Jean-Luc Jansens

Robotic-enhanced biventricular resynchronization: An alternative to endovenous cardiac resynchronization therapy in chronic heart failure

BACKGROUND Cardiac resynchronization therapy (CRT) by pacing the left and right ventricles is an emerging option for treatment of severe heart failure with ventricular conduction disturbances. Stimulation through a coronary vein is currently the technique of choice to achieve left ventricular (LV) pacing. Unfortunately, this approach carries significant limitations and drawbacks. Therefore we explored robotic-enhanced thoracoscopic implantation of an epicardial lead as an alternative technique to stimulate the LV in cardiac resynchronization therapy. METHODS A total of 15 patients were included in this study. Right (atrial and ventricular) leads were implanted classically through the left subclavian vein. Robotic-enhanced thoracoscopy was then performed to implant the LV epicardial lead. RESULTS Of the 15 patients, 13 underwent successful endoscopic robotic cardiac resynchronization therapy. Two patients underwent conversion to a small thoracotomy. No perioperative complication occurred in the patients who did not undergo conversion. Acute and chronic LV lead thresholds were satisfactory in all patients, improving over time. All were subjectively and objectively improved at 4 months. As compared with conventional methods, the procedural cost was not significantly affected. CONCLUSIONS Based on this feasibility study, we believe that robotic LV epicardial lead implantation is a valuable option to achieve biventricular resynchronization therapy. It allows for more reproducible acute thresholds for LV pacing and sensing than does the percutaneous approach; enables fine tuning of the LV lead position, thus potentially providing optimal hemodynamic benefit; and avoids the pitfalls and limitations of the endovenous approach. Therefore it deserves further prospective studies to assess its place in the therapeutic armamentarium against heart failure.

Left ventricular outflow tract obstruction after mitral valve replacement

We describe a patient with left ventricular outflow tract obstruction after mitral valve replacement preserving the anterior subvalvular apparatus. Postoperative transesophageal echocardiography demonstrated systolic narrowing of the left ventricular outflow tract by a bulging septum and systolic anterior motion of the preserved anterior mitral leaflet. Septal myectomy and transaortic mitral apparatus resection enabled us to relieve the left ventricular outflow tract obstruction. This suggests that septal hypertrophy might be a relative contraindication to the preservation of the anterior mitral subvalvular apparatus in mitral replacement.

Assessment based on EuroSCORE of ministernotomy for aortic valve replacement.

To assess the advantages of a ministernotomy over a standard sternotomy for aortic valve replacement, 191 patients were classified as low-, medium-, and high-risk by EuroSCORE. A ministernotomy was carried out in 100 patients, and a standard sternotomy was used in 91. Among low-risk patients, those who had a ministernotomy showed a marginal increase in atrial fibrillation. Of the medium-risk patients, those who had a sternotomy had significantly more atrial fibrillation and slightly more general infections. In the high-risk subgroup, significantly more atrial fibrillation was observed in the sternotomy group, and more neurologic events were observed in the ministernotomy group; the difference became nonsignificant when only severe events were considered. There was a significant benefit in terms of rhythm disturbances in medium- and high-risk patients who underwent a ministernotomy compared to those who had a full sternotomy. Mortality, duration of intensive care, and hospital stay were not influenced by the operative method.

Early alterations of myocardial blood flow reserve in heart transplant recipients with angiographically normal coronary arteries

