Warm Beating Heart, Robotic Endoscopic Cox-Cryomaze: An Approach for Treating Atrial Fibrillation

Unilateral robotic hybrid mini-maze: a novel experimental approach

BACKGROUND

A complete Cox maze IV procedure is difficult to accomplish using current endoscopic and minimally invasive techniques. These techniques are hampered by inability to adequately dissect the posterior structures of the heart and place all necessary lesions. We present a novel approach, using robotic technology, that achieves placement of all the lesions of the complete maze procedure.

METHODS

In three cadaveric human models, the technical feasibility of using robotic instruments through the right chest to dissect the posterior structures of the heart and place all Cox maze lesions was performed.

RESULTS

The entire posterior aspect of the heart was dissected in the cadaveric model facilitating successful placement of all Cox maze IV lesions with robotic assistance through minimally invasive incisions.

CONCLUSION

The robotic Cox maze IV procedure through the novel right thoracic approach is feasible. This obviates the need for sternotomy and avoids the associated morbidity of the conventional Cox-maze procedure.

The surgical treatment for atrial fibrillation: ablation technology and surgical approaches

The Cox maze procedure developed originally in 1987 by Dr James Cox has evolved from a "cut and sew" surgical procedure, where the maze was applied using multiple surgical cuts, to an extensive use of surgical ablation technology where ablation lesions are placed with alternative energy sources (radiofrequency, cryothermy, microwave, and high-frequency ultrasound). Furthermore, the procedure has changed from a median sternotomy approach only to one that can be performed minimally invasively and robotically. The purpose of this paper is to review the current available technology for the ablation of atrial fibrillation as well as the different procedural approaches for the surgical ablation of atrial fibrillation.

The hybrid approach for the surgical treatment of lone atrial fibrillation: one-year results employing a monopolar radiofrequency source

BACKGROUND

The hybrid technique combines a mono or bilateral epicardial approach with a percutaneous endocardial ablation in a single-step procedure. We present our early results with this technique employing a monopolar radiofrequency source through a right thoracoscopy in patients with lone atrial fibrillation (LAF).

METHODS

Between June 2009 and December 2010 nineteen consecutive patients (mean 60.8 ± 8.6 years, 84.2% male) underwent right unilateral minimally invasive hybrid procedure for LAF at our Institution. Ten patients (52.6.6%) had long-standing persistent AF while four (21.1%) had persistent and five (26.3%) paroxysmal AF. All patients were followed-up according the Heart Rhythm Society/European Heart Rhythm Association/European Cardiac Arrhythmia Society (HRS/EHRA/ECA) and Society of Thoracic Surgeon (STS) guidelines.

RESULTS

There were neither early nor late deaths. It was possible to complete all the procedures as planned without any conversion to cardiopulmonary bypass. No patient died during the follow up. At one year, 7/19 (36.8%) patients were in sinus rhythm with no episode of AF and off antiarrhythmic drugs (AAD). Time-related prevalence of postoperative AF peaked at 44.4% (41.3-47.4) at two weeks, was 30.4% (27.3-34.9) at three months, fell to 14.2% (11.6-18.1) by 6 months and was 13.3% (11.0-17.4) at 12 months Among patients with long-standing persistent (LSP) AF, 20% (2/10) were in Sinus rythm and off AAD. One-year success rates were 50% (2/4) in persistent and 60% (3/5) in paroxysmal AF. At 12 months estimated prevalence of antyarrhythmic drugs and Warfarin use were 26% (22.4-33.1) and 48% (37.2-53.2), respectively.

CONCLUSIONS

One year results combining the percutaneous endocardial with the right thoracoscopic epicardial technique were, in our experience, not satisfactory, particularly in patients with LSP and persistent AF. Our findings need to be confirmed by larger studies.

Minimally invasive surgical therapies for atrial fibrillation

Atrial fibrillation is the most common sustained arrhythmia and is associated with significant risks of thromboembolism, stroke, congestive heart failure, and death. There have been major advances in the management of atrial fibrillation including pharmacologic therapies, antithrombotic therapies, and ablation techniques. Surgery for atrial fibrillation, including both concomitant and stand-alone interventions, is an effective therapy to restore sinus rhythm. Minimally invasive surgical ablation is an emerging field that aims for the superior results of the traditional Cox-Maze procedure through a less invasive operation with lower morbidity, quicker recovery, and improved patient satisfaction. These novel techniques utilize endoscopic or minithoracotomy approaches with various energy sources to achieve electrical isolation of the pulmonary veins in addition to other ablation lines. We review advancements in minimally invasive techniques for atrial fibrillation surgery, including management of the left atrial appendage.

Robotic cardiac surgery: advanced minimally invasive technology hindered by barriers to adoption

Robotic cardiac surgery utilizes the most advanced surgical technology to offer patients a minimally invasive alternative to open surgery in the treatment of a broad range of cardiac pathologies. Although robotics may offer substantial benefits to physicians, patients and healthcare institutions, there are important barriers to its adoption that includes inadequate funding, competition from alternate therapies and challenges in training. There is a growing body of evidence to demonstrate the efficacy of robotic cardiac surgery. Technological innovations are improving patient safety and expanding the indications for robotic cardiac surgery beyond the treatment of mitral valve and coronary artery disease. Robotic cardiac surgery is rapidly becoming a feasible, safe and effective option for the definitive treatment of cardiac disease in the context of 21st century challenges to healthcare provision such as diabetes, obesity and an aging population.

Robotics in Cardiac Surgery

Minimally invasive surgery has revolutionized the surgical field over the last two decades. Robotic assisted surgery is the latest iteration towards less invasive techniques. Cardiac surgeons have slowly adapted minimally invasive and robotics techniques into their armamentarium. In particular, minimally invasive mitral valve surgery has evolved over the last decade and become the preferred method of mitral valve repair and replacement at certain specialized centres worldwide because of excellent results. We have developed a robotic mitral valve surgery program which utilizes the da Vinci® telemanipulation system allowing the surgeon to perform complex mitral valve repairs through 5mm port sites rather than a traditional median sternotomy. in this rapidly evolving field, we review the evolution and clinical results of robotically-assisted mitral valve surgery and take a look at the other cardiac surgical procedures for which da Vinci® is currently being used.