[Operation of Ebstein anomaly in adulthood - our experience]. / Operace Ebsteinovy anomálie v dospelém veku - nase zkusenosti.

INTRODUCTION: The outcome of the operation of the Ebstein anomaly in adulthood depends on the experience of the surgical team. METHODS AND RESULTS: We operated 38 adult patients with Ebstein anomaly at the age of 34.8 ± 12.7 (19-63) years at the Department of Cardiac Surgery, Hospital Na Homolce, Prague, in the period of 2005-2013. The majority of patients (71 %) had Ebstein anomaly type C or D. The 30-days postoperative mortality was 5.2 %. In the long-term follow-up 2 other patients died. Tricuspid valve repair was performed in 45 %, bioprosthesis was implanted in 53 %. Concomitant bi-directional cavo-pulmonary anastomosis was performed in 31.5 %, mitral valve repair in 8 %, closure of atrial communication in 83 %, right-sided MAZE or istmus cryo-ablation in 39 %. After the operation we found improvement of the functional NYHA class (from 2.2 ± 0.7 to 1.7 ± 0.6; p < 0.0001) as well as decrease of tricuspid regurgitation (from grade 3.8 ± 0.4 to 0.9 ± 1; p < 0.0001). The ejection fraction of the right ventricle (RVEF) improved in 86 % of patients, in 14 % RVEF decreased or did not change (RVEF before operation 36 ± 10.5 %, after operation 42 ± 9.5 %, p = 0.001). In the long-term follow-up we found dysfunction of the tricuspid valve repair in 12 % and degeneration of the bioprosthesis in 15 %. Among 86 adult patients with Ebstein anomaly from our database the mortality was significantly higher in unoperated compared to operated patients (26 % vs 12 %, p = 0.006). Patients with cyanosis had high mortality regardless of surgery (40 % with and 83 % without operation). Reoperation after surgery in childhood or adulthood was necessary in 20 % of adults. CONCLUSION: The adult patients with Ebstein anomaly should be examined in a specialized center even if the symptoms are mild. The operation should be performed by a team with good results and experience in surgery and post-operative care in Ebstein anomaly. According to our knowledge Hospital Na Homolce represents such specialized center for Czech Republic.

Single-site access robot-assisted epicardial mapping with a snake robot: preparation and first clinical experience.

CardioARM, a highly flexible "snakelike" medical robotic system (Medrobotics, Raynham, MA), has been developed to allow physicians to view, access, and perform complex procedures intrapericardially on the beating heart through a single-access port. Transthoracic epicardial catheter mapping and ablation has emerged as a strategy to treat arrhythmias, particularly ventricular arrhythmias, originating from the epicardial surface. The aim of our investigation was to determine whether the CardioARM could be used to diagnose and treat ventricular tachycardia (VT) of epicardial origin. Animal and clinical studies of the CardioARM flexible robot were performed in hybrid surgical-electrophysiology settings. In a porcine model study, single-port pericardial access, navigation, mapping, and ablation were performed in nine animals. The device was then used in a small, single-center feasibility clinical study. Three patients, all with drug-refractory VT and multiple failed endocardial ablation attempts, underwent epicardial mapping with the flexible robot. In all nine animals, navigation, mapping, and ablation were successful without hemodynamic compromise. In the human study, all three patients demonstrated a favorable safety profile, with no major adverse events through a 30-day follow-up. Two cases achieved technical success, in which an electroanatomic map of the epicardial ventricle surface was created; in the third case, blood obscured visualization. These results, although based on a limited number of experimental animals and patients, show promise and suggest that further clinical investigation on the use of the flexible robot in patients requiring epicardial mapping of VT is warranted.

[Six-year experience with cardiac surgery in adults with congenital heart disease]. / Sestileté zkusenosti s operacemi vrozených srdecních vad u dospelých.

BACKGROUND: Increasing number of adults with congenital heart disease (ACHD) require reoperation or primary repair. To define risk and outcome of operations of ACHD performed in adult cardiac surgery. METHODS: Between 2005-2010 we operated on 459 patients with ACHD, aged 40.4 +/- 15 years. Operations of ACHD represented 9.5% of 4854 cardiac operations in our department. RESULTS: The 30-days mortality was 1.1%, hospital mortality was 1.52%, long-term mortality among discharged patients was 1.3%. Reoperations after surgery in childhood represented 39%, repeated reoperations 9%, operations of 3 or 4 valves 2.6%. Robotic surgery or minithoracotomy was performed in 9%. Pulmonary hypertension was present in 11.3%, NYHA III-IV in 30%. The risk factors of mortality were: NYHA class III-IV (p < 0.001), cyanosis (p < 0.001), severe systolic dysfunction of left (p = 0.006) or right ventricle (p < 0.001).We did not confirm increased risk in older patients, women, pulmonary hypertension, reoperations and operations of 3-4 valves. CONCLUSIONS: Excellent surgical results among older adults with CHD were achieved by the co-operation of paediatric cardiac surgeon within the experienced centre for adult cardiac surgery. The highest risk was found in patients with NYHA class Ill-IV, cyanosis and ventricular dysfunction.