Intracardiac Surgery Research Articles

Advances in Cardiac Surgery and Therapeutics

In this review, in regard to the treatment of congenital heart disease, coronary artery diseases, valve disease and atrial fibrillation, novel surgeries and therapeutics are introduced according to our experience and recent report. In addition, robotics has gained acceptance in cardiac surgery, which is utilized to perform mitral valve repairs, coronary revascularization, atrial fibrillation ablation, intracardiac surgery and atrial septal defect closures. Thus, cardiac surgeries assisted by robotics are briefly summarized.

Minimally invasive paediatric cardiac surgery

The concept of minimally invasive surgery for congenital heart disease in paediatric patients is broad, and has the aim of reducing the trauma of the operation at each stage of management. Firstly, in the operating room using minimally invasive incisions, video-assisted thoracoscopic and robotically assisted surgery, hybrid procedures, image-guided intracardiac surgery, and minimally invasive cardiopulmonary bypass strategies. Secondly, in the intensive-care unit with neuroprotection and 'fast-tracking' strategies that involve early extubation, early hospital discharge, and less exposure to transfused blood products. Thirdly, during postoperative mid-term and long-term follow-up by providing the children and their families with adequate support after hospital discharge. Improvement of these strategies relies on the development of new devices, real-time multimodality imaging, aids to instrument navigation, miniaturized and specialized instrumentation, robotic technology, and computer-assisted modelling of flow dynamics and tissue mechanics. In addition, dedicated multidisciplinary co-ordinated teams involving congenital cardiac surgeons, perfusionists, intensivists, anaesthesiologists, cardiologists, nurses, psychologists, and counsellors are needed before, during, and after surgery to go beyond apparent technological and medical limitations with the goal to 'treat more while hurting less'.

The effects of antedgrade cerebral perfusion on immediate postoperative outcome in neonatal and infant aortic arch repair concomitant with intracardiac surgery

The effects of antedgrade cerebral perfusion on immediate postoperative outcome in neonatal and infant aortic arch repair concomitant with intracardiac surgery

Clinical and Surgical Experience in the Management of Cardiac Myxomas: The Early and Mid-Term Results

Objective: Cardiac myxoma is the most common benign heart tumor. In this study, early and mid-term results of patients who underwent intracardiac myxoma exicision surgery were examined. Methods: Between to 1988 and 2012 years, 31 patients with a median age of 56 years (range, 33 to 78 years) were operated for myxoma. Eighteen female and 13 male underwent surgical excision of primary intracardiac myxomas. Twelve patients (38.7%) presented with congestive heart failure symptoms and 19 patients (61.3%) with mitral obstruction symptoms. Preoperative diagnosis was established by transthoracic two dimensional echocardiography. Nineteen had right atrial (RA) myxomas, 12 patients had left atrial (LA) myxoma. The surgical management was performed by wide excision under cardiopulmonary bypass. Results: One patient with cerebral embolism died during the early postoperative period. Mean follow-up was 9.8±1.4 years. Thirty patients had on regular follow-up in NYHA Class I symptoms with no documented recurrences. Conclusions: All patients with cardiac myxoma have immediate surgical treatement indication. Surgical excision of atrial myxoma gives excellent short and mid-term results. (JAREM 2013; 3: 84-7)

Outcomes of Double Inlet Left Ventricle and Similar Morphologies: A Single Center Comparison of Initial Pulmonary Artery Banding Versus a Norwood-Type Reconstruction

