Abstrakt Kardiochirurgie Říjen 2009

“Advances in mitral valve repair.”

Anderson, C. A. and W. R. Chitwood Jr (2009).

Future Cardiology 5(5): 511-516.


The results of mitral valve repair for structural disease are durable and are generally accepted to be superior to mitral valve replacement. Following the early pioneering work of Carpentier, most advances in mitral repair have involved performing the same repair through ever smaller incisions in hopes of minimizing tissue trauma. Mitral repair is now possible thru port access with videoscopic and robotic assistance. Transcatheter repair techniques are now being investigated and offer the possibility of mitral repair without the utilization of cardiopulmonary bypass. © 2009 Future Medicine Ltd.




“On-pump beating-heart with axillary artery perfusion: a solution for robotic totally endoscopic coronary artery bypass grafting?”

Bonatti, J., J. Garcia, et al. (2009).

The heart surgery forum 12(3).


Robotic totally endoscopic coronary artery bypass grafting (TECAB) can be performed on the arrested heart or on the beating heart without heart-lung machine support. In high-risk patients or in patients where technical difficulties are expected with a complete off-pump approach, a beating heart concept with heart-lung machine support can be an important option. Femoral arterial cannulation is associated with additional risk of retrograde cerebral embolization, and axillary cannulation is an accepted method in aortic surgery. We describe a case where an axillary artery cannulation method was used for the first time in TECAB performed with the da Vinci telemanipulation system.




“Robotic technology-probably a safe tool for development of completely endoscopic coronary revascularization procedures.”

Bonatti, J., T. Schachner, et al. (2008).

Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery 3(3): 139-141.


Background: Totally endoscopic coronary artery bypass grafting (TECAB) requires telemanipulation technologies because attempts using conventional thoracoscopic instrumentation have completely failed. These complex operations require individual and team learning curves and necessitate a stepwise approach. The aim of this study is to assess risk adjusted outcome in robotically assisted coronary artery bypass grafting (CABG) after the first 6 years of application. Methods: From 2001 to 2007, 177 CABG procedures were performed using the da Vinci system. A low risk patient population [age 59 (31-76) years, EuroSCORE 1 (0-7)] was treated. The following procedures were carried out: endoscopic internal mammary artery takedown in minimally invasive direct coronary artery bypass, Off-pump coronary artery bypass, and CABG (n = 26); robotic suturing of left internal mammary artery to left anterior descending artery anastomoses through sternotomy (n = 32); TECAB on the arrested heart (n = 108); TECAB on the beating heart (n =11). Results: There was no hospital mortality, and cumulative risk adjusted mortality plots showed that 2.76 predicted events did not occur. Given 177 event free procedures Clopper Pearson estimations revealed a 95% confidence interval between 0.0% and 2.3% for perioperative mortality. Conclusions: Introduction of robotic TECAB grafting appears to meet current CABG safety standards. Initial application in low risk patients and a stepwise approach towards completely endoscopic versions of the operation are worthwhile. Despite a high grade of innovation and despite learning curves, perioperative mortality may be lower than predicted. Copyright © 2008 by the International Society for Minimally Invasive Cardiothoracic Surgery.




“Robotic artificial chordal replacement for repair of mitral valve prolapse.”

Brunsting, L. A., J. S. Rankin, et al. (2009).

Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery 4(4): 229-232.


Artificial chordal replacement (ACR) has emerged as a superior method of mitral valve repair with excellent early and late efficacy. It is also ideal to combine with robotic techniques for correction of mitral prolapse, and this article presents a current method of robotic Gore-Tex ACR. Patients with isolated posterior leaflet prolapse are approached with the fourth-generation DaVinci robotic system and endoaortic balloon occlusion. A pledgetted anchor stitch is placed in a papillary muscle, and a 2-o Gore-Tex suture is passed through the anchor pledget. After full annuloplasty ring placement, the Gore-Tex suture is woven into the prolapsing segment and positioned temporarily with robotic forceps. Chordal length is then “adjusted” by lengthening or shortening the temporary knot over 1-cm increments as the valve is tested by injection of cold saline into the ventricle. After achieving good leaflet position and valve competence, the chord is tied permanently. The “adjustable” ACR procedure preserves leaflet surface area and produces a competent valve in the majority of patients. Postoperative transesophageal echo shows a large surface area of coaptation. Patient recovery is facilitated by the minimally invasive approach, while long-term stability of similar open ACR techniques have been excellent with a 2% to 3% failure rate over 10 years of follow-up. Robotic Gore-Tex ACR without leaflet resection is a reproducible procedure that simplifies mitral repair for prolapse. The outcomes observed in early robotic applications have been excellent. It is suggested that most patients with simple prolapse might validly be approached in this manner. Copyright © 2009 by the International Society for Minimally Invasive Cardiothoracic Surgery.




