Totally endoscopic coronary artery bypass graft: initial experience with an additional instrument arm and an advanced camera system

Background Robotically enhanced telemanipulation for totally endoscopic coronary artery bypass does not provide adequate tactile feedback, traction, or counter-traction. The exposition of coronary target sites is difficult, the visual field is limited, and the epicardial stabilization may be troublesome. A fourth robotic arm for endothoracic instrumentation has been added to the da Vinci surgical system to facilitate totally endoscopic operations. The stereoendoscope was upgraded with a wide-angle feature. Methods The procedure was performed in five patients. Four of these patients had left internal thoracic artery (LITA) to left anterior descending artery (LAD) grafting on the beating heart and the fifth had sequential bypass grafting (LITA to diagnonal branch and LAD) on an arrested heart. The additional effector arm of the da Vinci surgical system was brought into the operative field beneath the operating table and used as a second right arm. The wide-angle view was activated by either the console or the patient side surgeon. Results The mean operative, port placement, and anastomotic times for a beating-heart totally endoscopic coronary artery bypass were 195±58, 25±10, and 18±5 min, respectively. All procedures were free of morbidity and mortality, with satisfactory angiographic control. The sequential arterial bypass grafting procedure was fully completed in totally endoscopic technique. Conclusions The additional instrumentation arm and wide-angle visualization are useful technical improvements of the da Vinci surgical system, solving the problem of traction, countertraction, and facilitated exposition of target sites as well as visualization of the surgical field. They provide potential for wider acceptance of totally endoscopic coronary artery bypass grafting in a larger surgical community. Online publication: 13 October 2004     

Extended trans-septal approach for mitral valve surgery: Our early experience

Background Extended trans septal (ETS) approach for mitral valve surgery often divides the artery to the Sino-Atrial node. The clinical implication of this is contentious. We analyzed our early results with ETS approach. Methods Between June 1998 and September 2003 eleven patients underwent mitral valve surgery by ETS approach. Six were females. Age ranged from 19 years to 67 years (median 40 years). Six underwent mitral valve replacement (MVR). Four underwent aortic and mitral (double) valve replacement (DVR). One had mitral valve repair. Three had additional procedures (tricuspid valve repair=1, Coronary artery bypass=1, Aorto bifemoral graft=1). Cardiopulmonary bypass ranged from 64 minutes to 77 minutes (median 72 minutes) for MVR and 112 minutes to 178 minutes (median 140 minutes) for DVR. Aortic cross clamp times ranged from 39 minutes to 52 minutes (median 47 minutes) for MVR and 74 minutes to 120 minutes (median 95 minutes) for DVR. Results There was no mortality or morbidity attributed to the ETS approach. One early death in emergency DVR was due to heart failure. Three patients needed seqeuntial pacing in the immediate post-operative period. Nine out of ten survivors were back to their preoperative rhythms on hospital discharge (6 sinus rhythm; 3 atrial fibrillation). One patient with preoperative trifascicular block who underwent reoperation to fix a paravalvular mitral leak needed a permanent pacemaker (VVI). The follow-up ranged from 1 month to 64 months (median 6 months) and is 100% complete. There was no late death or new arrhythmia. Conclusions Extended trans septal approach is safe. It gives excellent exposure of the mitral valve. division of the sinus node artery is not deleterious in the short to intermediate term. Presented at the 50th Annual Meeting of IACTS. New Delhi, Feb. 2004.     

Does multi-vessel off-pump coronary artery bypass grafting reduce post operative morbidity compared to on-pump CABG?