Patients with double inlet left ventricle (DILV)/transposition and similar morphologies have their systemic outflow traverse a bulboventricular foramen (BVF), which has a propensity to narrow over time. The aim of this study is to evaluate the outcomes of initial pulmonary artery banding (PAB) compared with the Norwood-type reconstruction in neonates. A retrospective study of children with DILV and similar morphologies presenting between 1982 and 2012. The outcomes of initial PAB (n=17) are compared with a Norwood-type reconstruction (n=20). The two groups were similar with respect to age, gender, weight, noncardiac syndromes, and Fontan completion. Mean follow-up was longer in PAB patients (13.3 ± 9.8 years) versus Norwood (4.5 ± 3.0 years, p=0.001). Survival was 75% at eight years in the Norwood group versus 71% in the PAB group (p=0.76). Mortality in the Norwood group was higher before 2002 (p=0.06). The age of patients who underwent a bidirectional Glenn shunt was significantly higher for PAB group (PAB, 9.1 ± 1.4 months vs. Norwood, 6.1 ± 1.6 months; p<0.001). Freedom from any type of reintervention (systemic outflow obstruction or coarctation) was similar (Norwood, 83% vs. PAB, 71%; p=0.62). Freedom from heart block with a pacemaker insertion was significantly better for Norwood patients (Norwood, 89% vs. PAB, 41%; p=0.001). The Norwood-type reconstruction provides good palliation in this subgroup of patients and avoids the need for subsequent intracardiac operations, maintaining an unobstructed systemic outflow tract and avoiding the risk of heart block. Survival does not differ depending on the type of procedure. Patients with PAB show comparable satisfactory early and long-term results, with an increasing reoperation risk and heart block remaining a major concern.

Robotic excision of aortic valve papillary fibroelastoma and concomitant maze procedure

: Cardiothoracic surgeons have utilized the surgical robot to provide a minimally invasive approach to a number of intracardiac operations, including tumor resection, valve repair, and ablation of atrial arrhythmia. We report the case of a 58 year-old woman who was found to have a mobile mass on her aortic valve during evaluation of atrial fibrillation. Both of these conditions were addressed when she underwent a combined robotic biatrial Maze procedure and excision of the mass, which proved to be a papillary fibroelastoma of the aortic valve.

Improved early postoperative outcome for extracardiac Fontan operation without cardiopulmonary bypass: a single-centre experience

The use of modified extracardiac Fontan operation (ECFO) for total cavo-pulmonary connection allows cardiopulmonary bypass (CPB) to be avoided and seems to improve early postoperative results. We evaluated our experience with the off-pump technique for ECFO. Since 2009, the last 17 consecutive patients of 137 (median age 3.2 years, median weight 14.5 kg) in whom no intracardiac surgery was necessary underwent ECFO without CPB. The non-fenestrated graft was connected end-to-side to the pulmonary artery without bypass; subsequently temporary passive inferior vena cava (IVC)-to-atrial bypass was used for the anastomosis between IVC and graft. The perioperative and postoperative course was compared between consecutive paediatric patients operated on using the CPB vs off-pump technique. There was no mortality in the off-pump group, with a total early mortality of 3.0%. Overall operation time for the Fontan operation using the off-pump technique was significantly reduced (160 vs 200 min, P < 0.001). The median Fontan pressure 24 and 48 h postoperatively was significantly lower in the off-pump group (P = 0.002/0.042). Duration of mechanical ventilation (9 vs 14 h, P = 0.016), pleural effusions (4 vs 8 days, P < 0.001) as well as the median intensive care unit (2 vs 4 days, P = 0.013) and hospital stay (median 10 vs 15 days, P < 0.001) was significantly shorter in patients who underwent the off-pump Fontan operation. The necessity of blood transfusions was significantly reduced with the off-pump in comparison with the on-pump technique (14 of 17 vs 34 of 84 patients, P = 0.003). The ECFO without CPB is an established low-risk surgical procedure that improves the early postoperative course and significantly reduces the use of blood products and the duration of pleural effusions in selected patients.

Endoscopic repair for left ventricular pseudoaneurysm with right minithoracotomy

Left ventricular pseudoaneurysm (LVPA) is a known serious complication of myocardial infarction or mitral valve replacement. As an alternative option, transmitral patch repair for LVPA has been reported. However, it is very difficult to complete the procedure for LVPA with a large defect. A 68-year old man with a history of inferior myocardial infarction had undergone mitral valve repair. At 4 months after surgery, the presence of a giant LVPA in the posteroinferior left ventricular wall was revealed. We performed transmitral patch repair through minithoracotomy under a three-dimensional videoscope. Since the intracardiac operation was performed under only camera vision, the perspective supplied by the three-dimensional videoscope was very useful. Endoscopic patch repair was a much less invasive procedure, and we could obtain a great intracardiac view. This technique can be an appropriate option for the treatment of LVPA after cardiac surgery.

