Guenther Laufer

Simultaneous Hybrid COronary Revascularization Using Totally Endoscopic Left Internal Mammary Artery Bypass Grafting and Placement of RapamycIN Eluting Stents in the SAme IntervenTIONal Session

Objectives: Hybrid coronary revascularization procedures apply minimally invasive coronary artery bypass grafting (CABG) and percutaneous coronary intervention (PCI) for treatment of multivessel coronary artery disease. For logistic reasons simultaneous procedures would be desirable. In a pilot study the feasibility of simultaneous robotic totally endoscopic CABG and PCI using drug eluting stents was assessed. Patients and Methods: Five patients were scheduled to undergo simultaneous combined coronary inter- vention. A left internal mammary artery bypass graft was placed to the left anterior descending artery (LAD) in a completely endoscopic fashion using the daVinciTM telemanipulation system. PCI was carried out in the surgical operating room with the GE OEC9800 mobile coronary angiography C-arm. Rapamycin coated Cypher™ stents were placed into stenotic non-LAD targets. Results: The procedure was feasible in 4 patients, one patient was converted to a double CABG operation. There were no significant postoperative clinical complications and patients were discharged from intensive care unit and the hospital after 19 (18–61) hours and 6 (5–7) days respectively. At 6 months postoperatively all patients are free from angina. Conclusion: We conclude that simultaneous robotic totally endoscopic left internal mammary artery to LAD placement and PCI to non-LAD targets using drug eluting stents is feasible in one session.

Effectiveness and Safety of Total Endoscopic Left Internal Mammary Artery Bypass Graft to the Left Anterior Descending Artery

Totally endoscopic coronary artery bypass grafting (CABG) has become a feasible option using robotic technology and remote access perfusion techniques. The aim of this study was to determine the progression of the procedures performance in the currently largest single-center series of arrested-heart totally endoscopic CABG. From 2001 to 2007, arrested-heart totally endoscopic CABG was performed in 100 patients (median age 59 years, range 46 to 70; 81 men, 19 women). All patients received left internal mammary artery grafts to the left anterior descending artery using the da Vinci Surgical System. Remote-access femoral perfusion and aortic balloon endo-occlusion were used in all patients. The series was divided into 4 phases: phase 1 (patients 1 to 25), phase 2 (patients 26 to 50), phase 3 (patients 51 to 75), and phase 4 (patients 76 to 100). The conversion rates to larger thoracic incisions were 7 of 25 (28%) in phase 1, 2 of 25 (8%) in phase 2, 1 of 25 (4%) in phase 3, and 1 of 25 (4%) in phase 4 (p = 0.018). Operative times and hospital stays decreased significantly with each subsequent phase, and clinical outcome showed corresponding improvements. There was no perioperative mortality. For the whole patient series, 5-year postoperative survival, freedom from angina, and freedom from major adverse cardiac and cerebral events were 100%, 91%, and 89%, respectively. In conclusion, after an initial steep learning curve, completely endoscopic left internal mammary artery-to-left anterior descending CABG can be performed safely, with low conversion rates. The learning curve for operative times and improvements in clinical outcome continued even at 100 procedures.

Training Surgeons to Perform Robotically Assisted Totally Endoscopic Coronary Surgery

BACKGROUNDnRobotic totally endoscopic coronary bypass (TECAB) surgery was developed during the past decade, and younger surgeons need to be trained in this new modality. This study assessed the learning curves and independent TECAB performance of 2 junior surgeons undergoing TECAB training.nnnMETHODSnTwo surgeons in training performed portions of 44 of 239 robotic TECAB operations, including left (LIMA) and right interior mammary artery (RIMA) harvesting, lipectomy, pericardiotomy, and IMA to left anterior descending coronary artery (LAD) anastomotic suturing.nnnRESULTSnThe procedure portions performed faster by the senior surgeon vs trainees were, in minutes (range), lipectomy, 5 (2 to 18) vs 10 (5 to 21; p < 0.001); pericardiotomy, 5 (1 to 21) vs 7 (3 to 16; p = 0.001); RIMA takedown, 35 (25 to 48) vs 49 (40 to 55; p = 0.034); and LIMA to LAD anastomosis, 26 (12 to 100) vs 34 (24 to 67; p = 0.043). After assuming senior roles in the robotic cardiac surgery program, the 2 trained surgeons performed 14 TECABs (LIMA to LAD) without the senior surgeon. Lipectomy took 5 (3 to 8) minutes; pericardiotomy, 5 (2 to 10) minutes; LIMA takedown, 43 (27 to 70) minutes; LIMA to LAD anastomosis, 24 (15 to 60) minutes, cardiopulmonary bypass time, 73 (40 to 126) minutes; and aortic endo-occlusion time, 53 (0 to 83) minutes. No hospital deaths occurred.nnnCONCLUSIONSnTECAB can be well taught with a stepwise training program involving portions of the procedure performed by trainees. With such an approach, independent performance after training can be within adequate time limits and yields seemingly acceptable results.

