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Sef D, Thet MS, Hashim SA, Kikuchi K. Minimally Invasive Coronary Artery Bypass Grafting for Multivessel Coronary Artery Disease: A Systematic Review. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2024:15569845241265867. [PMID: 39267397 DOI: 10.1177/15569845241265867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2024]
Abstract
OBJECTIVE We conducted a systematic review of all available evidence on the feasibility and safety of minimally invasive coronary artery bypass grafting (MICS CABG) in patients with multivessel coronary artery disease (CAD). METHODS A systematic literature search in PubMed, MEDLINE via Ovid, Embase, Scopus, and Web of Science was performed to identify all relevant studies evaluating outcomes of MICS CABG among patients with multivessel CAD and including at least 15 patients with no restriction on the publication date. RESULTS A total of 881 studies were identified, of which 26 studies met the eligibility criteria. The studies included a total of 7,556 patients. The average patient age was 63.3 years (range 49.5 to 69.0 years), male patients were an average of 77.8% (54.0% to 89.8%), and body mass index was 29.8 kg/m2 (24.5 to 30.1 kg/m2). Early mortality and stroke were on average 0.6% (range 0% to 2.0%) and 0.4% (range 0% to 1.3%), respectively. The average number of grafts was 2.8 (range 2.1 to 3.7). The average length of hospital stay was 5.6 days (range 3.1 to 9.3 days). CONCLUSIONS MICS CABG appears to be a safe method in well-selected patients with multivessel CAD. This approach is concentrated at dedicated centers, and there is no widespread application, although it has potential to be widely applicable as an alternative for surgical revascularization. However, large randomized controlled studies with longer follow-up are still required to compare the outcomes with conventional CABG and other revascularization strategies.
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Affiliation(s)
- Davorin Sef
- Department of Cardiac Surgery, University Hospitals of Leicester, UK
| | - Myat Soe Thet
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London & Imperial College Healthcare NHS Trust, UK
| | - Shahrul Amry Hashim
- Department of Cardiothoracic Surgery, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Keita Kikuchi
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Japan
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Vinzant NJ, Christensen JM, Yalamuri SM, Smith MM, Nuttall GA, Arghami A, LeMahieu AM, Schroeder DR, Mauermann WJ, Ritter MJ. Pectoral Fascial Plane Versus Paravertebral Blocks for Minimally Invasive Mitral Valve Surgery Analgesia. J Cardiothorac Vasc Anesth 2023:S1053-0770(23)00099-X. [PMID: 36948910 DOI: 10.1053/j.jvca.2023.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 01/24/2023] [Accepted: 02/06/2023] [Indexed: 02/13/2023]
Abstract
OBJECTIVES This study examined the postoperative analgesic efficacy of single-injection pectoral fascial plane (PECS) II blocks compared to paravertebral blocks for elective robotic mitral valve surgery. DESIGN A single-center retrospective study that reported patient and procedural characteristics, postoperative pain scores, and postoperative opioid use for patients undergoing robotic mitral valve surgery. SETTING This investigation was performed at a large quaternary referral center. PARTICIPANTS Adult patients (age ≥18) admitted to the authors' hospital from January 1, 2016, to August 14, 2020, for elective robotic mitral valve repair who received either a paravertebral or PECS II block for postoperative analgesia. INTERVENTIONS Patients received an ultrasound-guided, unilateral paravertebral or PECS II nerve block. MEASUREMENTS AND MAIN RESULTS One hundred twenty-three patients received a PECS II block, and 190 patients received a paravertebral block during the study period. The primary outcome measures were average postoperative pain scores and cumulative opioid use. Secondary outcomes included hospital and intensive care unit lengths of stay, need for reoperation, need for antiemetics, surgical wound infection, and atrial fibrillation incidence. Patients receiving the PECS II block required significantly fewer opioids in the immediate postoperative period than the paravertebral block group, and had comparable postoperative pain scores. No increase in adverse outcomes was noted for either group. CONCLUSIONS The PECS II block is a safe and highly effective option for regional analgesia for robotic mitral valve surgery, with demonstrated efficacy comparable to the paravertebral block.
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Affiliation(s)
- Nathan J Vinzant
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Jon M Christensen
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Suraj M Yalamuri
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Mark M Smith
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Gregory A Nuttall
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Allison M LeMahieu
- Department of Quantitative Health Sciences, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Darrell R Schroeder
- Department of Quantitative Health Sciences, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - William J Mauermann
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN
| | - Matthew J Ritter
- Department of Anesthesiology & Perioperative Medicine, Mayo Clinic College of Medicine and Science, Rochester, MN.
