of surgeons. Consequently, technological advances have facilitated totally endoscopic robotic cardiac surgery, which has allowed surgeons to operate endoscopically rather than through a median sternotomy during cardiac surgery. Thus, repairs for structural heart conditions, including mitral valve plasty, atrial septal defect closure, multivessel minimally invasive direct coronary artery bypass grafting (MIDCAB), and totally endoscopic coronary artery bypass graft surgery (CABG), can be totally endoscopic. Robot-assisted cardiac surgery as minimally invasive cardiac surgery is reviewed.     

Computer-enhanced "robotic" cardiac surgery: experience in 148 patients

OBJECTIVE: A computer-enhanced instrumentation system was used in 148 patients to minimize access in cardiac surgical procedures. METHODS: The da Vinci telemanipulation system (Intuitive Surgical, Mountain View, Calif) provides a high-resolution 3-dimensional videoscopic image and allows remote, tremor-free, and scaled control of endoscopic surgical instruments with 6 degrees of freedom. By April 2000, the system had been used in 131 patients for coronary artery bypass grafting and 17 patients for mitral valve repair. In the coronary bypass group, the system was used in one of three ways: (1) to take down the internal thoracic artery followed by a minimally invasive direct coronary bypass procedure (n = 81); (2) to perform the anastomosis between the internal thoracic artery and the left anterior descending coronary artery in standard-sternotomy coronary bypass (n = 15); or (3) for total endoscopic coronary artery bypass grafting to anastomose the left internal thoracic artery to the left anterior descending on the arrested heart (n = 27) or the beating heart (n = 8). In 17 patients with nonischemic mitral valve insufficiency the mitral valve was repaired. Closed-chest cardiopulmonary bypass with cardioplegic arrest (Port-Access technique; Heartport, Inc, Redwood City, Calif) was used for arrested-heart total endoscopic coronary bypass and mitral valve repair. RESULTS: The da Vinci system allows for precise tissue handling and enables the endoscopic performance of cardiac surgical tasks that require a high degree of dexterity (coronary anastomosis, mitral valve repair). No technical mishaps have occurred. The internal thoracic artery was successfully taken down in 79 of 81 patients in the group undergoing minimally invasive coronary bypass and, after a steep learning curve, is currently performed in less than 40 minutes. The postoperative patency rate is 96.3%. Total endoscopic coronary bypass was completed in 22 of 27 cases with 95.4% patency as demonstrated by angiography at 3 months' follow-up. Closed-chest endoscopic beating-heart bypass grafting was successfully performed in 2 out of 8 patients with the use of a new endoscopic stabilizer. In the group having mitral valve repair, primary endoscopic computer-enhanced repair was successfully completed in 14 of 17 patients; three others had to be changed to a standard endoscopic technique, including 1 who required valve replacement. At 3 months' follow-up, 1 additional patient underwent early reoperation for recurrent mitral insufficiency. Overall early and late mortality in this cohort of 148 patients was 2.0% and was not related to the use of the system. CONCLUSION: In conclusion, computer-enhanced endoscopic cardiac surgery can be performed safely in selected patients. Internal thoracic artery takedown is now routinely performed with good results. Total endoscopic coronary bypass is feasible on the arrested heart but does not offer a major benefit over the minimally invasive direct approach because cardiopulmonary bypass is still required. The early clinical experience with closed-chest beating-heart bypass grafting outlines the limitations of this approach despite some procedural success.     

Common cardiac surgical procedures: bypass,valve repair and replacement

Cardiac surgery has undergone profound changes since Ludwig Rehn successfully repaired a right ventricular stab wound in 1896. The following century saw the rapid development of open-heart surgery, with minimally invasive surgical approaches following suit. Traditionally, sternotomy has been the incision of choice for cardiac surgical procedures, but technological advances have been applied to develop non-sternotomy, video-assisted thoracoscopic surgery (VATS) and robotic approaches. Parallel to surgical innovation, percutaneous coronary intervention (PCI) and transcatheter valve replacement procedures have offered important alternatives to surgery, currently reserved for specific patient subgroups. Despite the availability of catheter-based techniques, cardiac surgery remains relevant – the majority of our patients present with coronary artery disease or valvular pathologies and therefore coronary artery bypass graft (CABG) surgery and surgical valve replacement constitutes a substantial part of our daily practice. In this article we discuss the relevance of surgical options and highlight the most up to date surgical techniques and innovations, with a focus on the advances of minimally invasive cardiac surgery.     

