Ramanan Umakanthan

Safety of Minimally Invasive Mitral Valve Surgery Without Aortic Cross-Clamp

BACKGROUNDnWe developed a technique for open heart surgery through a small (5 cm) right-anterolateral thoracotomy without aortic cross-clamp.nnnMETHODSnOne hundred and ninety-five consecutive patients (103 male and 92 female), age 69 +/- 8 years, underwent surgery between January 2006 and July 2007. Mean preoperative New York Heart Association function class was 2.2 +/- 0.7. Thirty-five patients (18%) had an ejection fraction 0.35 or less. Cardiopulmonary bypass was instituted through femoral (176 of 195, 90%), axillary (18 of 195, 9%), or direct aortic (1 of 195, 0.5%) cannulation. Under cold fibrillatory arrest (mean temperature 28.2 degrees C) without aortic cross-clamp, mitral valve repair (72 of 195, 37%), mitral valve replacement (117 of 195, 60%), or other (6 of 195, 3%) procedures were performed. Concomitant procedures included maze (45 of 195, 23%), patent foramen ovale closure (42 of 195, 22%) and tricuspid valve repair (16 of 195, 8%), or replacement (4 of 195, 2%).nnnRESULTSnThirty-day mortality was 3% (6 of 195). Duration of fibrillatory arrest, cardiopulmonary bypass, and skin to skin surgery were 88 +/- 32, 118 +/- 52, and 280 +/- 78 minutes, respectively. Ten patients (5%) underwent reexploration for bleeding and 44% did not receive any blood transfusions. Six patients (3%) sustained a postoperative stroke, eight (4%) developed low cardiac output syndrome, and two (1%) developed renal failure requiring hemodialysis. Mean length of hospital stay was 7 +/- 4.8 days.nnnCONCLUSIONSnThis simplified technique of minimally invasive open heart surgery is safe and easily reproducible. Fibrillatory arrest without aortic cross-clamping, with coronary perfusion against an intact aortic valve, does not increase the risk of stroke or low cardiac output. It may be particularly useful in higher risk patients in whom sternotomy with aortic clamping is less desirable.

Left thoracotomy HeartWare implantation with outflow graft anastomosis to the descending aorta: a simplified bridge for patients with multiple previous sternotomies.

Advances in mechanical circulatory support have been critical in bridging patients awaiting heart transplantation. In addition, improvement in device durability has enabled left ventricular assist device therapy to be applied as destination therapy in those not felt to be transplant candidate. Because of the increasing complexity of patients, there continues to be a need for alternative strategies for device implantation to bridge high-risk patients awaiting heart transplantation, wherein the risks of numerous previous sternotomies may be prohibitive. We present a unique technique for placement of the HeartWare ventricular assist device via left anterior thoracotomy to the descending aorta in a patient awaiting heart transplantation with a history of multiple previous sternotomies.

Do Hybrid Procedures Have Proven Clinical Utility and Are They the Wave of the Future? Hybrid Procedures Have No Proven Clinical Utility and Are Not the Wave of the Future

The LIMA-to-LAD graftis also superior to PCI in terms of long-term patency,event-free survival, and relief of angina. The major benefitsof multivessel PCI with drug-eluting stents (DES) to treatmultivessel coronary artery disease are that it is less invasive,has shorter recovery times, and has lower stroke ratescompared with CABG.Both coronary artery bypass grafting (CABG) surgery and percutaneous coronary intervention (PCI) have been shown to provide symptomatic relief and to increase long-term survival in patients with coronary artery disease.1–3 Hybrid coronary revascularization (HCR) seeks to combine the respective strengths of CABG and PCI in an attempt to offer a technique that is less invasive than conventional surgery without diminishing the efficaciousness of therapy offered.nnResponse by Shannon et al on p 2510nnThe major therapeutic benefits of CABG arise from the graft from the left internal mammary artery (LIMA) to the left anterior descending artery (LAD). This can be attributed to the fact that the LIMA-to-LAD graft has excellent long-term patency, reaching as high as 95% to 98% at 10 years,1–3 as opposed to saphenous vein grafts (SVGs), which have high early failure rates, ranging from 6.2% to 30%, averaging ≈20% throughout the literature.4–6 The LIMA-to-LAD graft is also superior to PCI in terms of long-term patency, event-free survival, and relief of angina. The major benefits of multivessel PCI with drug-eluting stents (DES) to treat multivessel coronary artery disease are that it is less invasive, has shorter recovery times, and has lower stroke rates compared with CABG.2,7 It also has lower stent failure rates than SVG (defined as stent restenosis and thrombosis compared with SVG occlusion).2,7 Tables 1 and 2 present existing data on current outcomes with DES and SVGs in non-LAD territories.4,5,8–18nnView this table:nnTable 1. nData From Randomized Trials on Drug-Eluting Stent Restenosis Rate and Stent Thrombosis for Non–Left Anterior Descending Artery Revascularization (n=3631)nnnnView this table:nnTable 2. nData From Studies of 12-Month Postoperative Saphenous Vein Graft Patency With Coronary Angiography for Non–Left Anterior Descending Artery Revascularization (n=7919)nnnnHence, the logic underlying the …

Minimally invasive mitral valve surgery expands the surgical options for high-risks patients.

