Patrycja Jonetzko

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.

Safety and Effectiveness of Levosimendan in Patients with Predominant Right Heart Failure

Background and Purpose:Levosimendan is a new calcium sensitizer that enhances the contractile force of the myocardium and exhibits additional vasodilating properties. The present study describes the hemodynamic effects of levosimendan in patients with acute predominant right heart failure in need of inotropic therapy.Patients and Methods:18 patients (15 male, age 60 ± 17 years) with acute heart failure, predominant right ventricular dysfunction, left ventricular ejection fraction (LVEF) ≤ 30%, cardiac index (CI) ≤ 2.5 l/min/m2, right atrial pressure (RAP) ≥ 10 mmHg, and pulmonary capillary wedge pressure (PCWP) ≥ 15 mmHg were investigated. Following a loading dose, levosimendan was administered intravenously for 24 h.Results:After 24 h, CI and left ventricular stroke work index increased from 1.7 ± 0.4 to 2.3 ± 0.6 l/min/m2 (p < 0.001) and 14 ± 6 to 17.3 ± 8 g-m/m2/beat (p < 0.05), respectively. PCWP and systemic vascular resistance decreased from 25 ± 7 to 21 ± 5 mmHg (p < 0.01) and 1,724 ± 680 to 1,096 ± 312 dyne * s * cm–5 (p < 0.0001), respectively. RAP was reduced from 15 ± 5 to 10 ± 3 mmHg (p < 0.001), whereas decreases in mean pulmonary artery pressure and pulmonary vascular resistance were not significant. Right ventricular stroke work index (RVSWI) increased from 4.8 ± 1.8 to 7.6 ± 3.4 g-m/m2/beat (p < 0.01).Conclusion:Levosimendan therapy is feasible and improves hemodynamics in patients with acute predominant right heart failure. Augmentation in RVSWI indicates an increase in right ventricular contractility rather than reduction in afterload as a possible pathophysiological mechanism.ZusammenfassungHintergrund und Ziel:Levosimendan ist ein Calciumsensitizer mit positiv inotroper und vasodilatierender Wirkung, dessen Anwendung sich bei der akuten Herzinsuffizienz als sehr effektiv erwiesen hat. In der vorliegenden Untersuchung wurden speziell die Wirkung und Sicherheit dieser neuen Substanz bei Patienten mit überwiegendem Rechtsherzversagen untersucht.Patienten und Methodik:In einer Serie von 18 Patienten mit hochgradig eingeschränkter überwiegend rechtsventrikulärer Pumpfunktion, deutlich reduziertem Herzindex (CI), erhöhtem Wedge-Druck (PCWP) und klinischen Zeichen eines manifesten Rechtsherzversagens wurde Levosimendan als 24-h-Infusion mit und ohne vorausgehenden Bolus verabreicht.Ergebnisse:Dabei bestätigten sich die bereits bekannten positiven Effekte auf die Hämodynamik (Zunahme des CI von 1,7 ± 0,4 auf 2,3 ± 0,6 l/min/m2; p < 0,001; Abnahme des PCWP von 25 ± 7 auf 21 ± 5 mmHg; p < 0,01; Abnahme des systemischen Gefäßwiderstands von 1 724 ± 680 auf 1 096 ± 312 dyn * s * cm–5; p < 0,0001). Auffällig waren die Abnahme des rechtsatrialen Drucks von 15 ± 5 auf 10 ± 3 mmHg (p < 0,001) und die signifikante Steigerung des rechtsventrikulären Schlagarbeitsindex von 4,8 ± 1,8 auf 7,6 ± 3,4 g-m/m2/Schlag (p < 0,01) bei weitgehend unverändertem Lungengefäßwiderstand. Der Herzfrequenzanstieg während der Behandlung war nicht signifikant, und es traten keine Tachykardien und/oder relevanten Arrhythmien auf. Patienten mit vasopressorpflichtiger Hypotonie bereits zu Beginn oder während der Behandlung wiesen die höchste 30-Tage-Mortalität auf.Schlussfolgerung:In dieser Fallserie erwies sich die Anwendung von Levosimendan bei Patienten mit überwiegender Rechtsherzdekompensation als sicher und effektiv. Die deutliche Zunahme der rechtsventrikulären Schlagarbeit spricht eher für die Kontraktilitätssteigerung des Ventrikels und weniger für die Nachlastsenkung als dem zugrundeliegenden Wirkmechanismus von Levosimendan am rechten Ventrikel.

Treatment of double vessel coronary artery disease by totally endoscopic bypass surgery and drug-eluting stent placement in one simultaneous hybrid session.

Hybrid coronary artery revascularization is a combination of minimally invasive coronary artery surgery and catheter-based coronary intervention. Hybrid procedures enable adequate revascularization of patients with multivessel coronary artery disease without complete opening of the chest and with the advantage of the most durable option, a left internal mammary artery (LIMA) graft is placed to the left anterior descending (LAD) artery. The hybrid concept is gaining renewed interest because totally endoscopic LIMA to LAD placement has become feasible and because drug-eluting stents in non-LAD targets may be competitive even for arterial bypass grafts. Simultaneous hybrid procedures would be desirable. We report on a case in which robotic totally endoscopic LIMA to LAD grafting using the da Vinci telemanipulation system was combined with placement of a rapamycin coated stent to the right coronary artery in one single procedure.

