Thoracoscopic Cardiac Surgery Research Articles

Technical exploration and early results of two-port total thoracoscopic aortic-mitral double-valve replacement

Objective: To examine the clinical outcomes of patients undergoing total thoracoscopic aortic-mitral double-valve replacement. Methods: This is a retrospective case series study. The clinical data of 50 patients who underwent double-valve replacement under a total thoracoscopic two-port approach from November 2021 to August 2022 in the Department of Cardiovascular Surgery, Fujian Medical University Union Hospital were retrospectively analyzed. There were 32 males and 18 females, with an age of (55.3±8.8) years (range: 21 to 62 years). Among them, 36 cases had rheumatic heart disease and 14 cases had infective endocarditis. The 3rd intercostal space between the right anterior axillary line and the midclavicular line was selected as the main operating hole, the total thoracoscopic double-valve replacement were successfully carried out. Baseline data, intraoperative information, surgical outcomes, and postoperative complications were collected for all patients. Results: The cardiopulmonary bypass time was (168.2±30.9) minutes (range: 125 to 187 minutes), the aortic cross-clamping time was (118.8±16.5) minutes (range: 96 to 147 minutes). Five patients received bioprosthetic valves, and 45 received mechanical prosthetic valves. Postoperative mechanical ventilation lasted (9.6±3.4) hours (range: 5.1 to 14.2 hours), the ICU stay was (24.8±7.3) hours (range: 16.3 to 30.1 hours), and the postoperative hospital stay was (6.5±1.2) days (range: 5.0 to 8.0 days). Four patients received red blood cell transfusions of (2.7±0.9) units (range: 2 to 4 units), and the postoperative chest drainage volume was (222.1±56.3) ml (range: 175 to 289 ml). No deaths occurred intraoperatively or in the early postoperative period. One patient required reoperation due to bleeding in the aortic incision. Three patients had mild to moderate paravalvular leakage around the prosthetic aortic valve, with no cases of third-degree atrioventricular block or conversions to median sternotomy. Conclusions: The early outcomes of total thoracoscopic double valve replacement surgery are satisfactory, demonstrating safety and efficacy. This surgical approach expands the scope of total thoracoscopic cardiac surgery, which warrants further investigation and research.

Innovations and Developments in Totally Thoracoscopic Cardiac Procedures

New technology is increasing being introduced to minimizing the invasiveness of cardiac surgery. In addition to catheter based interventions and robotic-assisted procedures, totally thoracoscopic cardiac surgery (TTCS) has emerged as a new minimally invasive technique in the cardiac surgeons' armamentarium to treat cardiovascular disease. This review summarizes the existing literature on TTCS and provides updates on the exploration and management of TTCS in various cardiac diseases including mitral and tricuspid valve dysfunction, congenital heart defects, tumors, and hypertrophic obstructive cardiomyopathy. Due to small port incisions and high cost-effectiveness, TTCS has been increasingly embraced by both patients and surgeons. This review summarizes the literature on TTCS and how it may minimize the morbidity associated with open cardiac surgical procedures and result in faster recovery and earlier discharge from the hospital.

Impact of One-Lung Ventilation on Oxygenation and Ventilation Time in Thoracoscopic Heart Surgery: A Comparative Analysis with Median Thoracotomy.

BACKGROUND One-lung ventilation is the separation of the lungs by mechanical methods to allow ventilation of only one lung, particularly when there is pathology in the other lung. This retrospective study from a single center aimed to compare 49 patients undergoing thoracoscopic cardiac surgery using one-lung ventilation with 48 patients undergoing thoracoscopic cardiac surgery with median thoracotomy. MATERIAL AND METHODS This single-center retrospective study analyzed patients who underwent thoracoscopic cardiac surgery based on one-lung ventilation (experimental group, n=49). Other patients undergoing a median thoracotomy cardiac operation were defined as the comparison group (n=48). The oxygenation index and the mechanical ventilation time were also recorded. RESULTS There was no significant difference in the immediate oxygenation index between the experimental group and comparison group (P>0.05). There was no significant difference for the oxygenation index between men and women in both groups (P>0.05). The cardiopulmonary bypass time significantly affected the oxygenation index (F=7.200, P=0.009). Operation methods (one-lung ventilation thoracoscopy or median thoracotomy) affected postoperative ventilator use time (F=8.337, P=0.005). Cardiopulmonary bypass time (F=16.002, P<0.001) and age (F=4.384, P=0.039) had significant effects on ventilator use time. There was no significant effect of sex (F=0.75, P=0.389) on ventilator use time. CONCLUSIONS Our results indicated that one-lung ventilation thoracoscopic cardiac surgery did not affect the immediate postoperative oxygenation index; however, cardiopulmonary bypass time did significantly affect the immediate postoperative oxygenation index. Also, one-lung ventilation thoracoscopic cardiac surgery had a shorter postoperative mechanical ventilation use time than did traditional median thoracotomy cardiac surgery.