Background Cardiopulmonary bypass (CPB) may contribute to the complications and it is assumed that eliminating cardiopulmonary bypass has the potential of reducing post operative morbidity after coronary artery bypass grafting (CABG). The study was carried out to compare mortality and morbidity in the off-pump and on-pump CABG groups. Methods We prospectively analysed 200 patients undergoing CABG. Group A consists of 100 patients underwent multi-vessel off-pump CABG and group B consists of 100 patients underwent CABG with CPB. The incidence of complications (mortality, re-exploration for bleeding, myocardial infarction, atrial fibrillation, neurological events, new onset renal failure (s. creatinine>1.6 mg/dL) pulmonary complications, length of ICU stay and hospital stay were recorded, analysed and compared. Results OPCAB patients received 2.73±0.61 grafts/patient and on-pump CABG patients received 3.39±0.75 grafts/patient (p value<0.00001). There was no significant statistical difference in mortality, incidence of stroke between OPCAB and CABG with CPB patients. Length of ICU stay was 32.84±4.22 vs 44.85±7.18 hrs (p value<0.00001) and hospital stay was 6.52±0.69 vs 7.94±0.92 days (p value<0.00001) between group A and group B respectively. Incidence of atrial fibrillation was less in OPCAB group 7% vs 12% although it was statistically not significant (p value 0.33). It was observed in our study that there was no significant deference in worsening of existing renal failure between on-pump CABG and OPCAB 6% vs 2% (P value 0.28). Blood utilization was significantly less in OPCAB group (p value<0.001). Conclusion There was no statistically significant difference in terms of mortality, incidence of stroke and new onset renal failure in both groups. But there was lesser incidence of post operative atrial fibrillation, worsening of existing renal failure in off-pump group though statistically not significant. There was significant reduction in blood utilization, length of ICU and hospital stay in OPCAB group.     

犬急性心肌梗死早期冠状动脉旁路移植术对左室壁运动的影响

目的 探讨犬急性心肌梗死早期冠状动脉旁路移植术对室壁运动的影响及其在唤醒冬眠心肌中的意义.方法 结扎犬冠状动脉前降支制备心肌梗死模型(30只).按手术日期随机分组,分别在心肌梗死后1、2、4、6周行冠状动脉旁路移植术作为实验组,其中第2周4只,其余每组6只;对每个实验组分别设立心肌梗死对照组(不进行冠状动脉旁路移植术),每组2只.实验组在冠状动脉旁路移植术前及冠状动脉旁路移植术8周后开胸利用多巴酚丁胺超声负荷试验结合组织多普勒成像技术标记冬眠心肌,并测定室壁运动记分;对照组在相同时间点同样的方法标记冬眠心肌并测定室壁运动记分.每只犬处死后分别测定心肌梗死面积.结果 每个实验组各存活4只,对照组均存活.1、2周实验组较4、6周实验组及对照组梗死区心肌室壁运动记分的变化明显减小(0.03±0.06,0.05 ±0.09,0.23 ±0.08,0.27±0.06,0.32 ±0.05,P＜0.05),所有实验组较对照组心肌室壁运动记分的变化明显减小(1.195±0.09,1.25±0.18,1.30±0.18,1.36 ±0.11,1.65 ±0.17,P＜0.05),所有实验组较对照组唤醒更多的冬眠心肌(0.27 ±0.12,0.22±0.04,0.31±0.09,0.23±0.03,0.03 ±0.04,P＜0.05).1、2周实验组较4、6周实验组及对照组心肌梗死范围明显减小[(20.75±2.63)％,(21.25±2.5)％,(27.25±1.71)％,(27.75±2.22)％,(26.50±0.71)％,(29.00±1.41)％,(27.00±1.41)％,(28.50±0.71)％,P＜0.05)].结论 犬急性心肌梗死早期冠状动脉旁路移植可以明显改善心肌室壁运动,唤醒更多的冬眠心肌,尤其2周内行冠状动脉旁路移植术可以最大限度地减少梗死心肌对室壁运动的影响,并可以减少心肌梗死范围.     

胆胰分流消化道重建在胰十二指肠切除术中的运用

目的 介绍一种新的胆汁胰液分流的消化道重建方式,并探讨其在胰十二指肠切除术中临床应用价值.方法 对136例胰十二指肠切除术采取胆汁胰液分流的消化道重建方式,57例为胰胃吻合,79例为胰肠吻合.手术主要步骤：①胰胃吻合术后,在距胰胃吻合口远端5～ 10 cm处行近端空肠胃后壁端侧吻合.②胰肠吻合术后,胰肠吻合口10 cm左右将胃后壁与空肠行侧侧吻合.随后在距胃肠吻合口40 ～ 50 cm处离断空肠,形成游离肠袢;远端封闭后与胆管行端侧吻合;在距胆肠吻合口40～50 cm处与游离肠袢的远端行侧侧或端侧Y形吻合.收集术前、术中和术后资料分析其临床应用效果.结果 136例消化道重建（含胰胃或胰肠吻合时间）中位时间为71min（62～97 min）,手术死亡率为0;术后并发症为13.2％（18例）,包括术后出血2例,胆漏2例,肺部感染2例,切口脂肪液化并感染2例,胃瘫3例,腹腔感染3例,胰漏4例（3例A级和1例B级胰漏）.结论 胆胰分流的消化道重建方式是一种安全有效的胰十二指肠切除术切除术后消化道重建方式,对降低胰十二指肠切除术后严重并发症发生具有一定的意义.     

