Coronary sinus catheterization made easy for Port-Access miimally invasive cardiac surgery

Transesophageal echocardiographic imaging of the coronary sinus: a retrospective analysis of mid-esophageal views and a novel transgastric view

Background

Transesophageal echocardiographic imaging plays an important role in assessing coronary sinus anatomy prior to placement of a retrograde cardioplegia cannula. The coronary sinus can be imaged in the long axis by advancing the TEE probe from the mid-esophageal 4-chamber view or using a modified mid-esophageal bicaval view, while a short axis view can be obtained in the mid-esophageal 2-chamber view. While use of a transgastric view is only briefly mentioned in the literature as an alternative to mid-esophageal views, the authors commonly include it in our comprehensive transesophageal echocardiographic exam of the coronary sinus. This study examines the various imaging strategies. We hypothesize that the transgastric view offers comparable coronary sinus imaging to the mid-esophageal views.

Methods

After approval by our institutional review board, the intraoperative transesophageal echocardiographic exams for 50 consecutive elective cardiac surgical patients with a comprehensive echocardiographic assessment of the coronary sinus were retrospectively reviewed and analyzed to evaluate imaging of the coronary sinus in the various views. For each view, we noted and recorded if the coronary sinus and coronary sinus cannula were visualized. Statistical analysis required pairwise comparisons between each of the 4 views. P values were calculated using McNemar’s Exact test.

Results

Both the coronary sinus and coronary sinus cannula were visualized a majority of the time for each view. There was no statistically significant difference between each view in its ability to visualize the coronary sinus, nor was there a statistically significant difference between each view in its ability to visualize the coronary sinus cannula.

Conclusions

Use of a transgastric window provides the echocardiographer with an effective alternate modality for imaging the coronary sinus when mid-esophageal views are limited.

Initial experience with percutaneous coronary sinus catheter placement in minimally invasive cardiac surgery in an academic center

Background

Placement of a percutaneous coronary sinus catheter (CSC) by an anesthesiologist for retrograde cardioplegia in minimally invasive cardiac surgery is relatively safe in experienced hands. However, the popularity of its placement remains limited to a small number of centers due to its perceived complexity and potential complications.

Methods

We retrospectively reviewed all cardiac cases performed by one surgeon between December 2009 and April 2012. The reviewed cases were divided into two groups: cardiac cases with percutaneous CSC placement (CSC group) and cardiac cases without placement (control group). Anesthesia preparation time (APT) was then compared between the CSC group and control group. In the CSC group, cases were further divided into two groups. One group contained cases with an APT of less than 90 min (success group) and the other contained cases with an APT greater than or equal to 90 min or cases with CSC placement failure (delay/failure group). Patients’ characteristics, type of surgery, and transesophageal echocardiography (TEE) findings were compared between the two groups (success group vs. delay/failure group) to identify variables associated with prolongation of the APT or CSC placement failure.

Results

Percutaneous CSC placement was required in 83 cases (CSC group). The catheter was successfully placed in 74 of those cases. We experienced one complication, coronary sinus injury after multiple attempts at placing the catheter. The mean APT was 102 ± 31 min in the CSC group (n = 81) and 42 ± 15 min in the control group (n = 285). We could not identify any variables associated with prolongation of the APT or catheter placement failure.

Conclusions

The success rate of the placement was 89.1 % in our academic center. On average, placing the CSC added approximately one additional hour to the APT. This time is not an accurate representation of true catheter placement time, as it included time for preparation of the CSC, TEE, and fluoroscopy. We experienced one documented complication (coronary sinus injury), which was immediately diagnosed by TEE and fluoroscopy in the operating room. No variables associated with prolongation of APT or CSC placement failure were identified.

Electronic supplementary material

The online version of this article (doi:10.1186/s12871-016-0203-4) contains supplementary material, which is available to authorized users.