Custodiol Histidine-Tryptophan-ketoglutarate Versus Blood Cardioplegia in Totally Thoracoscopic Cardiac Surgery

Objective: The present study aimed to evaluate and compare the myocardial protection performance between Custodial histidine-tryptophan-ketoglutarate cardioplegic solution and blood cardioplegic solution in the context of totally thoracoscopic cardiac surgery. Methods: A total of 101 patients who underwent thoracoscopic cardiac surgery adopting either blood cardioplegic or histidine-tryptophan-ketoglutarate solution at Guangdong Provincial People’s Hospital from January 2021 to December 2021 were retrospectively enrolled. Postoperative outcomes assessed by myocardial enzyme level, the capacity of return to spontaneous rhythm, left ventricle ejection fraction, myocardial infarction, vasoactive-inotropic score, mechanical ventilation time, intensive care unit stay, hospital stay, mechanical circulatory support, and in-hospital mortality were compared between the two groups. Results: 69 and 32 patients adopted blood cardioplegic and histidine-tryptophan-ketoglutarate solutions, respectively. The cardiac troponin I and creatine kinase-MB at the peak period or at the postoperative period of &lt;24h, 24-48h, and &gt;48h were similar between the two groups (p&gt;0.05). There was also no significance regarding the postoperative left ventricle ejection fraction, vasoactive-inotropic score, and incidence of myocardial infarction (p&gt;0.05). However, blood cardioplegic solution administration resulted in a significantly more occurrence of return to spontaneous rhythm in contrast to the histidine-tryptophan-ketoglutarate solution (p=0.025). Multivariate logistic regression for outcomes revealed that histidine-tryptophan-ketoglutarate administration was associated with a lower possibility to return to spontaneous rhythm (odds ratio (OR)=0.238; confidence interval CI=0.072-0.783; p=0.018]. Additionally, increased aortic cross-clamp time per 10 mins was associated with a higher risk of myocardial infarction (OR=1.499; CI=1.161-1.934; p=0.002) while increased total volume was associated with a lower risk of myocardial infarction (OR=0.997; CI=0.994-0.999; p=0.029) Conclusion: Delivery of histidine-tryptophan-ketoglutarate solution offered equivalent myocardial protection to the delivery of blood cardioplegic solution in patients undergoing totally thoracoscopic cardiac surgery. In this setting, the histidine-tryptophan-ketoglutarate seems to be associated with decreased incidence of postoperative return to spontaneous rhythm.

The anesthesia management of totally thoracoscopic cardiac surgery: A single-center retrospective study

Anesthesia management of Totally thoracoscopic cardiac surgery (TTCS) has been the subject of much debate and discussion. In this single center retrospective study, we summarize the experience of clinical anesthesia management for TTCS by review the medical records of our medical center and look forward to its future development. In this retrospective study, 103 patients (49 male and 54 female) were enrolled, the mean age was 56.7 ± 14.4 years old. The participants underwent Mitral Valve Replacement (MVR) + Tricuspid Valve Annuloplasty (TVA) (42, 40.8%), Mitral Valve Annuloplasty (MVA) + TVA (38, 36.9%), MVA (21, 20.4%), and MVR (2, 1.9%)，respectively. Intraoperative hypoxemia, radiographic pulmonary infiltrates, and pneumonia were observed in 19 (18.4%), 84 (81.6%), and 13 (12.6%) patients, respectively. The LOS of ICU and POD were as follows: MVR + TVA (55.1 ± 25h, 9.9 ± 3.5 d), MVA + TVA (56.5 ± 28.4h, 9.4 ± 4.2d), MVA (37.9 ± 21.9h, 8.1 ± 2.3d) and MVR (48 ± 4.2h, 7.5 ± 2.1d). No reintubation, reoperations, postoperative cognitive dysfunction, 30-day mortality were observed in the present study. The present study demonstrated that applying this anesthesia management for TTCS associated with acceptable morbidity, intensive care unit and postoperative hospital lengths of stay. The finding from the present study might provide some new approach for Anesthesia management of TTCS.

