Anyanwu, A. C. and D. H. Adams (2012). “Should complex mitral valve repair be routinely performed using a minimally invasive approach?” Current Opinion in Cardiology 27(2): 118-124.
PURPOSE OF REVIEW: To review selected recent publications on minimally invasive mitral valve surgery to help answer the question as to whether the minimally invasive approach should be routinely used in complex mitral valve repairs. RECENT FINDINGS: Other than cosmesis, there have not been demonstrable reproducible benefits of the minimally invasive approach. Although some workers report excellent results, there are other data that raise concern that complex repairs are less likely to be undertaken via the minimal access approach, resulting in lower repair rates, and also that the incidence of residual regurgitation may be higher. Some complications, such as stroke, may occur with greater frequency in patients having the minimally invasive approach. SUMMARY: The minimally invasive approach for complex mitral valve repair requires continued development and investigation, and current application should probably be largely restricted to high-volume reference minimally invasive surgery centers. © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Cho, D. S., C. Linte, et al. (2012). “Predicting target vessel location on robot-assisted coronary artery bypass graft using CT to ultrasound registration.” Medical Physics 39(3): 1579-1587.
Purpose: Although robot-assisted coronary artery bypass grafting (RA-CABG) has gained more acceptance worldwide, its success still depends on the surgeon’s experience and expertise, and the conversion rate to full sternotomy is in the order of 15%-25%. One of the reasons for conversion is poor pre-operative planning, which is based solely on pre-operative computed tomography (CT) images. In this paper, the authors propose a technique to estimate the global peri-operative displacement of the heart and to predict the intra-operative target vessel location, validated via both an in vitro and a clinical study. Methods: As the peri-operative heart migration during RA-CABG has never been reported in the literatures, a simple in vitro validation study was conducted using a heart phantom. To mimic the clinical workflow, a pre-operative CT as well as peri-operative ultrasound images at three different stages in the procedure (Stage 0-following intubation; Stage 1-following lung deflation; and Stage 2-following thoracic insufflation) were acquired during the experiment. Following image acquisition, a rigid-body registration using iterative closest point algorithm with the robust estimator was employed to map the pre-operative stage to each of the peri-operative ones, to estimate the heart migration and predict the peri-operative target vessel location. Moreover, a clinical validation of this technique was conducted using offline patient data, where a Monte Carlo simulation was used to overcome the limitations arising due to the invisibility of the target vessel in the peri-operative ultrasound images. Results: For the in vitro study, the computed target registration error (TRE) at Stage 0, Stage 1, and Stage 2 was 2.1, 3.3, and 2.6 mm, respectively. According to the offline clinical validation study, the maximum TRE at the left anterior descending (LAD) coronary artery was 4.1 mm at Stage 0, 5.1 mm at Stage 1, and 3.4 mm at Stage 2. Conclusions: The authors proposed a method to measure and validate peri-operative shifts of the heart during RA-CABG. In vitro and clinical validation studies were conducted and yielded a TRE in the order of 5 mm for all cases. As the desired clinical accuracy imposed by this procedure is on the order of one intercostal space (10-15 mm), our technique suits the clinical requirements. The authors therefore believe this technique has the potential to improve the pre-operative planning by updating peri-operative migration patterns of the heart and, consequently, will lead to reduced conversion to conventional open thoracic procedures. © 2012 American Association of Physicists in Medicine.
Dawood, M. Y., E. J. Lehr, et al. (2011). “Robotically assisted coronary endarterectomy.” Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery 6(6): 391-394.
