Min-Wen Yang

Video-Assisted Cardiac Surgery in Closure of Atrial Septal Defect

BACKGROUND Video-assisted endoscopy has been applied in the management of a variety of intrathoracic vascular lesions. Here we report its use in the correction of intracardiac congenital defects. METHODS Eight patients (3 male and 5 female) underwent operation for closure of an atrial septal defect. The patients ranged in age from 2.0 to 60.9 years (mean, 19.2 +/- 19.0 years). The patients weighed 11 to 66 kg (mean, 41.3 +/- 23.5 kg). The ratio of pulmonary blood flow to systemic blood flow ranged from 2.0 to 6.0 (mean, 3.4 +/- 1.3). The mean pulmonary artery pressure was 19.7 +/- 4.0 mm Hg (range, 13 to 24 mm Hg). The operations were performed through a right anterior minithoracotomy and guided by video-assisted endoscopic techniques under femorofemoral or femoral-right atrial extracorporeal circulation. The aorta was not cross-clamped, and the myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest (rectal temperature, 22.0 degrees +/- 2.0 degrees C). Transesophageal echocardiographic monitoring was maintained during the operations. The right atrium was entered after pericardiotomy. Primary closure of the defect was performed successfully in all patients. Conventional nondisposable instruments were used for dissection, grasping, suturing, and hemostasis. RESULTS The durations of extracorporeal circulation and operation ranged from 47 to 126 minutes (mean, 80 +/- 31 minutes) and from 2.2 to 4.5 hours (mean, 3.1 +/- 0.8), respectively. All patients recovered from the operation rapidly with an uneventful postoperative course. CONCLUSIONS Our experience demonstrates that video-assisted cardiac surgery is technically feasible and can be used with excellent results for the repair of congenital heart defects in general.

Video-assisted mitral valve operations

BACKGROUND Video-assisted endoscopy has been applied frequently in the management of a variety of surgical diseases. However, it has rarely been applied in mitral valve surgery. METHODS We report 2 patients who received emergency operations for thrombosis of a mitral prosthesis (patient 1, a 68-year-old man) and acute mitral regurgitation due to rupture of anterior chordae (patient 2, a 75-year-old woman). They both had severe congestive heart failure. Cardiogenic shock was noted in patient 2. The mitral valve was approached through a right anterior minithoracotomy with the aid of an endoscope by means of projected images on the video monitor under femorofemoral cardiopulmonary bypass. The aorta was not cross-clamped, and the myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest. The left atrium was entered posterior to the interatrial groove. Thrombectomy and mitral valve repair were performed successfully. RESULTS The duration of extracorporeal circulation was 204 and 147 minutes, respectively. Both patients recovered from the operation rapidly with uneventful postoperative courses. CONCLUSIONS Our preliminary results suggest that video-assisted endoscopic cardiac surgery is technically feasible and could be performed in the milieu of open heart surgery.

Minimally Invasive Cardiac Surgical Techniques in the Closure of Ventricular Septal Defect: An Alternative Approach

BACKGROUND Minimally invasive cardiac surgical techniques recently have been applied in the management of a variety of intracardiac lesions. METHODS Fourteen patients (6 boys and 8 girls; age, 8.9 +/- 5.5 years; body weight, 29.0 +/- 13.5 kg) were operated on using minimally invasive cardiac surgical techniques for the closure of a ventricular septal defect (subarterial in 11 patients and perimembranous in 3 patients). The operations were performed through a left anterior minithoracotomy and were guided by video-assisted endoscopic techniques under femorofemoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with hypothermic fibrillatory arrest. The right ventricular outflow tract was entered after pericardiotomy was performed. RESULTS Closure of the defect (directly in 4 patients and by patch in 10 patients) was performed successfully in all patients. A right ventricular outflow tract obstruction and ruptured sinus of Valsalva aneurysm also were repaired in 1 patient each. The duration of cardiopulmonary bypass was 41 +/- 10 minutes (range, 28 to 100 minutes) and the total operative time was 2.2 +/- 0.8 hours (range, 1.3 to 3.5 hours). All the patients recovered rapidly from their operation and had an uneventful postoperative course. Follow-up (mean, 6.2 months; range, 6 to 9 months) was complete in all patients. There were no late deaths. Transthoracic echocardiographic examination showed no residual shunt and no aortic regurgitation in all patients. CONCLUSIONS Our experience demonstrates that minimally invasive cardiac surgical techniques are technically feasible and an alternative option for the repair of a ventricular septal defect.

