Robotic Cardiac Surgery

Changqing Gao
Editor
Robotic Cardiac Surgery
123
Robotic Cardiac Surgery
Changqing Gao
Editor
Robotic Cardiac Surgery
Editor
Changqing Gao, MD
Department of Cardiovascular Surgery
PLA General Hospital
Beijing
Peoples’s Republic of China
ISBN 978-94-007-7659-3
ISBN 978-94-007-7660-9
DOI 10.1007/978-94-007-7660-9
Springer Dordrecht Heidelberg New York London
(eBook)
Library of Congress Control Number: 2013954804
© Springer Science+Business Media Dordrecht 2014
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Foreword
Robotic Cardiac Surgery is a comprehensive academic compilation of experience with robotic
surgery in all phases of cardiac surgery as well as an extensively illustrated manual of how to do
robotic cardiac surgery for several forms of acquired and congenital heart disease. The author,
Dr. Changqing Gao, is an experienced robotic surgeon who has published much of his work in
the peer-reviewed literature around the world and has held several excellent meetings and clinics to teach surgeons around the world how to do robotic cardiac surgery safely and
effectively.
One of the main principles illustrated in the book is in order to achieve excellent results
utilizing robotic cardiac surgery you have to have excellent results in the conventional approach
throughout all aspects of acquired and congenital heart surgery. It has been documented that
experienced surgeons will become the leaders in the field of robotic cardiac surgery. Dr. Gao
and his colleagues are very experienced surgeons, and their robotic surgery techniques and
results are of the highest quality and are well documented in the pages of this book.
Under acquired heart disease, primarily a robotic approach to mitral and tricuspid repair
and replacement are discussed. The results of robotic surgical treatment for atrial septal defects
and other smaller defects are outlined in the congenital section. The use of robotics for the
take-down of the left internal mammary artery in performing CABG either by itself or with
hybrid revascularization in conjunction with the placement of drug eluting or bare metal stents
in other arteries is described in great detail. Hybrid revascularization stems from early work
with minimally invasive valve surgery and single vessel lesions managed by a percutaneous
coronary stent rather than a CABG and followed by a minimally invasive valve operation. This
is now carried to the next step with robotic surgery performing a LIMA to the left anterior
descending artery in combination with percutaneous coronary stents for some less important
arterial obstructions. Again, the results are quite good and the techniques are extensively illustrated in this book. The last section is robotic left ventricular epicardial lead implantation, an
area that may be helpful in the treatment of heart block or other arrhythmogenic entities that
require cardiac rhythm therapy.
All chapters are beautifully illustrated so as to enhance the reader’s understanding of robotic
operations. Chapters in the book are primarily written by expert surgeons, anesthesiologists
and cardiologists in China where this technology has had very good results. This book will be
a landmark in presenting large clinical series results of conventional operations treated by
robotic technology.
Lawrence H. Cohn, MD
Harvard Medical School
v
Preface
Since robotic technology was introduced into the cardiac surgical field in 1998, the dream of
cardiac surgeons to perform cardiac procedures in the closed chest has come true. With an
outlook into the future, the PLA General Hospital took the lead to install the first da Vinci S
Surgical System in China in 2006. The surgical team of the PLA General Hospital has started
the cutting-edge techniques of minimally invasive robotic surgery in China.
Our team had gone through tremendous trial investigations and hard work before they
finally succeeded in using da Vinci S Surgical System in China. After working persistently
with da Vinci S Surgical System for 7 years, we now can perform the whole range of closedchest heart procedures that da Vinci S Surgical System was designed for. Exceeding and renovating the desired techniques designed for the System, the surgeons of the team created new
surgical techniques and standards, and completed the most types of robotic cardiac surgery on
the globe. So far, the team has performed 700 cases all of which were successful.
We were eager to share our experience with other surgical teams around the world. We
established the National and International Training Center for Robotic Cardiac Surgery in
Beijing, China. The center has provided training programs for groups of cardiac surgical professionals from other countries and regions like Japan, Singapore, Brazil, Korea, Hong Kong
and Taiwan. Advances in robotic heart surgery in China have exerted far-reaching impacts in
Asia and even around the world.
China has a tremendous patient base and a large pool of talented and innovative surgeons
with extensive surgical experience. For sure, the full potential of da Vinci surgery will be realized through the increased exchanges between Chinese surgeons and their counterparts around
the world.
We have written this book to record the landmark, to share our experience and to acknowledge the care and help given by our mentors and colleagues from all parts of the world.
Beijing, People’s Republic of China
Changqing Gao, MD
vii
Biography
Dr. Changqing Gao is currently the Vice President of the PLA General Hospital, the Chairman and
Professor of the Department of Cardiovascular Surgery, Director of the Institute of Cardiac Surgery,
the National Training Center for Robotic Cardiac Surgery, International Training Center for da
Vinci Surgery, and International Cooperation and Research Center for Robotic Cardiac Surgery.
Dr. Gao has performed over 4,000 cases of cardiovascular surgery and has become a nationrenowned expert in the surgical field. His professional interests include acquired heart disease,
mitral and aortic valve repair/replacement, and aneurysms of the thoracic aorta. He has a special interest in complex coronary artery bypass, off-pump coronary artery bypass, left ventricular aneurysms, and minimally invasive cardiac surgery.