Five-year results of 219 consecutive patients treated with extracorporeal membrane oxygenation for refractory postoperative cardiogenic shock

BACKGROUND: Postcardiotomy cardiogenic shock occurs in approximately 1% of patients. We prospectively evaluated the early and long-term outcome as well as predictors of survival when using temporary extracorporeal membrane oxygenation (ECMO) support. METHODS: During 5 years 219 of 18150 patients (1.2%) undergoing cardiac surgery (coronary artery bypass grafting, n = 119; aortic valve replacement, n = 24; coronary artery bypass grafting and aortic valve replacement, n = 21; coronary artery bypass grafting and mitral valve replacement, n = 11; other procedures, n = 44) required temporary postoperative ECMO support. The ECMO implantation was performed through the femoral vessels or through the right atrium and ascending aorta. Additional intraaortic balloon counterpulsation was employed in 144 patients to improve coronary blood flow. RESULTS: Mean duration of ECMO support was 2.8 +/- 2.2 days. One hundred thirty-four patients (60%) were successfully weaned from ECMO. Of these, 52 patients (24%) were discharged from the hospital after 29.9 +/- 24 days. The main cause of death was myocardial failure. Five-year follow-up is 96% complete; 37 patients (74%) were alive with reasonable exercise capacity. CONCLUSIONS: Extracorporeal membrane oxygenation is an acceptable technique for short-term treatment of refractory postoperative low cardiac output. It can save the lives of a group of very high risk patients.     

Predictors of transfusion requirements for cardiac surgical procedures at a blood conservation center

BACKGROUND: Previous studies defining perioperative risk factors for allogeneic transfusion requirements in cardiac surgery were limited to highly selected cardiac surgery populations or were associated with high transfusion rates. The purpose of this study was to determine perioperative risk factors and create a formula to predict transfusion requirements for major cardiac surgical procedures in a center that practices a multimodality approach to blood conservation. METHODS: We performed an observational study on 307 consecutive patients undergoing coronary artery bypass grafting, valve, and combined (coronary artery bypass grafting and valve) procedures. An equation was derived to estimate the risk of transfusion based on preoperative risk factors using multivariate analysis. In patients with a calculated probability of transfusion of at least 5%, intraoperative predictors of transfusion were identified by multivariate analysis. RESULTS: Thirty-five patients (11%) required intraoperative or postoperative allogeneic transfusions. Preoperative factors as independent predictors for transfusions included red blood cell mass, type of operation, urgency of operation, number of diseased vessels, serum creatinine of at least 1.3 mg/dL, and preoperative prothrombin time. Intraoperative factors included cardiopulmonary bypass time, three or fewer bypass grafts, lesser volume of acute normovolemic hemodilution removed, and total crystalloid infusion of at least 2,500 mL. The derived formula was applied to a validation cohort of 246 patients, and the observed transfusion rates conformed well to the predicted risks. CONCLUSIONS: A multimodality approach to blood conservation in cardiac surgery resulted in a low transfusion rate. Identifying patients' risks for transfusion should alter patient management perioperatively to decrease their transfusion rate and make more efficient use of blood resources.     

Development and clinical application of minimally invasive cardiac surgery using percutaneous cardiopulmonary support.

OBJECTIVES: Optimal cardiopulmonary support during minimally invasive cardiac surgery remains controversial. We developed cardiopulmonary bypass for minimally invasive cardiac surgery using percutaneous peripheral cannulation. METHODS: Subjects were 34 patients (age: 58 +/- 13 years; range: 17-73) undergoing minimally invasive cardiac surgery using percutaneous cardiopulmonary support between June 1997 and March 1999. Procedures included atrial septal defect closure (n = 14), partial atrioventricular septal defect closure (n = 1), mitral valve replacement (n = 8), mitral valve repair (n = 3), aortic valve replacement (n = 6), coronary artery bypass grafting (n = 1), and right atrial myxoma extirpation (n = 1). Bicaval venous drainage from the right internal jugular vein and the femoral vein and arterial return to the femoral artery were instituted by percutaneous cannulation. Venous drainage was implemented by negative pressure (-20 to -40 mmHg) and arterial return was by conventional roller pump. All procedures were conducted through a skin incision 8 +/- 1 cm, from 6 to 10 cm and partial sternotomy. Aortic cross clamping and cardioplegic solution were administered in the surgical field. RESULTS: The operation lasted 224 +/- 45 min., cardiopulmonary bypass 104 +/- 32 min., and aortic clamping 77 +/- 23 min.. No deaths occurred. One patient with residual atrial septal defect required reoperation through the same skin incision. Only 1 patient required homologous blood transfusion. The average postoperative hospital stay was 15 +/- 5 days. CONCLUSIONS: Minimally invasive cardiac surgery using percutaneous cardiopulmonary support is safe and an excellent option for selected patients affected by single valve lesion, simple cardiac anomalies, and coronary artery bypass grafting.     

178例冠状动脉搭桥手术的围术期处理

目的总结连续178例冠状动脉搭桥手术围术期主要并发症的发生率及处理经验。方法178例中男153例，女25例；平均年龄(57.7±7.5)岁；既往有陈旧性心肌梗死104例（58.1%），不稳定心绞痛112例（62.6%）、室壁瘤切除14例(7.9%)，冠状动脉内膜剥脱术31例(17.4%)，同期行瓣膜置换5例。结果围术期死亡4例（2.2%），围术期心肌梗死8例（4.5%），疗效尚满意。结论掌握接受冠状动脉搭桥手术人群的特殊性、熟练冠状动脉外科技术、合理选择适应证、及早发现和正确处理并发症是提高手术疗效，降低围术期死亡率的关键。