肺动脉灌注低温保护液减轻体外循环肺内炎性反应

目的　研究肺动脉灌注低温保护液减轻体外循环肺内炎性反应的作用。方法　 4 0例行法洛四联症 (TOF)根治术的病儿随机分为肺保护组 2 0例 ,对照组 2 0例。肺保护组体外循环期间肺动脉灌注低温肺保护液 ,对照组行常规TOF根治术。围手术期监测血浆肿瘤坏死因子 (TNF α)水平。收集术后6h气管吸出物 ,检测其中炎性介质白细胞介素 (IL) 6、IL 8水平。征得病儿家属同意 ,术后取右下肺组织活检 ,观察组织内炎性反应情况。同时监测围手术期肺功能及临床指标。结果　肺保护组血浆中TNF α水平低于对照组 ,以回ICU 0h、2 4h差异显著 (P <0 0 1、P <0 0 5 ) ;术后 6h内气管吸出物中IL 6和IL 8水平肺保护组低于对照组 (P <0 0 1) ;肺组织活检对照组可见中性粒细胞浸润 ,肺保护组无明显病理改变。肺保护组术后肺泡 -动脉氧分压差 (A aO2 )较对照组低 ,以回ICU 0h、12h和 2 4h差异显著(P <0 0 5、P <0 0 1和P <0 0 5 ) ;肺保护组呼吸机辅助通气时间短于对照组 (P <0 0 1)。结论　肺动脉灌注低温保护液可明显减轻体外循环中肺内的炎性反应和改善肺功能。     

氯胺酮对心脏瓣膜置换术患者血浆粘附分子及心肌损伤的影响

目的 探讨静脉注射氯胺酮对心脏瓣膜置换术患者血浆粘附分子及心肌损伤的影响。方法 20例择期行心脏瓣膜置换术的患者,随机分为氯胺酮组(K组)和对照组(C组),每组10例。K组于麻醉诱导和转流开始时静脉注射氯胺酮 2mg·kg-1,C组则给予等容量生理盐水。分别于麻醉诱导前(T0)、体外循环(CPB)开始后20 min(T1)、升主动脉开放后30 min(T2)、停机后4 h(T3)和24 h(T4)抽取动脉血,测定血浆颗粒蛋白-140(P-selectin)、白细胞粘附分子-1(L-selectin)、细胞间粘附分子-1(ICAM-1)、白细胞介素-6(IL-6)和心肌肌钙蛋白I(cTnI)的浓度。结果 与T0比较,T1-4时两组血浆ICAM-1、P-selectin、L-selectin和IL-6浓度均升高(P<0.01),T2-4时cTnI的浓度升高(P<0.01);与C组比较,K组T2-4时血浆P-selectin、L-selectin、cTnI浓度降低,T1-4时ICAM-1、IL-6浓度降低(P<0.05或0.01)。结论 氯胺酮能降低CPB期间患者血浆粘附分子和IL-6的水平,减轻CPB引起的炎症反应,对缺血再灌注心肌具有保护作用。     

微创冠状动脉旁路术33例中期结果报告

目的总结33例经左胸小切口微创冠状动脉旁路术(minimally invasive direct coronary artery bypass,MIDCAB)的中期疗效. 方法 2000年11月～2003年4月共行MIDCAB 33例,单纯MIDCAB 29例,杂交技术4例.25例采用经典MIDCAB,4例胸腔镜辅助,4例AESOP机器人辅助. 结果全组无手术死亡,无手术并发症.呼吸机脱机时间(7.5±1.9) h,引流量(274±197)ml,输血率9.1%(3/33),术后住院(6.9±1.7)d.随访33例,时间(24.3±5.7)个月,无远期死亡,心绞痛复发率9.1%(3/33).术后再次冠状动脉造影4例,1例吻合口狭窄50%,余3例前降支与左乳内动脉吻合口通畅.术后导管再次血管化2例(6.1%). 结论 MIDCAB术中期效果满意.     

