Stephan Schüler

Port-Access Coronary Artery Bypass Grafting With the Use of Cardiopulmonary Bypass and Cardioplegic Arrest ☆

BACKGROUND To reduce surgical trauma, we performed minimally invasive Port-Access (Heartport Inc, Redwood City, CA) coronary artery bypass grafting with cardiopulmonary bypass and cardioplegic arrest. METHODS Thirty-six men and 6 women with a median age of 59 years (range, 31 to 75 years) and isolated lesions of the left anterior descending branch of the coronary artery underwent Port-Access coronary artery bypass grafting. A small (6- to 9-cm) incision was made parasternally on top of the fourth rib. The left internal thoracic (mammary) artery was dissected and taken down through the minithoracotomy either alone or using an additional thoracoscopic approach. Cardiopulmonary bypass was instituted through femoral cannulation, and an additional endoarterial balloon catheter (Heartport Inc) was introduced into the ascending aorta for aortic occlusion, aortic root venting, and the delivery of cold antegrade crystalloid cardioplegia. After cardioplegic arrest, the left internal mammary artery was anastomosed to the left anterior descending artery under direct vision. RESULTS The median left internal mammary artery takedown time was 49.5 +/- 21.9 minutes, the duration of cardiopulmonary bypass was 59.5 +/- 32.8 minutes, the aortic occlusion time was 28.5 +/- 7.9 minutes, the intensive care unit stay was 1.0 +/- 3.2 days, and the total hospital stay was 5.0 +/- 2.5 days. Intraoperative angiograms were done in the first 10 patients and showed patent left internal mammary artery grafts without anastomotic complications in all cases. Two arterial dissections, including one aortic dissection, were observed in patients with preexisting peripheral vascular disease. The other complications were minor. All but 1 patient recovered well, with no major limitations in their daily activities. CONCLUSIONS Using this minimally invasive method, sternotomy-related complications can be avoided, the hospital stay can be reduced, and a safe coronary artery bypass grafting procedure can be performed with the advantage of cardiopulmonary bypass and cardioplegic arrest as are used routinely in conventional coronary artery operations.

New telemetric system for daily pulmonary function surveillance of lung transplant recipients

BACKGROUND Following lung transplantation, prompt diagnosis and therapy of acute pulmonary rejection and infection episodes relies primarily upon changes in pulmonary function and determines long-term outcome. We tested a new system that allows daily monitoring of the patients pulmonary status even after discharge from the hospital. METHODS Seven lung transplant recipients from our center were equipped with a telemetric monitoring device consisting of a portable flowmeter and a special modem unit. The flowmeter measures forced vital capacity (FVC), forced expiratory volume per second (FEV1), and mid expiratory flows (MEFs), encodes information like fever, cough, and dyspnea in a binary code form, and stores all values in a 32 kB memory unit. After its use, the patient positions the flowmeter onto the modem unit which automatically connects to a central computer at our center to transfer all saved data. The whole set can be used via any regular phone jack. The patients file in the computer can be checked every day. RESULTS All patients learned to use the unit during their postoperative stay or during later follow-up, and were able to apply the system at home. In a mean follow-up period of 10.3+/-2.2 months, 15 episodes of significant deterioration in home pulmonary function tests (PFTs) (>10%) were registered in 6 patients, which were all confirmed by in-hospital body plethysmography. They resulted in diagnoses of 4 episodes of acute rejection, 6 cases of beginning bacterial pneumonia, and 5 cases of, most likely, viral tracheobronchitis. Only 1 patient had to be admitted to the hospital. All patients PFTs returned to previous values after treatment. CONCLUSIONS Telemetric monitoring of graft function in lung transplant recipients allows reliable early diagnosis and treatment of infection or rejection, which might help to prevent exacerbation of the pathology and reduce quantity of amounting graft dysfunction.

