Utz Kappert

Technique of closed chest coronary artery surgery on the beating heart

OBJECTIVEnThe application of an endoscopic stabilizer (Intuitive Surgical, Mountain View, CA, USA) enables closed chest off-pump coronary artery bypass via a four-point stab incision avoiding sternotomy and minithoracotomy.nnnMETHODSnBetween May 1999 and January 2001 we operated upon a total of 37 patients (five female, 32 male, median age 62+/-9 years) suffering from coronary artery disease using totally endoscopic coronary artery bypass (TECAB), whereas an initial series of eight TECAB patients was operated upon using an endovascular bypass system (Heartport). The da Vinci surgical system was used in order to perform left internal mammary artery (LIMA) or right internal mammary artery (RIMA) harvesting and anastomoses on a beating heart in 29 patients (four female, 25 male, median age 64+/-9.8 years). Altogether 26 patients suffering from single-vessel coronary artery disease (SVCAD) were revascularized applying LIMA to the left anterior descending artery (LAD) and three patients with two diseased coronary vessels received bilateral internal mammary artery grafting (BIMA), respectively.nnnRESULTSnIn this series we had a 100% survival rate. Conversion rate to a median sternotomy was 3.4%. Patients were operated upon via four 1-cm chest incisions using the da Vinci robot for LIMA or BIMA harvesting and for performance of anastomoses on the beating heart. In the overall series of 56 patients intended to be treated by TECAB, 19 (33.9%) were converted to a minimally invasive direct coronary artery bypass procedure.nnnCONCLUSIONnThis new robotic-enhanced surgical technique promotes an optimistic way of thinking about the further development of this procedure and its application in patients suffering from single-vessel CAD.

Robotic-enhanced arterial revascularization for multivessel coronary artery disease.

BACKGROUNDnA tendency to reduce operative trauma is determining the evolution of cardiac surgical techniques lately. The introduction of robotic-enhanced endoscopic systems enables surgeons to perform arterial revascularization for multivessel disease without sternotomy.nnnMETHODSnFrom May 1999,17 (4 women, 13 men; median age 63+/-7.4 years) patients with multivessel coronary artery disease were treated surgically using arterial revascularization by means of bilateral internal mammary arteries. Both arteries were harvested endoscopically using the da Vinci system (Intuitive Surgical, Mountain View, CA). These vessels were anastomosed using the Dresden technique.nnnRESULTSnSurvival was 100%. Mean duration of the operation was 255+/-40.4 minutes. Bilateral internal mammary artery harvesting took 88.5+/-15.9 minutes; cross-clamp time was 36+/-8.7 minutes. An average of 2.06 anastomoses were performed per operation. Postoperatively, patients remained in the intensive care unit for 21+/-13 hours. One patient (5.8%) needed reexploration due to bleeding.nnnCONCLUSIONSnThe robotic surgical system introduces a new treatment of coronary artery disease to surgical practice, and enables arterial revascularization with distinctly reduced surgical trauma.

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.

Wrist-Enhanced Instrumentation: Moving Toward Totally Endoscopic Coronary Artery Bypass Grafting

BACKGROUNDnWith the introduction of the da Vinci robotic surgical system (Intuitive Surgical, Mountain View, CA) into minimally invasive cardiac operations the outlook for performing coronary artery bypass operations closed chest became a reality.nnnMETHODSnBetween May 1999 and December 1999 this new wrist-enhanced instrumentation was used in 61 patients. Six patients suffering from single-vessel coronary artery disease and one female patient with double-vessel disease underwent totally endoscopic coronary artery bypass. Thirty-seven patients with single-vessel disease underwent a minimally invasive direct coronary artery bypass procedure. Seventeen patients with double-vessel disease were treated using the robotic-enhanced Dresden technique.nnnRESULTSnPerioperative survival was 100%. In all patients the internal mammary arteries were safely harvested endoscopically and had excellent quality. In both totally endoscopic coronary artery bypass groups all patients were operated on through three stab incisions.nnnCONCLUSIONSnOur preliminary experience with this new surgical technique using robotic-enhanced minimally invasive methods for coronary artery disease promotes optimism regarding further development of these procedures and application in patients with coronary artery disease.

Off-pump surgery for anterior vessels in patients with severe dysfunction of the left ventricle

Abstract Background . Coronary artery revascularization in patients with severe dysfunction of the left ventricle remains a high-risk procedure due its high mortality and morbidity. Off-pump operation seems to be particularly attractive for this patient group. We report our experience with off-pump coronary revascularization in patients with severe dysfunction of the left ventricle. Methods . Between June 1997 and December 1999, 31 patients with left ventricle ejection fraction less than or equal 30% (mean left ventricle ejection fraction 24 ± 12%, range from 12% to 30%) underwent off-pump coronary artery bypass grafting without the use of cardiopulmonary bypass. There were 29 men (93.5%) and 2 women (6.5%). The Patients ages ranged from 55 to 77 years (61 ± 10 years). Results . Mean number of grafts was 2 ± 0.7 (range from 1 to 3). The internal mammary artery was used in 28 patients (90.3%). The hospital survival rate was 93.5%, in the 6-month follow-up the survival was 90%. Conclusions . Off-pump coronary revascularization seems to be an alternative concept for the treatment of patients with severe dysfunction of the left ventricle.

The Dresden approach for complete multivessel revascularization

BACKGROUNDnIn 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.nnnMETHODSnGroup 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).nnnRESULTSnThere 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.nnnCONCLUSIONSnSurgical 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.