Timing of high-risk vascular surgery following coronary artery bypass surgery: a 10-year experience from an academic medical centre

Major non-cardiac surgery within 40 days of coronary angioplasty with stenting has high cardiac complication rates. We have performed a case-control study to determine whether the risk of vascular surgery might have increased in recent survivors of coronary artery bypass surgery (CABG). Using our vascular database from 1990 to 1999, we matched the cases who had vascular surgery within a month of CABG with controls by pre-operative comorbidities of diabetes mellitus, history of myocardial infarction (MI), history of congestive heart failure (CHF), and chronic renal insufficiency and compared the incidence of peri-operative MI, CHF, death, and other complications. Compared to case-matched controls, patients who underwent vascular surgery within a month of CABG suffered significantly greater mortality (20.6% vs. 3.9%, p < 0.005). The incidence of non-fatal cardiac complications was not significantly different between the groups. We conclude that the risk of mortality may be significantly greater in patients undergoing major vascular surgery within a month of CABG.     

Preoperative glucocorticoids decrease pulmonary hypertension in piglets after cardiopulmonary bypass and circulatory arrest

BACKGROUND: Glucocorticoids during cardiopulmonary bypass benefit pediatric patients undergoing repair of congenital heart defects and are routine therapy, but underlying mechanisms have not been fully examined. The hypothesis was that glucocorticoids could improve cardiopulmonary recovery after cardiopulmonary bypass and deep hypothermic circulatory arrest. METHODS: Crossbred piglets (5 to 7 kg) were cooled with cardiopulmonary bypass, followed by 120-min deep hypothermic circulatory arrest. Animals were then warmed to 38 degrees C, removed from bypass, and maintained for 120 min. Methylprednisolone (60 mg/kg) was administered in the cardiopulmonary bypass pump prime (intraoperative glucocorticoids) or 6 hours before bypass (30 mg/kg) in addition to the intraoperative dose (30 mg/kg; preoperative and intraoperative glucocorticoids). Controls (no glucocorticoids) received saline. RESULTS: Pulmonary vascular resistance in controls increased from a baseline of 152 +/- 40 to 364 +/- 29 dynes. s/cm(5) at 2 hours of recovery (p < 0.001). Intraoperative glucocorticoids did not alleviate the increase in pulmonary vascular resistance (301 +/- 55 dynes. s/cm(5) at 2 hours of recovery, p < 0.001). However, animals receiving pre and intraoperative glucocorticoids had no increase in pulmonary vascular resistance (155 +/- 54 dynes. s/cm(5)). Plasma endothelin-1 in controls increased from 1.3 +/- 0.2 at baseline to 9.9 +/- 2.0 pg/mL at 2 hours recovery (p < 0.01), whereas glucocorticoid-treated animals had lower endothelin-1 levels (4.5 +/- 2.1 pg/ml, preoperative and intraoperative glucocorticoids; 4.9 +/- 1.7 pg/mL, intraoperative glucocorticoids) at the end of recovery (p < 0.05). Intracellular adhesion molecule-1 in lung tissue was lower in animals receiving pre and intraoperative glucocorticoids (p < 0.05). Myeloperoxidase activity was elevated in control lungs at 2 hours of recovery compared with glucocorticoid-treated groups (p < 0.05). Inhibitor kappaBalpha, the inhibitor of nuclear factor-kappaB, was higher in lungs of animals receiving glucocorticoids compared with controls (p < 0.05). CONCLUSIONS: Glucocorticoids prevented pulmonary hypertension after cardiopulmonary bypass and deep hypothermic circulatory arrest, which was associated with reduced plasma endothelin-1. Glucocorticoids also reduced pulmonary intercellular adhesion molecule-1 and myeloperoxidase activity. Inhibition of nuclear factor-kappaB, along with reduced neutrophil activation, contributed to glucocorticoid alleviation of pulmonary hypertension after cardiopulmonary bypass and deep hypothermic circulatory arrest.