Closed chest bilateral mammary artery grafting in double-vessel coronary artery disease

A clinical case of a closed chest double-vessel total endoscopic coronary artery bypass procedure was performed using a wrist-enhanced, three-dimensional-based robotic system. A patient suffering from lesions of the left coronary artery system was effectively treated surgically without median sternotomy or minithoracotomy. This encourages optimism for introducing closed chest endoscopic bypass operations into the surgical routine for patients suffering from double-vessel coronary artery disease.

Minimally Invasive Surgical Technique for the Treatment of Multivessel Coronary Artery Disease

BACKGROUND To avoid sternotomy-related complications after cardiac operations, we developed a minimally invasive surgical technique for the treatment of multivessel coronary artery disease. METHODS From November 1996 to May 1997, 39 patients (age range, 50 to 78 years) with coronary artery disease were treated with the use of this technique. Through a small (6- to 9-cm) left lateral chest incision in the third intercostal space, the left internal mammary artery was harvested directly. With the use of cardiopulmonary bypass and cardioplegic arrest in all patients except 1, the left internal mammary artery was anastomosed to the left anterior descending artery. In addition, vein grafts and other arterial conduits were used for revascularization of the other coronary arteries. RESULTS There were no intraoperative complications. All the patients survived the procedure and had an uneventful postoperative course. Wound complications occurred in 2 patients. The median (+/- standard error of the mean) hospital stay was 6 +/- 1 days. CONCLUSIONS This technique combines minimally invasive surgical conditions with the safety standards of routine cardiac operations. With the use of this approach, even extensive coronary artery disease can be treated.

The Dresden approach for complete multivessel revascularization

BACKGROUND In a prospective clinical trial, a group of patients receiving less invasive surgical procedure, including minithoracotomy in combination with cardiopulmonary bypass (group 1), was compared to a group of patients receiving conventional bypass surgery (group 2) for the treatment of coronary artery disease. METHODS Group 1 included 85 patients (71 men, 14 women, aged 39 to 82 years, median 61.1 +/- 9.0 years); group 2 included 53 patients (38 men, 15 women, aged 51 to 79 years, median 62.0 +/- 6.1 years). RESULTS There were no perioperative deaths in the whole series of patients. Time of operation was 256 +/- 43 minutes in group 1 and 150.0 +/- 53.6 minutes in group 2. Hospitalization was 6.0 +/- 1.4 days and intensive care unit stay 1 day for both groups. Back pain assessment on postoperative day 3 showed less pain in group 1. Three-month follow-up revealed ischemia in stress electrocardiogram in 2 patients (2.5%) in group 1 and in 2 patients (4.1%) in group 2. Coronary angiograms confirmed the stress-electrocardiogram findings. CONCLUSIONS Surgical results are equal for both techniques. Even though time of operation is longer in patients receiving less invasive procedures, intensive care unit stay and hospital stays are the same length. Early postoperative back pain is less in group 1 and combined with faster convalescence.

Minimally invasive surgical treatment of coronary artery multivessel disease

BACKGROUND If coronary artery multivessel disease is the target of a minimally invasive procedure, either median sternotomy or cardiopulmonary bypass can be avoided. METHODS We used an alternate technique instead of minithoracotomy and cardiopulmonary bypass to treat 102 patients (82 men, 20 women; age range, 39 to 82 years; median, 61.0 +/- 8.9 years) for coronary artery single-vessel, double-vessel, or multivessel disease between November 1996 and January 1998. Twenty-nine patients (22 men, 7 women; age range, 46 to 78 years; median, 69.0 +/- 8.4 years), who were in a high-risk group for the development of perioperative complications because of the use of cardiopulmonary bypass, received median sternotomy and a beating heart procedure using the Octopus stabilizing technique. The left anterior descending coronary artery was the target vessel in all patients except for 1, in whom the left internal mammary artery was used. RESULTS There was no intraoperative death in either series. In the beating heart group (Octopus) 2 patients died on postoperative day 31 and 35, respectively, of postoperative pneumonia. CONCLUSIONS Both techniques present safe alternative procedures to conventional coronary artery bypass grafting in patients with coronary artery multivessel disease.