“Extended videoscopic robotic thymectomy with the da Vinci telemanipulator for the treatment of myasthenia gravis: the Vienna experience.”

Fleck, T., M. Fleck, et al. (2009).

Interact Cardiovasc Thorac Surg 9(5): 784-787.


Surgical treatment of myasthenia gravis should include the complete resection of the thymus with the whole fatty tissue adherent to the pericardium for immunologic as well as oncologic reasons. The aim of the current study was to investigate the efficacy and safety of robotic approach. A total of 18 patients with myasthenia gravis (mean age 44 years) have been operated robotically via a left-sided approach. Preoperative MGFA (Myasthenia Gravis Foundation of America) classification was: Class I n=4, Class IIa n=4, Class IIb n=5, and Class IIIa n=3, IIIb n=2. Total endoscopic resection was feasible in 17/18 patients. One patient had to be converted due to bleeding. In the remaining patients, operative time was 175 min, intensive care unit (ICU) one day, hospital stay four days. In all patients it was possible to perform an extended thymic resection. MGFA post-intervention status after a mean of 18 months follow-up showed complete stable remission n=5, pharmacologic remission n=4, minimal manifestations n=5, unchanged n=1. Complete endoscopic thymus surgery with the da Vinci surgical system enables a complete and extended resection of all thymic tissue in the mediastinum. Due to the minimal trauma, patients can return to full activity within a short time.




“Excision of atrial myxoma using robotic technology.”

Gao, C., M. Yang, et al. (2009).

J Thorac Cardiovasc Surg.


OBJECTIVE: This study is to discuss a surgical approach for ideal and safe resection of atrial myxoma using the da Vinci S Surgical System (Intuitive Surgical, Inc, Sunnyvale, Calif). METHODS: Nineteen consecutive patients underwent resection of atrial myxomas with the da Vinci S Surgical System. Mean age of the patients was 46 +/- 16 years. Mean tumor size was 45 x 5.5 cm. Fifteen tumors were in the left atrium, of which 11 tumors arose from the interatrial septum, 2 from the posterocaudal wall, 1 from the root of the anterior leaflet of the mitral valve, and 1 from the left atrial roof. In 13 patients, exploration was conducted through a left atriotomy anterior to the pulmonary veins and excision was achieved by dissecting a plane through the atrial muscle at the point of attachment. In the first 2 patients, exploration and excision were conducted through an oblique right atriotomy. Four tumors were in right atrium, all of which were resected from the beating heart. The da Vinci instrument arms were inserted through three 1-cm trocar incisions in the right side of the chest. Via 4 port incisions and a 1.5-cm working port, all the procedures were completed with a 30 degrees angled endoscope facing upward with the da Vinci S robot. RESULTS: Resection was successful in all patients. There were no operative deaths, strokes, or other complications. All the patients were discharged. No recurrences of tumor or septal leakage were found in the complete 1- to 18-month follow-up. CONCLUSIONS: The excision of atrial myxomas with the da Vinci S Surgical System is feasible, efficacious, and safe. Surgical results are excellent.




“Japan’s first robot-assisted totally endoscopic mitral valve repair with a novel atrial retractor.”

Ishikawa, N., G. Watanabe, et al. (2009).

Artif Organs 33(10): 864-866.


