-
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVES: Endoaortic balloon occlusion (EBO) and aortic transthoracic clamping (TTC) are the dominant methods of remote access perfusion (RAP) in minimally invasive cardiac surgery. The aim of the study was to compare the two methods in terms of feasibility, success and complications. METHODS: From June 2001 to November 2011, 307 (median age; range) (57; 16-77 years) and 460 (62; 11-88 years) patients underwent minimally invasive CABG, ASD and mitral valve surgery using EBO and TTC, respectively. Perioperative procedure feasibility, success and postoperative complications were recorded. RESULTS: Overall 30-day mortality was 0 and 2 (0.43%) for the EBO and TTC groups, respectively (P = 0.52). Overall and RAP-associated conversions were noted in 21 (6.8%) and 4 (1.3%) patients in the EBO and in 9 (2%) and 6 (1.3%) patients in the TTC groups (P < 0.001, P = 1.00, respectively). Incidence of major complications, including aortic dissection, major vessel perforation, injury of intrapericardial structures, limb ischaemia, myocardial infarction and neurologic events, was similar [EBO: 12 (4%); TTC: 11 (2.4%); P = 0.23]. Minor complications such as minor vessel injury, groin bleeding or lymphatic fistula were noted in 31 (10.1%) and 35 (7.6%), respectively (P = 0.23). Successful RAP procedures defined as absence of RAP-associated conversions and major complications were equal [EBO: 295 (96%); TTC: 449 (97.6%); P = 0.23]. Complications detected during follow-up included pain: 30 of 249 (12%) and 13 of 279 (4.7%) (P = 0.002); sensational disturbances: 60 of 249 (24.1%) and 40 of 278 (14.4%) (P = 0.005) and wound-healing complications: 49 of 249 (19.7%) and 42 of 277 (15.2%) (P = 0.172) for EBO and TTC, respectively. CONCLUSIONS: RAP can be successfully and safely implemented in minimally invasive cardiac surgery. EBO and transthoracic clamping of the ascending aorta are performing equally in terms of feasibility and procedural success.
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 02/2013; · 2.40 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: A CT-scan of a 75-year-old patient showed an aneurysm of the descending aorta with a maximum diameter of 4.8 cm involving the left subclavian artery. Due to the fact that the patient had several comorbidities including a severe chronic obstructive pulmonary disease he was treated only conservatively. However, there were several interesting findings on the CT-scan: the branching pattern of the aortic arch revealed a left carotid artery arising as first side branch of the distal part of the ascending aorta. This vessel crosses the midline right in front of the trachea. Apart from that the patient did not have a brachiocephalic trunk: the right carotid artery arose as the first branch from the aortic arch and crossed the right subclavian artery anteriorly. Furthermore, the left subclavian seemed to arise from the descending aorta and not from the aortic arch. Clin. Anat., 2013. © 2013 Wiley Periodicals, Inc.
Clinical Anatomy 01/2013; · 1.29 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: Robotic totally endoscopic coronary artery bypass grafting (TECAB) is an evolving minimally invasive technology with the potential to reduce hospital length of stay (LOS). Little is known about the factors that influence LOS after this procedure. The aim of this study is to define the preoperative, intraoperative, and postoperative variables that predict LOS after TECAB. METHODS: From 2001 to 2011, 541 patients, aged 60 years (range, 26 to 90 years), 394 (72.8%) male, 147 (27.1%) female, underwent TECAB using the daVinci telemanipulation system at one European and one American institution. Three hundred forty-six (63.9%) single-, 171 (31.6%) double-, 23 (4.2%) triple-, and 1 (0.2%) quadruple-vessel TECABs were carried out with an overall LOS of 6 days (range, 2 to 54 days) and 30-day mortality of 0.9% (5 of 541); 44.5% of patients (241 of 541) were hybrid intent-to-treat candidates. RESULTS: The following variables showed significant positive correlation with LOS: age, r = 0.188 (p < 0.001); Society of Thoracic Surgeons risk score, r = 0.263 (p < 0.001); EuroSCORE, r = 0.191 (p < 0.001); creatinine, r = 0.135 (p = 0.002); and operative time, r = 0.216 (p < 0.001). Other factors that had significant influence on LOS were hemodialysis (p = 0.037), cerebrovascular disease (p = 0.002), learning curve case (p < 0.001), intraoperative surgical problem (p < 0.001), conversion or on-table revision (p < 0.001), revision for bleeding (p < 0.001), postoperative stroke (p < 0.001), intraaortic balloon pump (p < 0.001), hemodialysis (p < 0.001), and atrial fibrillation (p < 0.001). By multivariate analysis, learning curve case, conversion or on-table revision, and revision for bleeding were independent predictors for prolonged LOS (defined as LOS > 6 days). CONCLUSIONS: Multiple variables affect LOS after TECAB. Older patients, patients on hemodialysis, patients with cerebrovascular disease, and those with higher general risk scores should expect prolonged LOS. Intraoperative surgical difficulties and conversion to open coronary artery bypass grafting also lead to extended LOS. Postoperative events that are known to prolong LOS in open coronary artery bypass grafting also prolong LOS after TECAB.