Dr. Gao is a pioneering surgeon in robotic cardiac surgery in Asia. He has completed 700
cases of robotic cardiac surgery with da Vinci Surgical Systems since 2007. He has been a recipient of many research grants and fellowship, and numerous awards for his excellence and
achievements in science and technology. He is currently the principal investigator in a number
of major clinical research projects in China.
Dr. Gao is the Executive Councilor of the Asian Society for Cardiovascular and Thoracic
Surgery (ASCVTS), Board of Director of ISMICS and the Minimally Invasive Robotic
Association (MIRA), Charter member of the Society of Robotic Surgery (SRS), Member of
AATS, STS and EACTS, Councilor of the Chinese Medical Association, Vice President and
Secretary General of the Chinese Society of Thoracic and Cardiovascular Surgery, Vice
President of the Chinese Association of Cardiovascular Surgeons, President of the Beijing
Society of Cardiac Surgery, and Executive Councilor of the Beijing Medical Association.
ix
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Dr. Gao is the Co-editor of the Journal of Robotic Surgery of USA, Board member of the Heart
Surgery Forum, Board member of Innovations, Associate Editor-in-chief of the Journal of Thoracic
and Cardiovascular Surgery, Editor-in-chief of the Chinese Journal of Extracorporeal Circulation,
and Associate Editor-in-chief of the Chinese Journal of Thoracic and Cardiovascular Surgery. He
also holds membership of the editorial boards of many influential medical journals.
Biography
Acknowledgement
The authors gratefully acknowledge the assistance of the following individuals and organizations
whose contributions made publication of this book possible:
PLA General Hospital, PLA Medical School, Beijing, China
Karen Zhao, MA
Junlan Yan, RN
Jiali Wang, BS
Jiachun Li, BS
Guopeng Liu, MS
Yue Zhao, RN
Lixia Li, RN
Bojun Li, MD
Shengli Jiang, MD
Rong Rong, MD
xi
Contents
1
Overview of Robotic Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Changqing Gao
1
2
Anesthesia for Robotic Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Gang Wang and Changqing Gao
15
3
Intraoperative Transesophageal Echocardiography
in Robotic Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yao Wang and Changqing Gao
33
Peripheral Cardiopulmonary Bypass Establishment
for Robotic Cardiac Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Cangsong Xiao and Changqing Gao
49
4
5
Robotic Surgery in Congenital Heart Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . .
Changqing Gao and Ming Yang
61
6
Totally Robotic Myxoma Excision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Changqing Gao and Ming Yang
83
7
Robotic Mitral Valve Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Changqing Gao and Ming Yang
93
8
Robotic Coronary Bypass Graft on Beating Heart. . . . . . . . . . . . . . . . . . . . . . . . 111
Changqing Gao and Ming Yang
9
Hybrid Coronary Revascularization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 135
Mukta C. Srivastava, Bradley Taylor, David Zimrin, and Mark R. Vesely
10
Robotic Left Ventricular Epicardial Lead Implantation . . . . . . . . . . . . . . . . . . . 141
Changqing Gao, Chunlei Ren, and Ming Yang
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
xiii
Contributors
Changqing Gao, MD Department of Cardiovascular Surgery, PLA General Hospital,
Beijing, People’s Republic of China
Chunlei Ren Department of Cardiovascular Surgery, PLA General Hospital,
Beijing, People’s Republic of China
Mukta C. Srivastava, MD Division of Cardiology, University of Maryland Medical Center,
Baltimore, MD, USA
Bradley Taylor, MD Division of Cardiology, University of Maryland Medical Center,
Baltimore, MD, USA
Mark R. Vesely, MD Division of Cardiology, University of Maryland Medical Center,
Baltimore, MD, USA
Gang Wang, MD Department of Cardiovascular Surgery, PLA General Hospital,
Beijing, People’s Republic of China
Yao Wang, MD Department of Cardiovascular Surgery, PLA General Hospital,
Beijing, People’s Republic of China
Cangsong Xiao, MD Department of Cardiovascular Surgery, PLA General Hospital,
Beijing, People’s Republic of China
Ming Yang, MD Department of Cardiovascular Surgery, PLA General Hospital,
Beijing, People’s Republic of China
David Zimrin, MD Department of Medicine, University of Maryland School of Medicine,
Baltimore, MD, USA
xv
1
Overview of Robotic Cardiac Surgery
Changqing Gao
Abstract
It has been the dream of cardiac surgeons to perform cardiac procedures in the closed chest
that would offer patients the same benefits as those that open-incision procedures do.
The revolutionary minimally invasive surgery has certainly satisfied some of the desires of
cardiac surgeons but they have never been as satisfactory as what cardiac surgical robots
can ever have been.
Minimally invasive cardiac surgery has grown in popularity over the past two decades.
