W. Douglas Boyd

Hybrid robotic coronary artery surgery and angioplasty in multivessel coronary artery disease

BACKGROUND Complete surgical revascularization that includes left internal thoracic artery grafting to the left anterior descending coronary artery remains the gold standard of treatment for coronary artery disease. Not all patients are good candidates for sternotomy. Therefore, we sought to identify a strategy that would combine the long-term advantages of internal thoracic artery grafting to lessen surgical trauma while still allowing complete revascularization. METHODS A total of 54 consecutive patients from four institutions underwent hybrid revascularization combining surgery and angioplasty. All internal thoracic artery grafts were endoscopically harvested with robotic assistance using either the Aesop or Zeus system, and all anastomoses were manually constructed through a 4- to 6-cm anterior thoracotomy incision. Angioplasty was carried out to achieve total revascularization to ungrafted vessels. RESULTS There were no early or late deaths, myocardial infarctions, strokes, or wound infections. Of the patients, 37 (69%) were extubated in the operating room. Length of stay in the intensive care unit averaged 24.4 hours and hospital stay 3.45 days. In all, 16 patients (29.6%) required transfusion of packed red blood cells. Late complications included 1 patient with stent occlusion at 3 months and 2 patients with in-stent restenosis. Three patients were treated for postpericardiotomy syndrome. Mean follow-up was 11.7 months. Event-free was survival 87.1% and freedom from recurrent angina 98.3%. CONCLUSIONS Hybrid endoscopic atraumatic internal thoracic artery to anterior descending coronary artery graft surgery combined with angioplasty is a reasonable revascularization strategy in multiple vessel coronary artery disease in selected patients. Longer follow-up and more patient data in a randomized study are needed to determine the patient cohort most likely to benefit from this approach.

Pericardial Reconstruction Using an Extracellular Matrix Implant Correlates with Reduced Risk of Postoperative Atrial Fibrillation in Coronary Artery Bypass Surgery Patients

BACKGROUND Postoperative atrial fibrillation (AF) is a significant complication following open heart surgery, with potentially serious clinical and economic implications. To assess the effect of a novel procedure, pericardial reconstruction using a porcine-derived extracellular matrix (ECM) implant, on the risk of postoperative AF after primary isolated coronary artery bypass grafting (CABG), we performed a retrospective comparison of the incidence of postoperative AF in patients who underwent this procedure versus an untreated control group. METHODS We performed a retrospective comparison of the incidence of postoperative AF in 111 patients who underwent a pericardial reconstruction procedure with the CorMatrix ECM for Pericardial Closure (CorMatrix Cardiovascular, Atlanta, GA, USA) following primary isolated CABG, versus a control group of 111 patients who did not undergo pericardial reconstruction. RESULTS Postoperative AF occurred in 43 of 111 control patients (39%; lower control limit [LCL], 30%; upper control limit [UCL], 49%) but in only 20 of 111 treated patients (18%; LCL, 11%; UCL, 27%). This result represents a 54% reduction in relative risk in the treatment group (P < .001). There was a small but statistically insignificant decrease in the hospital length of stay for the treated patients. The 2 treatment groups exhibited similar postoperative complication profiles. CONCLUSIONS In this retrospective study, pericardial reconstruction with the ECM implant contributed directly to a statistically significant and clinically meaningful reduction in the rate of postoperative AF in patients undergoing primary isolated CABG. A prospective multicenter randomized trial has been planned to further test this approach.

Three-dimensional video-assisted thoracoscopic pericardiectomy

Video-assisted thoracic surgery has proven to be safe and effective for the diagnosis and management of pericardial disease. Three-dimensional (3-D) video imaging technology has been developed to allow the laparoscopic surgeon more precision and efficiency in advanced laparoscopic cases. This case report describes the marriage of 3-D video imaging and thoracoscopy that allowed performance of a technically difficult pericardiectomy without incident. Our aim is to describe the use of state-of-the-art 3-D video imaging to allow success in difficult cases.