This case report presents the first robot-assisted totally endoscopic mitral valve plasty in Japan. A 54-year-old woman was found by echocardiography to have grade III mitral valve regurgitation because of prolapse of the posterior leaflet. Surgical repair was performed using the da Vinci Surgical System. For the totally endoscopic mitral valve repair, a right-sided approach was used through four ports. A transthoracic aortic cross-clamp and novel flexible port access retractor were inserted through a 5-mm skin incision. Quadrangular resection of the posterior leaflet was performed, and an annuloplasty band was placed into the atrium. Resection of the valve segment took 13 min, and band implementation, 45 min. The total pump time was 197 min and the aortic cross-clamp time, 117 min. Postoperative echocardiography confirmed the absence of mitral insufficiency.




“Establishing the case for minimally invasive, robotic-assisted CABG in the treatment of multivessel coronary artery disease.”

Jones, B., P. Desai, et al. (2009).

The heart surgery forum 12(3).


The purpose of this review is to outline the most common objections about robotic coronary artery bypass graft (CABG), often expressed by cardiac surgeons, cardiologists, and administrators who have little direct knowledge of the procedure. The summarized objections include the high intraoperative costs of robotic versus traditional CABG, a prolonged and difficult learning curve for members of the surgical team, and concerns about compromising graft patency with this technique. Arguments for continued procedure development in robotically assisted CABG are provided.




“Minimally invasive heart and mitral valve surgery.”

Kamler, M., D. Wendt, et al. (2009).

Minimalinvasive herz- und mitralklappenchirurgie 34(6): 436-442.


During the last decades, minimally invasive operative techniques have been established in various subspecialties of modern cardiac surgery, offering now safe and efficient alternative treatment options for most of the patients. Those new and innovative options thereby aimed to reduce the operative trauma and perioperative morbidity, and furthermore, to increase patients’ satisfaction and optimize patients’ security. After continuous enhancement of these minimally invasive techniques during the last 10 years, numerous current reports demonstrate minimally invasive cardiac surgery techniques to be safe and efficient, resulting in equal or even better mortality and morbidity compared to conventional cardiac surgery. The underlying benefits of minimally invasive cardiac surgery are characterized by shorter hospital stay, less postoperative pain, accelerated rehabilitation, and superior cosmetic results. Minimally invasive treatment options in cardiac surgery should always be considered for suitable patients. © 2009 Urban & Vogel.




“Robotic catheter ablation of ventricular tachycardia in a patient with congenital heart disease and Rastelli repair.”

Koa-Wing, M., N. W. Linton, et al. (2009).

J Cardiovasc Electrophysiol 20(10): 1163-1166.


Robotically assisted catheter ablation has been proven feasible in patients with a variety of atrial arrhythmias. The potential to provide improved catheter tip maneuvering and stability potentially makes it ideal for complex ablation procedures. We present the case of a patient with complex congenital heart disease with previous Rastelli repair and recurrent ventricular tachycardia (VT) who underwent robotically assisted mapping and ablation for right ventricular VT, utilizing substrate mapping techniques.




“Fast track minimally invasive transmyocardial revascularization.”

Kurt, E. W., D. Jackson, et al. (2009).

Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery 4(4): 217-220.


Objective: We evaluated the initial results of a fast-track discharge protocol for patients undergoing minimally invasive transmyocardial revascularization (MiTMR). Methods: Fifteen male patients, aged 64.5 ± 9.2 years, with an ejection fraction of 46.8% ± 9.9%, underwent MiTMR through a mini-left anterior thoracotomy aided by robotic-controlled thoraco-scopic assistance. A postoperative management protocol included immediate extubation, early chest tube and pulmonary artery catheter removal, and mobilization within 12 hours. Results: There were no operative arrhythmias or in-hospital mortalities. Three of 15 patients developed left lower lobe atelectasis, delaying discharge between 2 and 5 days. Overall hospital length of stay was 1.4 ± 1.2 days, although 12 of 15 patients (80%) were discharged to home in 23 hours. Mild-moderate cardiomyopathy (ejection fraction 30%-50%) was not associated with prolonged length of stay. Mean hospital profit margin was $1882.50. One 30-day readmission occurred on day 23 for rapid atrial fibrillation, and one death occurred on day 11. Conclusions: Despite these high-risk patients having end-staged, ischemic coronary artery disease, most MiTMR patients can be discharged to home in less than 24 hours. Perioperative morbidity and mortality rates are relatively low, and hospital profit margins are modest. Copyright © 2009 by the International Society for Minimally Invasive Cardiothoracic Surgery.