And minimally invasive videoscope has been the most used approach. Minimally invasive
techniques can provide patients with more advantages in recovery process than open procedures. The 2-D camera of endoscope causes impaired visualization, absence of the depth of
the surgical field, and difficulty for complete precise manipulation by surgeons. The drive
for robotic surgery is rooted in the desire to overcome the shortcomings of endoscopic surgery and expand the benefits. Robotic technology was introduced into the cardiac surgical
field in 1998. AESOP (Automated Endoscopic System for Optimal Positioning) and ZEUS,
two surgical robotic systems, were approved by the FDA for clinical use in 1994 and 2001
respectively. In January 1999, Intuitive launched the da Vinci Surgical System, and in 2000,
it became the first robotic surgical system cleared by the FDA for general laparoscopic
surgery. In the following years, the FDA cleared the da Vinci Surgical System for cardiac
procedures. The robotic technique has been successfully used in atrial septal defect repair
on arrest or beating heart, mitral valve repair or replacement, coronary bypass graft, myxomas resection, atrial fibrillation ablation, left ventricular epicardial lead placemen and aortic surgery. Early results are encouraging with evidence that patients experience little blood
transfusion, shorter hospital stay, sooner return to preoperative function levels and improve
quality of life with robotic surgery than with sternotomy. However, long-term results are
needed to determine if robotic techniques could become the new standards in cardiac
surgery.
While conventional video endoscopic techniques were
revolutionary in their own right, they were hampered by
limited instrument maneuverability and 2-D visualization.
These technological shortcomings took away the wrist-like
motion of the human hand and the depth perception of human
C. Gao, MD
Department of Cardiovascular Surgery, PLA General Hospital,
No. 28 Fuxing Road, Beijing 100853, People’s Republic of China
e-mail: gaochq301@yahoo.com
eyes, and necessitated the design of new procedures which
were adapted to the technology. Robotics represents yet
another revolution in the application of minimally invasive
techniques to surgery. Robotics by virtue of wrist-like instrument maneuverability and 3-D visualization has returned the
advantages of the human wrist and eyes to the field of minimally invasive surgery.
For the first time in the history of minimally invasive
surgery, operations which were designed to be performed
by open incisions can be replicated using minimal access
C. Gao (ed.), Robotic Cardiac Surgery,
DOI 10.1007/978-94-007-7660-9_1, © Springer Science+Business Media Dordrecht 2014
1
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C. Gao
techniques today. Actually, robotic cardiac surgery became
feasible in the late 1990s of the last century. Over the last
10 years, robotic surgery has been increasingly recognized
by surgeons throughout the world. In fact, da Vinci Surgical
System has brought about a real revolution in many surgical
fields.
In China, da Vinci surgery has been enthusiastically
embraced by surgeons and robotic cardiac surgery is developing particularly fast. In 2007, the da Vinci S was first
introduced to China, at the PLA General Hospital (301),
where the first robotic cardiac surgery in China was performed. Since then, over 640 cases of robotic cardiac surgery have been performed at the Cardiovascular Surgery
Department, such as totally endoscopic coronary artery
bypass on beating heart, minimally invasive direct coronary
artery bypass grafting on beating heart, hybrid coronary
revascularization, mitral valve repair, mitral valve replacement, tricuspid repair, myxoma resection, atrial septal defect
repair, ventricular septal defect repair, left ventricular lead
implantation, and so on. And the surgical results are excellent as expected.
Our experience shows that with a well-trained robotic
team and after a substantial learning curve, surgeons could
achieve optimal outcomes in robotic surgeries, and continued development of expertise, technical skills and vigilance
of long term outcomes will prepare surgeons for future
advancements. We have to emphasize that the da Vinci
Surgical System is a surgical tool, and the kind of surgical
procedures the surgeon can perform depends on surgeon’s
own experience, not on da Vinci!
China has an enormous patient base and a large pool of
talented and innovative surgeons with extensive surgical
experience. For sure, the full potential of da Vinci surgery
will be realized through increased exchanges between
Chinese surgeons and their counterparts in other
countries.
1.1
History of Minimally Invasive Surgery
Minimally invasive surgeries are procedures that avoid use
of open invasive procedures for the same purpose in favor of
closed or local surgery, and are carried out through the skin
or through a body cavity or anatomical opening. These procedures generally involve use of laparoscopic devices and
remote-control manipulation of instruments with indirect
observation of the surgical field through an endoscope or
similar device [1].
As the most representative procedures of minimally invasive surgery, laparoscopic surgery was initiated from cholecystectomy, and was first reported in Germany (1985) and
France (1987) more than two decades ago [2–5]. In contrast
to open procedures, advantages to patients with laparoscopic
surgery include reduced hemorrhage, smaller incision, less
pain, reduced risks of infections, shortened hospital stay and
faster return to everyday living. Although these advantages
seem attractive, technical and mechanical natures of the
current laparoscopic equipment determine the inherent
limitations of laparoscopic surgery, such as fulcrum effect,
limited degrees of motion (4 degrees of freedom), loss of
haptic feedback (force and tactile), counterintuitive visual
feedback, and compromised dexterity. The desire to overcome these limitations motivated engineers and researchers
to develop surgical robots while expanding the benefits of
minimally invasive surgery.
A robot is a mechanical or virtual intelligent agent that
can perform tasks automatically or with guidance, typically
by remote control. The attempts to create artificial machines
and automata have a history of more than 2,000 years.
Derived from Slavic term Robota, meaning “forced labor,
chore,” the term robot was coined in 1920 and introduced
to the public by the Czech writer Karel Čapek in his play
R.U.R. (Rossum’s Universal Robots) [6]. Since then, robots
evolved throughout the twentieth Century, and entered
realms such as industry, military, aerospace, marine navigation, etc. It was a landmark in 1961 when the first industrial robot was online in a General Motors automobile
factory in New Jersey (Rover Ranch, 2005), which
announced the entrance of robots to mainstream human
life.