Percutaneous intracardiac beating-heart surgery using metal MEMS tissue approximation tools

Achieving superior outcomes through the use of robots in medical applications requires an integrated approach to the design of the robot, tooling and the procedure itself. In this paper, this approach is applied to develop a robotic technique for closing abnormal communication between the atria of the heart. The goal is to achieve the efficacy of surgical closure as performed on a stopped, open heart with the reduced risk and trauma of a beating-heart catheter-based procedure. In the proposed approach, a concentric tube robot is used to percutaneously access the right atrium and deploy a tissue approximation device. The device is constructed using a metal microelectromechanical system (MEMS) fabrication process and is designed to both fit the manipulation capabilities of the robot as well as to reproduce the beneficial features of surgical closure by suture. The effectiveness of the approach is demonstrated through ex vivo and in vivo experiments.

重症心室瘤に対する瘤切除後・人工心肺離脱困難例に対する補助心臓(LVAD)の治療例

重症心室瘤に対する瘤切除後・人工心肺離脱困難例に対する補助心臓(LVAD)の治療例

A novel cardioport for beating-heart, image-guided intracardiac surgery

Intracardiac beating-heart procedures require the introduction and exchange of complex instruments and devices. To prevent potential complications such as air embolism and bleeding, a universal cardioport was designed and tested. The design consists of a port body and a series of interchangeable sleeves. The port uses a fluid purging system to remove air from the instrument before insertion into the heart, and a valve system minimizes blood loss during instrument changes. The cardioport was tested exvivo and invivo in pigs (n=5). Beating-heart procedures, such as septal defect closure and mitral valve repair, were modeled. Exvivo trials (n=150) were performed, and no air emboli were introduced using the port. In comparison, air emboli were detected in 40% to 85% of the cases without the use of the port-based purging system. Port operation revealed excellent ergonomics and minimal blood loss. A novel cardioport system designed to prevent air entry and blood loss from transcardiac instrument introduction was shown to be an enabling platform for intracardiac beating-heart surgery. The port system improves safety and facilitates further development of complex instruments and devices for transcardiac beating-heart surgery.

Direct Endoscopy-Guided Mitral Valve Repair in the Beating Heart An Acute Animal Study

: The purpose of this study was to develop a new method for minimally invasive mitral valve repair under direct endoscopic visualization in the beating heart. : Fiberoptic cardioscopy of the left heart was conducted in 12 calves. Systemic perfusion was maintained by cardiopulmonary bypass through a median sternotomy. A clear solution (Ringer's lactate) was temporarily administered via the pulmonary artery to flush out the pulmonary vasculature, and additional perfusion of the left heart chambers enhanced visualization of the intracardiac anatomy. The endoscope, with an open-ended transparent flexible outer sheath, was inserted through the left ventricular apex, and an endoscopic clip was used for edge-to-edge mitral valve repair. Hemodilution was avoided by the drainage of irrigation fluid via a left ventricular cannula. : Direct endoscopic visualization of the mitral valve in an in vivo beating heart was obtained clearly, avoiding systemic hemodilution. In the last experiment, edge-to-edge repair using an endoscopic clip was successfully performed. Use of an effective intracardiac irrigation method was important for successful image acquisition and achievement of repair procedures. : This acute animal study showed the technical feasibility of beating-heart mitral valve surgery under direct endoscopic imaging. Although this study was performed under open-chest conditions, our successful experiment is a first step toward closed-chest intracardiac surgery with direct endoscopic visualization.

A novel method of hybrid intraoperative catheter‐based closure of ventricular septal defects using the Amplatzer® PDA occluder

In five patients, an apical muscular septal defect was closed in a hybrid approach using the Amplatzer® duct occluder during open heart surgery, whereas concomitant defects were treated surgically. In addition to their different heart defects that needed surgery, all had a muscular ventricular septal defect in the apex of the heart, poorly accessible for traditional, surgical approach. We describe the method and outcome in these patients. The tip of a forceps was advanced from the left into the right ventricle through the ventricular septal defect. The delivery sheath was caught under visual control in the right ventricle and pulled back into the left ventricle. The disc was developed and pulled back until it was felt tugging at the septum. Then the core was developed. The end of the device was visible in the right ventricle and was secured with a Prolene® suture. The procedures were event-free. During early follow-up there were either no or only insignificant shunts in the region of the prior trabecular defects in four patients. The unsatisfactory result in the last patient was caused by inaccurate preoperative assessment. The method seems valuable in patients in need of other intracardiac surgery.

