Port-access Cardiac Surgery Research Articles

Aortic dissection in Port-Access cardiac surgery: A safe procedure, based on Team approach, Protocols and TEE

Aortic dissection in Port-Access cardiac surgery: A safe procedure, based on Team approach, Protocols and TEE

Small right vertical infra-axillary incision for minimally invasive port-access cardiac surgery: a moving window method

Port-access cardiac surgery has been developed to minimize skin incision and improve cosmetic outcomes. Using this method, a skin incision is generally made just above where the thoracotomy will be placed, horizontally along the intercostal space at the anterolateral submammary position. However, this type of incision can affect the frontal view and shape of the breast. Here, we report our experience with minimally invasive cardiac surgery using a port-access approach via a small vertical right infra-axillary incision and a moving window method. Twenty patients underwent surgical procedures with this approach from December 2010 to January 2012. Thirteen patients underwent mitral valvuloplasty, four mitral valve replacement, one mitral and tricuspid valve replacement and atrial septal defect closure and two atrial septal defect closure. All surgical procedures were completed using this minimally invasive method. All patients had an uneventful recovery and indicated that they were satisfied with the cosmetic results during the follow-up. Our experience suggests that this technique can effectively minimize skin incision and improve cosmetic outcomes.

Patient temperature management with Koala underbody convective air in port-access cardiac surgery

Patient temperature management with Koala underbody convective air in port-access cardiac surgery

The Analgesic Efficacy of Local Anesthetics for the Incisional Administration following Port Access Heart Surgery: Bupivacaine versus Ropivacaine

To avoid large dose opioids, the authors investigated an alternative method for postoperative pain relief after Port Access cardiac surgery. Out of 104 patients who underwent Port Access heart surgery, 78 patients who were extubated in the operating room were enrolled in the retrospective study. The standardized fast track cardiac anesthesia was used for all patients, and the catheter was placed in the surgical wound at the end of the operation. Analgesia was started with a bolus of bupivacaine (B group) or ropivacaine (R group) through the catheter and followed by continuous infusion of local anesthetic. The variables recorded were visual analogue scale (VAS) at extubation and during the first 24 hours, additional requirements of local anesthetic (LA), and opioid analgetic. Possible complications that could be connected with the catheter in the wound or with the administration of LA were recorded as well. There was no statistical difference between the R and B groups in mean pain score at extubation and in the first 24 hours. The groups were also comparable concerning the need for bolus application of the LA and opioid analgetic. The microbiological analysis of 9 randomly chosen catheter tips from both groups was sterile. Both local anesthetics, ropivacaine and bupivacaine, are equally effective for pain relief after Port Access cardiac surgery. The catheter in surgical incision and application of LA through it does not increase the risk for wound infection and does not interfere with wound healing.

Usefulness of Osteosynthesis Device Made of Hydroxyapatite-Poly-L-Lactide Composites in Port-Access Cardiac Surgery

Port-access minimally invasive cardiac surgery has been developed with the aim of reducing surgical invasion. We conduct port-access cardiac surgery, generally through an intercostal space. To ensure sufficient visual field, either the upper or lower rib may be divided. In the process of restoration of divided ribs, we have developed a bone fixation technique using a new osteosynthesis device by way of prevention of pseudoarthrosis. Forty-five consecutive patients underwent right-sided anterior intercostal thoracotomy under the port-access method between July 2006 and July 2007. We used a totally resorbable osteosynthesis device (Super Fixsorb; Takiron Co., Ltd., Osaka, Japan) consisting of a mix of poly-L-lactide (PLLA) and particulate resorbable uncalcined hydroxyapatite (u-HA). Fixation of the rib-costal cartilage was sufficiently achieved in this manner. No clinical symptoms suggestive of inflammation or infection were identified in the areas corresponding to the site of bone junction, and no patients have suffered pseudoarthrosis perioperatively and up to one year after surgery. Computed tomographic (CT) scanning clearly visualized these devices, and their attachment to the rib surfaces was confirmed in the patient who underwent CT scanning after the longest tested interval of 133 days after surgery. In this study, the possibility was suggested that the advantages of u-HA/PLLA composite, such as early osteoconductive property and bioactive property, might beneficially affect bone fusion. We conclude that this osteosynthesis device can be applied in various fields, including cardiovascular surgery, and that its use will contribute to improvement of patients' postoperative quality of life.