The Annals of thoracic surgery 01/2013; · 3.74 Impact Factor
-
Nikolaos Bonaros,
Thomas Schachner,
Eric Lehr,
Markus Kofler,
Dominik Wiedemann,
Patricia Hong,
Brody Wehman,
David Zimrin,
Mark K Vesely,
Guy Friedrich,
Johannes Bonatti
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: Robotic technology has enabled totally endoscopic coronary artery bypass (TECAB) grafting. Little information is available on factors associated with successful and safe performance of TECAB. We report a 10-year multicenter experience with 500 cases, elucidating on predictors of success and safety in TECAB procedures. METHODS: Between 2001 and 2011, 500 patients (364 [73%] men; 136 [27%] women; median age [minimum-maximum] 60 years [31-90 years], median EuroSCORE 2 [0-13]), underwent TECAB. Single, double, triple, and quadruple TECAB was performed in 334, 150, 15, and 1 patient, respectively. Univariate analysis and binary regression models were used to identify predictors of success and safety. Success was defined as freedom from any adverse event and conversion procedure, safety was defined as freedom from major adverse cardiac and cerebral events, major vascular injury, and long-term ventilation. RESULTS: Success and safety rates were 80% (400 cases) and 95% (474 cases), respectively. Intraoperative conversions to larger thoracic incisions were required in 49 (10%) patients. The median operative time was 305 minutes (112-1,050 minutes), and the mean lengths of stay in the intensive unit (ICU) and in hospital were 23 hours (11-1,048 hours) and 6 days (2-4 days), respectively. Independent predictors of success were single-vessel TECAB (p = 0.004), arrested-heart (AH)-TECAB (p = 0.027), non-learning curve case (p = 0.049), and transthoracic assistance (p = 0.035). The only independent predictor of safety was EuroSCORE (p = 0.002). CONCLUSIONS: Single-vessel and multivessel TECAB procedures can be safely performed with good reproducible results. Predictors of success include procedure simplicity and non-learning curve cases, whereas predictors of safety are mainly associated with patient selection.
The Annals of thoracic surgery 01/2013; · 3.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Robotic total endoscopic coronary artery bypass grafting (TECAB) has been under development for 10 years. With increasing experience and technological improvement, double-vessel TECAB has become feasible. The aim of the present study was to compare the current outcomes of single- and double-vessel TECAB.
Between 2001 and 2011, 484 patients underwent TECAB by 4 surgeons at 2 institutions. The median patient age was 60 years (range, 31-90), and the median European System for Cardiac Operative Risk Evaluation was 2 (range, 0-13). Single-vessel (n = 334) and double-vessel (n = 150) procedures were performed using the da Vinci, da Vinci S, and da Vinci Si robotic systems.
Compared with the single-vessel procedure, double-vessel TECAB required a longer operative time (median, 375 minutes; range, 168-795; vs median, 240; range, 112-605; P < .001) and had an increased conversion rate to a larger thoracic incision (31/150 [20.7%] vs 31/334 [9.3%]; P < .001). The median ventilation time was 10 hours (range, 0-288) for double-vessel versus 8 hours (range, 0-278) for single-vessel procedures (P = .006). The hospital stay was comparable, with 6 days (range, 2-27) for double-vessel TECAB and 6 days (range, 2-33) for single-vessel TECAB (P = .794). Perioperative mortality was 0.3% (1/334) with single-vessel TECAB and 2.0% (3/150) with double-vessel TECAB (P = .090). Freedom from major adverse cardiac and cerebral events at 5 years was similar after double- and single-vessel TECAB (73.5% vs 83.1%, P = .150). The 5-year survival was 95.8% and 93.9% (P = .708).