Is tri-port totally thoracoscopic surgery for mitral valve replacement a feasible approach?

Minimally invasive cardiac surgery is an attractive approach for both surgeons and patients. This study aims to describe the experience of mitral valve replacement (MVR) with Ma's tri-port totally thoracoscopic cardiac surgery technique (MTCST) and to prove the feasibility and safety of this technique. A total of 490 consecutive patients undergoing MVR were divided into MTCST group (MT group, n=267) and conventional median sternotomy group (MS group, n=223). The perioperative characteristics and the follow-up information were recorded and analyzed between the two groups. The in-hospital mortality and re-operation rate were not significant between the two groups. Compared with the MS group, cardiopulmonary bypass time and aortic cross-clamp time were both longer in the MT group while total operative time was similar to the MS group. Patients in the MT group had less pain and required a decreased analgesic administration than that in the MS group. Intraoperative blood loss, perioperative blood transfusion and the postoperative drainage were all significantly reduced in the MT group as compared to the MS group. Mechanical ventilation time, ICU duration, hospitalization time and hospitalization cost were decreased in the MT group. Patients undergoing MVR with MTCST had a higher Medical Treatment Satisfactory Score than those with conventional sternotomy. MTCST for mitral valve disease was technically safe and feasible. The results showed that MTCST was a suitable minimally invasive alternative to the conventional sternotomy approach and was a desirable approach for patients with mitral valve disease.

The use of the Scar Cosmesis Assessment and rating scale to evaluate the cosmetic outcomes of totally thoracoscopic cardiac surgery

BackgroundConventional median sternotomy is widely used in cardiac surgery, while thoracoscopic cardiac surgery, which is considered to have aesthetic advantages, is being performed increasingly more often in China because patients’ requests for minimally invasive procedures yielding aesthetically pleasing results have significantly increased. Few studies have been conducted to assess surgical scars after cardiac surgery. Compared to the median sternotomy approach, multiple-incision totally thoracoscopic cardiac surgery requires smaller but numerous and scattered incisions. In addition to two working ports on the upper and lower margins of the right breast, an inguinal incision and an axillary incision are made. Therefore, does totally thoracoscopic cardiac surgery truly have aesthetic advantages? This study has the following objectives: (a) to compare median sternotomy cardiac surgery and total thoracoscopic cardiac surgery in terms of the long-term cosmetic outcomes of post-operative scars and (b) to evaluate the effectiveness of the Scar Cosmesis Assessment and Rating scale in combination with the numeric rating scale in the assessment of surgical scars after cardiac surgery.MethodsConsecutive patients who visited our institution from January 2019 to May 2019 for cardiac surgery via median sternotomy or the totally thoracoscopic approach and followed up for at least one year were included. Inter-rater reliability, internal consistency and convergent validity were evaluated for the Scar Cosmesis Assessment and Rating scale and the numeric rating scale. Clinical characteristics and the scores of the two scales were compared between the two groups using Student’s t test or the Mann-Whitney U test.ResultsThirty-one patients underwent cardiac surgery via the totally thoracoscopic approach, and 42 patients underwent cardiac surgery via the median sternotomy approach. No significant differences were found in the demographic or clinical data between the two groups. The validity and reliability of the two scales were satisfactory. For the Scar Cosmesis Assessment and Rating scale, the median sternotomy group scored statistically significantly higher than did the totally thoracoscopic group on the “overall impression” and “patient question” subscales (P < 0.05). The overall scores of the Scar Cosmesis Assessment and Rating scale and numeric rating scale were statistically significantly different (P < 0.05).ConclusionsThe Scar Cosmesis Assessment and Rating scale in combination with the numeric rating scale is an effective tool for the assessment of scar aesthetics after cardiac surgery. Surgical scars of totally thoracoscopic cardiac surgery can yield desirable cosmetic outcomes in Chinese individuals, especially in susceptible individuals with a high risk of keloid and hypertrophic scars. Patients with appropriate indications can undergo cardiac surgery with the totally thoracoscopic approach and exhibit a satisfactory scar appearance.

Dexmedetomidine Improves Lung Function by Promoting Inflammation Resolution in Patients Undergoing Totally Thoracoscopic Cardiac Surgery.

