Robotically enhanced coronary artery bypass surgery.

BACKGROUND: Robotically enhanced telemanipulation surgery is a fast developing technique which allows totally endoscopic cardiac surgery with utmost precision and perfection on both beating heart as well as arrested heart. METHODS AND RESULTS: Between December 2002 and February 2004, 125 patients underwent robotically enhanced coronary artery bypass surgery using the da Vinci telemanipulation system (Intuitive Surgical Inc., California). Eleven patients underwent totally endoscopic coronary artery bypass surgery. Of them 9 were done on beating heart while 2 were done on arrested heart. One hundred and fourteen patients had endoscopic takedown of internal mammary artery followed by minimally invasive direct coronary artery bypass in 63 patients and left anterolateral thoracotomy in 51 patients. The internal mammary artery mobilization time was 42 min (35-74 min) while the left internal mammary artery to left anterior descending artery anastomosis time ranged from 20 to 36 min for the totally endoscopic coronary artery bypass patients. In 1 patient, the right internal mammary artery was anastomosed to diagonal artery totally endoscopically. The mean internal mammary artery flow by Doppler measurement done in patients undergoing minimally invasive direct coronary artery bypass was 64 ml/min. Seven patients required conversion to median sternotomy and coronary bypass surgery on beating heart. The mean intensive care unit stay was 1.2 days and the mean hospital stay 4.5 days. There was 1 in-hospital mortality. All 11 patients who underwent totally endoscopic bypass surgery had coronary angiography done at 3 months interval which showed 100% patency in 10 patients while one patient had 50% anastomotic narrowing for which coronary angioplasty was done in the same sitting. CONCLUSIONS: Using telematic technology, a complete endoscopic anastomosis is possible in both single vessel and suitable double vessel disease patients. The use of robotics is now extended to achieve complete myocardial revascularization by harvesting both the internal mammary arteries and making a small thoracotomy for direct anastomosis as well.

Augmenting in vitro shoot multiplication by vipul (triacontanol) and adventitious rhizogenesis by rice bran extract in Dendrocalamus strictus.

Like other bamboo species, Dendrocalamus strictus flowers gregariously after a prolonged intermast period of 48 years and constitutes an ideal material for in vitro clonal propagation. In this study, MS liquid medium containing 0.5, 1.0 and 2.0 mL/L vipul (Godrej Agrovet, Ltd., Sachin, India), a commercial formulation of triacontanol, with or without BA (3.0 mg/L) was tested for in vitro shoot multiplication and 1.0, 2.5 and 5.0 mL/L of 20% (w/v) alcoholic/aqueous rice bran extract (alone or in combination) with NAA (3 mg/L) used for in vitro adventitious rhizogenesis in single node culture derived shoots of Dendrocalamus strictus.. After a multiplication cycle for 4-5 week, vipul (0.5 mL/L) with BA (3.0 mg/L) in the culture medium induced 4.59 fold shoot multiplication rate whereas application of BA and vipul alone had corresponding values of 3.29 and 0.53 fold respectively. Maximum vipul concentration (2 mL/L) with BA (3 mg/L) exhibited shoot multiplication higher than (or equal to) that of BA alone. Maximum in vitro rooting percentage (55.66%) was obtained on half MS medium enriched with alcoholic rice bran extract (2.5 mL/L) and NAA (3 mg/L). This is the first investigation reporting amelioration of in vitro shoot multiplication rate by triacontanol and rooting percentage by rice bran extract in explants from mature bamboo culms. The protocol is economical and rapid for in vitro clonal propagation of Dendrocalamus strictus.

Minimally invasive atrial septal defects repair.

This study reviews the current method of atrial septal defect closure at our institute with a minimally invasive approach without median sternotomy. From September 1997 to August 1998, 37 patients (13 males, 24 females) with mean age 36.5 years (range 18-67 years) underwent atrial septal defect closure by right anterior thoracotomy. Femoral vessels were cannulated through a small groin incision and extracorporeal circulation was established. Venous drainage was assisted with a centrifugal pump. Aortic crossclamping was performed through the intact chest wall using a special transthoracic clamp with sliding rod design inserted through a separate tiny 3 mm incision in the right second intercostal space in the mid clavicular line. Mean duration of cardiopulmonary bypass and aortic crossclamp time was 35 +/- 14 and 23 +/- 7 minutes respectively; mean endotracheal intubation time after surgery 6.2 +/- 3 hours; mean ICU stay 10.6 +/- 2.8 hours; mean length of thoracotomy incision 7.2 +/- 1.8 cm; and, mean hospital stay 4.2 +/- 1.8 days. There was no post-operative neurological dysfunction or femoral cannulation related complication. There was no perioperative or late mortality. No residual atrial septal defect was observed by transoesophageal echocardiography in any patient. The procedure described here provides secure closure of the atrial septal defects in minimally invasive fashion with good results.

Coronary artery bypass surgery without cardiopulmonary bypass: short- and mid-term results.

