Aubrey Almeida

A Cost-analysis Study of Robotic Versus Conventional Mitral Valve Repair

BACKGROUND Robotic mitral valve repair has been performed in Australia since 2004. The aim of this study was to perform a cost-analysis of robotic mitral valve repair (MVR) with direct comparison to conventional MVR surgery. METHODS All isolated MVRs performed within one metropolitan hospital network, between June 2005 and June 2008, were retrospectively compared. Ad hoc cost analysis was conducted. RESULTS There were 107 robotic and 40 conventional MVRs performed. The post-operative degrees of mitral regurgitation were comparable. Total operating time was 18% longer in robotic compared to conventional (239 min vs. 202 min, p<0.001, 95% CI: 11-27%). In robotic, Intensive Care Unit stay was reduced by 19% (p=0.002, 37 h vs. 45 h), and length of hospital stay was reduced by 26% (p<0.001, 6.47 days vs. 8.76 days). Mean hospital cost, without including capital costs, was not significantly increased (AUD

Epicardial High-intensity Focused Ultrasound Cardiac Ablation for Surgical Treatment of Atrial Fibrillation

18,503 vs. AUD

MANAGING DEEP STERNAL WOUND INFECTIONS WITH VACUUM‐ASSISTED CLOSURE

17,880 p=0.176, 95% CI: -282 to 1,530). CONCLUSIONS Robotic mitral repair can be performed with similar immediate repair success rates as conventional surgery with a shorter recovery time, but a slightly longer operative time. There is no significant increase in cost over conventional surgery.

Gastrointestinal complications after cardiac surgery: 10-year experience of a single Australian centre

BACKGROUND The available alternatives to an effective but technically complex Cox maze procedure for surgical treatment of atrial fibrillation include ablation using radiofrequency, microwave, laser, cryotherapy or ultrasound energy sources. The purpose of this study was to evaluate the safety and efficacy profile of high-intensity focused ultrasound cardiac ablation for the surgical treatment of atrial fibrillation. METHODS 14 patients underwent epicardial high-intensity focused ultrasound treatment for atrial fibrillation using the Epicor cardiac ablation system between August 2006 and August 2007. The procedure was performed on the beating heart prior to the commencement of cardiopulmonary bypass for concomitant cardiac procedures. Physical examination, electrocardiography and 24-h Holter monitoring were used to determine the postoperative heart rhythm. RESULTS There were no deaths directly related to the procedure. One patient with myelodysplastic syndrome died of septic complications. Three patients required cardioversion at 1 day, 3- and 4-month intervals postoperatively. The mean follow-up period was 9 months. Currently 10/13 (77%) patients are in sinus rhythm, one patient required insertion of a permanent pacemaker, one patient is in atrial fibrillation and another patient is in atrial flutter. CONCLUSION Epicardial high-intensity focused ultrasound ablation is a viable alternative to the Cox maze procedure for the surgical treatment of atrial fibrillation. It is a safe and efficient procedure that does not require cardiopulmonary bypass and may potentially be performed using less invasive surgical techniques.

Extra-aortic implantable counterpulsation pump in chronic heart failure.

Deep sternal wound infection is an uncommon but serious complication of cardiac surgery. Currently, there is no consensus on the optimal management. Vacuum‐assisted closure (VAC) has been increasingly used to facilitate wound healing. We aim to review the management of deep sternal wound infections using VAC dressing at our hospital. A retrospective review of consecutive cases of deep sternal wound infections was carried out. Median sternotomies were carried out in 2665 patients between July 2001 and June 2006. Thirty‐one patients developed deep sternal wound infections (1.2%). In 26 of these patients, VAC dressing was used either as a stand‐alone therapy or as an adjunct to late sternal reconstruction. Deep sternal wound infections were diagnosed on average 13 days from initial surgery. Of the patients treated with VAC dressing, 17 (65%) had stand‐alone VAC therapy and 9 had VAC therapy followed by sternal reconstruction. The average duration of VAC dressing in the two groups were 21 and 13 days respectively. There were seven in‐hospital deaths, six in the stand‐alone VAC group and one death from a reconstructive patient who did not have VAC therapy. The length of hospital stay was similar in two VAC groups (37 vs 45 days). Median follow up was 17 months. No late relapse was found in the stand‐alone group. In the intermediate therapy group, two patients had chronic wound sinuses and one patient had a wound collection. Vacuum‐assisted closure dressing may be used both as a stand‐alone and as an intermediate therapy for deep sternal wound infection. Reconstructive surgery may be avoided in a significant proportion of patients. No late relapse has been associated with VAC use.