BACKGROUND The evaluation of the coronary reserve provides valuable information on the status of coronary vessels. Therefore, we studied with positron emission tomography (PET) and 13N-ammonia the myocardial blood flow (MBF) reserve in heart transplant recipients free of allograft rejection and with angiographically normal coronary arteries early after heart transplantation (HTx). The MBF reserve was calculated as the ratio between MBF after dipyridamole injection and basal MBF normalized for the rate-pressure product. METHODS Patients were studied within 3 months (group A, n = 12) or more than 9 months (group B, n = 12) after HTx. Five patients have been studied both during the early and late period after HTx. Results were compared to those obtained in 7 normal volunteers (NL). RESULTS Group A recipients had a significantly lower dipyridamole MBF (in ml/min/100 gr of tissue) than that of group B recipients (142+/-34 vs 195+/-59, p<0.05). This resulted in a significant decrease in MBF reserve early after HTx (group A: 1.82+/- 0.33) and a restoration to normal values thereafter (group B: 2.52+/- 0.53 vs NL: 2.62+/-0.51, p = ns). Separate analysis of 5 patients studied twice is consistent with these results. CONCLUSION This study shows that in heart transplant recipients free of allograft rejection and with normal coronary angiography, MBF reserve is impaired early after HTx. Restoration within one year suggests that this abnormality does not represent an early stage of cardiac allograft vasculopathy.

Pulmonary vein isolation by robotic-enhanced thoracoscopy for symptomatic paroxysmal atrial fibrillation.

BACKGROUND Pulmonary vein isolation (PVI) has been shown to be effective treatment of patients with symptomatic paroxysmal atrial fibrillation (PAF). The percutaneous approach is currently the technique of choice. Unfortunately, this procedure has limitations and complications that lead to fluctuating success rates. We explored an alternative technique of robotic-enhanced, closed-chest PVI with an endoscopic microwave-based catheter. METHODS Seven symptomatic PAF patients were included in the study. The pulmonary veins were isolated through right (only) robotic-enhanced thoracoscopy on the beating heart. RESULTS Six patients underwent successful endoscopic PVI. In 1 patient the operation was converted into small right thoracotomy. Operative assessment of the ablation line showed a successful electric block in every patient. Three months after the procedure, the first 5 patients were in permanent sinus rhythm. The 2 other patients had AF but had less frequent and less symptomatic episodes compared with the preoperative situation. CONCLUSIONS On the basis of this preliminary experience, we believe that in the near future endoscopic right-chest robotic-enhanced PVI on the beating heart may become a valid option in the treatment of symptomatic PAF patients. This procedure allows for more-reproducible ablation lines and may avoid many of the pitfalls and drawbacks of the percutaneous approach. Therefore this technique deserves larger prospective evaluation in the treatment of AF.

Robotic-assisted surgical myotomy in a 27-year-old man with myocardial bridging of the left anterior descending coronary artery

Myocardial bridging (MB) is a frequent condition usually considered benign but it may be associated with myocardial ischemia. When bridging is symptomatic, therapeutic options are numerous and in the absence of guidelines all options are conceivable. This is a case of a 27-year-old man who benefited from a new surgical approach: myotomy for MB of the left anterior descending coronary artery with the help of left robotic thoracoscopy.

FIVE YEARS FOLLOW-UP AFTER Y-GRAFT ARTERIAL REVASCULARIZATION: ON PUMP VERSUS OFF PUMP; PROSPECTIVE CLINICAL TRIAL

OBJECTIVES We report our comparative experience of on-pump and off-pump full arterial coronary artery bypass grafting (CABG) using both internal mammary arteries (IMAs) anastomosed as a Y-graft. METHODS A single-center clinical study was conducted prospectively between January 2003 and May 2008. It compared the short- and mid-term clinical outcomes of on- and off-pump arterial revascularization where the left internal mammary artery (LIMA) was anastomosed to the left anterior descending (LAD) artery while the free right internal mammary artery (RIMA) graft taking off from the LIMA was used to bypass different coronary targets. RESULTS One hundred and ninety-two patients were divided into 77 on-pump and 115 off-pump procedures based on the intention to treat. The mean age in both groups was 60.2+/-11.7 and 68.1+/-10.6 years, respectively (P<0.05). Mean predictive logistic EuroSCORE was 3.5+/-6.7% for the on-pump group and 7.3+/-8.6% for the off-pump group (P<0.0001). Mean number of distal anastomoses were 2.7+/-0.6 (group ON) and 2.5+/-0.6 (group OFF) (P=NS). Postoperative mortality was two patients (2.6%) in the on-pump group and four patients (3.4%) in the off-pump group (P=0.63). No major adverse cardiac event, no stroke and no late death were reported during the follow-up that averaged 36.5+/-18.6 months. Angina recurrence was three patients (2.6%) in off-pump and two patients (3.5%) in on-pump group (P=NS). CONCLUSIONS The use of a free RIMA as Y-graft from the LIMA performed off pump eradicates aortic manipulations and provides complete revascularization to high-risk patients with mortality similar to the one of a lower risk population operated on pump. The morbidity and cost was lower in the off-pump group. This advocates for the widespread usage of the technique in high-risk patients.

