A new vacuum-assisted probe for minimally invasive radiofrequency ablation

Robotic cardiac surgery in Brazil

BACKGROUND

Brazil, the largest country and economy in South America, is a major driving force behind the development of new medical technologies in the region. Robotic cardiac surgery (RCS) has been evolving rapidly since 2010, when the first surgery using the DaVinci^® robotic system was performed in Latin America. The aim of this article is to evaluate short and mid-term results in patients undergoing robotic cardiac surgery in Brazil.

METHODS

From March 2010 to December 2015, 39 consecutive patients underwent robotic cardiac surgery. Twenty-seven patients were male (69.2%), with the mean age of 51.3±17.9 years. Participants had a mean ejection fraction of 62±5%. The procedures included in this study were mitral valve surgery, surgical treatment of atrial fibrillation, atrial septal defect closure, resection of intra-cardiac tumors, totally endoscopic coronary artery bypass and pericardiectomy.

RESULTS

The mean time spent on cardiopulmonary bypass (CPB) during RCS was 154.9±94.2 minutes and the mean aortic cross-clamp time was 114.48±75.66 minutes. Thirty-two patients (82%) were extubated in the operating room immediately after surgery. The median intensive care unit (ICU) length of stay was 1 day (ranging from 0 to 25) and the median hospital length of stay was 5 days (ranging from 3 to 25). For each type of procedure, endpoints were individually reported. There were no conversions to sternotomy and no intra-operative complications. Patient follow-up was complete in 100% of the participants, with two early deaths unrelated to the procedures and no re-operations at mid-term.

CONCLUSIONS

Despite the heterogeneity of this series, RCS appears to be feasible, safe and effective when used for the correction of various intra- and extra-cardiac pathologies. Adopting the robotic system has been a challenge in Brazil, where its limited clinical application may be related to the lack of specific training and the high cost of technology.

Right-Sided Minithoracotomy as a Surgical Approach for the Concomitant Treatment of Atrial Fibrillation

BACKGROUND

Atrial fibrillation (AF) is the most common arrhythmia diagnosed in humans and therefore causes a high socioeconomic burden. The Cox-Maze IV procedure is the gold standard treatment for atrial fibrillation. Minimally invasive surgery for the treatment of AF is also promising.

OBJECTIVES

Our aim is to evaluate the feasibility, safety, and immediate plus medium-term results of concomitant AF ablation therapy in patients undergoing minimally invasive valve surgery through right-sided minithoracotomy.

PATIENTS AND METHODS

Retrospective data were collected from January 2012 to December 2013. Seventy-five consecutive patients underwent radiofrequency ablation during valve surgery through a right-sided minithoracotomy.

RESULTS

All 75 patients underwent radiofrequency ablation. The pulmonary vein was isolated in 6 (8%) by encircling the left and right pulmonary veins. In 9 (12%) patients, endocardial box lesions were created using a monopolar probe, while in 47 (62.7%), epicardial box lesions were produced with a monopolar probe. Thirteen (17.3%) patients received a box lesion created with a bipolar probe. Finally, in 22 (29.3%) patients, a line of lesions was produced leading up to the posterior mitral annulus. Only 1 (1.3%) perioperative death was observed. At discharge, 43 (57.3%) patients were in sinus rhythm and 30 (40%) were in AF. After a mean follow-up of 21.6 ± 10.1 months, 46 patients (63%) were in a stable sinus rhythm and 27 were in (37%) in AF; 26 (56.5%) patients were free from antiarrhythmic therapy, while 19 (42.2%) were still taking at least one drug.

CONCLUSIONS

We can conclude that treatment of AF using a right-sided minithoracotomy approach and RF energy in patients undergoing cardiac surgery for various valve diseases is feasible, safe, and reproducible.

Robotic surgery in cardiology: a safe and effective procedure

Objective:

To evaluate the short and medium-term outcomes of patients undergoing robotic-assisted minimally invasive cardiac surgery.

Methods:

From March 2010 to March 2013, 21 patients underwent robotic-assisted cardiac surgery. The procedures performed were: mitral valve repair, mitral valve replacement, surgical correction of atrial fibrillation, surgical correction of atrial septal defect, intracardiac tumor resection, totally endoscopic coronary artery bypass surgery and pericardiectomy.

Results:

The mean age was 48.39±18.05 years. The mean cardiopulmonary bypass time was 151.7±99.97 minutes, and the mean aortic cross-clamp time was 109.94±81.34 minutes. The mean duration of intubation was 7.52±15.2 hours, and 16 (76.2%) patients were extubated in the operating room immediately after the procedure. The mean length of intensive care unit stay was 1.67±1.46 days. There were no conversions to sternotomy. There was no in-hospital death or deaths during the medium-term follow-up. Patients mean follow up time was 684±346 days, ranging from 28 to 1096 days.