Double-vessel TECAB appears feasible and reproducible. The operative times were longer and the conversion rates to a larger thoracic incision were greater than with single-vessel TECAB. Also, the postoperative ventilation time was longer. Other perioperative morbidity and mortality and the recovery time and long-term clinical outcomes, however, were comparable.
The Journal of thoracic and cardiovascular surgery 11/2012; 144(5):1061-6. · 3.41 Impact Factor
-
Johannes O Bonatti,
David Zimrin,
Eric J Lehr,
Mark Vesely,
Zachary N Kon,
Brody Wehman,
Andreas R de Biasi,
Benedikt Hofauer,
Felix Weidinger,
Thomas Schachner, Nikolaos Bonaros,
Guy Friedrich
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: Hybrid coronary revascularization combines minimally invasive coronary artery bypass grafting and catheter-based interventions. This treatment option represents a viable alternative to both open multivessel coronary bypass surgery through sternotomy and multivessel percutaneous coronary intervention. The surgical component of hybrid coronary intervention can be offered in a completely endoscopic fashion using robotic technology. We report on one of the largest series to date. METHODS: From 2001 to 2011, 226 patients (age, 61 years [range, 31 to 90 years]; 77.0% male; EuroSCORE, 2 [range, 0 to 13]) underwent hybrid coronary interventions on an intention-to-treat basis. Robotically assisted procedures were performed using the daVinci, daVinci S, and daVinci Si surgical telemanipulation systems (Intuitive Surgical, Inc, Sunnyvale, CA) and included 147 single, 72 double, and 7 triple endoscopic coronary artery bypass grafting procedures. Surgery was carried out first in 160 cases (70.8%), percutaneous coronary intervention was carried out first in 38 cases (16.8%), and 28 patients underwent simultaneous operations in a hybrid operating room (12.4%). Drug-eluting stents were used in 70.0% of the patients. RESULTS: Hospital mortality was 3 of 226 patients (1.3%), and hospital stay averaged 6 days (range, 3 to 54 days). Patients walked outside 7 days (range, 3 to 97 days) postoperatively and performed general household work 14 days (range, 7 to 180 days) postoperatively. Full activity was resumed at 42 days (range, 7 to 720 days). Five-year survival was 92.9%, and 5-year freedom from major adverse cardiac and cerebral events was 75.2%. At 5 years, 2.7% of bypass grafts and 14.2% of percutaneous coronary intervention targets needed reintervention. CONCLUSIONS: Robotically assisted hybrid coronary intervention enables surgical treatment of multivessel coronary artery disease with minimal trauma. Perioperative results and intermediate-term outcomes meet the standards of open coronary artery bypass grafting. Recovery time is short, and reintervention rates are acceptable.
The Annals of thoracic surgery 10/2012; · 3.74 Impact Factor
-
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 10/2012; · 2.40 Impact Factor
-
Karin Albrecht-Schgoer,
Wilfried Schgoer,
Johannes Holfeld,
Markus Theurl,
Dominik Wiedemann,
Christina Steger,
Rajesh Gupta,
Severin Semsroth,
Reiner Fischer-Colbrie,
Arno G E Beer,
Ursula Stanzl,
Eva Huber,
Sol Misener,
Daniel Dejaco,
Raj Kishore,
Otmar Pachinger,
Michael Grimm, Nikolaos Bonaros,
Rudolf Kirchmair
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: Secretoneurin is a neuropeptide located in nerve fibers along blood vessels, is up-regulated by hypoxia and induces angiogenesis. We tested the hypothesis that secretoneurin gene therapy exerts beneficial effects in a rat model of myocardial infarction and evaluated the mechanism of action on coronary endothelial cells. METHODS AND RESULTS: In-vivo secretoneurin improved left ventricular function, inhibited remodeling and reduced scar formation. In the infarct border zone secretoneurin induced coronary angiogenesis as shown by increased density of capillaries and arteries. In-vitro secretoneurin induced capillary tubes, stimulated proliferation, inhibited apoptosis and activated Akt and ERK in coronary endothelial cells. Effects were abrogated by a VEGF-antibody and secretoneurin stimulated VEGF receptors in these cells. Secretoneurin furthermore increased binding of VEGF to endothelial cells and binding was blocked by heparinase indicating that secretoneurin stimulates binding of VEGF to heparan sulfate proteoglycan binding sites. Additionally, secretoneurin increased binding of VEGF to its co-receptor neuropilin 1. In endothelial cells secretoneurin also stimulated FGF receptor-3 and IGF-1 receptor and in coronary vascular smooth muscle cells we observed stimulation of VEGF receptor-1 and FGF receptor-3. Exposure of cardiac myocytes to hypoxia and ischemic heart after myocardial infarction revealed increased secretoneurin m-RNA and protein. CONCLUSIONS: Our data show that secretoneurin acts as an endogenous stimulator of VEGF signaling in coronary endothelial cells by enhancing binding of VEGF to low affinity binding sites and neuropilin 1 and stimulates further growth factor receptors like FGF receptor-3. Our in-vivo findings indicate that secretoneurin might be a promising therapeutic tool in ischemic heart disease.