1.2
History of Robotic Systems
Computer-enhanced instruments have been developed to
provide telemanipulation and micromanipulation of tissues
with 6 degrees of freedom to allow free orientation in confined spaces. The use of a robot-assisted surgical procedure
was first documented in 1985, and PUMA 560 was used by
Kwoh et al. to perform neurosurgical biopsies with CT guidance [7]. The same system was used for soft-tissue surgery
3 years later, in the transurethral resection of the prostate
(TURP) for benign prostatic hyperplasia [8]. In 1988, the
PROBOT, developed at Imperial College London, was used
to perform prostatic surgery by Dr. Senthil Nathan at Guy’s
and St Thomas’ Hospital, London. Simultaneously,
RoboDoc, the first surgical robotic system was developed by
the Integrated Surgical Supplies Ltd. of Sacramento, CA.
RoboDoc was used to perform total hip replacements in
1992 [9] with confirmed ability to precisely core out the femoral shaft with 96 % precision, whereas a standard hand
broach provided only 75 % accuracy [10]. Despite its failure
to receive FDA approval, RoboDoc found extensive applications in Europe and Japan.
1
Overview of Robotic Cardiac Surgery
3
Computer Motion, Inc.®, a medical robotics company was
founded in 1989 by Yulun Wang, PhD, an electrical engineering graduate of the University of California, Santa
Barbara with funding from the U.S. government and private
industry. Computer Motion, Inc.® launched AESOP®
(Automated Endoscopic System for Optimal Positioning), a
robotic telescope manipulator, and the robotic surgical system ZEUS® [11, 12]. The two robotic systems were approved
by the FDA for clinical use in 1994 and 2001 respectively
[12] (Figs. 1.1 and 1.2).
1.3
Fig. 1.1 The AESOP surgical system
a
Fig. 1.2 The Zeus surgical system
The da Vinci Surgical System
Frederic H. Moll, MD, a physician with a keen business
sense saw the commercial value of the emerging robotic
technology, acquired the license to the robotic surgical system pioneered by the NASA-SRI team, and started a company called Intuitive Surgical Inc.® in 1995. In January
1999, Intuitive launched the da Vinci Surgical System,
which in 2000 became the first robotic surgical system
accredited by the FDA for general laparoscopic surgery. In
the following years, the FDA accredited the da Vinci
Surgical System for thoracoscopic surgery, cardiac procedures performed with adjunctive incisions, urologic, gynecologic, pediatric and transoral otolaryngology procedures.
The Intuitive Surgical Inc.® merged with Computer Motion,
Inc.® in June of 2003, strengthening its intellectual property
holdings [13].
b
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Fig. 1.3 The dual consoles of da Vinci Si at PLA General Hospital
The da Vinci Surgical System consists of three components: (1) surgical console, (2) patient cart, and (3) vision
cart (Figs. 1.3, 1.4, and 1.5). The system provides the following advantages to the surgeons: three-dimension visualization, control of endoscopic instrument, and control of the
camera. It enables direct real-time movement of endoscopic
instrument by the operating surgeons and allows the surgeons to use techniques of open surgery during endoscopic
procedures.
The surgeon console is physically removed from the patient
and allows the surgeon to sit comfortably (Fig. 1.6), resting
the arms ergonomically while immersing himself/herself in
the three-dimensional high-definition videoscopic image
with the depth of the field through the view port. The surgeon
controls the micro-instruments using the master controller.
The medical signal, such as, ECG, oxygen saturation, and cardiac echo can be seen through stereo viewer in the surgical
field (Fig. 1.7). Furthermore, various messages are displayed
on the stereo viewer using icons and text. These enable the
surgeon to monitor the status of the instruments and the arms
without removing his/her head from the console.
Fig. 1.4 Patient cart
The master controllers are used by the surgeon to control
the instruments, the instruments arms, and the camera. The
foot switches consists of instrument clutch, camera control
clutch, camera focus, and electrocautery control. The armrest switches on the left and right armrests are used to control
the motion and scaling of the robotic arms. And they are
replaced by a touch screen panel in da Vinci Si Surgical
System (Figs. 1.8 and 1.9).
Wrist and finger movements are digitally registered in
computer memory, and then transferred to the instrument
cart, where the synchronous end-effectors or micro instruments provide tremor-free movements with 7 degrees of
freedom (Fig. 1.10). The instrument cart holds three arms in
the first version (da Vinci®) and four arms in more recent
models (da Vinci S® and da Vinci Si®) (Fig. 1.11). One arm
supports the dual 5-mm diameter cameras to generate 3-D
1
Overview of Robotic Cardiac Surgery
5
Fig. 1.5 Vision cart
Fig. 1.7 The medical signal can be seen through the stereo viewer during the surgery
Fig. 1.6 The surgeon sits at the console at PLA General Hospital
image and the other two or three arms are for wrist-like
articulations equipped with EndoWrist Instruments that are
designed to provide surgeons with natural dexterity and full
range of motion.
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C. Gao
Fig. 1.8 The surgeon console and its components of da Vinci S Surgical System
The patient cart that rolls on wheels, is moved into the
operative field, and is positioned over the patient. The robotic
arms are designed like the human arm with a shoulder, an
elbow, and a wrist. The instruments are attached to a carriage
on the robotic arm. The carriage moves the instrument in and
out a cannula at the tip of the arm. The cannula acts as the
port that is introduced into the patient and carries the robotic
instruments. The patient cart is connected with cables to the
surgeon console.
