[Current applications of robotic heart surgery]. / Soucasné moznosti robotické kardiochirurgie.

OBJECTIVE: The objective of the article is to describe the history, development and current state of robotic heart surgery. INTRODUCTION: Robotic heart surgery is a new technology which has recorded dramatic growth in recent years. This is because of the effort to develop, in all fields of surgery, new and minimally invasive methods and to reduce surgical stress. METHOD: Overview of the relevant literature dealing with the history and development of robotic surgery, with a focus on heart surgery. RESULTS: The number of centres using a robot in clinical practice is growing fast. After a slow start, heart surgery is now the fastest growing field of robotic technology. It has been proven already that almost all heart surgeries can be performed with the use of a robot. Most of surgery fields have already introduced robots in current use. None of them, however, has yet advanced to a 100% robotic coverage of the whole range of interventions. Therefore it is a good strategy today to build multi-specialised operating theatres with robots that could be used for different fields of surgery. CONCLUSION: Even though robotic surgery is in its beginnings today, its great potential is quite apparent. Only the years to come will show the efficiency, safety, and the cost benefit of robotic technology as compared with traditional methods.

[Main clinical and surgical determinants of in-hospital mortality after surgical revascularization of left main coronary artery stenosis: 2 year retrospective study (1998-1999)]. / Les facteurs cliniques et opératoires associés à la mortalité hospitalière après chirurgie d'une sténose du tronc commun de l'artère coronaire gauche. Analyse rétrospective de janvier 1998 à décembre 1999.

UNLABELLED: Stenosis of left main coronary artery (LMCA) is a common finding on coronary angiographies (7 to 10%). Mortality is very high for conservative therapy in comparison with surgery, which provides very good long-term outcome and is accepted as the standard therapy of this condition. Over the last few years, percutaneous coronary intervention (PCI) has become a new alternative in selected patients. AIM OF THE STUDY: To assess in hospital mortality in subjects referred to our surgical unit for coronary artery bypass grafting (CABG) and to identify the main clinical and surgical determinants of in-hospital mortality. METHODS: Two year retrospective analysis (1998-1999) of in-hospital mortality and morbidity of patients having left main stenosis referred for CABG. RESULTS: Among a group of 1443 patients operated for coronary heart disease, LMCA stenosis was found in 330 patients (22.9%). The mean age was 63 +/- 8.6 years. Elective surgery was done in 173 patients (52.4%), and acute operation (i.e. urgent, emergent or desperate) in 157 patients (47.6%). The total in-hospital mortality was 4.2% (14/330). Elective surgery in-hospital mortality was 1.7% (3/173) and urgent surgery in-hospital mortality was 7% (11/157). The main risk factors of in-hospital mortality were age > 68 years, low ejection fraction (LVEF<0.4), history of myocardial infarction, gender (female) and urgency of the operation. CONCLUSION: The proportion of patients undergoing CABG for left main stenosis is relatively high in our center and their mortality is quite low especially for elective operations. As the mortality of patients treated by PCI for LMCA stenosis is similar to surgery in high-risk patients, we postulate that this approach can be a real alternative treatment for such patients. Because of its potential benefit, combined revascularisation is also an alternative that should be considered in some cases. Furthermore, as a new generation of coated stents has emerged in the treatment of restenosis after PCI, we hypothesize that this method can in the near future be accepted as equivalent to surgery. However several randomized clinical trials must first be conduced prove this point.

Targeted compartmental embolization of cavernous sinus dural arteriovenous fistulae using transfemoral medial and lateral facial vein approaches.

There are multiple transvenous approaches for treatment of cavernous dural arteriovenous fistulae (DAVF). The choice of a specific route depends on the compartment of the cavernous sinus involved in the fistula and its venous drainage. We used two different facial vein approaches to treat patients with cavernous DAVF draining directly into the anterior compartment of the cavernous sinus and thence to the superior ophthalmic vein. Other transvenous routes to the sinus were not apparent. Embolization was targeted to the involved compartment with preservation of those not embolized. No major post-procedure ophthalmic venous engorgement occurred. We believe that ideal treatment of cavernous DAVF is targeted transvenous coil deposition, which necessitates detailed knowledge of the anatomy of the facial veins and cavernous sinus compartments.