Early experience with a quadrileaflet stentless mitral valve

BACKGROUND Presently no ideal prosthesis for mitral valve replacement exists. The quadrileaflet mitral valve (SJM-Quattro-MV; St. Jude Medical, Inc, St. Paul, MN) is a chordally supported stentless bioprosthesis. Due to its specific geometry it seems to be particularly suited for mitral valve replacement. METHODS From March 1999 to October 2000, 12 patients (ages 71+/-2 years) received the SJM-Quattro-MV. Six patients suffered from valvular stenosis and 6 patients from incompetence. Preoperatively, all patients were in New York Heart Association functional class III, with left ventricular ejection fraction amounts of 54%+/-17%. RESULTS Eleven patients received a medium size SJM-Quattro-MV and one patient received a large size SJM-Quattro-MV. Cross-clamp time was 99.8+/-4.9 minutes. Additional procedures were coronary artery bypass grafting (n = 3) and left atrial microwave ablation (n = 2). Postoperative mortality (n = 1) was procedure related. At follow-up of 11.6+/-5.4 months, all patients were well, the transvalvular pressure gradient was 5.0+/-1.4 mm Hg, and the effective orifice area 2.7+/-0.2 cm2. CONCLUSIONS Our preliminary experiences with the SJM-Quattro-MV presented good clinical results and promoted an optimistic way of thinking about the further development of these valve prostheses.

Utility of Microwave Ablation for the Intraoperative Treatment of Atrial Fibrillation

Atrial fibrillation (AF) is the most common atrial arrhythmia and is associated with significant symptoms and morbidity. Epidemiologic studies show that about 1% of the population is affected by AF with a distinct dependence on age reaching 7% in people older than 70 years.1 The group of patients with high grade mitral valve defects represents the highest prevalence of AF reaching 80%. AF can cause a wide spectrum of clinical symptoms ranging from palpitations and tachycardias to diminished physical capacity, dyspnoea, dizziness, presyncopes, and syncopes. In addition, the risk of thromboembolic complication is distinctly increased in patients with AF, especially in those with mitral valve disease.2 For these reasons, curative treatment of AF is one of the main challenges of today’s electrophysiology. Many centers are working on an ideal treatment strategy, which should be effective, safe and easy to apply to ensure a widespread use. This chapter will focus on the substantial role of microwave energy in curative treatment of AF in heart surgery.

Minimally Invasive Bilateral Internal Mammary Artery Bypass Grafting

We report about a 71-year-old man with coronary artery double-vessel disease who received minimally invasive coronary artery bypass grafting through a 9-cm left lateral chest incision in the third intercostal space. Both mammary arteries were harvested either directly (left internal mammary artery) or thoracoscopically (right internal mammary artery) and anastomosed to the left anterior descending artery and the circumflex artery through this single left lateral chest incision. The postoperative course was uneventful, and the patient was discharged on postoperative day 5.

Persönliche Meinung¶Der symptomatische Koronarpatient mit pathologischem operationsbedürftigen Koronarangiogramm

Zusammenfassung: Die Bypasschirurgie hat sich bei exzellenten Kurz- und Langzeitergebnissen als fester Bestandteil in der Therapie der koronaren Herzerkrankung etabliert. Zur Anpassung an eine veränderte Patientenstruktur mit einem hohen Anteil an Hochrisikopatienten sind zunehmend minimalinvasive chirurgische Techniken in der Herzchirurgie zum Einsatz gekommen. Ergänzend zu chirurgischen Maßnahmen werden molekularbiologische Techniken in der Primär- und Sekundärtherapie der koronaren Herzkrankheit eingesetzt.Abstract: Bypass surgery has become a routine procedure for the treatment of coronary artery disease. Due to increase numbers of high-risk patients minimally invasive techniques were introduced in cardiac surgery with excellent clinical results. In addition molecular methods have been applied for primary and secondary treatment of coronary artery disease.