Effects on Cognition of Conventional and Robotically Assisted Cardiac Valve Operation

Gastrointestinal (GI) complications after cardiac surgery are uncommon, but are associated with high morbidity and mortality as well as significant hospital resource utilization.

Minimally invasive aortic valve replacement via hemi-sternotomy: a preliminary report

Extra-aortic counterpulsation for the management of chronic heart failure is a novel approach. We report the use of an extra-aortic implantable counterpulsation pump in the management of a 73-year-old patient with severe heart failure refractory to medical therapy. The implantable counterpulsation pump prolonged his life and greatly improved its quality. The patient lived almost 7 months after the implantation of the device and died of septic complications secondary to gas line infection.

Urgent and emergency coronary artery bypass grafting for acute coronary syndromes.

BACKGROUND The effect of valve surgical procedures on cognition was investigated in patients undergoing conventional or robotically assisted techniques. The confounding factors of surgical procedure, mood state, preexisting cognitive impairment, and repeated experience with cognitive tests were controlled for. METHODS Patients undergoing conventional valve procedures (n = 15), robotically assisted valve procedures (n = 15), and thoracic surgical procedures (n = 15), along with a nonsurgical control group (n = 15) were tested preoperatively, 1 week after operation, and 8 weeks after operation by use of a battery of cognitive tests and a mood state assessment. Surgical group data were normalized against data from the nonsurgical control group before statistical analysis. RESULTS Patients undergoing conventional valve procedures performed worse than those undergoing robotically assisted valve procedures on every subtest before operation, and this disadvantage persisted after operation. Age and premorbid intelligence quotient were significantly associated with performance on several cognitive subtests. Anxiety, depression, and stress were not associated with impaired cognitive performance in the surgical groups after operation. A week after operation, patients undergoing conventional valve procedures performed worse on the cognitive tests that had a motor component, which may reflect discomfort caused by the sternotomy. Patients undergoing robotically assisted valve procedures were significantly less impaired on information processing tasks 1 week after operation when compared with those undergoing conventional valve procedures. The majority of patients who were impaired 1 week after operation recovered to preoperation levels within 8 weeks. CONCLUSIONS The robotically assisted valve surgical procedure results in more rapid recovery of performance on cognitive tests. However, regardless of the type of surgical intervention, the prospect of a recovery of cognitive performance to preoperative levels is high.

Experience with unipolar radiofrequency ablation for atrial fibrillation.

OBJECTIVE Aortic valve replacement has been approached by standard sternotomy. We described a technique of aortic valve replacement where the aortic valve is exposed through a hemi-sternotomy. Good exposure is obtained for aortic valve surgery with standard aortic and right atrial cannulation to establish cardiopulmonary bypass (CPB). METHODS From October 1996 to April 1997, 19 consecutive aortic valve replacements (AVR) via hemi-sternotomy were performed by one surgeon. The results were collected and analysed prospectively. Results are expressed as mean +/- standard deviation. Nineteen patients (13 male, 6 female) had AVR with this approach. Two cases were redo AVR. The mean age was 58+/-15 years. The New York Heart Association (NYHA) class was 2.8+/-0.7. RESULTS Aortic cross clamp time was 54+/-13 min. One of six patients requiring defibrillation after reperfusion needed conversion to full sternotomy. Four patients were extubated at the conclusion of surgery. One patient died 4 h postoperatively from low cardiac output. All patients had normal valvular function demonstrated on postoperative transoesophageal echocardiography. There were no neurological events. CONCLUSIONS Minimally invasive aortic valve replacement can be safely performed via hemi-sternotomy with standard equipment. Less surgical trauma to the sternum has the potential benefit of less pain and shorter intensive care and hospital stay.

Transesophageal Echocardiography in an Operation for Pulmonary Arteriovenous Malformation

Background:  Urgent and emergency coronary artery bypass grafting may be associated with significant mortality and morbidity. We report our recent experience with this group of patients.