Alternative to left ventricular lead implantation through the coronary sinus: 1-year experience with a minimally invasive and robotically guided approach

Aims Left ventricular (LV) lead implantation through the coronary sinus (CS) can be limited and sometimes not possible—alternative approaches are needed. Minimally invasive, robotically guided LV lead implantation has major advantages, but there are little published data about the short- and long-term follow-ups, in terms of feasibility, safety, electrical performance, and impact on clinical outcome. Methods and results A total of 21 heart failure patients underwent robotically guided LV lead implantation using the Da Vinci Robotic System. Indications were failed implant with conventional approach through the CS (n = 16) and non-response to conventional cardiac resynchronization therapy (n = 5). During the procedure, the entire LV free wall was exposed through 3 transthoracic ports (10 mm diameter each) allowing ample choice of stimulation site and the ability to implant 2 LV leads via a Y connector. Patients were prospectively followed up for 1 year. The two LV leads were successfully implanted in all patients. No peri-procedural complications were observed. After a mean stay in the intensive care unit of 1.2 ± 4 days, the 21 patients were hospitalized in the EP department for 6.7 ± 2.9 days. Acute LV thresholds were excellent (1.0 V ± 0.6/0.4 ms) and stayed stable at 1-year follow-up (1.5 V ± 0.6/0.4 ms, P = 0.21). Four patients demonstrated an increased threshold (>2 V/0.4 ms). There was no phrenic nerve stimulation. After 12 months, in the failed implant group, 69% of the patients were echocardiographic and clinical responders. Conclusion The robotic approach was feasible, safe, and minimally invasive. Accordingly, robotically guided LV lead implantation seems to offer a new alternative when conventional approaches are not suitable.

Implantation of a cardiac resynchronization therapy and defibrillation system using a robotic approach

Case report A 67-year-old man with dilated cardiomyopathy (New York Heart Association [NYHA] class III and left bundle branch block) was implanted with a cardiac resynchronization therapy and defibrillation (CRT-D) device and was a good responder (NYHA class I and increase in left ventricular ejection fraction [LVEF] from 30% to 45%). After 2 episodes of device infection and 2 CRT-D extractions, a new device was required. As superior venous access was no longer available (thrombosis on 1 side, recent infection on the other), an epicardial approach was used. The whole procedure was minimally invasive and robotically guided by the da Vinci Robotic System (Intuitive Surgical Inc, Sunnyvale, CA). The patient was tilted to the right side, in order to get more intrathoracic space to facilitate left ventricle (LV) access (Figure 1). The patient was intubated with a double-lumen endotracheal Clarins device for single and right selected lung ventilation (left lung exclusion), mandatory to access the LV epicardium. The left chest was insufflated, allowing the introduction of a binocular camera and instruments via 3 transthoracic ports of 10 mm diameter in the anterior axillary line (the fifth intercostal space for the camera, the third and seventh for

Prélèvement de plaquettes pour la chirurgie cardiaque: première expérience d'aphérèse à l'Hôpital Général de Douala

Cardiac surgery with extracorporeal circulation (ECC) is usually associated with the loss of a significant amount of blood. Adequate prophylaxis against blood loss and good perioperative hemostasis are known as processes limiting postoperative bleeding. Until now, the need for platelets in patients operated with extracorporeal circulation in our Department has been compensated for by total blood transfusion or platelet concentrates collected from several donors. We here report our first experience with platelet concentrate collection by apheresis at the General Hospital in Douala.