Anesthesia for Port-Access Cardiac Surgery in a Pediatric Population

A less invasive approach to cardiac surgical procedures has become widely accepted. The Port-Access (Heartport Inc, Redwood City, CA) technique for correction of acquired and congenital heart defects in adults produces superior cosmetic results without increasing perioperative morbidity. This study evaluated the feasibility of the Port-Access approach for repairs of various congenital heart defects in children and describes the anesthetic management for this procedure. Prospective observational study. University hospital. Ten 3- to 15-year-old patients. Patients underwent repairs of congenital heart defects via minimal right thoracotomy. The induction and maintenance of anesthesia were tailored to achieve early extubation. Endotracheal intubation with a double-lumen tube was performed in 3 patients with body weight more than 25 kg. In other patients, lung separation was achieved with the use of a bronchial blocker. Arterial and venous cannulation were done under transesophageal echocardiography (TEE) guidance. A small surgical incision was performed in the fifth right intercostal space. In most patients, operations were performed on a fibrillating heart in normothermic condition. TEE-guided cannulation posed no technical difficulties. Flow rates, calculated for patients' body surface area, were easily achieved. No inotropic support was necessary for the separation from cardiopulmonary bypass. All patients but 1 were extubated in the operating room. Despite longer times of operation and cardiopulmonary bypass, intensive care unit stay and postoperative hospital length of stay were not different from the historic matched control group and were 2.7 +/- 1.1 days and 5.0 +/- 1.6 days, respectively. The Port-Access method for the correction of selected congenital cardiac defects is feasible in children.

Arterial Injuries from Femoral Artery Cannulation with Port Access Cardiac Surgery

Although minimally invasive (MI) cardiac surgery reduces blood loss, hospital stay, and recovery time, some MI approaches require femoral arterial cannulation, which introduces a heretofore unknown risk of femoral arterial injury. This study was performed to examine the risk of femoral arterial injury after Port Access MI cardiac surgery (PA-MICS) with femoral cannulation. Data were prospectively obtained on 739 consecutive patients who had PA-MICS with femoral cannulation between June 1996 and April 2000, identifying any patient with new (<30 days postoperative) arterial insufficiency from the cannulation site. Patient characteristics (gender, age, height, weight, body surface area, smoking, peripheral vascular disease, diabetes) and operative variables (cannula size, cross-clamp time) were examined with univariate and multivariate analysis to identify risk factors for arterial injury. Injuries were defined and classified by radiologic and intraoperative assessment, and follow-up was obtained by patient examination and from the medical records. Femoral arterial occlusion (FAC) occurred in 0.68% (5/739) of patients (4 women, 1 man; age range 26-74 years). The risk of femoral injury was higher in women: 1.31% vs 0.23% (p = 0.07). One patient had intraoperative limb ischemia from iliofemoral dissection and was treated by axillopopliteal bypass. Four patients presented postoperatively with claudication. Three of these had iliofemoral arterial occlusion or localized iliofemoral dissection and were treated with iliofemoral bypass, and 1 patient had localized femoral artery stenosis treated by angioplasty. With a mean follow-up of 17.8 months (range 13-26 months) limb salvage was achieved in all patients. Secondary or tertiary interventions were required in 40% (2/5), both in patients with iliofemoral occlusion, and 1 patient (20% of femoral injuries, 0.135% of overall series) has chronic graft occlusion and long-term claudication. The risk of arterial injury after femoral arterial cannulation and perfusion for Port Access surgery was low (0.68%). This risk is increased in women and is unpredictable. Initial vascular repair has a significant failure rate, and secondary interventions are often necessary. Although the femoral cannulation and perfusion technique is safe overall, the risk must be clearly recognized.