Robotic assistance has enabled coronary artery bypass surgery to be performed safely in a completely endoscopic fashion, but diffusely diseased target vessels may pose a technical challenge. We present a case in which coronary endarterectomy was performed on the left anterior descending coronary artery during a two-vessel totally endoscopic coronary artery bypass procedure. A 52-year-old woman presented with intermittent substernal pain. Preoperative studies showed diffuse disease in the left coronary artery system. Bilateral internal mammary arteries were harvested robotically using a skeletonized technique in a completely endoscopic fashion. Cardiopulmonary bypass was achieved via peripheral cannulation, and the heart was arrested with intermittent cold antegrade hyperkalemic blood cardioplegia delivered via an ascending aortic occlusion balloon catheter. The first obtuse marginal anastomosis was performed. The left anterior descending coronary artery was diffusely diseased and heavily calcified. An end-to-side anastomosis was attempted to the right internal mammary artery with unsatisfactory results. A localized coronary endarterectomy was performed, and an extended anastomosis was completed using the right internal mammary artery. The patient recovered uneventfully and was discharged home on postoperative day 6. Diffuse coronary artery disease was once thought to be a prohibitive challenge for minimally invasive coronary bypass procedures. This case demonstrates that local coronary endarterectomy is feasible and safe in robotic totally endoscopic coronary artery bypass surgery. Copyright © 2012 by the International Society for Minimally Invasive Cardiothoracic Surgery.
Grossi, E. A., D. F. Loulmet, et al. (2012). “Evolution of operative techniques and perfusion strategies for minimally invasive mitral valve repair.” Journal of Thoracic and Cardiovascular Surgery 143(4 SUPPL.): S68-S70.
Objective: Perfusion strategies and operative techniques for minimally invasive mitral valve repair have evolved over time. During the past decade, our institution’s approach has progressed from a port access platform with femoral perfusion to predominantly a central aortic cannulation through a right anterior minithoracotomy incision. We analyzed this institutional experience to evaluate the impact of approach on patient outcomes. Methods: Between 1995 and 2007, 1282 patients (mean age, 59.3 years; range, 18-99 years) underwent first-time, isolated mitral valve repair using a minimally invasive technique. Patient demographics included peripheral vascular disease (3.2%), chronic obstructive pulmonary disease (8.3%), atherosclerotic aorta (6.5%), cerebrovascular disease (4.3%), and ejection fraction less than 30% (4.3%). Retrograde perfusion was performed in 394 (30.7%) of all patients and endoaortic balloon occlusion in 373 (29.1%); the operative technique was a right anterior minithoracotomy in 1264 (98.6%) and left posterior minithoracotomy in 18 (1.4%). The etiology of mitral disease was degenerative in 73.2%, functional in 20.6%, and rheumatic in 2.4%. Data were collected prospectively using the New York State Cardiac Surgery Report System and a customized minimally invasive surgery data form. Logistic analysis was used to evaluate risk factors and outcomes; operative experience was divided into tertiles. Results: Overall hospital mortality was 2.0% (25/1282). Mortality was 1.1% (10/939) for patients with degenerative etiology and 0.4% (3/693) for patients younger than 70 years of age with degenerative valve disease. Risk factors for death were advanced age (P =.007), functional etiology (P =.010; odds ratio [OR] = 3.3), chronic obstructive pulmonary disease (P =.013; OR = 3.4), peripheral vascular disease (P =.014; OR = 4.2), and atherosclerotic aorta (P =.03; OR = 2.8). Logistic risk factors for neurologic events were advanced age (P =.02), retrograde perfusion (P =.001; OR = 3.8), and emergency procedure (P =.01; OR = 66.6). Interaction modeling revealed that the only significant risk factor for neurologic event was the use of retrograde perfusion in high-risk patients with aortic disease (P =.04; OR = 8.5). Analysis of successive tertiles during this 12-year experience revealed a significant decrease in the use of retrograde arterial perfusion (89.6%, 10.4%, and 0.0%; P <.001) and endoaortic balloon occlusion (89.3%, 10.7%, and 0%; P <.001). The overall frequency of postoperative neurologic events was 2.3% (30/1282) and decreased from 4.7% in the first tertile to 1.2% in the second and third tertiles (P <.001). Conclusions: Central aortic cannulation through a right anterior minithoracotomy for mitral valve repair allows excellent outcomes in patients with a broad spectrum of comorbidities and has become our preferred approach for most patients undergoing mitral valve repair. Retrograde arterial perfusion is associated with an increased risk of stroke in patients with severe peripheral vascular disease and should be reserved for select patients without significant atherosclerosis. © 2012 by The American Association for Thoracic Surgery.