Objective Totally thoracoscopic cardiac surgery under cardiopulmonary bypass combined with one-lung ventilation has been identified as the trend in cardiac surgery. The aim of this study was to examine the effects of the selective α2 adrenergic receptor agonist dexmedetomidine on the pulmonary function of patients who underwent mitral valve surgery using the totally thoracoscopic technique. Methods Fifty-seven patients who underwent thoracoscopic mitral valve surgery between July 2019 and December 2019 were selected. The patients were randomly divided into the control (Con) group (n = 28) and the dexmedetomidine (DEX) group (n = 29) using the random number table method. Arterial blood gas analyses were performed, and the oxygenation (PaO2/FiO2) and respiratory indexes (P(A-a)O/PaO2) were calculated 5 min after tracheal intubation (T1), 2 h after operation (T2), 6 h after operation (T3), and 24 h after operation (T4). Moreover, the serum cytokines interleukin-6 (IL-6), tumor necrosis factor-α (TNF-α), and intercellular adhesion molecule-1 (ICAM-1) were detected using the enzyme-linked immunosorbent method at all time points. Chest radiography was performed 24 h after surgery. Peripheral blood samples were collected before and after the operation for a complete hemogram. Additionally, the procalcitonin concentration was measured and recorded when the patients were transported to the intensive care unit (ICU). The postoperative extubation time, length of ICU stay, and pulmonary infection rate were also recorded. Results Inflammatory reaction after surgery was evident. However, the inflammatory cytokines IL-6, TNF-α, and ICAM-1 in the DEX group were lower than those in the Con group after surgery (T2 to T4; P < 0.05). Neutrophil counts and procalcitonin concentration were higher in the Con group than in the DEX group (P < 0.05). In addition, in the DEX group, pulmonary exudation on chest radiography was lower, and pulmonary function, as shown by an increase in oxidation index and decrease in the respiratory index, improved after surgery (P < 0.05). Moreover, the duration of mechanical ventilation in the Con group was 3.4 h longer than that in the DEX group. Conclusion Dexmedetomidine has a protective effect on pulmonary function in patients undergoing mitral valve surgery using a totally video-assisted thoracoscopic technique, which may be related to a reduction in the concentration of inflammatory cytokines in the early perioperative period.

Safety of total thoracoscopic cardiac surgery

Objective To explore the clinical effect of total thoracoscopic cardiac surgery. Methods A total of 110 patients undergoing mitral valve replacement surgery were enrolled in our hospital from August 2014 to November 2017 .They were divided into observation group (total thoracoscopic heart surgery) and control group (traditional center) according to different surgical methods. The surgical data were retrospectively analyze in the two groups. Results There was no significant difference in intraoperative blood transfusion and operation time between the two groups (t=0.710 and 1.610; P>0.05), but the aortic block time and extracorporeal circulation time in the observation group were significantly longer than those in the control group (t=4.380 and 6.340; P 0.05), and the proportion of postoperative analgesics used in 10 patients (18.18%) in the observation group was significantly lower than that in 29 patients (52.73%) in the control group (χ2=14.341, P<0.05). Conclusion Total thoracoscopic cardiac surgery and traditional median thoracotomy are effective mitral valve replacement methods, and the safety of the two is equivalent. Under the premise of reasonable understanding of the indications, total thoracoscopic cardiac surgery can effectively reduce the operation trauma and postoperative drainage, and promote recovery of patients as soon as possible after surgery, leading to the improvement of the quality of life of patients. Key words: Mitral valve replacement surgery; Total thoracoscopic surgery; Median thoracotomy; Safety

Experience of totally thoracoscopic cardiac surgery of cardiopulmonary bypass in children with congenital heart disease

Objective To review the experiences of 31 cases of totally thoracoscopic cardiac surgery of cardiopulmonary bypass in children with congenital heart disease. Methods Thirty one children with congenital heart disease received totally thoracoscopic cardiac surgery procedures during the period from October 2012 to May 2016. The ages of these children were ranged from 2 years and 7 months old to 6 years old with average value (4.6±1.4)years old. The body weights were ranged from 12~24 kg with average value (17±3.5)kg. Among 31 children, there were 12 cases of atrial septal defect, and 19 cases of ventricular septal defect. Through three-hole shape incision at the right chest wall, each hole was 1.5 to 2.0 cm long, and operation field were revealed totally by thoracoscope. Cardiopulmonary bypass was built through femoral arteriovenous intubation. Results Thirty one children were all cured. None of them suffered severe complications such as renal failure, respiratory failure, low cardiac output syndrome, atrioventricular block, and residual shunt. Duration of cardiopulmonary bypass was 62~185 (126.4±45.2)min, and duration of myocardial ischemia was 18~118 (53.4±31.2)min. Duration of Postoperative mechanical ventilation was 2~7 (5.3±1.5)h. Duration of intensive care unit (ICU) stay was 15~21 (19±1.3)h. Drainage volume of 24 hours after operation was 0~130(57±36.2)ml. Volume of red blood cell transfusion was 0~2 (1.2±0.8)U. Postoperative hospital stay was 4~7 (6.2±1.2)d. Conclusions For children with congenital heart disease as simple atrial septal defect or ventricular septal defect, thoracoscopic surgical repair can be achieved the same therapeutic results as traditional median sternotomy surgery while having advantages such as smaller incision, less bleeding and none sternal malunions. Key words: Thoracoscopy; Heart defects, congenital/SU; Extracorporeal circulation