Lung isolation during port-access cardiac surgery: double-lumen endotracheal tube versus single-lumen endotracheal tube with a bronchial blocker

Objective The purpose of this study was to compare the use of a double-lumen endotracheal tube to a single-lumen tube combined with a bronchial blocker for lung isolation during Port-Access cardiac surgery. Design Prospective, randomized, controlled trial. Setting Tertiary care university hospital. Participants Thirty-two patients undergoing Port-Access cardiac surgery via a right minithoracotomy. Interventions Patients were randomized to intubation with either a left-sided double-lumen tube (double-lumen group) or a single-lumen tube with concomitant use of a bronchial blocker (blocker group). Comparisons between groups included (1) intubation time, (2) number of laryngoscopy attempts, (3) time required for tube exchange at the end of the operation, and (4) surgical satisfaction with the lung deflation (1–5 scale: 5 = excellent). Measurements and main results The initial intubation time was similar between groups (118 ± 82 seconds, double-lumen v 144 ± 32 seconds, blocker; p = 0.2781). An additional 105 ± 37 seconds was needed to exchange the double-lumen tube at the end of the operation. The double-lumen group also required more laryngoscopy attempts compared with the blocker group (2.3 ± 0.6, double-lumen v 1.1 ± 0.4, blocker; p = 0.0001). The lung deflation was better in the double-lumen group (5 [4–5], double-lumen v 4 [3–5], blocker, p = 0.0414). Conclusions Compared with a single-lumen tube/bronchial blocker combination the double-lumen endotracheal tube required more laryngoscopy attempts and additional time to replace the tube at the end of the case but resulted in slightly better overall lung deflation.

Minimally invasive cardiac surgery by the port-access method.

Recently, minimally invasive surgery has come to be an important theory in cardiac surgery, the goal of which is shortening of hospital stay, earlier recovery of employment, and cosmetics. In this paper, we will describe our experience with port-access cardiac surgery conducted under the support of our new technology. This study assesses the quality of cardiac surgery performed by the port-access method. The author developed a direct endoaortic clamp balloon (Yozu balloon). This balloon is a triple-lumen balloon catheter of 3.6 mm in outer diameter and 40 cm in full length. The balloon is inserted directly into the ascending aorta. Injection of cardioplegic solution and aortic vent can be conducted. Also, we introduce a modified Cosgrove flex clamp to apply in small-incision surgery, aiming at a less invasive procedure. The modified point is that the original, united Cosgrove flex clamp can be divided into the handle part equipped with a ratchet, and the bellows part equipped with a clamp jaw. By this modification, it became possible to apply the Cosgrove flex clamp transthoracically; that is, it became possible to conduct aortic clamping safely and securely through this small port of 8 mm in diameter. Port-access cardiac surgery is one of the developing and promising methods of cardiac operation. In view of future technological progress, we can expect the gradual but wide popularization of this method.

Port-access cardiac surgery. Experience with 34 cases at Keio University Hospital.

We reviewed our experience with port-access cardiac surgery and evaluated the medical effects and benefits of this technique in view of postoperative quality of life and medical expenses incurred during hospitalization. From June 1998 to August 2000, port-access cardiac surgery was conducted on 34 patients--22 with atrial septal defect, 6 with mitral regurgitation, 2 with coronary artery disease, 2 with partial endocardial cushion defect, 1 with ventricular septal defect, and 1 with atrial and ventricular septal defects. Two types of endoaortic-balloon catheters were used to execute aortic cross-clamping. Skin incisions were 5 cm long. No hospital or late deaths were observed. Patients with atrial septal defect were discharged on postoperative day 3.7, patients of mitral regurgitation on postoperative day 4.2, and patient of ventricular septal defect on postoperative day 4.0 on the average. None were readmitted. Patients appeared undisturbed by early discharge and were able to resume physical work on day 22 on the average after discharge. Patients undergoing port-access cardiac surgery recovered quickly from surgery and resumed work quickly. This technique thus proved satisfactory both physically and mentally to patients and improved their quality of life. Medically and economically this technique proved extremely beneficial. We confirmed it to constitute a viable approach and option for cardiac surgery in selected patients.