[Trends and results of mitral valve surgery]. / Trendy a výsledky operací mitrální chlopne.

BACKGROUND: Retrospective study of 303 patients with mitral valve surgery operated in the last 7 years is evaluated. A mitral valve replacement was done in 271 patients (89.4%), mitral valve reconstruction in 32 patients (10.6%). Only the replacement of mitral valve was done in 70 patients (23.1%), replacement in combination with some other intervention, most frequently the revascularization was done in 27 patients. METHODS AND RESULTS: The total mortality in mitral valve replacements was 7.7% with the prevalence of combined surgery, including the acute cases. Mortality for patients with prosthetics was 8.6% during 1996 to 98, and only 6.5% in the following years. From patients with the mitral reconstruction four has died (12.5%), all were acute or emergent cases with combined surgery. The average length of hospitalisation was 7.5 days. Postoperative Q-IM occurred in one patient (0.41%), revision for bleeding was necessary in 16 patients (5.3%), neurological complications developed in 14 patients (4.6%). CONCLUSIONS: Results of early mitral replacements are comparable or in some combined surgeries better to the results given in the literature or in the international register. In the aetiology of disease, a comparative decrease of rheumatic origin and an increase of ischaemic and degenerative disorders become apparent. The paper demonstrates improving results in this field of cardiosurgery, shows the new trends in the development of surgical treatment of the mitral valve and it also stresses the necessity of early indication to the surgery.

[Popliteal artery aneurysms--acute ischemic complications]. / Výdut' podkolenní tepny--akutní ischemické komplikace.

The authors present a group of 10 patients with the diagnosis of acute ischaemia of an extremity caused by an aneurysm of the popliteal artery, during the period from 1997 till October 2002, who within a short time interval were treated by a combination of endovascular and surgical therapy. The group comprised 8 men and 2 women. The mean age was 58 years, the range 48-78 years. A bilateral aneurysm was present in 3 patients, coincidence with an aneurysm of the abdominal aorta was found in one patient. In all ten patients combined treatment was used involving local thrombolysis rtPA (Actilyse Boehringer Ingelheim) for 24-48 hours followed within 24 hours by exclusion of the aneurysm with vascular reconstruction. No death, amputation nor closure of the reconstruction was recorded during hospitalization. The medium term results suggest a 100% patency when an autologous vein was used, much poorer results are obtained when prostheses were used in particular in patients with femoropopliteal bypasses. In our opinion in acute ischaemia of the extremities as a result thrombosis of an aneurysm of the popliteal artery the application of a combination of local thrombolysis rtPA followed within a short time interval by vascular reconstruction increases the probability of saving the affected extremity and markedly reduces the necessity of amputation as compared with primary surgical treatment.

Idiopathic intracranial hypertension: the prevalence and morphology of sinovenous stenosis.

OBJECTIVE: To determine the prevalence and nature of sinovenous obstruction in idiopathic intracranial hypertension (IIH) using auto-triggered elliptic-centric-ordered three-dimensional gadolinium-enhanced MR venography (ATECO MRV). METHODS: In a prospective controlled study, 29 patients with established IIH as well as 59 control patients underwent ATECO MRV. In a randomized blinded fashion, three readers evaluated the images. Using a novel scoring system, each reader graded the degree of stenosis seen in the transverse and sigmoid sinuses of each patient. RESULTS: There was excellent agreement across the three readers for application of the grading system. Substantial bilateral sinovenous stenoses were seen in 27 of 29 patients with IIH and in only 4 of 59 control patients. CONCLUSION: Using ATECO MRV and a novel grading system for quantifying sinovenous stenoses, the authors can identify IIH patients with sensitivity and specificity of 93%.

[Thoracic outlet syndrome. An atypical etiology in a typical location]. / Thoracic outlet syndrome. Netypické etiologie na typickém míste.

We have described a clinical case of 46 years old man suffering from TOS with non typical symptomatology. Diagnostic guidelines and possibilities of surgical treatment are discussed in this work.

Vasa vasorum of the human great saphenous vein.