How to improve performance of robotic totally endoscopic coronary artery bypass grafting

BACKGROUNDnWe investigated whether specific surgical measures during the learning curve can influence procedural performance in robotic totally endoscopic coronary artery bypass grafting (TECAB).nnnMETHODSnFrom 2001 to 2006, 70 patients underwent TECAB using the da Vinci telemanipulation system (Intuitive Surgical, Sunnyvale, CA). The following measures were employed with the intent to improve procedure performance: (1) introduction of a fixed team of surgeons at case 14; (2) application of fibrin glue to seal the anastomosis at case 28; and (3) use of a fourth port for transthoracic assistance at case 49.nnnRESULTSnAll 3 measures resulted in a reduction of operating room (OR) time (27%, 20%, and 20%). Use of a stable OR team and peri-anastomotic fibrin glue reduced the rate of conversions and on-table revisions from 39% to 9% (P = .006) and from 26% to 7% (P = .038), respectively. Peri-anastomotic fibrin glue significantly reduced postoperative revisions for bleeding. Using transthoracic assistance, anastomotic time was shortened from 35 minutes (range 23-67) to 25 minutes (range 16-100) (P < .001).nnnCONCLUSIONnThe 3 measures can improve intraoperative and clinical results in TECAB.

The amounts of alpha 1 antitrypsin protein are reduced in the vascular wall of the acutely dissected human ascending aorta

BACKGROUNDnAneurysm and dissection of the ascending aorta carry the risk of life-threatening complications. The anti-protease alpha 1 antitrypsin plays an important role in the tissue protease - anti-protease equilibrium. We aim to investigate the molecular pathology of these diseases by differential proteomics and mass-spectrometric analysis.nnnMETHODSnFrom ascending aortic wall specimens of aneurysms, acute dissections and controls, protein amounts were analysed by the differential in-gel electrophoresis (DIGE). Significantly, different spots underwent qualitative analysis by nanospray mass spectrometry.nnnRESULTSnAmong the most significant differentially expressed protein spots in the DIGE analysis, the most notable protein identified by nanospray mass spectrometry was alpha 1 antitrypsin. This was significantly reduced in aneurysms and aortic dissections compared with controls (p<0.05). Western blot analysis confirmed the reduced amounts of alpha 1 antitrypsin in aortic dissections (p=0.008 vs controls) but not for aneurysms (p=0.258). By quantitative reverse transcription polymerase chain reaction (RT-PCR), mRNA level of alpha 1 antitrypsin was found to be increased in aortic dissections (p=0.035 vs controls), whereas in aneurysms a non-significant reduction of alpha 1 antitrypsin mRNA was present (p=0.123 vs controls).nnnCONCLUSIONnIn the vascular wall of ascending aortic dissections, alpha 1 antitrypsin protein amounts are reduced compared with healthy aortas. Local alpha 1 antitrypsin deficiency in the human ascending aorta might lead to proteolytic damage easing aortic dissection.

Successful administration of levosimendan in a patient with low-gradient low-output aortic stenosis

SummaryAortic valve replacement in patients suffering from low-gradient aortic stenosis and congestive heart failure is associated with high operative mortality, and the perioperative use of inotropes is common. Levosimendan is a calcium sensitizer with positive inotropic and vasodilatory effects and has been developed for treatment of decompensated heart failure. Although its use in patients with low-gradient aortic stenosis is not established, we hypothesized that it might have beneficial effects on outcome after aortic valve replacement. We report on a high-risk operation in a 73-year-old man with low-gradient aortic stenosis, congestive heart failure and coronary artery disease. Levosimendan was administered perioperatively (0.1 mg/kg/min 16 hours prior to the operation without a loading dose) and allowed rapid recovery of the patient, who required only brief treatment in the intensive care unit. No levosimendan-specific adverse events were observed, in particular no hypotension. The excellent postoperative result was maintained after the patient was discharged from hospital.ZusammenfassungEin Aortenklappenersatz bei Patienten mit einer Aortenklappenstenose mit niedrigem Druckgradienten und hochgradig eingeschränkter Linksventrikelfunktion ist mit einer hohen Mortalität assoziiert und der perioperative Einsatz von positiv inotropen Substanzen ist häufig erforderlich. Levosimendan ist ein Kalzium-Sensitizer, der für die Therapie der akuten Herzinsuffizienz entwickelt wurde. Der Einsatz bei Patienten mit Aortenklappenstenose mit niedrigem Druckgradienten ist nicht etabliert, wir erwarteten jedoch vom perioperativen Einsatz dieses Medikaments einen positiven Einfluss auf das Überleben. Wir berichten über eine Hochrisiko-Operation bei einem 73-jährigen Mann mit einer Aortenklappenstenose mit niedrigem Druckgradienten, einer hochgradig eingeschränkten Linksventrikelfunktion und koronarer Herzkrankheit. Levosimendan wurde perioperativ verabreicht (0,1 mg/kg/min ohne Bolusgabe, Beginn 16 Stunden präoperativ), was die schnelle Erholung des Patienten und damit eine kurze Intensivtherapie begünstigte. Es traten keine Levosimendan-assoziierten Komplikationen, insbesondere keine Hypotonie, auf. Das exzellente postoperative Ergebnis ist auch im Langzeitverlauf stabil.