Cardiac Surgery Increases Surgical Complexity

University of Chicago, Chicago, Illinois. mchaney@airway2.uchicago.eduIn Reply:—The comments of Dr. Glower et al. are much appreciated. All would agree that operative personnel (surgeons, anesthesiologists, perfusionists, nurses) become more comfortable and efficient with procedures involving new technology with increased exposure and experience. Although normalizing operative time is important from an economic standpoint, I believe that normalizing cardiopulmonary bypass time and demonstrating equivalent intermediate and long-term morbidity and mortality (when compared with conventional cardiac surgery) are the most important issues regarding port-access cardiac surgery. We, as have others, revealed that port-access cardiac surgery significantly increases cardiopulmonary bypass time when compared with similar procedures performed conventionally, which likely increases perioperative morbidity (neurologic, pulmonary, renal, hematologic). How port-access cardiac surgery compares with conventional cardiac surgery in terms of intermediate and long-term morbidity and mortality remains to be determined. I am always uncomfortable with the often-stated comparison of the development of port-access cardiac surgery to the development of laparoscopic cholecystectomy. I do not believe it is a fair comparison because the technical challenges that confront the cardiac surgeon (coronary anastomoses, valve repair and replacement, and others) are far greater than the surgeon’s performing a cholecystectomy.University of Chicago, Chicago, Illinois. mchaney@airway2.uchicago.edu

Case 5—2001 port-access cardiac surgery and aortic dissection: The role of transesophageal echocardiography

A 62-year-old man was admitted for mitral valve surgery and single-vessel coronary artery bypass graft (CABG) surgery. His history revealed surgery for an inguinal hernia, gout, arterial hypertension, percutaneous transluminal coronary angioplasty of the left anterior descending artery (LAD), and appendectomy. Current medications included allopurinol, 100 mg; hydrochlorothiazide, 12.5 mg; quinapril, 10 mg; atorvastatin, 10 mg; and metoprolol succinate, 100 mg; and aerosol inhalation daily. Clinical examination was not significant except for atrial fibrillation. Biochemical analysis revealed hypercholesterolemia. The patient suffered from angina of effort and dyspnea.

Port-access minimally invasive cardiac surgery in a patient without arms

INIMALLY INVASIVE cardiac surgery has gained prominence over the past several years and can be divided into two groups: beating-heart cardiac surgery without cardiopulmonary bypass (CPB) I and Port-Access (Heartport, Inc, Redwood City, CA) cardiac surgery with CPB. 2 Port-Access cardiac surgery uses a system of catheters and cannulae placed in the internal jugular vein and femoral artery to provide closed-chest CPB and enables the heart to be arrested and protected with cardioplegic solution in a manner equivalent to that used in conventional open cardiac surgery. Catheter and cannula placement are facilitated by transesophageal echocardiography and fluoroscopy. Application of the technique introduces unique monitoring considerations to the anesthesiologist. 2 During CPB, verification of proper positioning of the endoaortic balloon is vital because distal migration may compromise cerebral blood flow by occluding the brachiocephalic artery. Bilateral radial artery catheters are routinely used in most institutions to ensure proper positioning of the endoaortic balloon in the ascending aorta throughout CPB. 2 The authors report the successful management of a patient undergoing Port-Access cardiac surgery in whom radial artery pressures could not be monitored.

The Role of Transesophageal Echocardiography During Port-Access Minimally Invasive Cardiac Surgery: A New Challenge for the Echocardiographer.

The recent development of endovascular catheters that are placed via the femoral artery and vein has enabled patients to be placed on cardiopulmonary bypass without the need for direct visualization of the heart or great vessels via sternotomy. This has allowed cardiac surgery to be performed through smaller, thoracotomy incisions. Placement of these catheters initially was performed under fluoroscopic guidance, which has major imaging limitations. Now, transesophageal echocardiography (TEE) has replaced fluoroscopy as the primary imaging technique to assist in the placement of endovascular catheters during minimally invasive, port-access cardiac surgery. In our institution, 449 port-access procedures have been performed from May 1996 through July 1998. We found that TEE is able to adequately visualize the cardiac structures and assist in the placement of the endovascular catheters in all patients. Fluoroscopy is helpful only as an aid to the use of TEE for placement of the coronary sinus catheter.