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Kawashima T, Okamoto K, Wada T, Shuto T, Umeno T, Miyamoto S. Femoral artery anatomy is a risk factor for limb ischemia in minimally invasive cardiac surgery. Gen Thorac Cardiovasc Surg 2020; 69:246-253. [PMID: 32671552 DOI: 10.1007/s11748-020-01442-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 07/09/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE In minimally invasive cardiac surgery (MICS), femoral artery cannulation during cardiopulmonary bypass (CPB) can cause limb ischemia. This study evaluated the association between femoral artery anatomy and the risk of limb ischemia in MICS. METHODS Eighty-one patients who underwent MICS with CPB using single femoral artery cannulation between 2010 and 2018 were included. The patients were stratified by their femoral artery diameter and anatomy of ectopic side branch, i.e., medial or lateral femoral circumflex arteries: Type A, deep femoral artery (DFA) ≥ superficial femoral artery (SFA); type B, DFA < SFA with an ectopic side branch of the common femoral artery (CFA); type C, DFA < SFA with an ectopic side branch at the CFA bifurcation; and type D, DFA < SFA without an ectopic side branch. The ratio of the postoperative creatine kinase concentration and the cross-sectional area of the femoral muscles (CK/MA) was used as a surrogate marker of limb ischemia. Predictors of high CK/MA were evaluated. RESULTS No critical limb ischemia was observed in this study. The median postoperative creatine kinase and CK/MA were 1954 (1305-2872) IU/l and 15.2 (9.2-19.8) IU/l/cm2. Multivariable logistic regression found that anatomical type D (odds ratio 4.19, 95% confidence interval: (1.26-14.0); p = 0.020) and prolonged CPB time (OR 1.01, 95% CI (1.00-1.02); p = 0.045) were independent risk factors of high CK/MA. CONCLUSION Anatomical type D and prolonged CPB time were associated with risk of limb ischemia in MICS.
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Affiliation(s)
- Takayuki Kawashima
- Department of Cardiovascular Surgery, Oita University, 1-1 idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan.
| | - Keitaro Okamoto
- Department of Cardiovascular Surgery, Oita University, 1-1 idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
| | - Tomoyuki Wada
- Department of Cardiovascular Surgery, Oita University, 1-1 idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
| | - Takashi Shuto
- Department of Cardiovascular Surgery, Oita University, 1-1 idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
| | - Tadashi Umeno
- Department of Cardiovascular Surgery, Oita University, 1-1 idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
| | - Shinji Miyamoto
- Department of Cardiovascular Surgery, Oita University, 1-1 idaigaoka, Hasama, Yufu, Oita, 879-5593, Japan
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Tahara S, Inoue A, Sakamoto H, Tatara Y, Masuda K, Hattori Y, Nozumi Y, Miyagi M, Sigdel S. A case series of continuous paravertebral block in minimally invasive cardiac surgery. JA Clin Rep 2017; 3:45. [PMID: 29457089 PMCID: PMC5804641 DOI: 10.1186/s40981-017-0119-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 08/24/2017] [Indexed: 03/19/2023] Open
Abstract
Background Minimally invasive cardiac surgery (MICS), via minithoracotomy, is thought to be a fast track to extubation and recovery after surgery. For this, good coverage analgesia is essential. Epidural anesthesia, a standard technique for thoracic surgery, has high risk of complications, such as epidural abscess and spinal hematoma in open-heart surgery. Based on the hypothesis that continuous paravertebral block (CPVB), a less invasive regional anesthetic technique, is safe and effective in open-heart surgery, we applied CPVB to MICS with thoracotomy. Findings To assess whether CPVB could be used in open-heart surgery with fewer potential complications, we investigated our medical records of the 87 adult patients who underwent MICS at Akashi Medical Center, Hyogo, Japan, between March 2009 and May 2016. We collected data of CPVB-related complications, postextubation respiratory failure, duration of intubation, and other analgesic use from hospital clinical records. We observed no severe CPVB-related complications, such as hematoma, neuropathy, or abscess. PT-INR longer than 1.1 was associated with CPVB-related minor bleeding. Forty-three patients (47.4%) were extubated within 1 h after surgery, and there were no postextubation respiratory failures in any patients. Conclusions We observed no cases of severe CPVB-related complications or postextubation respiratory failure in any of our patients who underwent MICS. Preoperative prolongation of PT-INR was associated with CPVB-related minor bleeding.