The vision cart consists of the left eye camera control
unit, right eye camera control unit, light source, video
synchronizer and focus controller, assistant monitor, and
various recordings and insufflation devices specific to the
surgical application.
Using the most advanced technology available today, the
da Vinci Surgical System enables surgeons to perform
Fig. 1.9 A touch screen panel in da Vinci Si Surgical System replaces
the traditional buttons at PLA General Hospital
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Overview of Robotic Cardiac Surgery
7
Fig. 1.11 The four arms of da Vinci Si Surgical System docked at PLA
General Hospital
Fig. 1.10 The “wrist” instrument provides the natural dexterity and
full range of motion
delicate and complex operations through a few tiny incisions with an increased vision, precision, dexterity and
control.
1.4
Operating Room Configuration
and System Setup
The da Vinci Surgical System consists of three main
components: the Surgeon Console, the Patient Cart and the
Vision Cart. The components should be arranged well in the
operating room for maximum safety and ergonomic benefit
(Fig. 1.12). The Surgeon Console is placed outside of the
sterile field and is oriented where the Surgeon Console
operator will have a view of the operative field and a clear
line of communication with the Patient Cart operator
(Fig. 1.12).
The Patient Cart is draped prior to moving into place for
surgery. The draped arms should be covered by an additional
sterile coat (Fig. 1.13) to prevent coming into contact with
non-sterile objects or impede traffic. Once the Patient Cart is
draped, and the patient is positioned, prepared, draped and
ports are placed, use the Patient Cart motor drive to help
move the cart into the sterile field. The Vision Cart is placed
adjacent to the Patient Cart, just outside of the sterile field, to
allow the Patient Cart Operator to see the component displays (Fig. 1.14). The Vision Cart should be close enough to
the Patient Cart to allow unrestricted camera cable movement during surgery.
The components of da Vinci Surgical System are connected by three main cables. The three cables can be
distinguished by their diameter and color. The cables should
be arranged so that they are out of the path of OR traffic,
including other equipment, to avoid damaging the cables or
creating an obstacle or hazard.
Usually, a two-person team is assigned to handle nonsterile components: a scrub nurse and a circulating nurse
drape the arms. The arms are draped systematically, allowing
movement from left to right or right to left. Using the clutch
buttons, the circulating nurse should move each straightened
arm to provide plenty of room to maneuver around the arm.
Once an arm is draped, the scrub nurse should move the
draped arm away from the undraped arms and prepare to
drape the next arm.
The preoperative management is critical to the success
of robotic heart surgery. The patient should be positioned
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C. Gao
Fig. 1.12 The components of da Vinci Surgical System are arranged in the OR for clear communication at PLA General Hospital
Fig. 1.13 The draped arms are
covered by an additional sterile
coat to avoid contamination
prior to docking the da Vinci Surgical system. The operating table should be easily moved prior to driving the Patient
Cart into position. For robotic-assistant cardiac surgery,
there are two opposite approaching routs, the left and the
right chest walls. The surgical side of the patient’s chest is
elevated at approximately 30° and with the arm tucked at
the side (Figs. 1.15 and 1.16). Port placement is the key to
a successful da Vinci procedure. The goals of port placement
are to avoid Patient Cart arms collisions and maximize the
range of motion for instruments and endoscope. The
improper port placement may cause serious injury to the
patient. Examples of port placement recommendations for
cardiac surgery are provided in Figs. 1.6 and 1.7. Initial
port location should be selected giving consideration to the
procedure, specific anatomy, and the type of components
being used.
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Overview of Robotic Cardiac Surgery
9
Fig. 1.14 The Vision Cart is
placed adjacent to the Patient
Cart, to allow the Patient Cart
Operator to see the component
displays at PLA General Hospital
Fig. 1.16 The patient position for left approach of da Vinci cardiac
surgery with left side of the chest elevated at 30° and with the left arm
tucked at the side
Fig. 1.15 The patient position for right approach of da Vinci cardiac
surgery with right side of the chest elevated at 30° and with the right
arm tucked at the side
Placement of the right ports: a 12-mm endoscopic trocar
is placed into the right thoracic cavity through the incision
made at 2–3 cm lateral to the nipple in the fourth intercostal
space (ICS). A 1.5-cm incision is used as a working port in
the same ICS for the patient-side surgeon. Additionally two
8-mm port incisions are made in the second and sixth ICS to
allow insertion of the left and right instrument arms. The
right instrument arm generally is positioned 4–6 cm lateral to
the working port in the sixth ICS. The fourth arm trocar is
placed in the midclavicular line in the 4th or 5th ICS
(Fig. 1.17).
Placement of the left ports: Three trocars were placed in
the 3rd, 5th and 7th intercostal spaces that located about
3 cm lateral of the midclavicular line (Fig. 1.18).
Docking is the process of moving the Patient Cart up to
the OR table and connecting the Patient Cart arms to the
patient. Once the cannulas are inserted in the patient, the
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C. Gao
Fig. 1.17 Recommendatory ports placement for right approach of da
Vinci cardiac surgery
Fig. 1.19 The Patient Cart is moved into the sterile field
Fig. 1.18 Recommendatory ports placement for robotic coronary
artery bypass graft
Patient Cart motor is moved into the sterile field (Fig. 1.19).