Video-assisted minimal access in excision of left atrial myxoma

BACKGROUND Minimal access surgery with video-assisted endoscopy has been applied to the correction of intracardiac lesions. We report our experience using this technique in surgical excision of left atrial myxoma in 3 patients. METHODS From November 1995 to March 1997, 3 female patients, ages 45 to 80 years (mean, 62.7 years), received emergency operations for excision of left atrial myxoma. These operations were performed through a right anterior submammary minithoracotomy or right parasternal incision with the assistance of endoscopy during femoro-femoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with fibrillatory arrest or cardioplegic arrest with aortic cross-clamping. RESULTS All the tumors were excised completely through the right atrial approach. The bypass time was 92 to 148 minutes (mean, 111 minutes). The operation time was 3.2 to 4.4 hours (mean, 3.7 hours). There were no hospital deaths. Follow-up, which ranged from 6 to 19 months (mean, 10.5 months), was complete in all patients. Transthoracic echocardiographic examination showed good ventricular function without any residual tumors. Patients were found to be in New York Heart Association functional class I or II. They were satisfied with the good cosmetic healing of the incision. CONCLUSIONS Our experience demonstrates that minimal access surgery is a technically feasible, safe, and effective procedure in surgical excision of left atrial myxoma.

Surgical closure of atrial septal defect. Minimally invasive cardiac surgery or median sternotomy

AbstractBackground: Closure of ostium secundum atrial septal defect (ASD) vis median sternotomy (MS) is a simple procedure for most cardiac surgeons. Minimally invasive cardiac surgery (MICS) has recently been applied in the management of intracardiac lesions. Methods: We report our experience in surgical closure of isolated ASD via MICS in 60 patients and via MS in 58 patients. There was no difference between these two groups in gender, age, body weight, ratio of systemic to pulmonary blood flow, and pulmonary arterial pressure. Results: The duration of cardiopulmonary bypass was significantly longer in the MICS group than in the MS group [27 to 126 min (42 ± 12) and 14 to 158 min (27 ± 11), respectively; (p < 0.001]. However, the length of incision, incidence of temporary pacemaker wire insertion rate, duration of endotracheal intubation, timing of oral intake, postoperative day drainage amount, incidence of parenteral analgesic injection, postoperative length of stay, and return to normal activity interval were significant shorter and lower in patients of the MICS group than in those of the MS group. All the patients recovered rapidly from the surgery. Follow-up was complete in all patients, with no late complications and no residual shunt. Conclusion: Our results suggest that MICS is a good option for surgical closure of ASD.

Video-Assisted Coronary Artery Bypass Grafting During Hypothermic Fibrillatory Arrest

BACKGROUND Hypothermic fibrillatory arrest without aortic cross-clamping is a technique for quieting the heart during coronary artery bypass grafting. This report reviews the preliminary results with this technique in 4 patients having video-assisted coronary artery bypass grafting. METHODS Four male patients 28.5 to 64.5 years old (mean age, 45.4 years) underwent operation for unstable angina. With video-assisted techniques, coronary artery bypass grafting was performed through a left anterior minithoracotomy with femoral-femoral cardiopulmonary bypass without cross-clamping the aorta. The myocardium was protected by continuous coronary perfusion during hypothermic fibrillatory arrest. RESULTS A left internal thoracic artery graft was anastomosed to the left anterior descending coronary artery in each patient. The posterior descending branch of the right coronary artery was grafted with a pedicled right gastroepiploic artery in 1 patient. The duration of cardiopulmonary bypass was 72 to 127 minutes (mean duration, 92 +/- 21 minutes). The postoperative course of each patient was uneventful. Follow-up (range, 3.9 to 5.8 months; mean follow-up, 4.9 months) was complete for all patients. There were no late deaths. Coronary angiography showed patent grafts. All patients were in New York Heart Association functional class I or II (mean class, 1.25). CONCLUSIONS Hypothermic fibrillatory arrest is a simple and effective method of quieting the heart, thereby providing a motionless operative field for video-assisted coronary artery bypass grafting.