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Affiliation(s)
- Shintaro Tahara
- 1Department of Anesthesia, Akashi Medical Center, 743-33 Yagi, Ookubo-cho, Akashi, Hyogo 674-0063 Japan
| | - Akito Inoue
- 1Department of Anesthesia, Akashi Medical Center, 743-33 Yagi, Ookubo-cho, Akashi, Hyogo 674-0063 Japan
| | - Hajime Sakamoto
- 1Department of Anesthesia, Akashi Medical Center, 743-33 Yagi, Ookubo-cho, Akashi, Hyogo 674-0063 Japan
| | - Yasuaki Tatara
- 1Department of Anesthesia, Akashi Medical Center, 743-33 Yagi, Ookubo-cho, Akashi, Hyogo 674-0063 Japan
| | - Kayoko Masuda
- 1Department of Anesthesia, Akashi Medical Center, 743-33 Yagi, Ookubo-cho, Akashi, Hyogo 674-0063 Japan
| | - Yoichiro Hattori
- 1Department of Anesthesia, Akashi Medical Center, 743-33 Yagi, Ookubo-cho, Akashi, Hyogo 674-0063 Japan
| | - Yusaku Nozumi
- 1Department of Anesthesia, Akashi Medical Center, 743-33 Yagi, Ookubo-cho, Akashi, Hyogo 674-0063 Japan
| | - Mitsumasa Miyagi
- 1Department of Anesthesia, Akashi Medical Center, 743-33 Yagi, Ookubo-cho, Akashi, Hyogo 674-0063 Japan
| | - Surakshya Sigdel
- 2Department of Anesthesia, Ohnishi Neurological Center, 1661-1 Eigashima Ookubo-cho, Akashi, Hyogo 674-0064 Japan
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Minimally invasive cardiac surgery: A systematic review and meta-analysis. Int J Cardiol 2016; 223:554-560. [PMID: 27557486 DOI: 10.1016/j.ijcard.2016.08.227] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 08/12/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Minimally invasive (MI) cardiac surgery was introduced to reduce problems associated with a full sternotomy. This meta-analysis aimed to investigate the effects of minimally invasive cardiac surgery on a range of clinical outcomes. METHODS To identify potential studies (randomised/prospective clinical trials) systematic searches were carried out. The search strategy included the concepts of "minimally invasive" OR "MIDCAB" AND "coronary artery bypass grafting" OR "cardiac surgery". This was followed by a meta-analysis investigating cross-clamp time, cardiopulmonary bypass (CPB) time, operation time, ventilation time, intensive care unit (ICU) stay, hospital stay, incidence of myocardial infarction and of stroke/neurologic complications. RESULTS Eight studies (9 intervention groups), totalling 596 participants were analysed. MI cardiac surgery was associated with a shorter ICU stay mean difference (MD) -0.7days (95% confidence interval (CI) -1.23 to -0.18, p=0.009) and longer cross-clamp MD 6.7min (95% CI 1.24 to 12.17, p=0.02), CPB MD 26.68min (95% CI 10.31 to 43.05, p=0.001), and operation times MD 55.03min (95% CI 22.76 to 87.31, p=0.0008). However no differences were found in the ventilation time MD -3.94h (95% CI -8.09 to 0.21, p=0.06), length of hospital stay MD -1.14days (95% CI -3.11 to 0.83, p=0.26) and in the incidence of myocardial infarction odds ratio (OR) 1.97 (95% CI 0.49 to 7.9, p=0.34) or stroke/neurologic complications OR 0.67 (95% CI 0.11 to 4.05, p=0.66). CONCLUSIONS Minimally invasive cardiac surgery is as safe as conventional surgery and could reduce costs due to a shorter period spent in ICU.