Communication is critical when docking the Patient Cart.
Use the instrument arm or camera port clutch button to bring
the cannula mount to the cannula. If there are two instrument
arms on one side, ensure that the instrument arm closest to
the camera arm has adequate range of motion while minimizing collisions (Fig. 1.20).
1.5
Robotic Cardiac Surgery
Cardiac surgery has been conventionally performed via
median sternotomy for the convenience of adequate exposure and surgeons’ generous access to the heart and surrounding vessels. Since the notion of minimally invasive
Fig. 1.20 Instrument arm closest to the camera arm has adequate
range of motion
surgery was introduced to cardiovascular surgery, surgeons
are keen on developing less invasive methods without any
compromise on accessibility and dexterity thus resulting in
paradigm shift in cardiac surgery. With the application of
surgical robotic systems, surgeons are enabled to improve
dexterity and perform ambidextrous sutures in the limited
space. The procedures have hitherto been successfully performed such as mitral valve reconstruction and replacement,
coronary revascularization, atrial fibrillation surgery, left
ventricular lead placement, intra-cardiac tumor resection,
congenital surgery, etc.
1
Overview of Robotic Cardiac Surgery
1.5.1
Robotic Mitral Valve Surgery
The Intuitive surgical system was originally designed for
cardiovascular surgery, of which the first clinical application
in human was performed by Carpentier on May 7, 1998, to
repair an atrial septal defect by mini-thoracotomy. And he
subsequently performed the first truly endoscopic mitral
valve repair by an early prototype of da Vinci in the same
year [14]. Such pioneering work was soon followed by a
series of totally robotic cardiovascular surgery, announcing a
vitally important innovation which might later be a thorough
revolution in cardiovascular surgery.
The first complete mitral valve repair using da Vinci system was performed by Chitwood in May 2002 that encouraged initial attempts phase I [15] and phase II [16] US Food
and Drug Administration (FDA) trials which subsequently
led to the approval of the da Vinci system for mitral valve
surgery in November 2002. At specialized medical centers, totally robotic mitral valve repair has become a standardized procedure. Surgeons perform conventional mitral
valve repair techniques such as quadrangular leaflet resections, leaflet sliding-plasties, edge-to-edge approximations, chordal transfers, polytetrafluoroethylene neochordal
replacement, reduction annuloplasties, and annuloplasty
band insertions. The transthoracic Chitwood clamp (Scanlan
International, Minneapolis, Minnesota, USA) is applied
across the ascending aorta, as substitution for endoaortic
occlusion balloon yielding decreased morbidity, total operative and cross-clamp times and cost [17], as well as less
common aortic dissections [18]. The novel EndoWrist atrial
retractor (Intuitive Surgical Inc) manipulated by a four-arm
da Vinci Surgical System (Intuitive Surgical Inc, Sunnyvale,
CA) allows dynamic exposure of the valve structures and
minimized aortic valve distortion, resulting in more efficient
antegrade cardioplegia delivery and reduced air entry in the
aortic root [19]. The introduction of the above-mentioned
newer robotic instrumentation facilitated robotic mitral
repair. Furthermore, simpler repair techniques such as the
‘American correction’ [20], the ‘haircut posterior leafletplasty’ [21], premeasured artificial neochordea [22], and the
running annuloplasty suture technique [23] facilitated complex procedures which result in shorter operative times and
excellent outcomes. Since technology and techniques keep
improving, it is likely that more reproducible and preferable
results will be achieved.
1.5.2
Robotic Coronary Revascularization
The da Vinci system found its first clinical application for
coronary surgery in May 1998 by Mohr who harvested the
left internal mammary artery (LIMA) as bypass graft for
11
hand-sewn anastomosis through a small left thoracotomy
[24]. The scope of robot-assisted coronary operations has
hitherto ranged from internal mammary artery (IMA) harvest with a hand-sewn anastomosis, performed on pump
through a median sternotomy or mini-thoracotomy (minimally invasive direct coronary artery bypass (MIDCAB)), to
multivessel off-pump totally endoscopic coronary bypass
(TECAB). In 1998, Loulmet et al. were the first to report a
completely endoscopic LIMA to left anterior descending
artery (LAD) coronary bypass procedure [25]. Since most
patients who are apt to undergo coronary artery bypass surgery have multivessel diseases, the development of endoscopic multiple bypass grafting is mandatory. Thus further
development in technology and surgical techniques have
been prompted by patients’ needs to facilitate the progression from single-vessel LIMA to LAD to recently quadruplevessel bypass on beating heart TECAB [26] and triple-vessel
bypass on arrested heart TECAB [27]. Multivessel revascularization graft configurations can include combinations of
single, sequential, T, or Y grafts, generally based on one or
both IMAs [28] and can be combined with percutaneous
coronary interventions, which is termed as hybrid coronary
revascularization. Besides ever advancing anastomotic
techniques, novel suture technologies such as self-closing
surgical nitinol microclips termed U-Clip (Coalescent
Surgical, Sunnydale, CA, USA), endoscopic stabilizer
(Intuitive Surgical, USA) and target vessel identification systems will likewise facilitate TECAB procedures.
