Changqing Gao

Excision of atrial myxoma using robotic technology

OBJECTIVE This study is to discuss a surgical approach for ideal and safe resection of atrial myxoma using the da Vinci S Surgical System (Intuitive Surgical, Inc, Sunnyvale, Calif). METHODS Nineteen consecutive patients underwent resection of atrial myxomas with the da Vinci S Surgical System. Mean age of the patients was 46 +/- 16 years. Mean tumor size was 45 x 5.5 cm. Fifteen tumors were in the left atrium, of which 11 tumors arose from the interatrial septum, 2 from the posterocaudal wall, 1 from the root of the anterior leaflet of the mitral valve, and 1 from the left atrial roof. In 13 patients, exploration was conducted through a left atriotomy anterior to the pulmonary veins and excision was achieved by dissecting a plane through the atrial muscle at the point of attachment. In the first 2 patients, exploration and excision were conducted through an oblique right atriotomy. Four tumors were in right atrium, all of which were resected from the beating heart. The da Vinci instrument arms were inserted through three 1-cm trocar incisions in the right side of the chest. Via 4 port incisions and a 1.5-cm working port, all the procedures were completed with a 30 degrees angled endoscope facing upward with the da Vinci S robot. RESULTS Resection was successful in all patients. There were no operative deaths, strokes, or other complications. All the patients were discharged. No recurrences of tumor or septal leakage were found in the complete 1- to 18-month follow-up. CONCLUSIONS The excision of atrial myxomas with the da Vinci S Surgical System is feasible, efficacious, and safe. Surgical results are excellent.

Robotically assisted mitral valve replacement

OBJECTIVE In the present study, we determined the safety and efficacy of robotic mitral valve replacement using robotic technology. METHODS From January 2007 through March 2011, more than 400 patients underwent various types of robotic cardiac surgery in our department. Of these, 22 consecutive patients underwent robotically assisted mitral valve replacement. Of the 22 patients with isolated rheumatic mitral valve stenosis (9 men and 13 women), the mean age was 44.7 ± 19.8 years (range, 32-65). Preoperatively, all patients underwent a complete workup, including coronary angiography and transthoracic echocardiography. Of the 22 patients, 15 had concomitant atrial fibrillation. The surgical approach was through 4 right-side chest ports with femoral perfusion. Aortic occlusion was performed with a Chitwood crossclamp, and antegrade cardioplegia was administered directly by way of the anterior chest. Using 3 port incisions in the right side of the chest and a 2.5- to 3.0-cm working port, all the procedures were completed with the da Vinci S robot. RESULTS All patients underwent successful robotic surgery. Of the 22 patients, 16 received a mechanical valve and 6 a tissue valve. The mean cardiopulmonary bypass time and aortic crossclamp time was 137.1 ± 21.9 minutes (range, 105-168) and 99.3 ± 17.9 minutes (range, 80-133), respectively. No operative deaths, stroke, or other complications occurred, and no incisional conversions were required. After surgery, all the patients were followed up echocardiographically. CONCLUSIONS Robotically assisted mitral valve replacement can be performed safely in patients with isolated mitral valve stenosis, and surgical results are excellent.

Totally endoscopic robotic atrial septal defect repair on the beating heart.

BACKGROUND Atrial septal defect (ASD) repairs have successfully been performed on the arrested heart with the da Vinci S Surgical System (Intuitive Surgical). This study assessed the feasibility, safety, and efficacy of the use of the da Vinci S Surgical System for on-pump ASD repairs on the beating heart without cross-clamping the aorta. METHODS This prospective study included 24 consecutive patients who underwent ASD repair surgery between June 2008 and June 2009. All of the procedures were completed with the da Vinci S robot via 3 port incisions in the right chest and a 1.5-cm working port. The operations were carried out on the beating heart with mild hypothermic cardiopulmonary bypass (CPB) without cross-clamping the aorta. Venting the heart from the working port provided adequate visualization of the operative field. RESULTS All patients underwent complete repairs. Fourteen patients underwent ASD closure with a fresh autogenous pericardial patch, and 10 patients underwent direct ASD closure. Concomitant surgery was required in 4 patients. The mean (+/-SEM) CPB time was 65.6 +/- 17.7 minutes, and the mean operative time was 98.5 +/- 19.3 minutes. No patient required transfusion of red blood cells. The length of patient stay in the intensive care unit was 0.5 to 1.0 days. The length of hospital stay was 4 to 5 days. Follow-up transthoracic echocardiography evaluations showed no residual atrial septal leakage. There were no operative deaths, strokes, or other complications. All of the patients were discharged. CONCLUSIONS We have shown that use of the da Vinci S Surgical System to perform on-pump ASD repairs on the beating heart without cross-clamping the aorta is feasible, safe, and effective.