“Poor left ventricular function is not a contraindication for robotic totally endoscopic coronary artery bypass grafting.”

Rehman, A., J. Garcia, et al. (2009).

The heart surgery forum 12(3).


Robotic technology has enabled performance of totally endoscopic coronary artery bypass grafting (TECABG). Published series on TECABG were primarily performed in low-risk patients, and little is known about the outcome after totally endoscopic coronary surgery in patients with severely impaired left ventricular function. We report successful endoscopic placement of a left internal mammary artery bypass graft to the left anterior descending artery using the daVinci robotic system in a patient with a severely reduced left ventricular ejection fraction.




“Totally endoscopic coronary artery bypass grafting is feasible in morbidly obese patients.”

Rehman, A., J. Garcia, et al. (2009).

The heart surgery forum 12(3).


Development of robotic technology has enabled totally endoscopic coronary artery bypass grafting (TECAB) procedures. With complete preservation of sternal and thoracic stability, this operation would be an interesting option for obese patients, who are known to be at higher risk for deep sternal wound infection. We describe a case of successful totally endoscopic left internal mammary artery to left anterior descending artery bypass grafting using the da Vinci telemanipulation system in a patient who was morbidly obese. The patient underwent a so called staged hybrid coronary intervention with percutaneous angioplasty and placement of a stent to the right coronary artery.




“Minimally invasive revision for bleeding following totally endoscopic coronary surgery.”

Schachner, T., D. Wiedemann, et al. (2009).

The heart surgery forum 12(3).


We report 2 cases of minimal invasive revision for postoperative bleeding following totally endoscopic coronary surgery (TECAB). In the first case the revision was performed totally endoscopically without additional incisions. In the second patient revision was performed via enlargement of the camera port to a minithoracotomy. Both revisions were successfully conducted without sternotomy. We demonstrated that the technique of minimal invasive revision can further reduce the rate of conversion to sternotomy in TECAB operations.




“A novel internal thoracic artery harvesting technique via subxiphoid approach–for the least invasive coronary artery bypass grafting.”

Takata, M., G. Watanabe, et al. (2009).

Interact Cardiovasc Thorac Surg 9(5): 891-892.


We have performed 12 cases of robotically assisted coronary artery bypass grafting (CABG) to accomplish less invasive revascularization. In this report, we describe a new method of robotically assisted internal thoracic artery (ITA) harvesting via subxiphoid approach, using the da Vinci surgical system. A 22-year-old man with three-vessel coronary artery disease due to Kawasaki disease was referred to our institution for coronary artery revascularization. A small subxiphoid incision was made, and the xiphoid process at the lower end of the sternum was excised. A U-shaped hook was inserted into the retrosternal space, and the lower sternum was lifted. A 30 degrees angle-up camera was inserted under the U-shaped hook, bilateral ITAs were harvested in a totally skeletonized fashion endoscopically. The required time for right ITA harvesting was 50 min, and that for the left was 20 min. After bilateral ITAs were harvested, composite grafts were made, and then the distal anastomoses were made. The patient was discharged six days after the operation. We performed a new robotically assisted bilateral ITA harvesting technique via sub-xiphoid safely and with excellent results. This method might be an evolutionary step of minimally invasive direct coronary artery bypass (MIDCAB) using the da Vinci surgical system.




“Minimally Invasive Valve Surgery.”

Woo, Y. J. (2009).

Surgical Clinics of North America 89(4): 923-949.


Traditional cardiac valve replacement surgery is being rapidly supplanted by innovative, minimally invasive approaches toward the repair of these valves. Patients are experiencing benefits ranging from less bleeding and pain to faster recovery and greater satisfaction. These operations are proving to be safe, highly effective, and durable, and their use will likely continue to increase and become even more widely applicable. © 2009 Elsevier Inc. All rights reserved.