Three Dimensional Electroanatomical Mapping of Lower Loop Reentry in Patients with Intracardiac Operation

Introduction: The aim of this study was to clarify the characteristics of lower loop reentry (LLR. in patients who underwent cardiac surgery.Methods: Of 194 patients from 2000 to 2007 with negative flutter waves in the inferior leads (II, III, and aVf), 4 patients had LLR and reentrant circuits identified by a 3D activation sequence mapping system. We studied the characteristics of the surface electrocardiogram (ECG. patterns of those LLRs.Results: All 4 patients had a history of an intracardiac operation. The 3D activation sequence mapping system during the LLR exhibited a clockwise (CW. wavefront around the inferior vena cava (IVC. from the caudal view. During the LLR, the right atrium (RA. free wall was activated in a caudal‐cranial sequence and a collision of two activation wavefronts from the lower RA and upper RA occurred at the RA free wall.Conclusions: The 3D activation mapping during the AT revealed an activation wavefront propagating around the IVC and the diagnosis of LLR. Detailed 3D electroanatomical mapping and pacing study are needed to identify the reentrant circuit of LLR in patients with previous intracardiac surgery.

Three Dimensional Electroanatomical Mapping of Lower Loop Reentry in Patients with Intracardiac Operation

Three Dimensional Electroanatomical Mapping of Lower Loop Reentry in Patients with Intracardiac Operation

COMPORTAMENTO DA FREQUÊNCIA CARDÍACA E DA TEMPERATURA CORPÓREA EM COELHOS SUBMETIDOS À PARADA CIRCULATÓRIA CARDÍACA

The technique of total circulatory arrest (TCA), or inflow occlusion , consists in preventing the blood entry into the heart chambers by clamping the vena cava and the cranial and caudal vena azygos. However, changes in physiological parameters of the patient can be triggered with the application of this technique. This technique can be easily used in heart intra-cavity diseases, whose correction takes a few minutes, as in pulmonary stenosis or subaortic stenosis. Because low cost and simple implementation, it may be carried out in private clinics. In this trial, the behavior of heart rate and body temperature of rabbits submitted to two periods of five minutes of TCA, by the use of inflow occlusion technique, was evaluated. A period of blood recirculation between occlusions was performed to verify the potential benefits of this practice on the behavior of heart rate and body temperature of the animals. These parameters were assessed throughout the perioperative period. There were two deaths, both in the recirculation period due to the occurrence of ventricular fibrillation. Nevertheless, with the implementation of the period of blood recirculation, we verified that this technique can be used in intra-cardiac surgery lasting up to 10 minutes. KEYWORDS: Circulatory arrest, inflow occlusion, rabbits.

Successful Intracardiac Robotic Surgery Initial Results from Japan

: The purpose of this study is to report our 2-year experience of performing endoscopic intracardiac procedures using the da Vinci Surgical System. Our teams at Kanazawa University and Tokyo Medical University groups began using the da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA) in 2005. This series represents the first Japanese application of robotic technology for totally endoscopic open-heart surgery. : From January 2008 to February 2009, 10 patients (mean age: 46.8 ± 16.3 years, 70% women) underwent endoscopic atrial septal defect closure and resection of the left atrial myxoma using the da Vinci Surgical System and peripheral cardiopulmonary bypass technique. Of the 10 patients, nine were classified as New York Heart Association class II and 1 patient exhibited atrial arrhythmias. In addition, two patients required mitral valve plasty (n = 2) and tricuspid annuloplasty (n = 1). : Mean da Vinci Surgical System working time was 140.7 ± 57.4 minutes. Mean cardiopulmonary bypass and aortic cross clamp times were 103.1 ± 37.1 and 30.0 ± 16.9 minutes, respectively. There were no conversions to sternotomy or small thoracotomy. There were no hospital deaths. Mean intensive care unit and hospital stays were 1 day and 3.1 ± 0.3 days, respectively. All patients appreciated the cosmetic result and fast recovery. : Closed-chest atrial septal defect closure and myxoma resection performed using robotic techniques achieved excellent results and rapid postoperative recovery and provided an attractive cosmetic advantage over median sternotomy.