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Kiessling AH, Kisker P, Miskovic A, Papadopoulos N, Zierer A, Moritz A. Long-Term Follow-Up of Minimally Invasive Cardiac Surgery Using an Endoaortic Occlusion System. Heart Surg Forum 2014; 17:E93-7. [DOI: 10.1532/hsf98.2014316] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
<p><b>Objectives:</b> We reviewed the initial patient series (n=116) of our institution performing minimally invasive coronary artery bypass grafting (CABG) (n=79), mitral valve surgery (n=1), or atrial septal closure (ASD) procedures (n=26) using an endoaortic occlusion system. With this technique relevant intra-aortic pressures are exerted on the aortic wall during the clamping time. This might lead to late aortic degeneration and aneurysm formation. Our study sought to evaluate postoperative aortic complications and the quality of life (modified SF-12).</p><p><b>Methods:</b> One hundred sixteen patients (56% male; 54 years � 14.5; range 19 years to 77 years) underwent a cardiac procedure using an endoaortic clamp. The endoaortic balloon clamp catheter was used to occlude the ascending aorta at pressures >300 mmHg. Patients were rescheduled for echocardiographic examination after a mean follow-up period of 8.8 years.</p><p><b>Results:</b> The analysis performed among 78 patients showed no incidence of any structural damage to the ascending aorta at the intraoperative position of the endoaortic balloon. The physical and mental summary scores are equal to those of comparable patient groups.</p><p><b>Conclusions:</b> The endoaortic occlusion system causes no damage to the aortic wall. If the system causes any problems, they occur immediately during surgery. Patients treated with this minimally invasive technique exhibited the same quality of life as those undergoing conventional surgery.</p>
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Fukunaga N, Hashimoto T, Ozu Y, Komori S, Shomura Y, Fujiwara H, Nasu M, Okada Y. Mitral valve replacement via right thoracotomy approach for prevention of mediastinitis in a female patient with long-term uncontrolled diabetes mellitus: a case report. J Cardiothorac Surg 2010; 5:38. [PMID: 20478046 PMCID: PMC2880967 DOI: 10.1186/1749-8090-5-38] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2009] [Accepted: 05/17/2010] [Indexed: 11/25/2022] Open
Abstract
A 76-year-old woman with a history of percutaneous transvenous mitral commissurotomy and repeated hospital admissions due to heart failure was referred for an operation for severe mitral valve stenosis. She presented with hypertension, hyperlipidemia and cerebral infarction with stenosis of right internal carotid artery, retinopathy, neuropathy and nephropathy caused by long-term uncontrolled diabetes mellitus, hemoglobin A1c of 9.4%, and New York Heart Association (NYHA) functional classification of 3/4. Echocardiography revealed severe mitral valve stenosis with mitral valve area of 0.6 cm2, moderate tricuspid valve regurgitation, and dilatation of the left atrium. Taking into consideration the NYHA functional classification and severe mitral valve stenosis, an immediate surgical intervention designed to prevent mediastinitis was performed. The approach was via the right 4th thoracotomy, as conventional sternotomy would raise the risk of mediastinitis. Postoperative antibiotics were administered intravenously for 2 days, and signs of infection were not recognized. In patients with long-term uncontrolled diabetes mellitus, mid-line sternotomy can easily cause mediastinitis. The choice of operative approach plays an important role in preventing this complication. In this report, the importance of the conventional right thoracotomy for prevention for mediastinitis is reviewed.
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Affiliation(s)
- Naoto Fukunaga
- Department of Cardiovascular surgery, Kobe City Medical Center General Hospital, 4-6 Minatojimanakamachi, Chuo-ku, Kobe, Hyogo 650-0046, Japan.
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Zhao Q, Sun X, Chen A, Xia L, Wang, M.D. Z. Endoscopy-Guided Occlusion of Secundum Atrial Defect Permits Use of Smaller, Cosmetically Superior Thoracotomy. J Card Surg 2009; 24:181-4. [DOI: 10.1111/j.1540-8191.2008.00804.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Huang TJ, Weng YJ, Li YY, Cheng CC, Hsu RWW. Actin-free Gc-globulin after minimal access and conventional anterior lumbar surgery. J Surg Res 2009; 164:105-9. [PMID: 19540525 DOI: 10.1016/j.jss.2009.01.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2008] [Revised: 01/08/2009] [Accepted: 01/13/2009] [Indexed: 12/19/2022]
Abstract
BACKGROUND Minimally invasive total knee or hip replacement has been increasingly adopted in recent years. However, literature indicates that minimally invasive joint arthroplasty may not always reduce pain or tissue trauma. We hypothesized that the tissue damage would be reduced in minimal access surgery (MAS) than the conventional open surgery (OS) for anterior lumbar disorders through quantifying measurement of serum actin-free Gc-globulin (Af-Gc), myoglobin (MG), and total creatine kinase (CK). MATERIALS AND METHODS This prospective study enrolled 23 patients, including 10 who underwent MAS and thirteen who underwent conventional OS. Blood samples for Af-Gc, MG, and CK were taken simultaneously before surgery and then at intervals of 12, 24, 48, 72, 120, and 168 h thereafter. RESULTS All serum level changes in Af-Gc, MG, and CK were significantly lower in the MAS than in the OS group. A significant negative correlation was noted between changes in Af-Gc and MG levels (P = 0.012), and a significant positive correlation was noted between changes in CK and MG levels (P < 0.001). However, at 12 h postop, CK level was transiently higher in MAS group than the OS group. CONCLUSIONS The changes of Af-Gc, MG, and CK levels indicate that MAS is less tissue invasive than OS. Further, Af-Gc proved to be a more sensitive marker than MG or CK in response to surgical trauma. The transiently higher CK level at 12 h postop in MAS patients may indicate that a more soft tissue manipulation is required in MAS than the OS patients for the initial surgical approach.