The use of multiplane transesophageal echocardiography to evaluate residual patent ductus arteriosus during video-assisted thoracoscopy in adults

AbstractBackground: Video-assisted thoracoscopic surgery (VATS) has emerged as an innovative and popular procedure for interruption of patent ductus arteriosus (PDA), while intraoperative transesophageal echocardiography (TEE) has proven to be an effective monitor in the evaluation of residual patency. Previous reports on the adequacy of surgical interruption of PDA under VATS and TEE are available for pediatric patients, but only limited information is available for adults with PDA. Materials and methods: Between August 1995 and October 1997, we monitored 35 adult patients undergoing PDA interruption via VATS with Hewlett-Packard color Doppler multiplane TEE throughout the procedure. The average PDA diameter was 10.2 ± 1.8 mm. All the PDA were completely ligated. Results: Thirty-two patients showed no ductal flow after double ligation. In the other three patients, residual flow was detected intraoperatively after double ligation, but it was quickly abolished by the third ligation. One patient showed faint ductal flow by transthoracic echocardiography at postoperative follow-up, but no reintervention was needed. Conclusions: Our study showed that, with the refinement of adult PDA interruption via VATS, intraoperative multiplane TEE provides higher resolution for direct evaluation of the entire course of PDA ligation without interrupting the surgical procedure and minimizes the incidence of complications.

Minimally invasive approach for coronary artery bypass surgery

Forty-two patients, 33 male and 9 female, aged 35.7 to 81.6 years old (mean 62.7), were operated on for left main and/or triple vessel coronary artery disease by using minimally invasive cardiac surgical techniques. A myocardial infarction had occurred in 26 patients (61.9%). The left ventricular ejection fraction ranged from 17 to 83% (52+/-22). The surgeries were performed through left parasternal minithoracotomy (8 to 12 cm in length) under femoro-femoral or aorto-atrial cardiopulmonary bypass. The myocardium was protected by blood cardioplegic solution with the aorta crossclamped. Under direct vision, average 3.8 distal anastomoses were performed in each patient, with the saphenous vein grafts and the left internal thoracic arterial graft. The aortic crossclamp time was 62 to 137 min (80+/-15). The duration of cardiopulmonary bypass was 88 to 168 min (115+/-24). The postoperative course was uneventful in all patients. Follow-up (1.0 to 5.6 months, mean 2.9) was complete in all patients and there were no late deaths or angina. Coronary angiography of ten patients showed patent grafts. Our experience demonstrates that minimally invasive cardiac surgery during cardioplegic arrest is technically feasible and can be performed in coronary artery disease safely and effectively for complete revascularization.

Comparison of right ventricular measurements by perioperative transesophageal echocardiography as a predictor of hemodynamic instability following cardiac surgery

Background The relationship between perioperative right ventricular (RV) performance and hemodynamic instability after cardiac surgery seemed less portrayed. Therefore, we sought to elucidate this relationship and compare the accuracy of different RV systolic indices in predicting outcome of cardiac surgery. Methods This study enrolled consecutive patients referred for cardiac surgeries. Exclusion criteria were non‐sinus rhythm or contraindications to transesophageal echocardiography (TEE). TEE exam and simultaneous pulmonary hemodynamics were recorded in two stages: after induction of anesthesia and before sternotomy (stage 1), and after sternal closure (stage 2). RV measurements performed offline included fractional area change (RVFAC), tricuspid annular plane systolic excursion (TAPSE), peak systolic tricuspid annular velocity (RVS′), myocardial performance index (RVMPI), and global longitudinal strain (RVGLS). The end point was defined as prolonged use (>24 h) of postoperative inotropic agent in the intensive care unit (ICU). Results The study population included 68 patients (mean age 61 ± 11 y; 49 men). Twenty‐two of these patients (32%) were administered inotropic agents for a prolonged period with a mean duration of 63.9 ± 5.3 h, accompanied with significantly longer ventilator use (p = 0.006) and longer ICU stay (p = 0.001) than patients without a prolonged inotropic agent use. Multivariable analysis demonstrated that only RVGLS in either stage 1 (odds ratio [OR] 1.11, p = 0.048) or stage 2 (OR 1.15, p = 0.018) was significantly associated with the outcome, especially a RVGLS > −13.5% in stage 2 demonstrating high risk of prolonged inotropic agent use after cardiac surgery (OR 7.37, p = 0.016). Conclusion RVGLSs performed using perioperative TEE are reliably associated with hemodynamic instability following cardiac surgery. This finding adds substantial information to postoperative critical care.