Complications of port-access cardiac surgery.

Port-Access cardiac surgery is a recent technology that is undergoing rapid development. The learning curve associated with this technique is a challenge even for the skilled and experienced cardiac surgeon. Mainly because of femoral cannulation, the use of guidewires, and working through small incisions, Port-Access cardiac surgery contains certain pitfalls that are clearly associated with the technology involved. These pitfalls currently require troubleshooting, but as the technology progresses, this may become less of an issue. Communicating these pitfalls to others is important to help others to avoid or better manage complications and to contribute to improving the technology of Port-Access techniques.

Complications of Minimally Invasive Cardiac Surgical Procedures

All surgical and anesthetic procedures convey some degree of risk. New procedures in cardiac surgery are being developed for which patterns of complications are just beginning to emerge. The experience with minimally invasive direct coronary bypass, transmyocar dial laser revascularization, and Port-Access cardiac surgery is reviewed with emphasis on perioperative complications and causes of early morbidity and mortal ity.

Port-Access Cardiac Surgery: Anesthetic Techniques, Equipment, Applications, Experience, and Outcomes

Port-Access (Heartport, Inc, Redwood City, CA) mini mally invasive surgery has been developed to allow surgeons to complete a wide variety of cardiac surgical procedures while avoiding a median sternotomy and the associated trauma and debility. Cardiopulmonary bypass is established using the EndoDirect (Heartport, Inc) or EndoCPB systems which consist of five catheters and cannulae providing the same functions as those used in conventional cardiac surgery. These systems enable surgeons to obtain appropriate myocardial pro tection, circulatory support, and operating conditions while operating through a small intercostal incision or port. Transesophageal echocardiography and/or fluoros copy are used to evaluate patient anatomy including assessment of the aorta, to facilitate the placement of catheters and cannulae, and to monitor during the conduct of cardiopulmonary bypass. Clinical reports have shown broad applicability of Port-Access proce dures with favorable outcomes. Morbidity and mortal ity compare well with reported rates for conventional surgery. Experience with multivessel coronary artery bypass grafting suggests that complete revasculariza tion for all coronary beds can be accomplished using a variety of venous and arterial conduits. Clinical studies suggest that Port-Access surgery is associated with short postoperative duration of tracheal intubation, intensive care unit stay, and hospital stay, a low inci dence of new-onset atrial fibrillation, and rapid return to normal activities. Clinical experience continues to ex pand the indications for Port-Access minimally invasive cardiac surgery as well as to refine and enhance surgical procedures.

Clinical Experience with Minimally Invasive Coronary Artery and Mitral Valve Surgery with the Advantage of Cardiopulmonary Bypass and Cardioplegic Arrest Using the Port Access Technique

To minimize surgical trauma, the use of Port Access cardiac surgery was initiated in patients (pts) with coronary artery disease (CAD) (42 pts) or mitral valve disease (MVD) (24 pts) in March 1996 at our institution. Altogether 42 pts (36 men, 6 women; age 31-75 years, median 59.0 years) with isolated lesions of the left anterior descending (LAD) artery underwent Port Access coronary artery surgery (PACAS). A small (5-9 cm) incision was done parasternally on top on the fourth rib. The left internal mammary artery (LIMA) was dissected through the minithoracotomy or by using an additional thoracoscopic approach. A total of 24 pts (12 men, 12 women; age 30-75 years, median 62 years) underwent Port Access mitral valve surgery (PAMVS). In these pts the procedure was performed through a small right thoracotomy (6-8 cm). In all cases, endovascular cardiopulmonary bypass (CPB) was instituted through femoral cannulation, and an additional endoaortic balloon catheter was introduced into the ascending aorta for aortic occlusion. In pts with PACAS the survival was 98% (41/42) and in the PAMVS group 100%. All pts but one survived the PACAS and are well today. There were no deaths in the PAMVS group. The hospital stay was reduced by 1 day on average after PACAS and 3 days after PAMVS. Thus in well selected patients Port Access cardiac surgery represents a safe and feasible minimally invasive surgical approach that avoids the potential complications of a sternotomy while offering the advantages and safety of CPB and cardioplegic arrest. This minimally invasive approach offers a shortened hospital stay and earlier rehabilitation.

