Extending the Use of the Pacing Pulmonary Artery Catheter for Safe Minimally Invasive Cardiac Surgery

Robotically assisted minimally invasive mitral valve surgery

Increased recognition of advantages, over the last decade, of minimizing surgical trauma by operating through smaller incisions and its direct impact on reduced postoperative pain, quicker recovery, improved cosmesis and earlier return to work has spurred the minimally invasive cardiac surgical revolution. This transition began in the early 1990s with advancements in endoscopic instruments, video & fiberoptic technology and improvements in perfusion systems for establishing cardiopulmonary bypass (CPB) via peripheral cannulation. Society of Thoracic Surgeons data documents that 20% of all mitral valve surgeries are performed using minimally invasive techniques, with half being robotically assisted. This article reviews the current status of robotically assisted mitral valve surgery, its advantages and technical modifications for optimizing clinical outcomes.

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.

Edwards EndoVent as a pacing catheter for minimally invasive aortic valve surgery: a novel approach

OBJECTIVE

The placement of epicardial pacing wires before weaning from bypass during port-access heart surgery can be difficult or impossible. Sometimes, it is necessary to pacing the patient to wean from bypass, and it is problematic to exchange the Edwards pulmonary vent (EndoVent) for a pace catheter under the drapes. Our objective was to devise an effective means of pacing the patient using the pulmonary vent catheter.

METHODS

All patients having aortic valve minimally invasive port-access surgery have a pacing wire deployed through the Edwards EndoVent catheter. We did a retrospective chart analysis of these cases.

RESULTS

After reviewing the anesthesia records, we determined that we were able to reliably convert the pulmonary vent catheter, which is beneficial for the surgery, into a pacing catheter before weaning from bypass 100% of the time. The mean pacing threshold current was 1.60 mA with the wire in the right ventricular apex.

CONCLUSIONS

We found that in all 25 patients we were able to rapidly convert the vent catheter into a reliable pacing catheter without any complications.

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.