Ongoing procedure development in robotically assisted totally endoscopic coronary artery bypass grafting (TECAB).

BACKGROUND Totally endoscopic coronary artery bypass grafting (TECAB) using robotics requires stepwise introduction into a heart surgery program. It is the aim of this study to evaluate the state of procedure development after continued application of telemanipulation techniques in the clinical setting. We also sought to assess perioperative and intermediate term clinical results after robotically assisted CABG. PATIENTS AND METHODS From June 2001 to March 2005, robotically assisted CABG using the daVinci system was carried out in 107 patients with single and multi-vessel coronary artery disease. The following procedures were performed: robotically assisted endoscopic left internal mammary artery (LIMA) harvesting and completion of the procedure as conventional CABG, MIDCAB, or OPCAB (n = 22), robotically assisted suturing of LIMA-to-LAD anastomoses during conventional CABG (n = 28), TECAB on the arrested heart using remote access perfusion (n = 48), TECAB on the beating heart using an endostabilizer (n = 8), takedown of adhesions (TECAB intended) (n = 1). RESULTS Hospital mortality was 0% and cumulative risk adjusted mortality reached 1.6 lives saved versus EuroSCORE predictions. Undesirable surgical events (USE) such as conversion, on table revision, or postoperative revision procedures occurred in 34 out of 107 (32%) patients. Median ventilation time and ICU stay, however, were 11(0-278) hours and 21(11-389) hours, respectively. Cumulative 3 years survival was 100% and freedom from angina at 3 years was 97%. CONCLUSIONS We conclude that despite being surgically challenging robotically assisted coronary artery surgery can be implemented with acceptable safety. TECAB procedures have reached a reproducible state. Perioperative mortality after robotically assisted CABG may be lower than predicted. Intermediate term clinical results are very satisfactory.

Fatal course of parvovirus B19-associated myocarditis in a female liver transplant recipient.

Acute myocarditis may result in severe hemodynamic compromise with fatal outcome. Furthermore, recent studies suggest myocarditis as a major cause of sudden unexpected death. A variety of cardiotropic viral, rickettsial, and bacterial infectious agents have been identified to date. Parvovirus B19 (PVB19) is usually benign in childhood, but it may also cause death due to myocarditis. We present here the case of an adult female who presented with fatigue, dyspnea on exertion, and orthostatic dizziness 8 months after successful liver transplantation. Cardiologic work‐up, including left ventricular endomyocardial biopsy, revealed acute myocarditis secondary to PVB19. Since no specific therapy for this virus is available, the patient was treated symptomatically with an angiotensin‐converting enzyme inhibitor plus beta‐blocker and diuretics. After a period of stabilization, new‐onset rapid atrial fibrillation caused acute low‐output syndrome within 14 days after hospital admission. The patient eventually died because of refractory cardiogenic shock. In conclusion, to our knowledge this is the first report of PVB19‐induced myocarditis confirmed by detection of viral genome in myocardium in a liver transplant recipient. (Liver Transpl 2005;11:463–466.)

Experience on the Way to Totally Endoscopic Atrial Septal Defect Repair

BACKGROUND Remote-access perfusion and robotics have enabled totally endoscopic closure of atrial septal defect (ASD) and patent foramen ovale (PFO). We report on a stepwise approach to a totally endoscopic procedure. METHODS Seventeen patients (median age, 39 years; range, 21-55 years) underwent limited-access ASD or PFO closure. As a preparative step, the operation was carried out through minithoracotomy in 11 patients. In parallel, experience with robotic surgery was gained with totally endoscopic coronary artery bypass grafting procedures. After performance of ASD closures in dry-laboratory models using the da Vinci telemanipulation system, 6 patients were operated on in a totally endoscopic fashion. RESULTS With the endoscopic approach, significant learning curves were noted for cardiopulmonary bypass time y(min) = 226 - 41 * ln(x) (P = .03) and aortic cross-clamp time y(min) = 134 - 42 * ln(x) (P = .01) (x = number of procedures). There was no hospital mortality, and no residual shunts were detected at postoperative echocardiography. Median ventilation time was 9 hours (range, 0-18 hours) for the minithoracotomy group and 6 hours (range, 4-19 hours) for the totally endoscopic group. Median intensive care unit stay was 20 hours (range, 18-24 hours) and 18 hours (range, 18- 120 hours), respectively. CONCLUSIONS The implementation of robotic totally endoscopic closure of ASD or PFO in a heart surgery program seems to be safe. An intermediate step of performing the operations through minithoracotomy, adapting to remote access perfusion systems, and gaining experience in other robotic cardiac surgical procedures seems worthwhile. Learning curves are apparent, and adequate defect closure does not seem to be compromised by the totally endoscopic approach.

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.