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Affiliation(s)
- Tsung-Jen Huang
- Department of Orthopedic Surgery, Chang Gung Memorial Hospital at Chia-Yi, College of Medicine, Chang Gung University, Taipei, Taiwan.
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Safety of Minimally Invasive Mitral Valve Surgery Without Aortic Cross-Clamp. Ann Thorac Surg 2008; 85:1544-9; discussion 1549-50. [DOI: 10.1016/j.athoracsur.2008.01.099] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2007] [Revised: 01/27/2008] [Accepted: 01/28/2008] [Indexed: 11/17/2022]
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Woo YJ, Seeburger J, Mohr FW. Minimally Invasive Valve Surgery. Semin Thorac Cardiovasc Surg 2007; 19:289-98. [DOI: 10.1053/j.semtcvs.2007.10.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2007] [Indexed: 11/11/2022]
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Raja SG, Dreyfus GD. Modulation of systemic inflammatory response after cardiac surgery. Asian Cardiovasc Thorac Ann 2006; 13:382-95. [PMID: 16304234 DOI: 10.1177/021849230501300422] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Cardiac surgery and cardiopulmonary bypass initiate a systemic inflammatory response largely determined by blood contact with foreign surfaces and the activation of complement. It is generally accepted that cardiopulmonary bypass initiates a whole-body inflammatory reaction. The magnitude of this inflammatory reaction varies, but the persistence of any degree of inflammation may be considered potentially harmful to the cardiac patient. The development of strategies to control the inflammatory response following cardiac surgery is currently the focus of considerable research efforts. Diverse techniques including maintenance of hemodynamic stability, minimization of exposure to cardiopulmonary bypass circuitry, and pharmacologic and immunomodulatory agents have been examined in clinical studies. This article briefly reviews the current concepts of the systemic inflammatory response following cardiac surgery, and the various therapeutic strategies being used to modulate this response.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Royal Hospital for Sick Children, Yorkhill NHS Trust, Dalnair Street, Glasgow G3 8SJ, Scotland, United Kingdom.
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Schachner T, Bonaros N, Feuchtner G, Müller L, Laufer G, Bonatti J. How to Handle Remote Access Perfusion for Endoscopic Cardiac Surgery. Heart Surg Forum 2005; 8:E232-5. [PMID: 16112934 DOI: 10.1532/hsf98.20051124] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Remote access is a prerequisite for endoscopic cardiac surgery on the arrested heart. Despite careful patient selection, technical problems and complications occur with the use of this sophisticated technique, and we aim to describe these problems and suggest solutions. PATIENTS AND METHODS From 2001 to 2004 remote access cardiopulmonary bypass (CPB) was installed in 70 patients, aged 55 (16-70) years. The operations performed were AHTECAB in 44, ASD repair via minithoracotomy in 10, totally endoscopic ASD repair in 11, and minimally invasive mitral valve operation in 5 cases. CPB time was 134 (72-342) minutes and aortic endoocclusion time was 70 (35,223) minutes. RESULTS In 3 cases the guide wire had to be detected in the aortic root fluoroscopically because it could not be detected in the aortic root on TEE. Initial balloon migration requiring repositioning occurred in 30 cases. After achieving a stable balloon position and incision of the atrium/coronary artery balloon migration occurred in 2 cases, which could be overcome by a quick repositioning maneuver. In 1 patient no stable position of the balloon could be achieved and conversion to median sternotomy was necessary. Balloon rupture occurred in 2 cases. In one case, rupture of the balloon occurred before the endoscopic LIMA-to-LAD anastomosis was started. The cannula could be successfully replaced and the TECAB procedure finished without complications. In the second case, the balloon ruptured after finishing the LIMA-to-LAD anastomosis and no replacement of the cannula was necessary. Inadequate CPB flow was found in 1 case, and sufficient flows were achieved by an additional 15 F arterial cannula which was placed in the contralateral groin. We had no major surgical complication related to the use of the remote access perfusion device, such as aortic dissection, leg ischemia reperfusion injury, or neurological injury and no hospital death. Wound infection of the groin occurred in 1 patient, which resolved after surgical revision. Ten patients suffered temporarily from lymphatic secretion of the groin. CONCLUSION Remote access is technically challenging, but most difficulties can be overcome if regular application by a dedicated team is guaranteed. Remote access perfusion can be performed with an acceptable risk if exclusion criteria are carefully observed.