Early experience with a quadrileaflet stentless mitral valve

BACKGROUNDnPresently 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.nnnMETHODSnFrom 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%.nnnRESULTSnEleven 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.nnnCONCLUSIONSnOur 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.

Three‐Year Follow‐Up After Port‐Access Mitral Valve Surgery

Abstract Introduction: After the promising early results with Port‐Access mitral valve (MV) surgery, the mid‐term results were evaluated. Methods: Among 31 patients receiving this surgery, there were two subgroups (A and B). The 14 patients in group A (7 men, 7 women, 64.0 ± 12.8 years, LVEF 0.62 ± 0.118) received the procedure exactly as proposed by Heartport. The 17 patients in group B (6 men, 11 women, 63.0 ± 11.48 years, LVEF 0.61 ± 0.117) received a modified technique for a low complex procedure. The underlying diseases were MV insufficiency (n = 14), MV stenosis (n = 9), and combined MV disease (n = 8). One female patient had a partial atrial ventricular canal. Results: Perioperative mortality was 3.2%. Survival at 39.0 ± 6.3 months (median ± SEM) was 93.5%. Two patients required intraoperative inotropic and mechanical support (intro‐aortic balloon pump [IABP]). One of these two patients died on postoperative day 3 due to low cardiac output syndrome. All ther patients survived the procedure. Twenty‐four patients underwent MV replacement, 7 patients recalved MV repair, and 1 patient received, in addition, ASD repair. In group B, operative time, ICU stay, and hospitalization was shorter. Conclusions: Good early results after Port‐Access MV surgery were confirmed by equal mid‐term results. The patients are satisfied with the surgical and the cosmetic results, however, Port‐Access MV surgery still has to prove superior outcome compared to conventional MV surgery. In selected cases a true reduction of the surgical trauma is possible.

Experiences with a minimally invasive surgical technique for the treatment of coronary artery multivessel disease in 100 patients.

OBJECTIVEnThe treatment of coronary single vessel disease under minimally invasive surgical conditions was followed by the treatment of coronary multivessel disease using a new technique.nnnMETHODSnUsing this technique 100 patients (80 male, 20 female, median age 61.0+/-8.9 years, ranged from 39 to 82 years) with coronary single vessel disease, double vessel disease or multivessel disease were treated between November 1996 and December 1997. Via a small (6-9 cm) left lateral chest incision in the second or third intercostal space, the left internal thoracic mammary artery (LIMA) was harvested and access to the central portion of the heart including the ascending aorta was obtained. In parallel, saphenous vein segments were harvested. Arterial cannulation was instituted via the ascending aorta, thus avoiding retrograde flow. In all patients except three the LIMA was used for the left anterior descending artery (LAD). In addition vein grafts were used for revascularization of the other coronary arteries. All cardiac anastomoses were performed during cardioplegic arrest after external aortic cross clamping and antegrade application of cardioplegia.nnnRESULTSnNo death or intraoperative complications were observed in this series. The median hospital stay was 6.0+/-1.4 days (median+/-SEM). Postoperative complications were reexplored for bleeding (n = 1), delayed wound healing (n = 2), wound infections (n = 4), lymphatic fistulas (n = 4), and a chest wall hernia (n = 1).nnnCONCLUSIONSnThis minimally invasive surgical technique presents a safe alternative to conventional coronary artery surgery avoiding sternotomy related complications and decreasing hospital stay and morbidity.

Female sex is not a risk factor for post procedural mortality in coronary bypass surgery in the elderly: A secondary analysis of the GOPCABE trial

Objective Female sex is considered a significant risk in cardiac surgery and is included in the majority of scores for risk assessment. However, the evidence is controversial and older women undergoing cardiac surgery have not specifically been investigated. We assessed the influence of female sex on surgical risk (30-day mortality) in a secondary analysis of the GOPCABE trial (German Off-Pump Coronary Artery Bypass grafting in the Elderly (GOPCABE) trial, comparing on- to off-pump) and also evaluated its impact on risk prediction from commonly used risk scores. Methods We performed logistic regression analyses on the GOPCABE trial population, where patients were randomized to either on- or off-pump CABG. The study was performed in 12 cardiac surgery centers in Germany and analyzed 2394 patients having undergone CABG at age ≥75 years (1187 on-pump, 1207 off-pump). Of the 2394 patients, 755 (32%) were women. The logistic EuroSCORE and the German KCH score were calculated as expected (E) mortality and values were compared to observed (O) 30-day mortality (O/E ratio). Results There was no difference in mortality or major cardiovascular adverse events after 30 days between men and women for both on- and off-pump CABG (men: on- vs. off-pump OR = 0.90, 95%-CI: [0.63;1.27]; women: on- vs. off-pump OR = 1.07, 95%-CI: [0.62;1.87]). Therefore, groups were combined for further analyses. Both men and women had considerable and similar comorbidities. Expected mortality was significantly higher for women than for men (logistic EuroSCORE: 8.88±6.71% vs. 7.99±6.69%, p = 0.003; KCH score: 4.42±3.97% vs. 3.57±3.65%, p = 0.001). However, observed mortality rates (O) tended to be even lower in women (2.1% vs. 3.0%). The O/E ratio was closer to 1 in men than in women (0.84 vs. 0.47). Excluding female sex from the risk models increased O/E ratio to 0.69. Conclusions Female sex is not a risk factor in coronary bypass surgery in the GOPCABE population. The result is the same for on- and off-pump surgery. Since female sex is a component of most risk scores, the findings may identify a potential inaccuracy in current surgical risk assessment, specifically for elderly women. Trial registration Clinicaltrials.gov GOPCABE trial No. NCT00719667