The distribution of the vasa vasorum of the human great saphenous vein (GSV) was studied on veins taken both post-mortem and peroperatively. It was found that the stems of feeding vessels approach the venous wall at intervals of 1.5-2.5 cm; their smaller branches first passed the fascial compartments of the GSV and then entered the adventitia at intervals of 0.5-1.5 cm on both the stem and the largest tributaries of the GSV. In the stem regions vasa vasorum arteries and veins ran together but, between neighboring stems, isolated venae vasorum were regularly found which opened individually into terminal segments of the largest tributaries of the GSV. Neither by dissection nor by injection methods were venae vasorum found to open directly into the lumen of the GSV stem. The total thickness of the media ranged between 500 and 1300 micro m, according to the state of constriction of the venous wall before fixation. Two structurally different layers of GSV tunica media were present: an inner loose layer and an outer dense layer, both of similar thickness. The innermost capillaries of the vasa vasorum network were found in all cases on the border between the two layers of media. No lymphatic was found in any of the layers of GSV wall. From the findings the authors recommend extremely careful dissection of the GSV wall during in situ grafting surgery, to ensure the best viability of the venous wall.

[Video-assisted myocardial revascularization and left-sided minithoracotomy using the Symmetry automatic connector]. / Videoasistovaná revaskularizace myokardu z levostranné minitorakotomie s pouzitím automatického konektoru Symmetry.

OBJECTIVE: Introduction of the new method of videoassisted multiple direct revascularization of the heart muscle from left-sided minithoracotomy (LAST--Left Anterior Small Thoracotomy) using an automatic connector of central anastomoses Symmetry (St. Jude Medical ATG, Inc., St. Paul, MN) in patients indicated for re-operation of bypasses of the coronary arteries or with pathological conditions of the sternum and for the cosmetic effect of submammary incisions in women. METHOD: From September 2001 to the end of February 2002 15 patients with affections of three arteries had an operation from a LAST approach with videoscopic construction of central anastomoses by means of a Symmetry connector with portal entries and the use of extracorporeal circulation introduced from the groin without cardioplegic arrest. Nine men and six women were operated with a mean age of 68.7 years and a mean ejection fraction (EF) of 58.2%. In seven instances reoperation of aortocoronary bypasses was involved; two patients with multiple myelomas (morbus Kahler) had a brittle and cavernously altered sternum, all six women wanted a small skin incision below the breast. The criterion for ruling out the mentioned procedure was marked atherosclerotic affection of the ascendent aorta, affection of the arteries in the aortoiliac area and affection of one or two coronary arteries suitable for miniinvasive revascularization without extracorporeal circulation. Fourteen patients had an angiographic check up examination of the patency of grafts before they were discharged. RESULTS: The total number of distal anastomoses per patient was 3.13 +/- 0.6, the median period of extracorporeal circulation was 112 +/- 34 minutes and the mean time of operation 186 +/- 52 minutes. Blood losses were on average 425 ml/24 h without necessity of revision on account of haemorrhage. Eleven (73%) patients were subjected to an ultra fast track protocol with extubation on the operating table. The mean time spent in the postoperative department was 8.6 hours and the total hospitalization period 5.5 days. None of the operated patients died. Peroperative ischaemia of the heart muscle was not observed, in one instance the authors observed a newly developed atrial fibrillation. During an angiographic check-up the authors detected 6 (13.6%) stenoses and occlusions in 44 checked bridged vessels. CONCLUSION: The alternative approach reduces the risk of cardiac injury during reoperation and the danger of impaired healing of the sternotomical wound in patients with pathological conditions of the sternum, with contamination of the surrounding tissue (e.g. in tracheostomy) or malignant disease. The cosmetic effect of the submammary incision, the small inguinal incision and endoscopic saphenous vein harvesting should be considered in elective direct revascularization of the heart muscle in women. Bridging of the coronary arteries with optical assistance from minithoracotomy and with an automatic connector of central anastomoses seems to be a safe alternative of standard sternotomy only with methodological but not anatomical or functional restriction.

[Comparison of short-term and long-term results after aortocoronary bypass in ischemic heart disease in diabetics and non-diabetics]. / Porovnání krátkodobých a dlouhodobých výsledku po aortokoronárním bypassu pro ischemickou chorobu srdecní u diabetiku a nediabetiku.