Circulation 10/2012; · 14.74 Impact Factor
-
Karin Albrecht-Schgoer,
Wilfried Schgoer,
Johannes Holfeld,
Markus Theurl,
Dominik Wiedemann,
Christina Steger,
Rajesh Gupta,
Severin Semsroth,
Rainer Fischer-Colbrie,
Arno G.E. Beer,
Ursula Stanzl,
Eva Huber,
Sol Misener,
Daniel Dejaco,
Raj Kishore,
Otmar Pachinger,
Michael Grimm, Nikolaos Bonaros,
Rudolf Kirchmair
Circulation 10/2012; · 14.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: BACKGROUND: Transcatheter aortic valve implantation (TAVI) has emerged as an alternative treatment for high-risk and inoperable patients. Advanced multimodality imaging, including computed tomography (CT), plays a key role for optimized planning of TAVI. METHODS: Forty-nine patients (25 women; age, 82.3 ± 8.8 year) with severe aortic stenosis scheduled for TAVI were examined with 128-slice high-pitch dual-source prospective aortoiliac CT angiography (CTA). The 3-coronary-sinus-alignment (3-CSA) plane, comprising left and right anterior oblique and craniocaudal projection, was defined from three-dimensional volume-rendered technique data sets and compared with the intraoperative angiographic plane (deployment plane) used for device implantation. A tolerance level of ±5-degree deviation was acceptable. Volume of intraoperative iodine contrast agent was compared before and after the implementation of the 3-CSA plane estimation by CT. RESULTS: All 49 patients underwent TAVI, during which 6 CoreValves (Medtronic, Minneapolis, MN) and 43 Sapien valves (Edwards Lifesciences, Irvine, CA) were successfully implanted using transapical (n = 29), transfemoral (n = 17), and transaxillary access (n = 4). No severe complications occurred. In 47 patients (96%), CTA correctly predicted the 3-CSA plane used for device implantation. Mean left anterior oblique by CTA was 5.3 ± 6.5 degrees and craniocaudal was -1.3 ± 10.1 degrees. Mean left anterior oblique deviation between CTA and the intraoperative projection was 2.1 ± 2.7 degrees and craniocaudal was 1.7 ± 3.0 degrees. Ostium heights of the right and left coronary arteries were 12 ± 1.9 and 12.9 ± 3.3 mm. No over-stenting occurred in left coronary artery ostia of 8 mm or more. Contrast volume was reduced from 81.8 ± 25.6 to 59.4 ± 40.2 mL (p = 0.05) when using 3-CSA plane estimation by CT for final prosthesis implantation plane. CONCLUSIONS: Aortoiliac high-pitch 128-slice dual-source CT contributes to TAVI planning, including reliable prediction of the 3-CSA valve deployment plane, which saves contrast volume during the procedure and may facilitate correct valve placement.
The Annals of thoracic surgery 08/2012; · 3.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Coronary artery bypass surgery is a highly effective and durable therapy of coronary artery disease. Together with internal mammary arteries the saphenous vein grafts are the most important conduits for coronary surgery. We reviewed the topic of local pharmacologic and gene therapeutic treatment approaches to prevent neointimal hyperplasia in vein grafts. Perivascular therapy of veins before arterialization would be a simple approach that avoids systemic side effects of medications. The current data available show that there are promising experimental approaches (in vitro models, animal in vivo models) for pharmacological and gene therapeutic treatment of vein graft failure.