Conclusion:

Robotic-assisted cardiac surgery proved to be feasible, safe and effective and can be applied in the correction of various intra and extracardiac pathologies.

Positioning of the ablation catheter in total endoscopic ablation

Minimally invasive ablation of atrial fibrillation is an option in patients not suitable for or refractory to catheter ablation. Total endoscopic ablation can be performed via a monolateral approach, whereby a left atrial box lesion is created. If the ablation is introduced from the right side, the positioning of the ablation catheter on the partly hidden left pulmonary veins is of vital importance. Using thoracoscopy in combination with multiplane transoesophageal echocardiography, the anatomical position of the ablation catheter can be established. Our experience in over 60 procedures has confirmed this to be a safe technique of total endoscopic ablation.

Hybrid Therapy for Atrial Fibrillation: where the Knife meets the Catheter

During the past decades there has been a consistent evolution of both surgical and catheter-based techniques for the treatment of stand-alone atrial fibrillation, as alternatives or in combination with anti-arrhythmic drugs. Transcatheter ablation has significantly improved outcomes, despite often requiring multiple procedures and with limited success rates especially in presence of persistent atrial fibrillation. Surgical procedures have dramatically evolved from the original cut-and-sew Maze operation, allowing nowadays for closed-chest epicardial ablations on the beating heart. Recently, the concept of a close collaboration between the cardiac surgeon and the electrophysiologist has emerged as an intriguing option in order to overcome the drawbacks and suboptimal results of both techniques; therefore, the hybrid approach has been proposed as a potentially more successful strategy, allowing for a patient-tailored therapeutical approach. We reviewed the recent advancements either from the transcatheter and surgical standpoint, with a peculiar focus on the current option to merge both techniques along with an up-to-date review of the preliminary clinical experiences with the hybrid, surgical-transcatheter treatment of stand-alone atrial fibrillation.

Radiofrequency ablation for treatment of atrial fibrillation

INTRODUCTION

Atrial Fibrillation (AF) is the most common cardiac arrhythmia which represents a major public health problem. The main purpose of this research is to evaluate the Radiofrequency (RF) ablation effects in the patients with chronic AF scheduled for cardiac surgery because of different heart diseases.

METHODS

The descriptive and prospective study was conducted on 60 patients with AF scheduled for surgery along with RF ablation. The data were collected by questionnaire and included: patients' age, sex, NYHA class, operation type, past medical history, type and cause of valvular heart disease, preoperative ECG (electrocardiogram), duration of surgery, clamping time, cardiopulmonary bypass, and RF ablation time. RF ablation was followed by the main operation. The follow up examination, ECG, and echocardiography were performed 3 and 6 months after operation.

RESULTS

The mean age of patients was 48±10 years (18-71 years). Forty one patients had permanent AF and 19 had the persistent AF. The left ventricular ejection fraction was 48.27±9.75 percent before operation, and reached to 56.27±7.87 percent after the surgery (P<0.001). The mean NYHA class before the surgery was 2.83±0.68 which decreased to 1.34±0.46 6 months after the surgery with RF ablation (P<0.001). One patient (1.6%) died after surgery. Complete relief and freedom from AF recurrence was observed in 70% of patients in the mean follow up in 7 months after the surgery. The sinus rhythm with efficient atrial contraction was established in 100% of discharged patients.

CONCLUSION

RF ablation is an effective procedure to cure atrial fibrillation in patients undergoing cardiac surgeries.

Novel approaches for the surgical treatment of atrial fibrillation: time for a guideline revision?

Atrial fibrillation is a major health problem in Western countries, and is associated with considerable morbidity and resource consumption. Safe and reliable surgical techniques for the termination of this arrhythmia have been developed since the time of the original Cox "maze I" procedure. Novel equipment based on radiofrequency and microwave technologies can be employed to create transmural atrial lesions, even in the context of minimally invasive surgery to the atrioventricular valves via right minithoracotomy. The aim of this paper is to review the recent literature on this approach, and the clinical results in terms of arrhythmia termination and postoperative morbidity. With the aim to substantiate the practice of a simple, yet reliable, surgical ablation during minimally invasive heart valve surgery, we discuss the results of different patterns of atrial lesions having different degrees of surgical complexity. Finally, minimally invasive epicardial ablation for lone atrial fibrillation represents an emerging surgical indication. The results of state-of-the-art transcatheter ablation represent now its benchmark of comparison.