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Affiliation(s)
- Thomas Schachner
- Department of Cardiac Surgery and Radiology, Innsbruck Medical University, Innsbruck, Austria.
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Likosky DS, Roth RM, Saykin AJ, Eskey CJ, Ross CS, O'Connor GT. Neurologic Injury Associated with CABG Surgery: Outcomes, Mechanisms, and Opportunities for Improvement. Heart Surg Forum 2004; 7:E650-62. [PMID: 15769701 DOI: 10.1532/hsf98.20041103] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Neurologic injuries, whether subtle or overt, are a major source of morbidity secondary to coronary artery bypass graft (CABG) surgery. A comprehensive review of research in the area of neurologic injury is provided. We conclude this article by providing insight regarding areas requiring further investigation in order to reduce sustainably the risk of these iatrogenic events among patient undergoing CABG surgery.
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Affiliation(s)
- Donald S Likosky
- Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire 03756, USA.
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Gründeman PF, Budde R, Beck HM, van Boven WJ, Borst C. Endoscopic exposure and stabilization of posterior and inferior branches using the endo-starfish cardiac positioner and the endo-octopus stabilizer for closed-chest beating heart multivessel CABG: hemodynamic changes in the pig. Circulation 2003; 108 Suppl 1:II34-8. [PMID: 12970205 DOI: 10.1161/01.cir.0000087901.78859.f9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Closed-chest, off-pump, multivessel CABG requires modified instruments to expose and stabilize posterior and inferior coronary branches. Using three new prototype devices, we explored the feasibility of endoscopic bypass grafting on these branches and assessed cardiac function during cardiac displacement. METHODS Eight pigs (75 to 85 kg) were instrumented for hemodynamics and paced at 80 to 100 bpm. After closure of the sternotomy wound, the Da Vinci endoscope was inserted subxiphoidally. A sternal hook was used to hoist the sternum ventrally by 5 cm. The articulating EndoStarfish cardiac positioner was placed through a trocar (Ø12 mm). The positioner was fixed to the apex using -400 mm Hg suction and the heart was displaced anteriorly to 90 degrees. In 12 other pigs (75 to 85 kg), both internal mammary arteries (IMA) were harvested and the sternal wound was closed. Five trocar ports were placed for instrumentation (Ø12 mm, two in left chest, two in right chest, and one subxiphoidally). For coronary stabilization, a novel deployable EndoOctopus cardiac stabilizer was employed (suction -400 mm Hg). The Da Vinci robot-telemanipulator system was used for endoscopic grafting of the left and right IMA on posterior and inferior branches (16 anastomoses). RESULTS When circumflex arteries were fully exposed and accessible for coronary surgery, stroke volume decreased by 18%+/-3 versus baseline (P=0.02) and mean arterial pressure decreased by 27%+/-6 (P=0.001). Additional 10 degrees Trendelenburg head-down positioning normalized stroke volume and arterial pressure. In the displaced heart, obtuse marginal branches (OM) and the ramus descending posterior (RDP) of the right coronary artery became fully exposed with a mean arterial pressure >70 mm Hg during grafting. No accidental detachment occurred. Coronary target motion was restrained to approximately 1x1 mm. In two test cases, five sham distal anastomoses were created (grafts sewn to epicardium, left IMA to OM2 jump to OM3, right IMA to RDP, and composite graft from left IMA jump to diagonal branch). In 10 animals, 16 successfully completed anastomoses to RPD and OM branches of Ø1.75 to 2.5 mm required 25 to 60 minutes each to construct. At sacrifice, all anastomoses were patent. CONCLUSIONS In the closed-chest pig in Trendelenburg position and during lifting of the sternum, the EndoStarfish and EndoOctopus enabled IMA grafting of posterior and inferior branches on the beating heart without mean arterial pressure dropping below 70 mm Hg.
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Affiliation(s)
- Paul F Gründeman
- Heart Lung Center Utrecht, Department of Cardiology, University Medical Center Utrecht (Rm G02.523), P.O. Box 85500, 3508 GA Utrecht, the Netherlands.
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