Totally endoscopic atrial septal repair in adults with computer-enhanced telemanipulation

AbstractObjectiveStandard surgical closure of an atrial septal defect via sternotomy is a safe and effective procedure with low morbidity and mortality. Considering that young female patients are frequently operated on for atrial septal defects, a minimally invasive procedure avoiding sternotomy is convincingly desirable and led to the approach through a right anterolateral minithoracotomy. The recent clinical introduction of robotically assisted surgery further reduced skin incisions and enabled totally endoscopic procedures through ports. This article reports on a first series of atrial septal defect closures of which the first case was operated on August 24, 1999, in a totally endoscopic closed chest technique using a computer-enhanced telemanipulation system.MethodsWe performed totally endoscopic atrial septal repair using the da Vinci surgical system (Intuitive Surgical, Mountain View, Calif) in 10 consecutive adult patients. Median age was 45.5 ± 10.0 years, and preoperative New York Heart Association functional class was 1.8 ± 0.1. Left ventricular ejection fraction was normal in all patients and mean pulmonary artery pressure amounted to 35 ± 7 mm Hg. Shunt volume ranged from 24% to 70%. All patients displayed a fossa ovalis type of atrial septal defect; 2 of them multiperforated.ResultsNeither intraoperative nor postoperative complications occurred. Two patients had to be converted to minithoracotomy due to endoaortic balloon clamp failure. Length of operation was 262 ± 37 minutes, and cardiopulmonary bypass time was 161 ± 26 minutes. Intraoperative transesophageal echocardiography certified complete closure of the atrial septal defect in all patients. The totally endoscopic computer-enhanced technique yielded excellent cosmetic results.ConclusionTotally endoscopic atrial septal repair is a feasible and safe procedure with good clinical results and excellent cosmetic outcomes. It may be considered as perfect adjunct to interventional treatment options. Further studies with larger cohorts and randomized trials are necessary to document potential benefits. Evolution in robotic technology and refinement of procedural flow may shorten procedural time and decrease costs

Changes in tryptase levels during cardiac surgery in patients at low risk for allergic reaction

Tryptase test can be used as a clinical marker of mast cell activation. The present study is was aimed to identify variations in serum tryptase levels and their possible relationships with allergic reactions to protamine in low-risk patients undergoing cardiac bypass surgery. Thirty patients according to American Society of Anesthesiologists physical status III who underwent cardiac bypass surgery were enrolled. This prospective, non-randomised, clinical study was conducted in an operating room. Venous blood samples for tryptase measurements were obtained from cardiac bypass surgery patients upon admission to the operating room and immediately before and 30 min after the initiation of protamine administration. Signs of allergic reactions were recorded and management steps based on rapid effect response-based clinical assessments for diagnosis and treatment decisions during protamine administrations were described. Serum tryptase levels and clinical signs of allergic reactions, primarily mean arterial pressure (MAP), were recorded. Serum tryptase levels increased significantly and progressively during the bypass procedure (study power, 80%; sample size, 28; power of analysis, 99.8% with α=0.05); however, tryptase levels did not reach a sufficiently high level to confirm an allergic reaction. The MAP and heart rate decreased in 50% of the patients. Although tryptase increased significantly when compared with baseline levels, protamine-associated increases were not significant and failed to provide an unequivocal indication of an allergic response to protami

Inhibition of neutrophil activity improves cardiac function after cardiopulmonary bypass

Background The arterial in line application of the leukocyte inhibition module (LIM) in the cardiopulmonary bypass (CPB) limits overshooting leukocyte activity during cardiac surgery. We now studied in a porcine model whether LIM may have beneficial effects on cardiac function after CPB. Methods German landrace pigs underwent CPB (60 min myocardial ischemia; 30 min reperfusion)without (group I; n=6) or with LIM (group II; n=6). The cardiac indices (CI) and cardiac function were analyzed pre and post CPB with a Swan-Ganz catheter and the cardiac function analyzer. Neutrophil labeling with technetium, scintigraphy, and histological analyses were done to track activated neutrophils within the organs. Results LIM prevented CPB-associated increase of neutrophil counts in peripheral blood. In group I, the CI significantly declined post CPB (post: 3.26 +/- 0.31; pre: 4.05 +/- 0.45 l/min/m2; p<0.01). In group II, the CI was only slightly reduced (post: 3.86 +/- 0.49; pre 4.21 +/- 1.32 l/min/m2; p=0.23). Post CPB, the intergroup difference showed significantly higher CI values in the LIM group (p<0.05) which was in conjunction with higher pre-load independent endsystolic pressure volume relationship (ESPVR) values (group I: 1.57 +/- 0.18; group II: 1.93 +/- 0.16; p<0.001). Moreover, the systemic vascular resistance and pulmonary vascular resistance were lower in the LIM group. LIM appeared to accelerate the sequestration of hyperactivated neutrophils in the spleen and to reduce neutrophil infiltration of heart and lung. Conclusions Our data provide strong evidence that LIM improves perioperative hemodynamics and cardiac function after CPB by limiting neutrophil activity and inducing accelerated sequestration of neutrophils in the spleen