Totally endoscopic robotic ventricular septal defect repair in the adult

OBJECTIVE We have previously reported total endoscopic ventricular septal defect repair in the adult using the da Vinci S Surgical System. The optimal results encouraged us to extend the use of this technology to more complicated patients with ventricular septal defect. METHODS From January 2009 to July 2010, 20 patients underwent total endoscopic robotic ventricular septal defect repair. The average patient age was 29.0 ± 9.5 years (range, 16-45). Of the 20 patients, 9 were female and 11 were male. The echocardiogram demonstrated that the average diameter of the ventricular septal defect was 6.1 ± 2.8 mm (range, 2-15), and 4 patients had concomitant patent foramen ovale. Ventricular septal defect closure was directly secured with interrupted mattress sutures in 14 patients and patched in 6 patients. All the procedures were completed using the da Vinci robot by way of 3 port incisions and a 2.0- to 2.5-cm working port in the right side of the chest. RESULTS All patients were operated on successfully. The mean cardiopulmonary bypass and mean crossclamp time was 94.3 ± 26.3 minutes (range, 70-140) and 39.1 ± 12.9 minutes (range, 22-75), respectively. The mean operation time was 225.0 ± 34.8 minutes (range, 180-300). The postoperative transesophageal echocardiogram demonstrated an intact ventricular septum. No residual left-to-right shunting and no permanently complete atrioventricular dissociation was found postoperatively. The mean hospital stay was 5 days. No residual shunt was found during a mean follow-up of 7 months (range, 1-22). The patients returned to normal function within 1 week without any complications. CONCLUSIONS Total endoscopic robotic ventricular septal defect repair in adult patients is feasible, safe, and efficacious.

Comparison of postoperative quality of life for patients who undergo atrial myxoma excision with robotically assisted versus conventional surgery

BACKGROUND Robotically assisted cardiac surgery is an alternative to conventional, open-chest surgery. Although studies have been done on the clinical effect, morbidity, and mortality of robotically assisted atrial myxoma excision, few have addressed surgical outcomes, such as pain, quality of life (QOL), and length of sick leave from work. In this study, our aim was to evaluate these clinical variables among patients after they undergo robotically assisted atrial myxoma excision surgery. METHODS Between January 2007 and January 2013, a total of 93 patients underwent either conventional sternotomy or robotically assisted atrial myxoma excision in our unit. The 36-item Medical Outcomes Study Short Form Survey was used to assess the clinical outcomes in these patients postoperatively, at day 30 and 6 months. RESULTS The QOL scores for 7 of 8 variables in the robotically assisted group were significantly higher than those in the conventional group at postoperative day 30 (P < .05). The degree of pain and its influence on work or life was lower in the robotically assisted group (P < .05), and these patients returned to work after 0.9 ± 0.1 months, whereas those in the conventional group needed a sick leave of 3.3 ± 0.4 months. CONCLUSIONS The level of restoration of normal QOL within 30 days after atrial myxoma surgery is excellent with the robotically assisted approach, which may enable early return to employment and satisfactory recovery.

Combined treatment of ulinastatin and tranexamic acid provides beneficial effects by inhibiting inflammatory and fibrinolytic response in patients undergoing heart valve replacement surgery.