In the presented study we have evaluated short-term and long-term results of the multiple aortocoronary bypass surgery in the patients with ischemic heart disease. We have compared the incidence of the preoperative and postoperative complications, short-term and long-term mortality in the group of diabetics in comparison to nondiabetics as well as the entry characteristics of both groups. Among 2518 patients who were treated with aortocoronary bypass surgery there were 773 (30.6%) diabetics. The diabetic patients were significantly elder, we have found more women among them, more frequent presence of hypertension, chronic heart failure and peripheral vascular disease. Contrary in the incidence of the previous myocardial infarction we have not found any significant difference between both groups. The patients with diabetes mellitus had lower ejection fraction of the left ventricle and significantly more extensive coronary artery disease which explains that in this group of patients the number of coronary bypasses was significantly higher. Comparing the incidence of preoperative complications we have not seen any significant difference between the patients with and without diabetes mellitus. Out of the postoperative complications we have noticed significantly more renal failure, infectious complications, low cardiac output syndrome and bleeding disorders in the diabetic patients. The duration of hospitalisation in the intensive care unit was significantly longer in diabetics (55.11 +/- 89.09 hours to 47.84 +/- 65.18 hours in nondiabetics, p < 0.05). 30 days mortality in diabetics was 3.75% and 2.4% in nondiabetics (p < 0.05). This difference was mainly due to the significantly higher incidence of multiorgans failure as a cause of death among diabetics (1.3% in diabetics, 0.5% in nondiabetics, p < 0.05). 89.1% of nondiabetics and 86.9% of diabetics lived 2-6 years after aortocoronary bypass surgery (n.s.). We have found the significantly higher long-term cardiovascular mortality (2-6 years) in diabetics (10.3%) then in nondiabetics (7.6%, p < 0.05).

[Myocardial revascularization via a median sternotomy without cardiopulmonary bypass in 250 patients--midterm results and study of graft patency]. / Revaskularizace myokardu ze strední sternotomie bez pouzití mimotelního obehu u 250 nemocných--strednedobé výsledky a studie pruchodnosti stepu.

OBJECTIVES: To evaluate mid-term results and one-year graft patency of less invasive coronary artery bypass grafting through a median sternotomy. METHODS: From January 1, 1998, to December 31, 1999, 250 patients had coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) through a median sternotomy. The patient base of 188 men and 62 women averaged 61.7 years, mean ejection fraction (EF) was 55.1%. An average of 2.7 (range 1 to 5) distal anastomoses per patient was achieved. Results are compared with a CPB subgroup of patients operated on through a median sternotomy in the same time (N = 1126). In a random subgroup of 100 patients (50 per group) an angiographic control of graft patency was done. RESULTS: A non-CPB group showed lesser occurrence of postoperative acute myocardial infarction (p = 0.038), atrial fibrillation (p = 0.029) and lower incidence of renal (p = 0.033) complications. We observed lower operative mortality (p = 0.019), as well as the occurrence of low cardiac output syndrome (p < 0.001) in the off pump group. The follow-up is 36 +/- 12 months and the number of patients with recurrent angina (5.4%), late AMI (0%) and late death (0.4%) is acceptable. We did not find an inordinate number of vein grafts occlusions (2.2%) and stenoses (7.8%) at anastomotic sites. None of the arterial grafts in both groups were occluded. CONCLUSIONS: We detected lower incidence of postoperative complications and decreased operative mortality in a non-CPB group. Angiographic assessment displayed an excellent run-off in both groups of patients. Off-pump coronary bypass grafting is associated with sufficient short-term graft patency and mid-term clinical outcomes.

[The in situ saphenous vein--more possibilities for vascular reconstruction?]. / Saféna in situ--rozsírení mozností zilních rekonstrukcí?

A clinical study of 47 patients with reconstruction of the large saphenous vein by the in situ technique indicates a statistically insignificant difference in the patency for venous grafts from 3 to 4 mm as compared with those above 4 mm. This confirms that the in situ technique extends the possibilities of venous reconstructions. In the author's group it extended the possibility to use a venous graft by 12.8%. The study confirms also the fundamental importance of patency of the pedal arch for long-term patency. Secondary patency of reconstructions in situ and reverse reconstructions in our department is comparable during the five-year period: 82 and 84%.

Off-pump coronary artery bypass grafting. The 1st Medical Faculty of Charles University study.

