Feasibility, safety, and efficacy of totally endoscopic coronary artery bypass grafting: multicenter European experience.

OBJECTIVE: The invention of robotic systems has begun a new era of endoscopic cardiac surgery. Reports on totally endoscopic coronary artery bypass grafting are limited, however, and data regarding feasibility, safety, and efficacy are needed to determine this technique's position in the therapeutic armamentarium. This study describes the largest multicenter experience in the literature with robotic totally endoscopic coronary artery bypass grafting specifically addressing procedural feasibility, safety, and efficacy. METHODS: Between September 1998 and November 2002, a total of 228 patients with coronary artery disease were scheduled for totally endoscopic coronary artery bypass grafting with the da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale, Calif.) at five European institutions. Patients underwent totally endoscopic coronary artery bypass grafting with either an on-pump (group A, n = 117) or an off-pump approach (group B, n = 111). Patients underwent postoperative angiography or stress electrocardiography and were followed up for 6 months. RESULTS: Procedural feasibility was demonstrated through the completion of 164 successful totally endoscopic cases. Sixty-four patients (group C, 28%) had conversion to nonrobotic procedures. Conversion rates decreased with time. The overall procedural efficacy, as defined by angiographic patency or lack of ischemic signs on stress electrocardiography, was 97%. The incidence of major adverse cardiac events within 6 months was 5%. CONCLUSION: Both on- and off-pump totally endoscopic coronary artery bypass grafting are feasible, with a conversion rate that diminishes with increasing experience. Conversion does not adversely affect outcome and thus constitutes a safe alternative. Although target vessel reintervention may be slightly higher than that reported for open coronary artery bypass grafting, graft patency and major adverse cardiac events for both approaches are comparable to those reported in the Society of Thoracic Surgeons database, demonstrating the safety and efficacy of the totally endoscopic coronary artery bypass grafting procedure.

Attenuation of reperfusion-induced systemic inflammation by preconditioning with nitric oxide in an in situ porcine model of normothermic lung ischemia.

STUDY OBJECTIVES: Inhalation of nitric oxide (NO) can ameliorate pulmonary ischemia/reperfusion (I/R) injury of the lung in several experimental models, but toxic effects of NO were also reported. Here we investigate whether NO inhalation for a short period prior to surgery is sufficient to prevent symptoms of lung I/R injury, especially the inflammatory response. DESIGN: Using an in situ porcine lung model, normothermic left lung ischemia was maintained for 90 min, followed by a 5-h reperfusion period (group 1, n = 7). In group 2 (n = 6), I/R was preceded by inhalation of NO (10 min, 15 ppm). Animals in group 3 (n = 7) underwent sham surgery without NO inhalation or ischemia. MEASUREMENTS: Oxygenation and hemodynamic parameters were measured as indicators of lung functional impairment. Plasma levels of interleukin (IL)-1beta, IL-6, and transforming growth factor (TGF)-beta1 were determined throughout the I/R maneuver. In addition, tissue macrophages were analyzed by lectin binding. RESULTS: Symptoms of I/R injury (pulmonary hypertension and decreased oxygenation) in group 1 animals were attenuated by NO inhalation. The reperfusion-induced increases of the levels of IL-1beta and IL-6 in plasma were reduced by NO pretreatment. A peak of TGF-beta1 immediately after NO administration was observed in group 2, but not in groups 1 and 3. There was no significant effect of NO on tissue macrophages. CONCLUSION: NO inhalation for a short period prior to lung I/R is sufficient to protect against pulmonary hypertension, impaired oxygenation, and the inflammatory response of pulmonary I/R injury.

[The influence of anxiety, depression and post traumatic stress disorder on quality of life after thoracic organ transplantation]. / Psychosoziale Belastung und Lebensqualität bei Patienten nach Herz- oder Lungentransplantation.