OBJECTIVE To investigate the effect of ulinastatin and tranexamic acid administered alone or in combination on inflammatory cytokines and fibrinolytic system in patients undergoing heart valve replacement surgery during cardiopulmonary bypass (CPB). BACKGROUND CPB-induced fibrinolytic hyperfunction and systemic inflammatory response syndrome (SIRS) are the leading causes responsible for the occurrence of postsurgical complications such as postsurgical cardiac insufficiency and lung injury, which may lead to an increase in postsurgical bleeding, prolongation of hospital stay, and increased costs. METHODS One hundred twenty patients undergoing heart valve replacement surgery during CPB were randomly assigned into 4 groups of 30 patients each: blank control group (Group C), tranexamic acid group (Group T), ulinastatin group (Group U), and tranexamic acid-ulinastatin combination group (Group D). Physiological saline, tranexamic acid, ulinastatin, and a combination of tranexamic acid and ulinastatin were given to each group, respectively. Arterial blood was collected from the radial artery at 4 time points: after induction of anesthesia (T1), unclamping the ascending aorta (T2), and at 1 hour (T3) and 24 hours (T4) after CPB. The levels of plasma tumor necrosis factor alpha (TNF-α), interleukin 6 (IL-6), neutrophil elastase (NE), and the concentrations of tissue plasminogen activator (t-PA) and α2-antiplasmin (α2-AP) were detected. The changes in the volume of pericardial mediastinal drainage after surgery were observed and recorded. RESULTS The plasma TNF-α, IL-6, and NE levels significantly increased in patients from all 4 groups at time points of T2, T3, and T4 in comparison to those before CPB (P < .05), and the plasma TNF-α and IL-6 levels in groups U and D were significantly lower than those in the other 2 groups (P < .05). The plasma t-PA, α2-AP, and D-dimer concentrations significantly increased in patients from all 4 groups at T2 and T3 compared with those before CPB (P < .05), and the plasma t-PA and D-dimer concentrations were significantly lower in groups T and D than those in groups U and C (P < .05) at T2 and T3. The plasma α2-AP concentrations in groups T and D were significantly higher than those in Group C at T3 (P < .05). The volumes of pericardial mediastinal drainage per body surface area were significantly lower in groups T and D than those in Group C 6 hours after the surgery (P < .05). CONCLUSIONS Ulinastatin inhibits the release of inflammatory medium and reduces the inflammatory response during CPB. Tranexamic acid can effectively inhibit the fibrinolytic hyperfunction caused by CPB and thus decreases postsurgical bleeding. In addition, it exhibits a minor anti-inflammatory response. As a consequence, a combined treatment of ulinastatin and tranexamic acid reduces postsurgical bleeding and shortens postoperative hospital stay in patients undergoing heart valve replacement surgery.

Analysis of the learning curve for beating heart, totally endoscopic, coronary artery bypass grafting.

BACKGROUND Robotic cardiac surgery has been proved safe and feasible in dedicated centers. We systematically analyzed the learning curve issues associated with totally endoscopic coronary artery bypass grafting (TECAB) using a stepwise approach by a single surgeon who had successfully performed >650 cases of various types of robotic cardiac surgery at our single center. METHODS From January 2007 to March 2013, 230 patients underwent robotic coronary bypass grafting on the beating heart. Of these patients, 90 had successfully undergone beating heart TECAB using the da Vinci S/Si Surgical System without conversion to sternotomy. All beating heart TECAB procedures were completed using the following modules: endoscopic left internal thoracic artery (LITA) harvesting, pericardiotomy and target vessel identification, and anastomosis of the LITA to the target vessel. The perioperative outcomes were compared among 3 quintiles of 30 consecutive patients each and the learning curve results were evaluated. RESULTS No in-hospital mortality or severe morbidity occurred. The comparison among the 3 quintiles showed a significant decrease in operative time (P=.000), LITA harvesting time (P=.037), and anastomotic time (P=.000). A significant learning curve was observed for the operative time [y(min)=223-17×ln(x); r2=0.217, P=.000]; LITA harvesting time [y(min)=37-3×ln(x); r2=0.097, P=.003]; and LITA-left anterior descending artery anastomotic time [y(min)=18-2×ln(x); r2=0.298, P=.000]. No differences were found in the mean transit flow (P=.102) or perioperative complications among the 3 quintiles. CONCLUSIONS Modular-based TECAB procedures can be successfully performed; however, each module has a steep learning curve. A stable and well-trained robotic cardiac team and an experienced cardiac surgeon can achieve good, reproducible results after this substantial learning curve.