Minimally invasive cardiac surgery using the heartport technique

Background: Minimally invasive cardiac surgery has been developed in part as a result of progress in video-assisted and endovascular surgical techniques. Port-access cardiac surgery, which provides cardiopulmonary bypass, cardioplegic arrest, myocardial protection, and ventricular decompression, permits various procedures to be performed through smaller, less invasive incisions. Methods: Proper patient selection is emphasised in order to minimise potential complications with the port-access system. For port-access coronary revascularisation procedures, a limited left anterior thoracotomy allows harvesting of the internal mammary artery and access to the target coronary arteries. The ascending aorta can be exposed for placement of vein grafts. For port-access mitral valve surgery, a limited right thoracotomy provides direct visualisation of the left atrium and the mitral valve. Results: The feasibility and efficacy of port-access coronary revascularisation and mitral valve surgery have been demonstrated in experimental and clinical settings. Peripheral cardiopulmonary bypass with cardioplegic arrest has been reproducibly achieved based on indices of cardiac function. Port-access multivessel coronary revascularisation and port-access mitral valve procedures have been performed with acceptable results. Conclusions: The port-access catheter system effectively achieves peripheral cardiopulmonary bypass, aortic occlusion, cardioplegia delivery, and left ventricular decompression. Alternative, less invasive methods of coronary revascularisation and various intracardiac procedures can be performed without a conventional median sternotomy.

PORT-ACCESS MINIMALLY INVASIVE MULTI-VESSEL CABG IS ASSOCIATED WITH SHORT POST-OPERATIVE DURATION OF TRACHEAL INTUBATION, ICU STAY AND HOSPITAL STAY

Introduction: Avoidance of a median sternotomy with minimally invasive cardiac surgery may alter the duration of post-operative tracheal intubation, intensive care stay, and hospitalization. Port-Access minimally invasive cardiac surgery uses a system of catheters and cannulae which permit cardiopulmonary bypass and myocardial protection to be achieved without accessing the heart via a median sternotomy. With this system, coronary artery bypass grafting is accomplished through a small intercostal incision. Methods: A multi-center, prospectively collected database of Port-Access cardiac surgery patients was queried with respect to duration of post-operative tracheal intubation (TI), intensive care stay (ICU), post-operative length of hospital stay (POLOS), pre-operative medical history, and perioperative morbidity and mortality. Certain centers participated in data collection by completing a simplified case report form which did not include TI, ICU and some elements of pre-operative medical history. POLOS, morbidity, and mortality data were collected for all patients. The database is maintained by an independent contract research organization and analyses are directed by a steering committee of cardiac physicians. The identified population was patients who received multi-vessel Port-Access CABG in the United States. Results: Between June 2, 1997 and August 25, 1998, 804 patients had multi-vessel Port-Access CABG (mean grafts=2.6) at 75 institutions with 579 patients reported on the simplified form. There were 10 (1.2%) peri-operative deaths, and these patients were excluded from further analysis. The following Table 1 and Table 2 describes results from the present study. To facilitate interpretation of these data, results from a University HealthSystem Consortium (UHC) study of 1,094 non-emergent, non-fatal, first time CABG procedures performed at 40 academic hospitals are also shown [1]:Table 1Table 2Conclusions: Port-Access minimally invasive multi-vessel CABG is associated with short post-operative duration of tracheal intubation, ICU stay and hospital stay. Further investigation will permit direct comparison of various surgical methods.