Robotic and minimally invasive cardiac surgery

The transition of mitral valve surgery away from the traditional sternotomy approach toward more minimally invasive strategies continues to evolve. The use of telemanipulative robotic arms with near 3-dimensional valve visualization has allowed for near complete endoscopic robotic-assisted mitral valve surgery, providing increased patient satisfaction and cosmesis. Studies have shown rapid recovery times without sacrificing perioperative safety or the durability of surgical repair. Although a steep learning curve exists as well as high fixed and disposable costs, continued technological development fueled by increasing patient demand may allow for further expansion in the use of robotic-assisted minimal invasive surgery.

Minimally invasive mitral valve surgery: a systematic review

In the recent years minimally invasive mitral valve surgery (MIMVS) has become a well-established and increasingly used option for managing patients with a mitral valve pathology. Nonetheless, whether the purported benefits of MIMVS translate into clinically important outcomes remains controversial. Therefore, in this paper we provide an overview of MIMVS and discuss results, morbidity, mortality, and quality of life following mitral minimally invasive procedures. MIMVS has been proven to be a feasible alternative to the conventional full sternotomy approach with low perioperative morbidity and short-term mortality. Reported benefits of MIMVS include also decreased postoperative pain, improved postoperative respiratory function, reduced surgical trauma, and greater patient satisfaction. Finally, compared to standard surgery, MIMVS demonstrated comparable efficacy across a range of long-term efficacy measures such as freedom from reoperation and long-term survival.

The Swan-Ganz catheter as a teaching tool for the anesthesiologist learning minimally invasive cardiac surgery

OBJECTIVE

To perform minimally invasive cardiac surgery through the smallest possible wound and with the least number of incisions in the heart or aorta, the necessary cannulations to undergo cardiopulmonary bypass must be done through peripheral vessels. A difficult skill to learn for the cardiac anesthesiologist is how to safely and efficiently position the coronary sinus catheter (Endoplege; Edwards Lifesciences LLC, Irvine, CA USA) required for retrograde cardioplegia administration.

METHODS

In patients in whom a Swan-Ganz catheter was inserted as part of the operative management strategy for non-minimally invasive heart surgery, we have been using it as a training tool to learn how to visualize and manipulate right-sided catheters under transesophageal echocardiography. We developed this teaching technique to help hone some of the necessary skills needed to place the Endoplege catheter for minimally invasive cardiac surgery. Manipulation was done with the goal of visualizing the catheter and guiding it into the coronary sinus. For a 4-month period, anesthesia records were retrospectively reviewed.

RESULTS

Fifteen patients, for a total of 19 catheter manipulations, were found in whom we had documented the use of the Swan-Ganz catheter and details about the insertion as a training tool. The coronary sinus and the catheter were visualized 100% of the time. The Swan-Ganz catheter was successfully inserted into the coronary sinus in 17 of 19 catheter manipulations.

CONCLUSIONS

The Swan-Ganz catheter can be used as a training tool to develop some of the necessary skills to place catheters into the coronary sinus with transesophageal echocardiography guidance.

Cannulation of the middle cardiac vein during MICS

Coronary sinus cannulation for retrograde cardioplegia administration during cardiac surgery is common practice. Several of the cannulas that are placed by the cardiac surgeon on open procedures are now placed by the cardiac anesthesiologist during minimally invasive cardiac surgery, including the coronary sinus catheter. The understanding of the cardiac venous anatomy is very important during coronary sinus catheter placement. We present a case where a percutaneously placed coronary sinus catheter was inadvertently placed into the middle cardiac vein but detected with the use of fluoroscopy.

Anesthetic considerations during minimally invasive mitral valve surgery

Advances in instruments and visualization tools as well as circulatory systems for cardiopulmonary bypass during the late 1990s have stimulated widespread adoption of minimally invasive mitral valve surgery (MIMVS). Today, MIMVS is the standard approach for many surgeons and institutions. There are multiple benefits of MIMVS. Patient satisfaction and improved cosmesis are important. Additionally, studies have consistently shown faster recovery times and less associated pain with MIMVS. Statistically significant improvement in bleeding, transfusion, incidence of atrial fibrillation, and time to resumption of normal activities with MIMVS has also been shown when comparing MIMVS with conventional mitral surgery. Most important, these benefits have been achieved without sacrificing perioperative safety or durability of surgical repair. Although a steep learning curve still exists given the high level of case complexity, continued development fueled by increasing patient demand may allow for even further expansion in the use of minimal invasive techniques.