1.5.3
Robotic Congenital Surgery
Totally endoscopic close-chest congenital surgery can be
achieved through several 8–15-mm microincisions on the
right thoracic wall. This procedure benefits from the ever
rapidly advancing robotic technology. Torracca et al. were
the first to report a small cohort of patients undergoing
robotic atrial septal defect (ASD) repair in Europe [29].
Argenziano et al. demonstrated that ASDs in adults could be
closed safely and effectively using totally endoscopic robotic
approaches with a median cross-clamp time of 32 min in
2003 [30], and robotic ASD repair subsequently gained its
FDA approval. Although patent ductus arteriosus closure and
vascular ring repair have also been successfully completed
robotically [31], ASD repairs remain the most common
totally robotic congenital surgery. Till June 2012, the authors’
team have completed a series of 130 ostium secundum ASD
repairs, of which 76 cases were completed on beating heart.
Besides atrial septal defect repair on beating heart [32], we
have further initiated robotic congenital surgical procedures
such as atrial septal defect repair plus tricuspid valve repair
on beating heart, partial anomalous pulmonary venous con-
12
C. Gao
nection correction, ventricular septal defect repair [33] and
ostium primum defect repair. The feasibility and effectiveness of robotic congenital surgery have been proved and the
optimal results encouraged our team to extend the use of this
technology to patients with more complicated congenital
heart diseases.
1.5.4
Atrial Fibrillation Surgery
Various energy sources have been introduced to simplify the
traditional ‘cut and sew’ approach to allow development of
less invasive therapies for atrial fibrillation. Full Cox-Maze
III right and left lesion sets can be made with robotic assistance as an excellent alternate technology. Lesions can be
significantly visualized to minimize the risks of gaps and
bleeding, which may result in failures. Rodriguez E et al.
described their experience of resecting the right-sided lesions
on CPB while left-sided lesions were treated after opening
the left atrium, and reported their cryolesion set in 2009 [36].
1.5.6
Aortic Valve Surgery
Experience with robotic aortic valve surgery is limited to a
few case reports [39] with only some steps of the procedure
performed robotically. In March 2010, the first in-human
robot-assisted endoscopic aortic valve replacement was
reported to be performed by Balkhy H. [40]. The reproducibility remains to be confirmed by more clinical trials.
Robotic Intracardiac Tumor Resection
Intracardiac tumors generally require active treatment by
surgical resection to prevent thromboembolic complications,
although they are uncommon and mostly benign. Resection
can be achieved through either a left atriotomy or right atriotomy, with trans-septal approach if necessary, autologous
pericardial patches can be used to repair septal defects following excision. The author and colleagues reported the currently largest series of consecutive patients with atrial
myxoma undergoing robotic excision. Resection was
achieved in all patients without surgical mortality or stroke.
Follow-up echocardiograms up noted no recurrence or atrial
septal defect [34]. Similarly, Woo et al. described successful
excision of an aortic valve papillary fibroelastoma [35].
1.5.5
1.5.7
Left Ventricular Epicardial
Lead Implantation
Implantation of the left ventricular lead is usually performed
percutaneously via coronary sinus cannulation, advancing
the lead into a major cardiac vein. This technique is associated with long fluoroscopy times and is limited by coronary
venous anatomy. Early reports by DeRose et al. demonstrated the efficacy of robot-assisted LV lead implantation
without complications or technical failures [37]. Though
larger series of similar procedures have been reported [38],
randomized studies comparing minimally invasive surgical
approach with conventionally transvenous implantation is in
progress.
1.6
Summary & Perspective
Surgical robotics is a state-of-the-art technology that holds
significant promises. As iteration toward a less-invasive surgical tool, robots allow surgeons to perform sophisticated
cardiac surgical procedures that are otherwise limited only to
conventionally median sternotomy.
Surgical robots well demonstrate their unquestionable
benefits over conventionally open surgery in items of
decreased hospitalization time, lowered complication rates,
reduced postoperative pain, improved cosmetic results, and
faster return to normal daily activities. Furthermore, they
overcome many of the obstacles of thoracoscopic surgery as
they improve visualization with 3-D visioning in high definition, in-depth perception and up to 10× magnification, eliminate the fulcrum effect while restore more intuitive hand-eye
coordination, increase maneuverability through elimination
of physiological tremors and ability to scale motions, and
moreover, ergonomically friendly design for stable and untiring surgical performance.
Analogous to thoracoscopy, robotic systems are not yet
available for spectrum of cardiac diseases as broad as surgeries through conventional thoracotomy. Contraindications are
as follows. Optimal port location can occasionally be difficult in the presence of abnormal thoracic anatomy or cardiac
dislocation. Patients with severe pleural adhesions secondary to prior thoracotomy or pleuritis may have higher
potential of injury by introducing trocars and working with
endoscopic instruments. Patients with severe peripheral
artery diseases should be excluded for unfitness to perform
femoro-femoral cardiopulmonary bypass. Furthermore, creation of pneumothorax by insufflating CO2 can lead to hemodynamic impairment. Thus patients who have poor cardiac
functions and poor tolerance of high intrathoracic pressures
may not be the ideal candidates.
In respect to the ever-advancing surgical robotic systems,
with a price tag of several million dollars, their costs seem
prohibitive, let alone the costs of maintenance and upgrading. Thus robotic cardiac surgeries are confined to some specialized centers though the number is expanding. Absence
of haptic sensation and consequent loss of tactile feedback
impair the manipulation of tissue as well as suturing material, which may be the most technical obstacle for surgeons
1
Overview of Robotic Cardiac Surgery
to perform delicate suturing because of their inability to
judge qualitatively. Lack of more compatible instruments
for retraction, exposure and visioning increases the reliance
on tableside assistance to perform certain part of the surgery
such as knotting, retracting, replacing instruments, etc.