Successful Intracardiac Robotic Surgery Initial Results from Japan

Successful Intracardiac Robotic Surgery Initial Results from Japan

Dismal Lung Transplant Outcomes in Children With Tetralogy of Fallot With Pulmonary Atresia Compared to Eisenmenger Syndrome or Pulmonary Vein Stenosis

Certain congenital heart lesions in children can lead to irreversible lung disease thus making lung transplantation a therapeutic option. We retrospectively analyzed our experience with lung transplantation in 32 children with three distinct underlying congenital heart defects: (1) Eisenmenger syndrome (EIS); (2) tetralogy of Fallot with pulmonary atresia (PA); and (3) pulmonary vein stenosis (PVS). Pediatric patients <18 years of age with either EIS (n = 7), PA (n = 8) or PVS (n = 17), who underwent lung or heart-lung transplantation, were analyzed. We compared survival rates between the three groups. Pre- and peri-operative variables were also assessed for their effect on outcome. Compared with EIS and PA patients, PVS patients were younger and sicker at the time of transplantation. All EIS and PA patients required either additional intracardiac repairs or a heart transplant at the time of lung transplantation. PA patients had the highest rate of major post-operative complications and in-hospital deaths. Median survival was comparable between EIS (6.1 years) and PVS (6.5 years) patients. Outcomes for PA patients were dramatically worse, with a median survival of only 0.12 year ( approximately 47 days). Needing additional intracardiac surgery or a heart transplant at the time of lung transplantation did not impact survival. The diagnosis of PA itself correlated with a worse outcome. Outcomes in EIS and PVS patients undergoing lung transplantation compare favorably to that of all pediatric lung transplant recipients (median survival 4.3 years). For PA patients, their underlying pathology appears to make them high-risk candidates for lung transplantation. For the younger and acutely sicker PVS patients, lung transplantation is a viable therapeutic alternative.

Minimally Invasive, Minimally Reimbursed? Anesthesia for Endoscopic Cardiac Surgery Is Not Reflected Adequately in the German Diagnosis-Related Group System

In the German diagnosis-related group (G-DRG) system, hospital reimbursement for anesthesia is linked to specific surgical procedures, irrespective of case duration. Accordingly, costs of innovative procedures, such as endoscopic cardiac surgery, may be underreimbursed. The authors assessed to what extent anesthesia costs for endoscopic cardiac surgery are reimbursed with the G-DRG system. Retrospective analysis. University hospital. Eighty-four patients were studied undergoing general anesthesia for minimally invasive endoscopic port-access intracardiac surgery (n = 42) or conventional "open" surgery (n = 42) for similar indications. None. The authors measured anesthesia staffing time, costs, and reimbursement for endoscopic cardiac surgery and compared results with data from a matched group undergoing conventional surgery. Endoscopic surgery increased anesthesia staffing time per case by 521 minutes (977 minutes +/- 177 v 456 +/- 92, mean +/- standard deviation, p = 0.0001) and costs by approximately 200%. Anesthesia duration increased by 152 minutes (503 minutes +/- 89 v 351 +/- 69, p = 0.0001). In contrast, staffing reimbursement did not increase at the time of the patient's surgery (euro500/case [446-569] v 492 [452-508], p = 0.75, median [interquartile range]) or with the 2007 G-DRG matrix (euro548/case [463-559] v 503 [503-568], p = 0.48). Cost recovery was only 66% +/- 17.4% and 72.7 +/- 38.9 in the 2007 G-DRG matrix, respectively. It was shown that (1) endoscopic cardiac surgery consumed more anesthesia resources and was underreimbursed both relative to actual costs and to conventional surgery, (2) costs for such anesthesia services were inappropriately reflected in the G-DRG system, and (3) a DRG system's inability to adapt timely to innovative procedures may adversely affect anesthesia departments and medical progress.