OBJECTIVES: To explore the surgical technique, anaesthesiological management, immediate and mid-term results, graft patency and effectiveness of less invasive coronary artery bypass grafting through a median sternotomy. METHODS: From January 1998 through December 1999, 144 patients had coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) done by one surgeon through a median sternotomy. The cohort of 107 men and 37 women averaged 60.8 years, mean ejection fraction (EF) was 51.8%. An average of 2.7 (range 1 to 5) grafts/patients was achieved. Results are compared with a CPB subgroup of patients operated on through a median sternotomy in the same time (N = 234). In a random subgroup of 100 patients (50 per group) an angiographic control of graft patency was done. RESULTS: A non-CPB group showed less postoperative acute myocardial infarction (0.7% vs. 3.8%, p < 0.05) and atrial fibrillation (14.6% vs. 26%, p < 0.05), lower incidence of renal (2.8% vs. 5.1%, p < 0.05) and respiratory complications (2.0% vs. 3.8%, NS). We observed lower operative mortality (0.7% vs. 3.4%, p < 0.05), as well as the occurrence of low cardiac output syndrome (0.7% vs. 5.6%, p < 0.05) in the off-pump group. The follow-up is 36 +/- 12 months and the number of patients with recurrent angina, late AMI and late death is acceptable. We did not find an inordinate number of vein grafts occlusions (0.7% vs. 1.8%, NS) and stenoses (6.6% vs. 6.7%, NS) at anastomotic sites. None of the arterial grafts in both groups were occluded. CONCLUSIONS: There was little known about the efficacy of the less invasive coronary artery bypass grafting at the beginning of our study. Starting with pioneering the operative technique, we have discovered and proposed three types of a heart verticalization and a reusable stabilizing device. We detected lower incidence of postoperative complications and decreased operative mortality in a non-CPB group. Angiographic assessment displayed an excellent run-off in both groups of patients. Off-pump coronary bypass grafting is associated with sufficient short-term graft patency and mid-term clinical outcomes.

[Early results of mitral valve surgery]. / Casné výsledky operací mitrálních chlopní.

The authors submit a retrospective group of 245 patients operated in the course of 6 years at the Second Surgical Clinic of Cardiovascular Surgery of the General Faculty Hospital and First Medical Faculty Charles University on account of mitral valve disease. The early results of mitral valve prostheses are comparable or in some combined operations better than reported in world statistics. In the etiology the authors found a relative decrease of rheumatic defects and higher incidence of ischaemic affections. The general mortality in mitral valve prostheses was 7.1%, combined operations incl. acute ones being predominant. In mitral plastic operations the authors lost 4 patients, i.e. 19%. In all instances acute combined operations were involved and the result is consistent with the predicted mortality according to the Merged Cardiac Registry. The mean hospitalization period was 7.52 days. A postoperative QIM was recorded in one patient, i.e. in 0.46%, revision after mediastinitis also in one patient (0.41%) and revision after haemorrhage in 14 patients, i.e. in 5.7%. Neurological complications were recorded in 10 patients i.e. 4%. The work emphasizes the trend of improving results in this important area of cardiosurgery and indicates further possibilities and ways of development in the treatment of mitral valve diseases.

[The first successful therapeutic pulmonary lavage in pulmonary alveolar proteinosis in the Czech Republic]. / První úspesná lécebná plicní laváz u plicní alveolární proteinózy v Ceské republice.

Whole lung lavage represents a possible therapeutic method in pulmonary alveolar proteinosis which can lead to an improvement of blood oxygenation in the lungs. In the Czech Republic there has been no experience with this method so far. A case of 69-year-old female with idiopathic pulmonary alveolar proteinosis treated with the whole lung lavage sequentionally conducted is reported. The whole lung lavage led to the improvement of dyspnoe and arterial blood gases. Whole lung lavage leads to the improvement of clinical status in patients with pulmonary alveolar proteinosis.

[Contribution to the theory of venous grafting using the great saphenous vein. An experimental study]. / Príspevek k teorii zilních náhrad velkou safenou. Experimentální studie.