Live 3-dimensional echocardiography guidance for the insertion of a retrograde cardioplegic catheter through the coronary sinus

OBJECTIVE

We evaluated the feasibility and accuracy of live 3-dimensional (3D) epicardial echocardiography (echo) to guide the insertion of a retrograde cardioplegic catheter into the coronary sinus.

METHODS

A real-time 3D echo system with a x4 matrix transducer was used. Live 3D echo-guided catheter insertion was compared with blind insertion. Completion times and success rates were recorded. During all experiments, the operator was blinded to the target and, in the echo-guided group, the procedure was performed with only ultrasonic guidance.

RESULTS

Live 3D echo provided sufficient spatial resolution and a satisfactory frame rate to provide a "virtual surgeon's view" of the relevant anatomy. Although there was no significant difference in completion time, live 3D echo guidance significantly improved the success rate of catheter insertion as compared to the blind group (90% versus 35%; P <.001).

CONCLUSIONS

Live 3D echo-guided coronary sinus catheter insertion is feasible and safe.

[Minimally invasive cardiac surgery: surgical techniques and anesthetic problems]

OBJECTIVE

To review current data on minimally invasive cardiac surgery.

DATA SOURCES

Search through the Medline data base of French or English articles.

DATA EXTRACTION

The articles were analysed to make a synthesis of the various techniques with their main indications and contra-indications.

DATA SYNTHESIS

Minimally invasive cardiac surgery includes various surgical procedures. The usual techniques are described, their major benefits and drawbacks are discussed. The main goals of anaesthetic management are preservation of ventricular function and systemic perfusion, detection and treatment of myocardial ischaemia, prevention of hypothermia in case of coronary artery bypass grafting on the beating heart via sternotomy, intermittent selective ventilation of the collapsed lung using CPAP in case of limited thoracotomy. Expertise in transoesophageal echocardiography is essential for insertion and checking the accurate positioning of the various catheters of the endovascular CPB Heartport system (pulmonary vent, endosinus catheter, venous cannula, endoaortic clamp) allowing coronary artery bypass grafting and mitral valve surgery through limited thoracotomy and finally, detection of retained intracardiac air and assessment of complete clearing of cardiac cavities after mitral valve surgery through limited thoracotomy and aortic valve surgery via ministernotomy. Short-acting anaesthetic agents allow rapid recovery from anaesthesia, early extubation and discharge to the surgical ward within 24 h, whereas overall time spent in the operating room is often longer than with conventional cardiac surgery.

Port-Access Cardiac Surgery: Anesthetic Techniques, Equipment, Applications, Experience, and Outcomes

Port-Access (Heartport, Inc, Redwood City, CA) mini mally invasive surgery has been developed to allow surgeons to complete a wide variety of cardiac surgical procedures while avoiding a median sternotomy and the associated trauma and debility. Cardiopulmonary bypass is established using the EndoDirect (Heartport, Inc) or EndoCPB systems which consist of five catheters and cannulae providing the same functions as those used in conventional cardiac surgery. These systems enable surgeons to obtain appropriate myocardial pro tection, circulatory support, and operating conditions while operating through a small intercostal incision or port. Transesophageal echocardiography and/or fluoros copy are used to evaluate patient anatomy including assessment of the aorta, to facilitate the placement of catheters and cannulae, and to monitor during the conduct of cardiopulmonary bypass. Clinical reports have shown broad applicability of Port-Access proce dures with favorable outcomes. Morbidity and mortal ity compare well with reported rates for conventional surgery. Experience with multivessel coronary artery bypass grafting suggests that complete revasculariza tion for all coronary beds can be accomplished using a variety of venous and arterial conduits. Clinical studies suggest that Port-Access surgery is associated with short postoperative duration of tracheal intubation, intensive care unit stay, and hospital stay, a low inci dence of new-onset atrial fibrillation, and rapid return to normal activities. Clinical experience continues to ex pand the indications for Port-Access minimally invasive cardiac surgery as well as to refine and enhance surgical procedures.