Background:A simplified minimally invasive mitral valve surgery (MIMVS) approach avoiding cross-clamping and cardioplegic myocardial arrest using a small (5 cm) right antero-lateral incision was developed. We hypothesized that, in high-risk patients and in patients with prior sternotomy, this approach would yield superior results compared to those predicted by the Society of Thoracic Surgeons (STS) algorithm for standard median sternotomy mitral valve surgery. Methods:Five hundred and four consecutive patients (249 males/255 females), median age 65 years (range 20–92 years) underwent MIMVS between 1/06 and 8/09. Median preoperative New York Heart Association function class was 3 (range 1–4). Eighty-two (16%) patients had an ejection fraction ⩽35%. Forty-seven (9%) had a STS predicted mortality ≥10%. Under cold fibrillatory arrest (median temperature 28°C) without aortic cross-clamp, mitral valve repair (224/504, 44%) or replacement (280/504, 56%) was performed. Results:Thirty-day mortality for the entire cohort was 2.2% (11/504). In patients with a STS predicted mortality ≥ 10% (range 10%–67%), the observed 30-day mortality was 4% (2/47), lower than the mean STS predicted mortality of 20%. Morbidity in this high-risk group was equally low: 1 of 47 (2%) patients underwent reexploration for bleeding, 1 of 47 (2%) patients suffered a permanent neurologic deficit, none had wound infection. The median length of stay was 8 days (range 1–68 days). Conclusions:This study demonstrates that MIMVS without aortic cross-clamp is reproducible with low mortality and morbidity rates. This approach expands the surgical options for high-risk patients and yields to superior results than the conventional median sternotomy approach.

Surgical Update Hybrid Procedures, Do They Have a Role?

A hybrid strategy is a combination of catheter-based therapy and traditional surgical intervention. This concept of combining the tools available only in the catheterization laboratory with the tools available only to the surgeon in order to minimize surgical morbidity has evolved since its implementation in the 1990s.1 Over the past decade, with advancement in stent technology and refinement of minimally invasive surgical approaches, a hybrid strategy has become an attractive alternative to standard surgical or catheter-based techniques. The indications, patient selection, and standardization of these procedures are still under way. Currently, there are no randomized clinical trials on hybrid procedures, and the clinical practice is based on single institutional experiences. The National Heart, Lung, and Blood Institute has just launched the first observational trial on hybrid coronary intervention to define the population eligible for hybrid coronary revascularization (HCR). Until more data become available, the hybrid strategy depends on close collaboration between the surgeon and the cardiologist at single institutions and should be tailored to individual patient needs.nnBoth coronary artery bypass graft (CABG) surgery and conventional percutaneous coronary intervention (PCI) offer certain advantages in the treatment of patients with multivessel coronary artery disease (CAD).2,3 Although CABG provides superior clinical outcomes compared to PCI in certain high-risk patients, including most with diabetes, the majority of patients with left main CAD, and many patients with reduced cardiac function,4,5 it is likely that the major aspect of CABG that confers these benefits is the left internal mammary artery (LIMA) graft to the left anterior descending artery (LAD). The LIMA-to-LAD graft has excellent patency at 10- to 20-year angiographic follow-up,6 setting the gold standard with which other revascularization strategies should be compared. It is important to emphasize that although all patients with significant multivessel coronary disease …

Benefits of ambulatory axillary intra-aortic balloon pump for circulatory support as bridge to heart transplant.

OBJECTIVEnAxillary intra-aortic balloon pump therapy has been described as a bridge to transplant. Advantages over femoral intra-aortic balloon pump therapy include reduced incidence of infection and enhanced patient mobility. We identified the patients who would benefit most from this therapy while awaiting heart transplantation.nnnMETHODSnWe conducted a single-center, retrospective observational study to evaluate outcomes from axillary intra-aortic balloon pump therapy. These included hemodynamic parameters, duration of support, and success in bridging to transplant. We selected patients on the basis of history of sternotomy, elevated panel-reactive antibody, and small body habitus. Patients were made to ambulate aggressively beginning on postoperative day 1.nnnRESULTSnBetween September 2007 and September 2010, 18 patients underwent axillary intra-aortic balloon pump therapy. All patients had the devices placed through the left axillary artery with a Hemashield side graft (Boston Scientific, Natick, Mass). Before axillary placement, patients underwent femoral placement to demonstrate hemodynamic benefit. Duration of support ranged from 5 to 63 days (median = 19 days). There was marked improvement in ambulatory potential and hemodynamic parameters, with minimal blood transfusion requirements. There were no device-related infections. Some 72% of the patients (13/18) were successfully bridged to transplantation.nnnCONCLUSIONSnAxillary intra-aortic balloon pump therapy provides excellent support for selected patients as a bridge to transplant. The majority of the patients were successfully bridged to transplant and discharged. Although this therapy has been described in previous studies, this is the largest series to incorporate a regimen of aggressive ambulation with daily measurements of distances walked.