Clinical outcome of totally thoracoscopic cardiac surgery for mitral valve replacement: a series of 634 cases

To summarize the clinical outcome of totally thoracoscopic cardiac surgery for mitral valve replacement. Clinical data of 634 cases undergoing totally thoracoscopic cardiac surgery for mitral valve replacement from May 2004 to February 2016 in Department of Thoracoscopic Cardiacsurgery, Shanghai Yodak Cardiothoracic Hospital was analyzed retrospectively. There were 292 male and 342 female patients, aged from 17 to 68 years with a mean of (45±13) years. All the 634 patients had moderate-severe mitral valve stenosis and (or) incompetence, 263 patients had moderate-severe tricuspid valve incompetence, 356 patients had atrial fibrillation, 46 patients had left atrium thrombosis. Cardiopulmonary bypass was established with right femoral artery and a single 2 stage venus cannula in the right atrium. The ascending aorta was cross-clamped and the myocardium was protected by coronary perfusion with cold crystalloid cardioplegia. Totally thoracoscopic mitral valve replacement were performed. Thirteen cases had incision expanded and 8 cases had conversions to sternotomy. Cardiopulmonary bypass and aortic cross-clamp time were (89±18) minutes and (51±12) minutes, respectively. Operation time was (3.1±1.2) hours. Mechanical ventilation time and intensive care unit stay were (17±6) hours and (27±8) hours, respectively. Postoperation drainage quantity was (390±70) ml. The hospital days was (9.2±2.1) days. There were 5 cases in-hospital deaths. Postoperative complications occurred in 42 cases (6.6%), including 18 cases of right hemoneumothorax, 12 cases of reoperation for bleeding, 3 cases of perivalvular leakage (reoperation was done in 1 patient), 3 cases of low cardiac output syndrome, 2 cases of acute renal failure, 2 cases of inferior vena cava injury, 1 case of right femoral artery thrombosis and liver injury, respectively. The mean duration of follow-up was (58±9) months in 608 cases, with a follow-up rate of 96.7% (608/629). Three patients had died during the period of follow-up caused by congestive heart failure (2 patients) and stroke (1 patient). Late complication among 605 survivors were 37 cases, including 32 cases of moderate tricuspid valve insufficiency, 3 cases of stroke, 1 case of perivalvular leakage and infective endocarditis, respectively.There was no reoperation during the period of follow-up. Totally thoracoscopic cardiac surgery for mitral valve replacement is safe and effective, with unique superiority and clinical feasible.

Clinical experience of 2 543 cases of congenital heart diseases undergoing totally thoracoscopic cardiac surgery in a single center