The experimental study took interest in measurement of the flow through great saphenous vein graft. This study compared the flow through reversed vein graft and nonreversed vein graft with cutting vein valvules in the similar conditions. The flow in nonreversed graft lenght of 65 cm was Q = 697 +/- 26 ml/min, in reversed graft lenght of 65 cm Q = 836 +/- 8.61 ml/min. The flow in nonreversed graft lenght of 55 cm was Q = 1002.5 +/- 12.9 ml/min in reversed graft 55 cm Q = 1059 +/- 7.36 ml/min. The results of measurements show higher flow the shorter the graft as well as higher flow through the reversed graft. The statistically significant difference in values of the flow was also confirmed by Wilcoxon-Mann-Whitney test. The conclusion of our study can be applied on usage of allogenous vein grafts and autogenous vein grafts that could be transferred on the other leg. In these indications we can recommend the usage of reversed technique, because the measured flow through the reversed graft is statistically higher than through the nonreversed graft.

[A nontraditional method of surgical treatment of an aortocaval fistula. Case report]. / Netradicní zpusob chirurgické lécby aortokavální pístele. Kazuistika.

Unusual method of aortocaval fistula and venous aneurysm repair is discussed and possible advantages of this type of surgery are cleared up. The aortoiliac prosthetic substitution and exclusion of the region, where aorta and inferior vena cava communicate without direct suture of the fistula makes the operation safer and lowers the risk of postoperative bleeding. In authors' opinion, this method is effective even in acutely rising aortocaval fistulas.

[Comparison of the effectiveness of crystalloid and warm blood cardioplegia in patients with significant left ventricular dysfunction]. / Srovnání úcinnosti krystaloidní a krevní teplé kardioplegie u pacientu s významnou dysfunkcí levé komory srdecní.

UNLABELLED: In a group of 84 patients undergoing elective coronary artery bypass surgery and with the ejection fraction lower than 40% two types of myocardial protection were studied. Group I (41 cases) was given intermittent cold crystalloid cardioplegia and group II (43 patients) was given intermittent warm blood cardioplegia followed by normothermic reperfusion. Preoperative, intraoperative and postoperative data were retrospectively collected. There were no differences between the two groups except more rhythm disturbances in group I and higher incidence of neurological complications in group II. CONCLUSIONS: Warm blood cardioplegia is an effective, cheap and practical myocardial protection technique.

[Aneurysm of the descending aorta causing destruction of vertebral bodies. Case report]. / Výdut sestupné aorty jako prícina destrukce obratlových tel. Kazuistika.

A case report of 59-year-old woman with combined lesion of the aneurysm of the descending thoracic aorta and the destruction of vertebral bodies is presented. Considering the infectious aetiology of the whole lesion and the possibility of the future orthopaedic intervention we use the less usual operative approach and technique in this case. Only indirect method to prevent the spinal cord injury was used and the aneurysm was repaired with bypass and exclusion. The only postoperative complication requiring future surgery was the dissection and thrombosis of the right superficial femoral artery used for blood pressure monitoring. We perform, in local heparinization, the proximal femoropopliteal prosthetic bypass. The latter postoperative course was uneventful. Follow-up digital angiography of the aorta 12 month later showed good filling of the prostheses and normal anastomosis, X-ray film and CT scans one, three and five years after operation showed almost complete reconstruction of the vertebral bodies. This article also discusses the technical and tactical aspects of the thoracic aortic aneurysm repair and also analyses the diagnostic and therapeutic chance to influence the spinal cord ischaemia.

[New methods of surgery on the arteries supplying the brain]. / Nová taktika operací tepen zásobujících mozek.

INTRODUCTION: Brain ischaemia as a sequelae of atherosclerosis involving the brain-supplying arteries is one of the commonest causes of death in the industrialized nations. MATERIAL AND METHODS: A total of 236 procedures on the internal and common carotid arteries in 227 patients with a mean age of 67 years were performed. General anaesthesia was used in 18.5% of patients, cervical block in 81.5%. RESULTS: The hospitalization morbidity of our group of patients was 8.9%, hospitalization mortality was zero. No association between the technique of anaesthesia and morbidity was found. However, cervical block allowed a marked shortening of postoperative hospitalization time from 5.5 days to 2 days. CONCLUSION: The results obtained justify surgical procedures on the internal and common carotid arteries even in asymptomatic stenoses, and are especially useful before a scheduled cardiac surgical or vascular surgical procedure.