Similarities and Differences of the Aortic Root After Arterial Switch and Ross Operation in Children

Pulmonary root dilation and valve regurgitation if translocated into the aortic position is frequently seen in children with transposition of the great arteries (TGA) after an arterial switch operation, as well as in patients after the Ross procedure. Many mechanisms are thought to be responsible for the progressive dilation. Despite the differences between the 2 groups, the similarity of having the pulmonary valve and its adjacent tissue working in the systemic circulation might have a comparable effect on the neoaortic root dimensions and elasticity. We prospectively recruited 52 patients with TGA, 23 Ross patients, and 48 healthy subjects for echocardiographic assessment of their aortic valve, root, sinutubular junction, and ascending aortic dimensions and elasticity. The data were compared, stratified by patient age at investigation and the duration of follow-up postoperatively. In relation to the healthy subjects, the neoaortic root dimensions were significantly larger and the tissue stiffer and less distensible in those with TGA and those who had undergone the Ross procedure. Although the pulmonary valve of the Ross patients had been under systemic pressure load for a significantly shorter period (4.4 ± 3.6 vs 10.1 ± 5.5 years), the dimensions and elasticity values had deteriorated more. These differences could neither be clearly attributed to the age differences at surgery or to an auxiliary congenital ventricular septal defect in those with TGA or the aortic valve phenotype before the Ross operation. In conclusion, the worse outcome of the neoaortic root dimensions and elasticity in the Ross patients should at least be partly related to the different predefined pulmonary artery structures and the different development of the normal and transposed pulmonary arteries.

Left main compression syndrome by idiopathic pulmonary artery aneurysm caused by medial necrosis Erdheim-Gsell combined with bicuspid pulmonary valve.

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Single time point measurement by C2 or C3 is highly predictive in cyclosporine area under the curve estimation immediately after lung transplantation

Abstract:u2002 Background:u2002 The twou2003h post‐dose cyclosporine (CsA) concentration has been advocated as the optimal time point measurement for CsA area under the curve (AUC) estimation after solid organ transplantation. The aim of the study was to investigate whether intensified CsA monitoring is necessary, or if a single time point measurement is accurate to estimate the AUC in the very early period following lung transplantation (LuTX).

Everolimus attenuates neointimal hyperplasia in cultured human saphenous vein grafts

OBJECTIVEnNeointimal hyperplasia is the first step in a cascade leading to a reduced patency rate of saphenous vein grafts in comparison to arterial grafts in coronary artery bypass grafting. Using cultured human saphenous vein grafts as a model for coronary artery bypass grafting, we investigated if the mammalian target of rapamycin inhibitor everolimus attenuates neointimal hyperplasia.nnnMETHODSnSaphenous vein grafts from 10 patients undergoing coronary artery bypass grafting were processed as follows: from each patient, one segment served as baseline control at day 0. Two segments were cultured in a neointimal hyperplasia model separately. One received no treatment and the other everolimus (1 microM). All vein grafts underwent histomorphometric analysis, assessment of proliferation by Ki-67 immunostaining and quantification of phospho-S6 ribosomal protein using western blot analysis.nnnRESULTSnEverolimus treatment resulted in reduced neointimal hyperplasia (thickness 3.7+/-1.2 microm) compared to untreated controls (10.1+/-2.5 microm, p=0.008). The intima/intima+media-ratio was reduced in the everolimus group (0.10+/-0.02) compared to untreated controls (0.24+/-0.07, p=0.008). The number of Ki-67 positive proliferating cells in everolimus treated vein grafts (15+/-7 cells/high power field) showed a tendency of reduction compared to untreated controls (36+/-20 cells/high power field, p=0.036). Finally, everolimus treatment resulted in downregulation of S6 ribosomal protein phosphorylation in comparison to untreated controls.nnnCONCLUSIONnEverolimus is able to reduce neointimal proliferation in cultured human saphenous vein grafts by inhibition of the mammalian target of rapamycin, even though different transfection methods are to be evaluated for a clinical application in coronary artery bypass grafting.