To summarize the experience of totally thoracoscopic cardiac surgical (TTCS) at congenital heart diseases (CHD) treatment. From April 2000 to March 2016, 2 543 patients with CHD underwent TTCS in Department of Cardiovascular Surgery, Xijing Hospital, Fourth Military Medical University, including 957 male and 1 586 female patients. The age ranged from 0.5 to 66.0 years with a mean age of (21±18) years. The body weight ranged from 6 to 118 kg with a mean of (49±30) kg. Patients were diagnosed with echocardiography or transesophagel echocardiography as complex or complicated CHD which was unsuitable for percutaneous procedure. Surgical procedures were performed through 3 holes inserted at the right chest wall, and catheters were placed in the right femoral artery and vein to set up cardiopulmonary bypass.The ascending aorta was cross-clamped with long tailor-made forceps and the myocardium was protected by coronary perfusion with cold crystalloid(blood)cardioplegia. There were 787 cases (from January 2013 to December 2015) were selected to compare with 710 cases underwent conventional thoracotomy over the same period. Statistical analysis was performed by t test, t' test, rank-sum test, χ(2) test and Fisher exact test, respectively. The total death rate and the major complication rate of the operation were 0.35% (9/2 543) and 2.28% (58/2 543), respectively. All patients were followed up 1 to 190 months and the average follow-up time was (75±34) months. No residual shunt or obvious mitral/tricuspid regurgitation was observed, and the patients gained better cardiac function as level Ⅰ to Ⅱ (New York Heart Association classification). There was no significant difference in aorta clamp time, ICU stay, hospital cost, and surgical fatality rate between 787 patients underwent TTCS and 710 conventional thoracotomy. The cardiopulmonary bypass time ((31±20) minuets vs. (40±17) minuets, t'=9.407, P=0.001), operation time ((91±27) minuets vs. ( 102±64) minuets, t'=4.251, P=0.000), hospital stay ((5.3±2.2) d vs. (13.0±4.0) d, t'=45.463, P=0.000), postoperative drainage (M(QR): 33(17) ml vs. 121(53) ml, T=2.632, P=0.000) and major complications (7/787 vs. 23/710, χ(2)=10.49, P=0.001) were significantly reduced and no sternal deformation occurrence (0 vs. 192/710, χ(2)=244.10, P=0.000) in TTCS group. While the cost was higher in TTCS group ((24 000±400) yuan vs. (20 000±400) yuan, t=19.320, P=0.000). TTCS is feasible, safe, and minimal invasive for patients with CHD, resulting in quick recovery and good median-long term outcomes.

Thought on the techniques of totally thoracoscopic cardiac surgery

Minimally invasive surgery has become the guiding principle of the entire surgical treatment. In last 16 years, totally thoracoscopic cardiac surgery (TTCS) has developed rapidly, and achieved good results. However, there are obvious differences between the basic surgical techniques of TTCS and of conventional cardiac surgery. At present, there is still lack of standard and in sufficient evidence in the surgical techniques of TTCS. It requires professional and standardized training and evidence-based research on TTCS, including indication selection and procedure standardization, to improve the therapy level of TTCS further.

Totally thoracoscopic repair of atrial septal defect reduces systemic inflammatory reaction and myocardial damage in initial patients

BackgroundTo compare the effect of totally thoracoscopic with conventional, open repair of atrial septal defect.MethodsForty atrial septal defect cases were divided into two groups by surgical approach: totally thoracoscopic approach (group A, n = 20) and conventional open approach (group B, n = 20). In group A, surgical procedures were performed through three portal incisions in the right lateral chest wall under thoracoscopic vision without the aid of a computerized robotic surgical system. Notably, all operations were completed by one surgeon who had just begun using this technique. In group B, the atrial septal defects were repaired in conventional open fashion. Clinical outcomes and serum levels of tumor necrosis factor α (TNF-α), interleukin-6 (IL-6), interleukin-10 (IL-10), intercellular adhesion molecule 1 (ICAM-1), and creatine kinase isoenzyme-myocardial band (CK-MB) for the two groups were evaluated and compared.ResultsAll operations were performed successfully without serious complications. Durations of cardiopulmonary bypass (CPB), CPB setup, aortic cross-clamping, and operative procedure were significantly longer in group A than in group B (P < 0.05). The recovery times for body temperature and laboratory values of leukocytes were significantly shorter for group A than for group B (P < 0.05). There were no differences in durations of postoperative assisted ventilation or intensive care unit and hospital stays, volumes of blood transfused intraoperatively or thoracic drainage, or medical costs between the two groups. Serum levels of inflammatory factors (TNF-α, IL-6, IL-10, and ICAM-1) and CK-MB increased significantly in both groups after surgery. However, 6 h and 12 h after surgery, levels of these inflammatory factors and CK-MB were significantly lower in group A than in group B (P < 0.05).ConclusionsThoracoscopic cardiac surgery is technically feasible and safe, with less trauma and quicker recovery even when done by a surgeon newly introduced to the technique.

