Zeng-Shan Ma

Totally thoracoscopic repair of atrial septal defect without robotic assistance: A single-center experience

OBJECTIVE The recent advent of robotically assisted surgery has enabled totally endoscopic repair of atrial septal defects and patent foramen ovale. This study investigates the feasibility and safety of totally endoscopic repair of an atrial septal defect through small incisions on the chest without robotic assistance. METHODS Forty patients (23 female patients; average age, 15.4 ± 8.7 years; age range, 6-47 years) with secundum-type ASDs were selected for this study. Cardiopulmonary bypass was achieved peripherally. Through 3-port incisions in the right chest, pericardiotomy, bicaval occlusion, atriotomy, and ASD repair were performed by a surgeon through a thoracoscopy. RESULTS The cardiopulmonary bypass and aortic crossclamp times were 56.2 ± 21.1 and 38.3 ± 8.6 minutes, respectively. The length of stay in the intensive care unit was 23.0 ± 4.1 hours. There were no mortalities and no major complications in this cohort. Patients were discharged from the hospital 4 to 6 days after the operation. Transesophageal echocardiographic analysis immediately after the operation and at 30 days showed complete closure of the defect without residual shunt. CONCLUSIONS Totally endoscopic atrial septal defect repair can be achieved without a robotically assisted surgical system. This technique is safe and effective and can be used as a therapeutic option for ASD.

Totally thoracoscopic closure for atrial septal defect on perfused beating hearts

OBJECTIVES To investigate the feasibility and safety of non-robotically assisted totally thoracoscopic closure for atrial septal defect (ASD) on perfused beating hearts. METHODS Twenty-four patients (8-45 years, mean 14.4 ± 18.7) underwent ASD closure on beating hearts by a totally thoracoscopic approach without the aid of a robotic surgical system. Additional 72 patients undergoing totally thoracoscopic ASD closure on cardioplegic arrested hearts were selected as a control. Cardiopulmonary bypass (CPB) was achieved peripherally. The aorta was not cross-clamped in the study group but it was cross-clamped in the control group. RESULTS ASD closure was successful in all study and control group patients without in-hospital mortality or major complications. The total duration of operation (76 ± 9 vs. 98 ± 6 min, P = 0.012), CPB time (32 ± 5 vs. 48 ± 4 min, P = 0.001), duration of intensive care stay (10.0 ± 5.1 vs. 19.2 ± 4.2 h, P = 0.003) and post-operative hospital stay (4.5 ± 0.8 vs. 5.0 ± 1.1 days, P = 0.045) in the study group were shorter than in the control group. There was no statistically significant difference in the proportion of patients requiring in-operation blood transfusion between study group and control group (25.0 vs. 36.1%, P = 0.226). Follow-up transthoracic echocardiography on Day 5 and Day 30 showed no residual shunts in study or control group patients. CONCLUSIONS Non-robotically assisted totally thoracoscopic closures of ASD on perfused beating hearts are feasible and safe. These procedures are associated with a shorter operation time and a shorter hospital stay than in surgeries on cardioplegic arrested hearts.

Quality of life in patients undergoing totally thoracoscopic closure for atrial septal defect.

BACKGROUND Quality of life in patients undergoing totally thoracoscopic closure of atrial septal defect is unclear. METHODS Thoracoscopic atrial septal defect repair was performed in 96 patients (37 males, aged 19.4 ± 8.7 years) without the aid of a computerized robotic surgical system. An additional 56 patients (23 males, aged 21.0 ± 16.1 years) undergoing conventional atrial septal defect closure through sternotomy were enrolled as a control group. Quality of life was assessed with the Medical Outcomes Study Short Form Survey on day 60 after surgery. RESULTS Atrial septal defect closure was successful in all patients. There was no perioperative mortality or reoperation for bleeding. Total duration of operations (98 ± 11 versus 128 ± 21 minutes, p < 0.01) and hospital stays (5.3 ± 1.7 versus 6.9 ± 2.1 days, p = 0.024) were shorter in the study group than in the control group, respectively. At discharge, patients with moderate to severe incisional pain in the study and control groups was 11.6% and 62.5%, respectively (p = 0.008). The time interval between discharge and returning to school or work in the study group was shorter than in the control group (28 ± 4 versus 42 ± 7 days, p = 0.003). The mean scores of eight variables in the Short Form Survey, such as physical function, bodily pain, social function, and general or mental health in the study group were higher than in the control group (p < 0.05 or p < 0.01). CONCLUSIONS Compared with conventional sternotomy, totally thoracoscopic atrial septal defect closure was associated with a faster recovery of physical function and a better quality of life.