Current Opinion in Pharmacology 03/2012; 12(2):203-16. · 6.86 Impact Factor
-
European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 03/2012; 42(3):577-8. · 2.40 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Closed-chest totally endoscopic coronary artery bypass grafting (TECAB) is feasible using robotic technology. During the early phases, TECAB was restricted to single bypass grafts to the left anterior descending artery system. Because most patients referred for coronary artery bypass surgery have multivessel disease, development of endoscopic multiple bypass grafting is mandatory. Experimental work on multivessel TECAB was carried out in the early 2000s, and first clinical cases were already performed. With further technological development of operating robots, double, triple, and quadruple TECAB has become feasible both on the arrested heart and on the beating heart. To date, 161 cases of multivessel TECAB using the da Vinci telemanipulation systems are published in the literature. The main advances enabling multivessel TECAB were the availability of a robotic endostabilizer for beating heart procedures and increased surgeon skills using remote access heart-lung machine perfusion and endo-cardioplegia. Both internal mammary arteries can be harvested and both radial artery and vein graft can be used in multivessel TECAB. Y-grafting and sequential grafting are feasible. Multivessel endoscopic surgical revascularization can be combined with percutaneous coronary interventions in advanced hybrid coronary revascularization. Time requirements for multivessel TECAB are significant, and conversion rates to larger thoracic incisions are higher than those observed for single-vessel TECAB. Clinical short- and long-term outcomes, however, seem to meet the standards of open coronary bypass surgery through sternotomy. The main advantages of multivessel TECAB are a completely preserved sternum, use of double internal mammary artery even in risk groups, and a remarkably short recovery time.
Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery 01/2012; 7(1):3-8.
-
12/2011; , ISBN: 978-953-307-600-3
-
Journal of the American College of Cardiology 12/2011; 58(24):2545-6; author reply 2546. · 14.16 Impact Factor
-
The Annals of thoracic surgery 12/2011; 92(6):2234. · 3.74 Impact Factor
-
Circulation 09/2011; 124(13):1401-3. · 14.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Since aortic root reoperations are challenging procedures, alternative lower-risk procedures should be considered in certain cases. Herein are presented two different approaches to high-risk root reoperations. The first patient, a 59-year-old male who had undergone root replacement 11 years previously with an Edwards Prima stentless valve, presented with severe aortic regurgitation and a heavily calcified aortic root. An open implantation of an Edwards Sapien valve was performed via an aortotomy distal to the calcified aortic root. The second patient, a 60-year-old female, underwent transapical implantation of an Edwards Sapien transcatheter valve for stenosis of the aortic valve in an aortic homograft implanted 11 years previously. The long-term durability of these implants has yet to be evaluated.
The Journal of heart valve disease 09/2011; 20(5):593-5. · 0.81 Impact Factor
-
Circulation 07/2011; 124(2):236-44. · 14.74 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Robotically assisted totally endoscopic coronary artery bypass grafting (TECAB) is a viable option for closed chest coronary surgery, but it requires learning curves and longer operative times. This study evaluated the effect of extended operation times on the outcome of patients undergoing TECAB.
From 2001 to 2009, 325 patients underwent TECAB with the da Vinci telemanipulation system. Correlations between operative times and preoperative, intraoperative, and early postoperative parameters were investigated. Receiver operating characteristic analysis was used to define the threshold of the procedure duration above which intensive care unit stay and ventilation time were prolonged. Demographic data, intraoperative and postoperative parameters, and survival data were compared.
Patients with prolonged operative times more often underwent multivessel revascularization (P < .001) and beating-heart TECAB (P =.023). Other preoperative parameters were not associated with longer operative times. Incidences of technical difficulties and conversions (P < .001) were higher among patients with longer operative times. Prolonged intensive care unit stay, mechanical ventilation, hospital stay, and with requirement of blood products were associated with longer operative times. Receiver operating characteristic analysis showed operative times >445 minutes and >478 minutes to predict prolonged (>48 hours) intensive care unit stay and mechanical ventilation, respectively. Patients with procedures >478 minutes had longer hospital stays and higher perioperative morbidity and mortality. Kaplan-Meier analysis revealed decreased survival among patients with operative times >478 minutes.
Multivessel revascularization and conversions lead to prolonged operative times in totally endoscopic coronary artery bypass grafting. Longer operative times significantly influence early postoperative and midterm outcomes.
The Journal of thoracic and cardiovascular surgery 06/2011; 143(3):639-647.e2. · 3.41 Impact Factor