Hassan, M., A. Kerdok, et al. (2012). “Near Infrared Fluorescence Imaging with ICG in TECAB Surgery Using the da Vinci Si Surgical System in a Canine Model.” Journal of Cardiac Surgery.
Abstract Background: This study assessed the clinical utility of near-infrared fluorescence imaging using indocyanine green in off-pump beating heart total endoscopic and robotic-assisted coronary artery bypass using the fluorescence imaging system for the da Vinci Si on a canine model for vessel identification, graft patency, and correlation of graft patency with ultrasound transit-time flow measurement probe. Methods: Beating heart total endoscopic robotic-assisted coronary artery bypass was performed on eight canine using indocyanine green and fluorescence imaging to identify the internal mammary artery prior to harvesting, the coronary vessel anatomy, and the patency of the beating heart total endoscopic coronary artery bypass anastomosis. Three to four injections of indocyanine green with a dose of 1.25 mg to 2.5 mg were administered per animal. Transit-time flow was measured in each of the dogs. Results: High definition 3D images were obtained. The camera working distance, indocyanine green dosage, internal mammary artery visualization, coronary artery visualization, patency by indocyanine green injection, and patency by transit-time flow were recorded. Six cases were completed successfully, and all demonstrated correlation between indocyanine green measurements of flow, and the transit-time flow measurement. Conclusion: Use of near-infrared fluorescence with indocyanine green was feasible in our study, and would be of great benefit during total endoscopic robotic-assisted coronary artery bypass using the fluorescence imaging-capable da Vinci Si system to help identify the internal mammary artery, delineate the coronary anatomy, and also determine patency of the anastomoses. This procedure correlated well with transit-time flow measurement. (J Card Surg 2012;**:1-5).
Hussain, S., C. Adams, et al. (2012). “Minimally invasive robotically assisted repair of atrial perforation from a pacemaker lead.” Int J Med Robot.
BACKGROUND: We present the first reported case of robotic-assisted right atrial perforation repair and pacemaker lead extraction. METHODS: A 75-year-old female with symptomatic sinus node dysfunction underwent atrial single chamber permanent pacemaker insertion via a persistent left superior vena cava approach. At one week follow-up a chest radiograph and a computerized dynamic tomography demonstrated that the right atrial lead had perforated the right atrial free wall. The patient remained asymptomatic without signs of pericardial tamponade, however urgent repair was warranted. RESULTS: Utilizing the da Vinci robotic system (Intuitive Surgical Inc., Sunnyvale, California, USA), the pacer lead perforation was visualized, the lead retracted, and the right atrium repaired. The existing atrial lead was repositioned in the right atrial appendage. CONCLUSION: The patient’s postoperative convalescence was uneventful, and she was discharged home on the third post-operative day. This case demonstrates the increasing clinical utilization of robotic-assisted technology in minimally invasive cardiac surgery. Copyright (c) 2012 John Wiley & Sons, Ltd.
Petracek, M. R. (2011). “Minimally invasive mitral valve surgery: Without aortic cross-clamping.” Texas Heart Institute Journal 38(6): 701-702.
Randolph Chitwood Jr, W. (2011). “Robotic cardiac surgery by 2031.” Texas Heart Institute Journal 38(6): 691-693.
Stevens, L. M., E. Rodriguez, et al. (2012). “Impact of Timing and Surgical Approach on Outcomes After Mitral Valve Regurgitation Operations.” Annals of Thoracic Surgery.