Intraoperative Echocardiography for the Patient Undergoing Minimally Invasive Heart Surgery

Minimally invasive heart surgeries are commonly used to avoid large surgical incisions and facilitate early extubation and recovery after cardiac surgeries. Trans esophageal echocardiography (TEE) is especially valu able in minimally invasive cardiac surgery because the inherently limited access to the thorax and mediasti num impairs direct visualization of the heart. TEE influ ences the clinical decision making process in several ways. Changes to the anesthetic management include alteration in volume loading in the presence of diastolic dysfunction or left ventricular outflow tract obstruction, as well as augmenting coronary perfusion pressure and implementing coronary vasodilators for new regional wall motion abnormalities. Changes to the surgical plans include replacement or repair for regurgitant valves, placement of intra-aortic balloon pumps for persistent regional wall motion abnormalities, and changing the surgical approach in the presence of severe aortic disease. Currently, two approaches are commonly used in minimally invasive cardiac surgery. The first approach, port-access minimally invasive car diac surgery, continues to use cardiopulmonary bypass. This approach relies extensively on TEE to correctly place endovascular devices necessary for cardiopulmo nary bypass in addition to routine assessment of car diac function. The second approach, minimally invasive direct coronary artery bypass, involves performing the revascularization on a beating heart. Here, TEE is essen tial for assessment of ventricular function if ischemic preconditioning is used as a strategy for myocardial protection.

Intraoperative considerations during minimal-access cardiac surgery

The range of minimal-access cardiac surgery approaches has many implications in intraoperative management. A modified anesthetic regimen is required to deal with the type of surgical exposure, hemodynamic instability, whether cardiopulmonary bypass is used, and early extubation. Intraoperative considerations include hemodynamic monitoring, one-lung ventilation, pharmacological stabilization of the myocardium, pacing, hypothermia, bleeding, and rapid emergence with a minimum of postoperative mechanical ventilation. As a result, anesthetic methods and intraoperative management were modified to meet these specific needs of minimally invasive cardiac procedures.

Anesthetic implications of new surgical approaches to myocardial revascularization

New surgical techniques for bypassing coronary artery lesions are being explored with the goals of avoiding cardiopulmonary bypass, minimizing disfiguring scars, and decreasing hospital stay and costs. These forms of cardiac surgery have significant anesthetic implications. Intraoperatively there is an obligatory period of myocardial ischemia, which may lead to significant hemodynamic consequences. Postoperative trends towards early extubation and patient mobilization require anesthetic techniques that facilitate rapid recovery.

An institution's initial experience with port-access minimally invasive cardiac surgery

OBJECTIVE

To assess the learning curve associated with Port-Access minimally invasive cardiac surgery.

DESIGN

Retrospective.

SETTING

Single university hospital.

PARTICIPANTS

Initial 10 patients undergoing Port-Access minimally Invasive cardiac surgery.

INTERVENTION

Minimally invasive cardiac surgery.

MEASUREMENTS AND MAIN RESULTS

All 10 patients experienced an uneventful intraoperative and immediate postoperative course. Only one patient experienced postoperative cardiovascular morbidity, which was an episode of new-onset atrial fibrillation after mitral valve surgery that was successfully treated with pharmacologic therapy. Extubation times and postoperative discharge times were less than historic controls receiving the same anesthetic technique at the same institution.

CONCLUSION

This institution's initial experience with 10 patients undergoing Port-Access minimally invasive cardiac surgery suggests an acceptable learning curve and decreased extubation and postoperative discharge times, which should translate into reduced health care costs.