Results of Completion Arteriography After Minimally Invasive Off-Pump Coronary Artery Bypass

BACKGROUNDnThe benefits of a minimally invasive approach to off-pump coronary artery bypass remain controversial. The value of completion arteriography in validating this technique has not been investigated.nnnMETHODSnFrom April 2007 to October 2009, fifty-six patients underwent isolated minimally invasive coronary artery bypass grafting through a left thoracotomy without cardiopulmonary bypass. Forty-three of these patients underwent completion arteriography.nnnRESULTSnSixty-five grafts were performed in these 56 patients, (average, 1.2 grafts per patient; range, 1 to 3). Forty-eight grafts were studied in the 43 patients undergoing completion arteriography. There were 4 findings on arteriogram leading to further immediate intervention (8.3%). These included 3 grafts with anastomotic stenoses or spasm requiring stent placement, and 1 patient who had limited dissection in the left internal mammary artery graft and underwent placement of an additional vein graft. These findings were independent of electrocardiographic changes or hemodynamic instability. The remainder of the studies showed no significant abnormalities. There were no deaths. One patient who did not have a completion arteriogram suffered a postoperative myocardial infarction requiring stent placement for anastomotic stenosis. Patients were discharged home an average of 6.8 days postoperatively. There were no instances of renal dysfunction postoperatively attributable to catheterization.nnnCONCLUSIONSnMinimally invasive coronary artery bypass is safe and effective. Findings of completion arteriography occasionally reveal previously under-recognized findings that, if corrected in a timely fashion, could potentially impact graft patency and clinical outcomes. Our experience validates this minimally invasive technique.

Extending the use of the pacing pulmonary artery catheter for safe minimally invasive cardiac surgery.

OBJECTIVEnIn this study, the therapeutic use of pacing pulmonary artery catheters in association with minimally invasive cardiac surgery was evaluated.nnnDESIGNnA retrospective study.nnnSETTINGSnA single institutional university hospital.nnnPARTICIPANTSnTwo hundred twenty-four consecutive patients undergoing minimally invasive cardiac surgery through a small (5-cm) right anterolateral thoracotomy using fibrillatory arrest without aortic cross-clamping.nnnMEASUREMENTS AND MAIN RESULTSnTwo hundred eighteen patients underwent mitral valve surgery (97%) alone or in combination with other procedures. Six patients underwent other cardiac operations. In all patients, the pacing pulmonary artery catheter was used intraoperatively to induce ventricular fibrillation during the cooling period, and in the postoperative period it also was used in 37 (17%) patients who needed to be paced, mainly for bradyarrhythmias (51%). There were no complications related to the insertion of the catheters. Six (3%) patients experienced a loss of pacing capture, and 2 (1%) experienced another complication requiring the surgical removal of the catheter. Seven (3%) patients needed postoperative implantation of a permanent pacemaker.nnnCONCLUSIONSnIn combination with minimally invasive cardiac surgery, pacing pulmonary artery catheters were therapeutically useful to induce ventricular fibrillatory arrest intraoperatively and for obtaining pacing capability in the postoperative period. Their use was associated with a low number of complications.

Minimally invasive cardiac surgery.

he definition of the term “minimally invasive cardiac surgery” encomasses a rather vast area. Conventional cardiac surgery generally entails xposure of the heart and great vessels through a median sternotomy. inimally invasive cardiac surgical approaches enable surgeons to erform heart operations through substantially smaller incisions and may ven circumvent the need for cardiopulmonary bypass (CPB). The aims of minimally invasive cardiac surgical procedures are to educe postoperative pain, to promote a faster postoperative recovery eriod, and to provide a cosmetically superior result. Other general dvantages are that they provide access to the relevant parts of the heart hile reducing the need for extensive dissection of surrounding tissue. urrent data seem to indicate that minimally invasive cardiac surgery is ot inferior to conventional surgery and also provides several advantages hen compared with conventional approaches. Minimally invasive cardiac surgical techniques have been used to erform a variety of procedures in the fields of coronary artery bypass rafting (CABG) and valve surgery. Every one of these respective echniques has a unique approach and consideration, which must be arefully taken into account.

Hybrid Options for Treating Cardiac Disease

The options for treating heart disease have greatly expanded during the course of the last 2 1/2 decades with the advent of hybrid technology. The hybrid option for treating cardiac disease implies using the technology of both interventional cardiology and cardiac surgery to treat cardiac disease. This rapidly developing technology has given rise to new and creative techniques to treat cardiac disease involving coronary artery disease, coronary artery disease and cardiac valve disease, and atrial fibrillation. It has also led to the establishment of new procedural suites called hybrid operating rooms that facilitate the integration of technologies of interventional cardiology catheterization laboratories with those of cardiac surgery operating rooms. The development of hybrid options for treating cardiac disease has also greatly augmented teamwork and collaboration between interventional cardiologists and cardiac surgeons.