BACKGROUND: This study investigated whether the timing of mitral valve (MV) repair or surgical approach affects outcomes in patients with MV regurgitation. METHODS: Between 1992 and 2009, 2,255 patients underwent MV operations, including 1,305 with isolated MV regurgitation operations (1,054 repairs, 251 replacements). Surgical approaches were sternotomy in 377, video-assisted right minithoracotomy in 481, or robot-assisted in 447. Mean follow-up was 6.4 +/- 4.5 years (maximum, 19 years). RESULTS: Sternotomy MV repairs decreased during the study while minimally invasive MV repairs increased. Robotic MV repair patients were younger, with fewer women, had better left ventricular ejection fractions, and were more likely to have myxomatous degeneration (all p < 0.001). The robotic approach led to a higher MV repair rate and increased use of leaflet/chordal procedures but had longer cardiopulmonary bypass and aortic cross-clamp times (all p < 0.001). The 30-day mortality for isolated MV repair was similar for all approaches (p = 0.409). Fewer neurological events were observed in the videoscopic and robotic groups (p = 0.013). Adjusted survival was similar for all approaches (p = 0.357). Survival in patients in New York Heart Association class I to II with myxomatous degeneration or annular dilatation was similar to a matched population but was worse for patients in class III to IV or undergoing MV replacement. CONCLUSIONS: MV repair in patients with severe MV regurgitation should be performed before New York Heart Association class III to IV symptoms develop. Minimally invasive MV repair techniques render similar outcomes as the sternotomy approach.
Subramanian, S., J. Seeburger, et al. (2011). “Future perspectives in minimally invasive cardiac surgery.”Texas Heart Institute Journal 38(6): 678-679.
Suri, R. M., R. M. Antiel, et al. (2012). “Quality of life after early mitral valve repair using conventional and robotic approaches.” Annals of Thoracic Surgery 93(3): 761-769.
Background: Early mitral valve (MV) repair of degenerative mitral regurgitation is associated with superior clinical outcomes compared with prosthetic replacement and restores normal life expectancy, even in those without symptoms. Although current guidelines recommend prompt referral for effective MV repair in those with severe mitral regurgitation, some are reluctant to pursue early correction due to the perception that short-term quality of life (QOL) may be adversely affected by the operation. Methods: Between January 2008 and November 2009, 202 patients underwent conventional transsternotomy or minimally invasive port-access robot-assisted MV repair, with or without patent foramen ovale closure or left Maze, and were mailed a postsurgical QOL survey. Results: Unadjusted QOL scores for patients undergoing MV repair were excellent early after the operation using both approaches. Robotic repair was associated with slightly improved scores on the Duke Activity Status Index, the Short Form-12 Item Health Survey Physical domain, and the Linear Analogue Self-Assessment frequency of chest pain and fatigue indices during the first postoperative year; however, differences between treatment groups became indistinguishable after 1 year. Robotic repair patients returned to work slightly quicker (median, 33 vs 54 days, p < 0.001). Conclusions: Functional QOL outcomes within the first 2 years after early MV repair are excellent using open and robotic platforms. A robotic approach may be associated with slightly improved early QOL and return to employment-based activities. These results may have implications regarding future evolution of clinical guidelines and economic health care policy. © 2012 The Society of Thoracic Surgeons.
Wehman, B., E. J. Lehr, et al. (2012). “Robotic totally endoscopic coronary artery bypass grafting for spontaneous coronary artery dissection.” Int J Med Robot.
BACKGROUND: Patients with spontaneous coronary artery dissection may require surgical revascularization. Reports on the surgical management of this pathology are primarily limited to classic coronary artery bypass grafting via sternotomy on cardiopulmonary bypass, although a limited number of reports of alternatives also exist. METHODS: We describe a case of robotic completely endoscopic coronary surgery using the daVinci(R) Si system in a patient with spontaneous coronary artery dissection. RESULTS: Robotically assisted single left internal mammary artery grafting to the left coronary artery system was carried out successfully in a completely endoscopic fashion. CONCLUSIONS: Selected patients with spontaneous coronary artery dissection may benefit from a totally endoscopic approach to surgical coronary revascularization. Copyright (c) 2012 John Wiley & Sons, Ltd.
Anyanwu, A. C. and D. H. Adams (2012). “Should complex mitral valve repair be routinely performed using a minimally invasive approach?” Current Opinion in Cardiology 27(2): 118-124.