The radial artery as a conduit for coronary artery bypass grafting : review of current knowledge

The effect of coronary artery bypass grafting (CABG) lasts as long as the grafts are patent. The internal mammary artery has been considered the "golden" graft due to the superb long-term patency, exceeding 90% at 10 years. The saphenous vein grafts, unfortunately, tend to occlude with a rate of 10-15% within a year after surgery, and eventually, at 10 years after the operation, as much as 60-70% of these vein grafts are either occluded or have angiographic evidence of atherosclerosis. The search for another "arterial conduit", the radial artery, has intensified through the last 15 years in hope to provide a better graft than the saphenous vein for CABG. This article reviews the current knowledge for the radial artery as a conduit in CABG. (Anadolu Kardiyol Derg 2006; 6: 153-62)Koroner arter baypas greft cerrahisinin (CABG) etkisi greftler patent olduğu sürece devam eder. Internal mammariyan arter 10 yılda %90'lık olağanüstü kabul edilen uzun dönem açıklık oranı ile "altın" greft olarak nitelendirilmifltir. Safen ven grefti ne yazık ki cerrahiden bir yıl sonra % 10-15 oranında oklüde olmaktadır ve nihayet 10 yıl sonra da ven greftlerinin % 60-70'i ya oklüde olurlar ya da anjiyografik olarak aterosklerotiktirler. Son 15 yılda CABG için safen venden daha iyi bir greft sağlamak amacıyla baflka bir "arteryel konduit", yani radiyal arter için arayıfllar yoğunlaflmıfltır. Bu makale radiyal arterin CABG'de kullanımı için mevcut bilgileri gözden geçirmektedir. (Anadolu Kardiyol Derg 2006; 6: 153-62

An unusual cause of angina pectoris due to dynamic coronary artery compression and successful treatment with cardiac surgical reconstruction

Extrinsic compression of coronary arteries causing angina pectoris is very unusual. No data regarding the optimal treatment for coronary artery compression due to dilated cardiac chambers have been reported. In this case report, we describe a man with severe mitral valve stenosis and the dilated left atrium, which resulted in coronary artery compression, and the successful management of his condition by surgical reconstruction

Robotic coronary artery surgery : past, present and future

Minimal invazif endoskopik giriflimlerin kalp cerrahisinde kullanımı ancak telemanipülatör sistemlerin kullanıma girmesiyle mümkün olmufltur. Bu çalıflmada total endoskopik revaskülarizasyon için kullanılan robotik destekli telemanipülasyon sistemleri gözden geçirilip, çalıflan ve duran kalpte uygulamalar derlenmifltir. Robotik cerrahi günümüzde halen geliflme aflamasındadır. Maliyetin yüksek oluflu ve sadece seçilmifl bir hasta grubunda uygulanabiliyor olması bu yeni tekni¤in en büyük sınırlayıcı faktörleridir. Ancak teknoloji üzerine çalıflmalar ve özellikle anastomoz tekniklerinin geliflmesiyle koroner revaskülarizasyon için bir alternatif olacaktır. Henüz istenen hedeflere ulaflılmamıflsa da gelecek umut vericidir.Minimally invasive endoscopic procedures in cardiac surgery have only become possible since the introduction of telemanipulator systems. In this study we review robotic assisted telemanipulation systems and procedures on beating and arrested heart for total endoscopic revascularization. Robotic surgery is still under development. The most important factors limiting this new technique are high costs and the fact that only selected patients are able to be operated on. But studies on technology especially to improve anastomotic techniques are going on to produce an alternative for coronary revascularisation. We didn’t yet hit all goals but the future seems promising

Changes in tryptase levels during cardiac surgery in patients at low risk for allergic reactions

Tryptase test can be used as a clinical marker of mast cell activation. The present study is was aimed to identify variations in serum tryptase levels and their possible relationships with allergic reactions to protamine in low-risk patients undergoing cardiac bypass surgery. Thirty patients according to American Society of Anesthesiologists physical status III who underwent cardiac bypass surgery were enrolled. This prospective, non-randomised, clinical study was conducted in an operating room. Venous blood samples for tryptase measurements were obtained from cardiac bypass surgery patients upon admission to the operating room and immediately before and 30 min after the initiation of protamine administration. Signs of allergic reactions were recorded and management steps based on rapid effect response-based clinical assessments for diagnosis and treatment decisions during protamine administrations were described. Serum tryptase levels and clinical signs of allergic reactions, primarily mean arterial pressure (MAP), were recorded. Serum tryptase levels increased significantly and progressively during the bypass procedure (study power, 80%; sample size, 28; power of analysis, 99.8% with α=0.05); however, tryptase levels did not reach a sufficiently high level to confirm an allergic reaction. The MAP and heart rate decreased in 50% of the patients. Although tryptase increased significantly when compared with baseline levels, protamine-associated increases were not significant and failed to provide an unequivocal indication of an allergic response to protamine