Superior Vena Cava Drainage During Thoracoscopic Cardiac Surgery: Bilateral Internal Jugular Vein Sheaths Versus One Percutaneous Superior Vena Cava Cannula

To evaluate bilateral internal jugular vein sheaths as a replacement of one percutaneous superior vena cava cannula for superior vena cava drainage during thoracoscopic cardiac surgery. A prospective and randomized study. Single cardiovascular institute. Adults undergoing thoracoscopic cardiac surgery. Patients were randomized into a percutaneous superior vena cava cannula group and a bilateral internal jugular vein sheaths group. The superior vena cava drainage for cardiopulmonary bypass was performed with one percutaneous superior vena cava cannula (14-18 Fr) or the bilateral internal jugular vein sheaths (8 Fr). Both interventions reached theoretic flow rate in all patients. In patients weighing<50 kg (n=38) and 50-70 kg (n=64), the average central venous pressure values during cardiopulmonary bypass of both groups showed no significant differences. The patients weighing>70 kg (n=15) in the bilateral internal jugular vein sheaths group had a normal average central venous pressure value, but it was significantly higher than that of percutaneous superior vena cava cannula group ([10.5±3.1] mmHg vs. [4.5±4.4] mmHg, p=0.013). The patient satisfaction scale scores for the cervical incisions were significantly higher in the bilateral internal jugular vein sheaths group than in the percutaneous superior vena cava cannula group ([2.6±0.9] vs. [2.1±0.8], p=0.002). The bilateral internal jugular vein sheaths were a feasible and effective option to replace one percutaneous superior vena cava cannula during thoracoscopic cardiac surgery, with better patient satisfaction.

Technical Aspects of Anesthesia and Cardiopulmonary Bypass in Patients Undergoing Totally Thoracoscopic Cardiac Surgery

The use of fast-track general anesthesia in patients undergoing nonrobotically assisted and totally thoracoscopic cardiac surgeries has not been previously reported previously. A prospective clinical study. A university hospital. Ninety-six patients (41 males; mean age, 13.2 ± 6.2 years; range, 5-47 years). Nonrobotically assisted totally thoracoscopic surgeries were performed for atrial (n = 58) or ventricular septal defect (n = 32), tetralogy of Fallot (n = 2), left atrial myxoma (n = 3), and pulmonary valve stenosis (n = 1). Fast-track general anesthesia was induced with midazolam, propofol, fentanyl, and vecuronium and was maintained with remifentanil and sevoflurane. Cardiopulmonary bypass was established peripherally through the femoral vein and artery. All surgeries were successful. There were no perioperative mortality or major complications. The mean cardiopulmonary bypass and aortic cross-clamp times were 42 ± 21 minutes and 33 ± 8 minutes, respectively. In 82 cases, the heart regained beats automatically after the release of the aortic cross-clamp, whereas in 14 patients external defibrillation was required. Extubation was conducted in 32 patients (33.3%) in the operating room 15 minutes after the operation. The mean times of mechanical ventilation and stay in the intensive care unit were 1.5 ± 0.2 hours and 20.1 ±1.2 hours, respectively. Cardiopulmonary bypass for totally thoracoscopic cardiac surgery can be established through the femoral artery and femoral vein. With fast-track anesthesia, early extubation in the operating room can be achieved in more than one third of patients.

Totally Thoracoscopic Surgical Closure of Atrial Septal Defect in Small Children

Totally thoracoscopic cardiac surgery is an alternative to traditional cardiac surgery in adults, and in few cases, in small children. This study assesses totally thoracoscopic cardiac surgery and its advantages for application to small children with low body weight. From March 2009 to October 2010, 28 patients, with a mean age of 5.8±2.1 years and mean weight of 15.0±4.65 kg (range, 13.5 to 22 kg), underwent totally thoracoscopic atrial septal defect closure. Three incisions 1.0 cm to 2.5 cm in length were made on the chest wall. Direct sutures were made in 20 patients, whereas Dacron patches were used in 8 patients. Mean follow-up was 6 months (range, 0 to 24 months). Cardiopulmonary bypass time was 56 to 126 minutes, and the aortic cross-clamp time was 36 to 65 minutes. A total of 28 cases were classified as New York Heart Association functional class I. No patient required further operation. Totally thoracoscopic surgical atrial septal defect closure in small children is feasible, minimally invasive, safe, and has good cosmesis.