Congenital mitral valve regurgitation in adult patients.

OBJECTIVE Congenital mitral valve regurgitation (MVR) is a rare disease found in adults. We report on our 5-year surgical experience with congenital MVR in adults. METHODS We reviewed the data for 48 consecutive patients (26 men), aged >18 years (median, 42 years; range, 18-78 years) who underwent operations for severe congenital MVR between June 2005 and May 2010. Patients with atrioventricular septal defect were excluded. RESULTS Congenital MVR was preoperatively diagnosed in 28 cases (58%). The lesions consisted of annular dilation (100%), valvular cleft (58%), prolapsed leaflet (40%), papillary muscle abnormality (5%), commissure fusion (2%), and leaflet deficiency (2%). Mitral valve repair was performed in 42 cases (88%) by means of Carpentier techniques. The other 6 patients underwent mitral valve replacement; one of these patients died of ventricular fibrillation 2 days after surgery. There were no other hospital deaths or late mortality. At the last follow-up (median, 38 months; range, 2-50 months), all 47 patients were in New York Heart Association functional class I or II. Echocardiography evaluations for the 42 patients who underwent the repairs revealed that 32 (76%) of the patients had no or trivial MVR and 10 patients (24%) had mild MVR. No patient underwent reoperation. CONCLUSION Congenital MVR is rare and often misdiagnosed in adults. Mitral valve repair is feasible in the majority of patients, with excellent immediate and medium-term results.

Surgery on a Patient with Iatrogenic Aortic Valve Leaflet Perforation after Repair of a Congenital Ventricular Septal Defect

Aortic valve regurgitation caused by a leaflet perforation occurs most often with infective endocarditis involving the aortic valve. Although rare, leaflet perforation can be caused by suture-related injury during cardiac operations, such as mitral valve replacement, ventricular septal defect (VSD) repair, and repair of an ostium primum atrial septal defect. Few reports have described this form of iatrogenic aortic valve leaflet perforation. We used a pericardial patch in a successful repair of an iatrogenic perforation in an aortic valve leaflet that occurred after simple VSD repair.

Anesthesia management of totally endoscopic atrial septal defect repair with a robotic surgical system.

STUDY OBJECTIVE To investigate anesthetic techniques for robot-assisted endoscopic atrial septal defect (ASD) repair. DESIGN Clinical observational study. SETTING Operating room of a general military hospital. PATIENTS 56 adult, ASA physical status 1 and 2 patients undergoing elective general anesthesia. INTERVENTIONS After induction of general anesthesia, a left-sided, double-lumen endotracheal tube was positioned to allow single left-lung ventilation and contralateral CO(2) pneumothorax (capnothorax). With ultrasound guidance, peripheral cardiopulmonary bypass (CPB) catheters were placed. MEASUREMENTS AND MAIN RESULTS All patients tolerated single left-lung ventilation before CPB; however, hypoxia (oxygen saturation < 90%) occurred in 11 (19.6%) patients post-CPB, which required treatment with continuous positive airway pressure. Fifteen (26.8%) patients had hypotension secondary to capnothorax, which was treated with transfusion and vasopressors. Aortic cross-clamp time was 43.6 ± 11.2 minutes, and CPB time was 106.7 ± 12.4 minutes. The median intensive care unit stay was 21 hours and postoperative hospital stay was 4 to 7 days. CONCLUSIONS The key issue for anesthetic management of robot-assisted totally endoscopic ASD repair is maintaining stable hemodynamics and oxygenation, especially during one-lung ventilation and capnothorax.