PURPOSE OF REVIEW: To review selected recent publications on minimally invasive mitral valve surgery to help answer the question as to whether the minimally invasive approach should be routinely used in complex mitral valve repairs. RECENT FINDINGS: Other than cosmesis, there have not been demonstrable reproducible benefits of the minimally invasive approach. Although some workers report excellent results, there are other data that raise concern that complex repairs are less likely to be undertaken via the minimal access approach, resulting in lower repair rates, and also that the incidence of residual regurgitation may be higher. Some complications, such as stroke, may occur with greater frequency in patients having the minimally invasive approach. SUMMARY: The minimally invasive approach for complex mitral valve repair requires continued development and investigation, and current application should probably be largely restricted to high-volume reference minimally invasive surgery centers. © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins.
Stevens, L. M., E. Rodriguez, et al. (2012). “Impact of Timing and Surgical Approach on Outcomes After Mitral Valve Regurgitation Operations.” Annals of Thoracic Surgery.
BACKGROUND: This study investigated whether the timing of mitral valve (MV) repair or surgical approach affects outcomes in patients with MV regurgitation. METHODS: Between 1992 and 2009, 2,255 patients underwent MV operations, including 1,305 with isolated MV regurgitation operations (1,054 repairs, 251 replacements). Surgical approaches were sternotomy in 377, video-assisted right minithoracotomy in 481, or robot-assisted in 447. Mean follow-up was 6.4 +/- 4.5 years (maximum, 19 years). RESULTS: Sternotomy MV repairs decreased during the study while minimally invasive MV repairs increased. Robotic MV repair patients were younger, with fewer women, had better left ventricular ejection fractions, and were more likely to have myxomatous degeneration (all p < 0.001). The robotic approach led to a higher MV repair rate and increased use of leaflet/chordal procedures but had longer cardiopulmonary bypass and aortic cross-clamp times (all p < 0.001). The 30-day mortality for isolated MV repair was similar for all approaches (p = 0.409). Fewer neurological events were observed in the videoscopic and robotic groups (p = 0.013). Adjusted survival was similar for all approaches (p = 0.357). Survival in patients in New York Heart Association class I to II with myxomatous degeneration or annular dilatation was similar to a matched population but was worse for patients in class III to IV or undergoing MV replacement. CONCLUSIONS: MV repair in patients with severe MV regurgitation should be performed before New York Heart Association class III to IV symptoms develop. Minimally invasive MV repair techniques render similar outcomes as the sternotomy approach.
Suri, R. M., R. M. Antiel, et al. (2012). “Quality of life after early mitral valve repair using conventional and robotic approaches.” Annals of Thoracic Surgery 93(3): 761-769.
Background: Early mitral valve (MV) repair of degenerative mitral regurgitation is associated with superior clinical outcomes compared with prosthetic replacement and restores normal life expectancy, even in those without symptoms. Although current guidelines recommend prompt referral for effective MV repair in those with severe mitral regurgitation, some are reluctant to pursue early correction due to the perception that short-term quality of life (QOL) may be adversely affected by the operation. Methods: Between January 2008 and November 2009, 202 patients underwent conventional transsternotomy or minimally invasive port-access robot-assisted MV repair, with or without patent foramen ovale closure or left Maze, and were mailed a postsurgical QOL survey. Results: Unadjusted QOL scores for patients undergoing MV repair were excellent early after the operation using both approaches. Robotic repair was associated with slightly improved scores on the Duke Activity Status Index, the Short Form-12 Item Health Survey Physical domain, and the Linear Analogue Self-Assessment frequency of chest pain and fatigue indices during the first postoperative year; however, differences between treatment groups became indistinguishable after 1 year. Robotic repair patients returned to work slightly quicker (median, 33 vs 54 days, p < 0.001). Conclusions: Functional QOL outcomes within the first 2 years after early MV repair are excellent using open and robotic platforms. A robotic approach may be associated with slightly improved early QOL and return to employment-based activities. These results may have implications regarding future evolution of clinical guidelines and economic health care policy. © 2012 The Society of Thoracic Surgeons.