From March 1994 to April 1997, 433 patients had undergone coronary artery bypass grafting without cardiopulmonary bypass in our institute. Sixty-eight patients had various organ dysfunctions and/or aortic atheroma or calcification and were regarded as high risk for cardiopulmonary bypass. In 277 patients surgery was performed through midline sternotomy, while in 156 minithoracotomy approach was used. In 361 patients single coronary artery bypass grafting was done, and in 72 two-coronary arteries were bypassed. In 63 patients who had graftable vessels in anterior wall and diffusely diseased ungraftable vessels in posterolateral and/or inferior wall, transmyocardial laser revascularisation was also done along with coronary artery bypass grafting to achieve complete myocardial revascularisation. Nine patients in this series were also subjected to simultaneous carotid endarterectomy along with myocardial revascularisation. In two patients complementary percutaneous transluminal coronary angioplasty of left circumflex coronary artery was done five days after minithoracotomy and left internal mammary artery to left anterior descending coronary artery bypass grafting. Forty-two cases were extubated in operating room. Average blood loss was 260 ml. Six patients were reexplored for postoperative bleeding. Seven patients had perioperative myocardial infarction. One developed neurological complication. Hospital mortality was 2.3 percent (10/433 cases) and four deaths were due to malignant ventricular arrhythmias. Nine patients developed chest wound complications. Average hospital stay after operation was six days, 423 patients were discharged from hospital and all of them were asymptomatic. During three years follow-up (range 3 to 38 months) there were three known cardiac deaths. Ninety percent (391) patients reported to the follow-up clinic and 91 percent of them were angina-free. In patients who were subjected to transmyocardial laser revascularisation along with coronary artery bypass grafting, myocardial perfusion scan showed a step-wise improvement in reversible ischemia. The perfusion index increased from 52 percent at three months to 90 percent at 12 months. We conclude that coronary artery bypass grafting without cardiopulmonary bypass can be done with relatively low mortality, more so in a group of patients in whom cardiopulmonary bypass poses a high risk. Transmyocardial laser revascularisation is a suitable means to provide complete myocardial revascularisation along with coronary artery bypass surgery in patients who have graftable vessels in anterior wall and ungraftable vessels in posterolateral and inferior walls.

Limitations of using arterial conduit for myocardial revascularization in patients with combined coronary and other arterial lesions.

To explore the limitations of using arterial conduit for myocardial revascularization in patients with combined coronary and other arterial lesions, we evaluated 195 patients with combined lesions undergoing CABG, either alone or in combination with peripheral vascular reconstruction between October 1987 to October 1990. Doppler flow and spectral analysis revealed that 14 patients (7.1%) had atherosclerotic lesions of the subclavian artery, in whom ipsilateral internal mammary artery pedicle graft was contraindicated for myocardial revascularization. Out of 195 patients, 165 patients were subjected for aortography, 18 of whom (10.9%), revealed atherosclerotic involvement of the celiac trunk, thereby contraindicating the use of gastroepiploic artery for myocardial revascularization. Thus in our experience use of arterial conduit for myocardial revascularization in patients with combined coronary and other arterial lesions is limited.

Antegrade and retrograde cardioplegia with different reperfusion techniques in patients with multiple coronary artery lesions.

To evaluate the effectiveness of retrograde cardioplegia and reperfusion, a total of 266 patients undergoing coronary bypass surgery between Nov 1987 to Dec 1989 were divided into three groups depending on the method of cardioplegic fluid delivery and reperfusion. In group I (80 patients) antegrade cardioplegia and reperfusion was used. In group II (98 patients) antegrade and retrograde cardioplegia and antegrade reperfusion was used while in group III antegrade and retrograde cardioplegia and retrograde reperfusion was used. Myocardial functions were studied with the help of an on-line computer on the basis of mathematical model of heart before and after cardiopulmonary bypass. Biopsy specimens were collected before, during and after cardiopulmonary bypass in order to study myocardial structural changes. In group I patients there was decrease in myocardial function in the immediate post perfusion period while group II patients had considerable improvement in their myocardial function and groups III patients showed further improvement in it. Ultrastructural myocardial study revealed considerable detrimental changes in group I, minimal changes in group II and no change in group III patients. Thus in our experience retrograde cardioplegia and retrograde reperfusion with warm oxygenated blood provide maximum myocardial protection in patients with multiple coronary artery lesions.

Unilateral ocular myasthenia gravis--a case report.

Unilateral ocular myasthenia gravis is being reported. He had significant involvement of one eye with no involvement of the fellow eye.

A clinical study of effect of oral atenolol on normal intraocular pressure and systemic blood pressure.

Atenolol is a newer betablocker, widely used as an antihypertensive drug. It cause a large and rapid fall in IOP when used orally and topically. A total of 33 patients both having normal and raised IOP were included in the study. The drug was given in a dose of 50 mg. tab. orally once a day for 7 days at 8 A.M. and IOP recorded after 24 hours, 72 hours and on 7th day. It produces significant and sustained fall in IOP in both normal and raised IOP patients besides lowering of systematic B.P. and pulse rate. The IOP on patients with systemic hypertension with Atenolol will be reduced and stoppage of therapy may cause glaucoma damage.