Thoracoscopic cardiac surgical procedures: a report of 674 cases

To evaluate the efficacy and safety of thoracoscopic cardiac surgical procedures under extracorporeal circulation. From May 2000 to May 2006, 674 patients received thoracoscopic cardiac surgery under extracorporeal circulation. These procedures included atrial septal defect occlusion for 238 patients, ventricular septal defect occlusion for 380 patients and mitral valve replacement for 56 patients. Thirty degree thoracoscopes and femoral extracorporeal circulation were used. The aorta was cross-clamped and the myocardium was protected by coronary perfusion with cold crystal or blood cardioplegia. The operation succeed in 645 patients (96%, 645/674). Enlarging the incision was performed in 28 patients. Operation time was from 1.8 h to 5.6 h with the mean of (2.8 +/- 1.2) h. Cardiopulmonary bypass time was from 56 min to 198 min with the mean of (78 +/- 2.3) min. Aortic cross-clamp time was from 8 min to 96 min with the mean of (31 +/- 19) min. The volume of chest drainage was (140 +/- 46) ml. None but one postoperative death occurred, the mortality was 0.15%. Postoperative complications occurred in 48 cases (7%), including bleeding in 8 patients, leakage in 5 patients (reoperation in 2 patients) and hemo-pneumothorax in 33 patients. One patient died postoperatively from cerebral hemorrhage (0.15%, 1/647). Thoracoscopic cardiac surgical procedures for atrial septal defect occlusion, ventricular septal defect occlusion and mitral valve replacement is feasible and safe.

Emprego de sistemas robóticos na cirurgia cardiovascular

O desenvolvimento de sistemas roboticos para cirurgia teve inicio na decada de 80, por solicitacao do exercito norte-americano, que antevia a possibilidade de realizar operacoes em teatros de guerra, distantes do local onde estava o cirurgiao. Entretanto, o primeiro uso em humanos so ocorreu anos mais tarde, numa resseccao transuretral de hiperplasia benigna de prostata. Cirurgioes cardiacos foram logo atraidos pela tecnica robotica devido a possivel aplicacao com reduzido carater invasivo; esperava-se menor trauma cirurgico e reducao da dor, morbidade, tempo de internacao e custo do procedimento. Atualmente, de forma restrita e em casos selecionados, robos sao usados para revascularizacao do miocardio e implante de marcapasso em cirurgias cardiacas totalmente endoscopicas; podendo tambem constituir apoio visual na retirada de arteria toracica interna, reconstrucao valvar mitral e correcao de defeitos congenitos. Utilizando o robo auxiliar AESOP® para controle do videotoracoscopio, com controle vocal por meio do sistema HERMES®, temos realizado disseccao da arteria toracica interna, implante de eletrodo ventricular esquerdo e abordagem de defeitos congenitos na cirurgia de correcao. Apesar do entusiasmo cientifico inicial com a cirurgia robotica, ainda nao existe evidencia clara de superioridade desta tecnica em relacao a operacao convencional, em termos de resultado. Isto se aplica tambem ao custo, pois o investimento inicial na aquisicao de sistema cirurgico completo (console, controle de video, instrumental) provavelmente e compensado apos muitos procedimentos e longo intervalo. Mas e certo que a cirurgia robotica tera um lugar no futuro, possibilitando aprendizagem, telepresenca e realizacao de procedimentos pouco invasivos, embora complexos.

Minimally invasive cardiopulmonary bypass with cardioplegic arrest: A closed chest technique with equivalent myocardial protection

Thoracoscopic cardiac surgery is presently under intense investigation. This study examined the feasibility and efficacy of closed chest cardiopulmonary bypass and cardioplegic arrest in comparison with standard open chest methods in a dog model. The minimally invasive closed chest group (n = 6) underwent percutaneous cardiopulmonary bypass and cardiac venting, as well as antegrade cardioplegic arrest through use of a specially designed percutaneous endovascular aortic occluder and cardioplegic solution delivery system. The control group (n = 6) underwent standard sternotomy and conventional open chest cardiopulmonary bypass, aortic crossclamping, and antegrade cardioplegia. Ischemic arrest time was 1 hour in each group. Ventricular pressures and sonomicrometer segment lengths were recorded before bypass and at 30 and 60 minutes after bypass. Left ventricular function did not differ significantly between the two groups, as demonstrated by measurements of elastance and end-diastolic stroke work. Also, the preload recruitable work area was 69% and 60% of baseline at 30 and 60 minutes after bypass in the minimally invasive group versus 65% and 62% in the conventional control group (p = not significant); the stroke work end-diastolic length relationship was 78% and 71% of baseline in the minimally invasive group at these intervals versus 77% and 74% in the conventional control group (p = not significant). Myocardial temperatures were similar throughout bypass in the two groups, and ultrastructural examination of prebypass and postbypass biopsy specimens showed no differences between groups. These results demonstrate that minimally invasive cardiopulmonary bypass with cardioplegic arrest is as feasible, safe, and effective as conventional open chest cardiopulmonary bypass. Thus current technology may allow wider clinical application of closed chest cardiac surgery. (J T horac C ardiovasc S urg 1996;111:556-66)