Three-dimensional echocardiography–guided beating-heart surgery without cardiopulmonary bypass: A feasibility study

Abstract

BackgroundThere is no current acceptable approach for intracardiac beating-heart interventions. We have adapted real-time 3-dimensional echocardiography with specialized instrumentation to facilitate beating-heart repair of atrial septal defects and mitral valve plasty to investigate the feasibility of real-time 3-dimensional echocardiography–guided cardiac surgery.MethodsIn experiment I a modified real-time 3-dimensional echocardiography system with x4 matrix transducer was compared with 2-dimensional echocardiography in the performance of common surgical tasks. Completion times, deviation from an ideal trajectory, and an echogenic target were measured. In experiment II porcine atrial septal defects were closed with an original semiautomatic suturing device (n = 4) and with a 5-mm endoscopic stapler and a pericardial or polytetrafluoroethylene patch (n = 4). In experiment III a pulsatile porcine mitral valve model was developed, and suture placement through the anterior and posterior mitral leaflets was performed (n = 8). During all experiments, the operator was blinded to the target and operated on only with ultrasonic guidance.ResultsIn experiment I, compared with 2-dimensional echocardiographic guidance, completion times improved by 21% (P < .01) with high-trajectory accuracy, and suture deviation was significantly smaller (2-dimensional echocardiography, 5.4 ± 2.7 mm; 3-dimensional echocardiography, 1.7 ± 0.7 mm; P < .05) in real-time 3-dimensional echocardiography–guided tasks. In experiments II and III in both atrial septal defect closure and mitral valve plasty, real-time 3-dimensional echocardiography provided satisfactory images and sufficient anatomic detail for suturing and patch deployment. All surgical tasks were successfully performed with accuracy.ConclusionsReal-time 3-dimensional echocardiography provides adequate imaging and anatomic detail to act as a sole guide for surgical task performance. These initial experiments demonstrate the feasibility of beating-heart direct or patch closure of atrial septal defects and mitral valve plasty without cardiopulmonary bypass. There is no current acceptable approach for intracardiac beating-heart interventions. We have adapted real-time 3-dimensional echocardiography with specialized instrumentation to facilitate beating-heart repair of atrial septal defects and mitral valve plasty to investigate the feasibility of real-time 3-dimensional echocardiography–guided cardiac surgery. In experiment I a modified real-time 3-dimensional echocardiography system with x4 matrix transducer was compared with 2-dimensional echocardiography in the performance of common surgical tasks. Completion times, deviation from an ideal trajectory, and an echogenic target were measured. In experiment II porcine atrial septal defects were closed with an original semiautomatic suturing device (n = 4) and with a 5-mm endoscopic stapler and a pericardial or polytetrafluoroethylene patch (n = 4). In experiment III a pulsatile porcine mitral valve model was developed, and suture placement through the anterior and posterior mitral leaflets was performed (n = 8). During all experiments, the operator was blinded to the target and operated on only with ultrasonic guidance. In experiment I, compared with 2-dimensional echocardiographic guidance, completion times improved by 21% (P < .01) with high-trajectory accuracy, and suture deviation was significantly smaller (2-dimensional echocardiography, 5.4 ± 2.7 mm; 3-dimensional echocardiography, 1.7 ± 0.7 mm; P < .05) in real-time 3-dimensional echocardiography–guided tasks. In experiments II and III in both atrial septal defect closure and mitral valve plasty, real-time 3-dimensional echocardiography provided satisfactory images and sufficient anatomic detail for suturing and patch deployment. All surgical tasks were successfully performed with accuracy. Real-time 3-dimensional echocardiography provides adequate imaging and anatomic detail to act as a sole guide for surgical task performance. These initial experiments demonstrate the feasibility of beating-heart direct or patch closure of atrial septal defects and mitral valve plasty without cardiopulmonary bypass.