Totally endoscopic atrial septal repair with or without robotic assistance: A systematic review and meta-analysis of case series

OBJECTIVE To evaluate the safety and efficacy of totally endoscopic repair of atrial septal defect (ASD). METHODS A review of the literature was conducted. Studies were obtained from the following sources: MEDLINE, EMBASE, Web of Science and CENTRAL Library. Inclusion criteria were: (1) randomised controlled trials, non-randomised trials, observational studies, case series, and full text conference proceedings; (2) use of totally endoscopy closure of ASD; and (3) outcomes reported as clinical efficacy. When available, we also quantified the complication rates from each included study. Meta-analysis was performed on outcomes with a random-effects model. RESULTS Six studies met all inclusion criteria. The pooled average success rate of totally endoscopic ASD repair was 94.8% from a total of 114 cases (95% CI, 88.0% to 97.8%), with a minimal heterogeneity in the group of studies (Q value x(2)=1.807, I(2)=0.000). In the studies with no robotic assistance, an average success rate of totally endoscopic ASD repair was 96.9% (95% CI, 85.9-99.4%), with a minimal heterogeneity in the two studies (Q value x(2)=0.683, I(2)=0.000). There were few complications for totally endoscopic ASD repair in the studies with and without robotic assistance. There were no statistically significant differences in success rates between robotically and non-robotically assisted totally endoscopic repairs (p>0.05). CONCLUSIONS Totally endoscopic ASD repair was associated with a high success rate and a low complication rate. There is a need for prospective controlled clinical trials comparing totally endoscopic and conventional surgical repair of ASD.

Thoracoscopic closure of ventricular septal defect in young children: technical challenges and solutions.

OBJECTIVES To investigate the feasibility and safety of totally thoracoscopic repair of ventricular septal defects (VSDs) in young children. METHODS VSD repair was conducted in 36 children (21 boys, mean age 2.5 ± 1.7 years, range 2-5, mean body weight 17.4 ± 2.1 kg) by a totally thoracoscopic approach. Cardiopulmonary bypass (CPB) was achieved peripherally. Through three port incisions in the right chest wall, pericardiotomy, atriotomy and VSD repair were performed under the direct view of a thoracoscopy. Forty patients who were treated with a traditional VSD closure through a sternotomy were selected as a control group. RESULTS There was no statistically significant difference in age, sex or types of VSD between the study and control group (P > 0.05). In the study group, CPB was established through femoral vessels in 28 (77.8%) patients, and through both the right internal jugular vein and the femoral vessels in eight (22.2%). The aortic cross-clamp time (32 ± 6 vs 29 ± 3 min, P = 0.06) and CPB time (46 ± 11 vs 48 ± 4 min, P = 0.107) were similar between the study and control groups. However, the total operation time, mechanical ventilation time, intensive care stay and overall hospital stay in the study group were shorter than in the control group (P < 0.05). Transthoracic echocardiography 3 months after the operation showed no residual shunt in the ventricular septum. CONCLUSIONS Thoracoscopic closure of VSDs in young children appears feasible and safe.

Effect of captopril on pulmonary artery pressure following corrective surgery for tetralogy of fallot.

Abstract  Background: This study was designed to investigate the effect of captopril on systolic pulmonary arterial pressure (PAP) and circulating endothelin‐1 (ET‐1) following surgical repair of tetralogy of Fallot (TOF). Methods and Results: Seventy‐six consecutive patients were divided into captopril and control groups following successful repair of TOF. The captopril group was treated with oral captopril (0.2 mg/kg/day) for 12 months. Venous blood was taken before and after the surgery for the analysis of ET‐1. Systolic PAP and ventricular function were assessed by Doppler echocardiography. In the control group, there was an increase in ET‐1 and systolic PAP following the surgery (p < 0.05). In the captopril group, there was no significant increase in the systolic PAP and ET‐1 during the 12‐month follow‐up. The PAP and ET‐1 values in the captopril group were lower than those in the control group following the surgery (p < 0.05). Conclusions: Systolic PAP is elevated following the complete surgical repair of TOF. Increased circulating ET‐1 may be responsible for the elevation of PAP. Captopril treatment prevents postsurgical increases in systolic PAP and circulating ET‐1.

Effect of prostaglandin E1 on pulmonary arterial hypertension following corrective surgery for congenital heart disease

Objective: To evaluate the therapeutic effects of prostaglandin E1 (PGE1) on residual pulmonary arterial hypertension (PAH) after corrective surgery for congenital heart disease. Methods: Thirty-one patients with postoperational PAH were randomly divided into control group (n = 15) and PGE1 group (n = 16, 6 courses of intravenous PGE1 plus conventional therapy). Mean pulmonary arterial pressure (MPAP), right ventricular ejection fraction (RVEF), and left ventricular ejection fraction (LVEF) were measured by echocardiography before and 3, 6, and 12 months after the treatment. Arterial oxygen pressure (Pao 2) was monitored. Results: In both groups, MPAP decreased and RVEF, LVEF, and Pao 2 increased at 6 and 12 months following surgery. In the PGE1 group, the MPAP (32.2 ± 5.2 vs 40.2 ± 5.1 mm Hg; P = .008) was lower and RVEF (66.6% ± 6.5% vs 54.9% ± 2.1%; P = .019), LVEF (65.9% ± 3.9% vs 53.5% ± 5.1%; P = .031), and Pao 2 (94.3% ± 11.2% vs 93.1% ± 11.3%; P = .009) was higher than in the control group 12 months after the surgery. Four patients (26.7%) in the control group died of pulmonary hypertension crisis, but there was no death in the PGE1 group (P = .029). Cumulative survival rate in the control group were 86.7%, 80%, 73.3%, and 73.3% at 1, 2, 3, and 5 years, respectively. Conclusions: Intravenous PGE1 therapy after corrective surgery for congenital heart disease was associated with a reduction in mean pulmonary arterial pressure and a lower risk of death.