Division of the brachioradialis muscle: a modification of the current technique in endoscopic radial artery harvesting.

BACKGROUND Utilization of the radial artery as a conduit for coronary artery bypass grafting has increased significantly over the past 8 years. Concurrently, minimally invasive surgical techniques have been increasingly applied resulting in improved aesthetics, less pain, and decreased morbidity and length of hospital stay. Endoscopic radial artery harvesting (ERAH) has been shown to be of benefit to patients undergoing coronary artery bypass grafting. The brachioradialis is a recognized limitation in ERAH. To date, the standard operative techniques for ERAH have included maintaining the integrity of the brachioradialis muscle. Objective. The aim of this study was to assess the effect of dividing the medial border of the brachioradialis muscle during ERAH. METHODS We performed ERAH on 9 cadaveric arms using standard endoscopic vein harvesting equipment (30-degree/5-mm endoscope, subcutaneous retractor, and pig-tail vessel dissector) and ultrasonic harmonic coagulating shears. In 5 cadaveric arms, the medial aspect of the brachioradialis muscle was preserved during the dissection. In 4 arms, the medial border of the brachioradialis muscle was divided. All 9 harvests were timed and compared. At the completion of the endoscopic dissection, all 9 arms were opened and examined for neurovascular injury. RESULTS In cadaveric arms, modifying the current ERAH technique by dividing the medial border of the brachioradialis muscle resulted in a visible increase in tunnel size. In the group where the brachioradialis muscle was divided, a statistically significant reduction in harvest time of 32% was observed (P = .02). Post-harvest examination revealed no gross neurovascular injury; specifically, no injuries to the superficial branches of the radial nerve or the lateral antebrachial cutaneous nerves were identified. CONCLUSION Division of the medial border of the brachioradialis muscle during endoscopic radial artery harvesting appears to be a safe technique modification that subjectively improves working space and vision of vital structures, facilitating ease of the procedure. Objectively, division of the medial border of the brachioradialis muscle resulted in a statistically significant reduction in harvest time in cadaveric arms when compared with the current technique of ERAH. A clinical pilot study to verify the efficacy and safety of this technique modification is warranted.

Mitral valve papillary fibroelastoma: surgical considerations.

Cardiac papillary fibroelastomas are uncommon primary cardiac tumors. Due to their infrequent occurrence, an appropriate management strategy has been difficult to define. We report a 51-year-old female with a papillary fibroelastoma of the mitral valve diagnosed during a source of embolism evaluation, where the association between symptoms and the tumor were equivocal. The mitral valve papillary fibroelastoma was electively surgically excised, based on the proposed guidelines that allow for identification of patients at greatest risk of embolic events. We review the evaluation and selection of those patients who might benefit from surgical therapy even in the absence of symptoms.

Robotic Surgery Using Zeus™ MicroWrist™ Technology:

In this paper, Dr. Isgro and colleagues describe their preliminary experience with telerobotic internal thoracic artery (ITA) harvesting and describe the first clinical use of the ZeusTM MicroWristTM (Computer Motion, Goletta, CA, USA) technology. Most importantly they describe their methodical progression from the dry lab to beating heat model to graded clinical application of robotics and video-assisted techniques. This group is to be congratulated for their systematic, stepwise approach toward the clinical performance of a totally endoscopic coronary procedure, and centers initiating robotic programs would be wise to follow their approach. All too often, enthusiasm and impatience at centers wanting to clinically use their new robot overpowers the more prudent but time-consuming methodical approach, and as a result, the skills necessary to perform endoscopic robotic procedures are not adequately developed. The MicroWristTM robotic system used for the last 12 patients in Dr. Isgro’s study differs in a number of ways from the system they used in their first 44 patients. First of all, the new MicrowristTM master console is placed behind the surgeon, and a separate video console has been