OBJECTIVES: This study examines stress factors, resources of coping, psychopathological symptoms and their influence on health-related quality of life (QoL) in patients after heart or lung transplantation. METHODS: 82 Patients were examined with the questionnaires SF-36 (QoL), HADS-D (anxiety and depression), IES-R and PTSS-10 (post traumatic stress disorder, PTSD) 32.3 (4-86) months after transplantation. Stress factors, resources and diagnostic criteria for PTSD were investigated by structured interview. RESULTS: In the entire sample, anxiety, depression and QoL were in the range of normal population. A subgroup of 13 patients with a PTSD diagnose had significantly reduced QoL. Anxiety and intrusion explained the 42 % variance of psychosocial score of QOL. CONCLUSIONS: There was a lower influence of depression on the medical score of QoL. Psychological symptoms such as anxiety, depression and PTSD significantly influence QoL after heart or lung transplantation. Patients with a PTSD diagnose had poor QoL. Screening for PTSD should be part of routine evaluation after organ transplantation.

Improving hemodynamics by atrial pacing during off-pump bypass surgery.

BACKGROUND: To avoid hemodynamic deterioration during tilting of the heart in off-pump surgery, we perform atrial pacing. We describe hemodynamic evaluation of this simple maneuver. METHODS: Eleven consecutive patients (8 men, 3 women; age, 68.14 +/- 10.3 years; left ventricular ejection fraction, 51.17% +/- 18.6%) admitted for coronary artery bypass grafting were equipped with a PiCCO catheter (Pulsion Medical Systems, Munich, Germany) for monitoring of cardiac output (CO), cardiac index (CI), stroke volume (SV), heart rate (HR), and systemic vascular resistance. In addition, mean and systolic arterial pressure (RRm, RRs) as well as left atrial pressure (LAP) were monitored. During the procedure, temporary pacemaker wires were installed, and hemodynamic monitoring was performed before and after atrial pacing. All procedures were performed with the same standardized offpump technique. RESULTS: All patients survived the procedure without inotropic support. In all cases a branch of the circumflex artery was grafted. The number of grafts per patient was 2.7. There was a statistically significant increase in RRs (11.12 mm Hg), RRm (9.72 mm Hg), HR (31.6 beats/min), CO (1.09 L/min), and CI (0.61 L/min per m2) (P <.005). SV decreased statistically significantly (11.8 mL, P <.005) as did LAP (6 mm Hg, P < .05). CONCLUSIONS: Atrial pacing increases intraoperative RRs, RRm, CO, and CI and decreases SV and LAP significantly, thus offering stable hemodynamics during off-pump surgery. In the last 400 consecutive off-pump coronary artery bypass grafting procedures, there was only 1 (0.25%) conversion to cardiopulmonary bypass.

Combined atrial fibrillation and mitral valve surgery using microwave technology.

Atrial fibrillation is associated with a significant morbidity and mortality and is typically related to patients with mitral valve disease. Microwave ablation is a new option for surgical treatment of chronic atrial fibrillation. We present our experience with surgical treatment of mitral valve disease and microwave ablation in patients with chronic atrial fibrillation. In 105 patients (73 women, 32 men, 68.6 +/- 8 years of age from 45 to 83 years, ejection fraction 28% to 80%, left atrial diameter 56 +/- 9.1 mm from 35 to 97 mm) with mitral valve disease, chronic atrial fibrillation was documented for 8.6 +/- 6.8 years. Microwave ablation was performed using a continuous ablation line starting at the posterior mitral valve annulus and incorporating the interior of all pulmonary veins. In 33 patients, mitral valve reconstruction was performed. Ten patients received biologic valve replacement; 3 of them got a stentless quattro mitral valve prosthesis. Survival rate was 99.1% (n = 104). In the 6-month follow-up, 42 of 69 patients were in sinus rhythm (61%); in the 1-year follow-up, 37 of 64 patients were in sinus rhythm (57.8%). Microwave ablation is a safe and efficient method for surgical treatment of chronic atrial fibrillation in patients with mitral valve disease.