Anticoagulation therapy with combined low dose aspirin and warfarin following mechanical heart valve replacement

INTRODUCTION This study was designed to evaluate safety and efficacy of combined low dose aspirin and warfarin therapy following mechanical heart valve replacement. METHODS A total of 1496 patients (686 males, mean age 35±8.5 years) undergoing mechanical heart valvular replacement were randomly divided into study (warfarin plus 75-100 mg aspirin) or control (warfarin only) group. International normalized ratio (INR) and prothrombin time was maintained at 1.8-2.5 and 1.5-2.0 times of the normal value, respectively. Thromboembolic events and major bleedings were registered during follow up. RESULTS Patients were followed up for 24±9 months. The average dose of warfarin in the study and control group was 2.92±0.87 mg and 2.89±0.79 mg, respectively (p>0.05). The overall thromboembolic events in study group were lower than in control group (2.1% vs. 3.6%, p=0.044). No statistically significant differences were found in hemorrhage events (3.5% vs. 3.7%, p>0.05) or mortality (0.3% vs 0.4%, p>0.05) between the two groups. CONCLUSIONS Following mechanical valve replacement, combined low dose aspirin and warfarin therapy was associated with a greater reduction in thromboembolism events than warfarin therapy alone. This combined treatment was not associated with an increase in the rate of major bleeding or mortality.

Effect of Preoperational Mechanical Ventilation on Short-Term Postoperative Outcomes in Patients with Severe Tetralogy of Fallot

BACKGROUND This study is designed to investigate the effect of preoperational mechanical ventilation on the short-term postoperative outcomes following corrective surgery for severe tetralogy of Fallot (TOF). METHODS Ninety-two patients (58 males, mean age 20.5±8.5 months) with severe TOF were randomised into study and control groups. In the study group, mechanical ventilation was performed in PEEP/PRVC mode in the intensive care unit to correct blood gas imbalances for the corrective surgery. In the control group, preoperative oxygen supply was provided via face mask or nasal tubes. RESULTS The postoperative mechanical ventilation time (14.3±1.9 vs 22.5±2.2h, p=0.02), intensive care stay (2.3±1.2 vs 4.7±1.1d, p=0.03) and duration for positive inotropic drug administration (2.5±1.1 vs 4.8±1.2d, p=0.04) in the study group were shorter than those in the control group. The postoperative capillary leak syndrome in the study group was lower than that in the control group (4.3% vs 23.9%, p=0.006). There was no statistically significant difference in the postoperative mortality between the study and control groups (2.1% vs 6.5%, p=0.606). CONCLUSIONS Preoperational mechanical ventilation in patients with severe forms of TOF was associated with improved short-term outcomes following the corrective surgery. The effect of the preoperational ventilation on postoperative mortality requires further investigation.

Determinants of immediate extubation in the operating room after total thoracoscopic closure of congenital heart defects.

Objective: This study was designed to assess the factors that influence immediate extubation following totally thoracoscopic closure of congenital heart defects. Subjects and Methods: Clinical and operational data of 216 patients (87 males, average age 13.6 ± 10.9 years) were retrospectively analyzed. Atrial (ASD, n = 90) or ventricular septal defects (VSD, n = 126) were closed via a totally thoracoscopic approach. Ultra-fast-track anesthesia (UFTA) was used in all patients. Results: Immediate extubation in the operating room was successfully performed in 156 (72.2%) patients. A delayed extubation was completed in the intensive care unit in the remaining 60 (27.8%) patients. There was no significant difference in the age, sex, body weight, or type of congenital heart defect between the immediate and delayed extubation groups (p > 0.05). However, more patients in the delayed extubation group had severe preoperational pulmonary hypertension [8 (13.3%) vs. 4 (2.3%), p < 0.05]. The cardiopulmonary bypass time, aortic clamp time, and total duration of the surgery in the immediate extubation group were shorter than in the delayed extubation group (p < 0.05). Multivariate logistic regression analysis showed that preoperational pulmonary hypertension, duration of the surgery or cardiopulmonary bypass, and dosage of fentanyl used during the surgery were independent predictors for immediate extubation. Conclusions: UFTA and immediate extubation in the operating room was feasible and safe in the majority of patients undergoing totally thoracoscopic closure of ASD or VSD. Preoperational pulmonary hypertension, duration of the surgery, and the dosage of fentanyl used for UFTA were the determining factors for immediate extubation.