Driven by the market as well as patient demands, an
increasing number of centers compete to acquire and incorporate this advanced technology though considerable centers
currently lack practical experience. To such centers, critical
and objective evaluations are requisite for informed decision
before hopping on the “robotic bandwagon” in haste, since
surgical robot is only one of many tools that are prerequisite
for successful cardiovascular surgery.
Hitherto, there has been a paucity of data regarding longterm follow-up studies which are actually in urgent need to
determine whether robotic techniques could become new
standards in cardiovascular surgery. Much remains to be
done before full potential of robotic cardiac surgery can be
realized. Nevertheless, current disadvantages and obstacles
will undoubtedly be remedied with time and improvement in
both techniques and technology.
Robotic surgery, of which the emergence and advancement embodies the humanistic evolution of medical science
and technology, is often heralded as part of a natural and
logical evolution of minimally invasive surgery. Since we are
simply at one point on a continuum and robotic technologies
as well as surgical techniques are progressing stepwise, the
future of robotic cardiac surgery is limited only by
imagination.
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2
Anesthesia for Robotic Cardiac
Surgery
Gang Wang and Changqing Gao
Abstract
Robotic cardiac surgery presents anesthesiologists with new challenges and requires a
necessary learning curve. The key issues of anesthesia for robotic cardiac surgery are
respiratory and cardiovascular changes associated with the patient’s single-lung ventilation
and CO2 pneumothorax, which may reduce cardiac output, increase pulmonary vascular
resistance, resulting in hypoxemia and hemodynamic compromise. The magnitude of the
physiological disturbances is influenced by the patient’s age, the patient’s underlying
myocardial and respiratory function and the anesthetic agents administered. In addition,
transesophageal echocardiography is needed for guidance of central venous cannula in
establishing peripheral cardiopulmonary bypass. Undoubtedly, anesthesiologist plays a
more important role in robotic cardiac surgery than in any other surgeries. This chapter
describes anesthetic strategies and clinical experience for robotic cardiac surgery.
Keywords
Anesthetic strategies • Robotic cardiac surgery • da Vinci
2.1
Introduction
Since the introduction of the da Vinci Surgical System
(Surgical Intuitive, Inc, Mountain View, California, USA)
more than 10 years ago, there has been a widespread interest
in its use in minimally invasive surgery. Many of the difficulties and limitations of conventional endoscopic approaches
have been overcome with the development of the da Vinci
Surgical System. For the patient, a da Vinci procedure can
offer all the potential benefits of a minimally invasive procedure in addition to a much smaller incision and a much
smaller scar. Moreover, other possible benefits are reduced
risk of infection, less pain and trauma, less bleeding and less
need for blood transfusion, shortened length of stay in the
hospital after the procedure and decreased recovery time [1].
Up to today, 18 sets of da Vinci Surgical Systems have been
G. Wang, MD • C. Gao, MD (*)
Department of Cardiovascular Surgery, PLA General Hospital,
No. 28 Fuxing Road, Beijing 100853, People’s Republic of China
e-mail: gaochq301@yahoo.com
introduced to medical facilities in Mainland China, yet, very
few reports have covered anesthetic implications or complications related to the use of this technology. The surgeons at
the PLA General Hospital have completed over 640 cases of
robotic cardiac surgeries since 2007, the largest cohort of da
Vinci robotic cardiac surgeries so far in Asia.
In order to keep pace with the developing technologies in
this field, it is imperative for cardiac anesthesiologists to
have a working knowledge of these systems to formulate an
anesthetic plan, recognize potential difficulties and
complications, provide safe patient care and adapt to the fast
development of robotic cardiac surgery. Objectively speaking, the advent of robotic cardiac surgery has brought new
challenges to both surgeons and the anesthesiologists.
Publications have described in great detail the difficulties
surgeons confront during these procedures [2, 3]. The use of
the robotic system for cardiac surgeries, particularly offpump totally endoscopic coronary artery bypass (TECAB),
is limited to only a few cardiac centers around the world. For
robotic cardiac surgery, due attention should be given not
only to anesthetic considerations like alterations imposed by
C. Gao (ed.), Robotic Cardiac Surgery,
DOI 10.1007/978-94-007-7660-9_2, © Springer Science+Business Media Dordrecht 2014
15
16
G. Wang and C. Gao
the surgical procedure, but also to the patient’s underlying
status. Anesthesia for robotic cardiac surgery involves some
peculiar perioperative anesthetic concerns which are related
to respiratory and cardiovascular changes mainly associated
with the patient’s one-lung ventilation (OLV) and CO2 insufflation (CO2 pneumothorax), the increased intrapleural pressure and the CO2 absorption and its general effects, which
may reduce cardiac output (CO), increase pulmonary vascular resistance (PVR), resulting in hypoxemia and hemodynamic compromise [4]. In addition, the magnitude of the
physiological disturbances associated with surgery is influenced by the patient’s age, the patient’s underlying myocardial and respiratory function and the anesthetic agents
administered [5–7]. Apart from off-pump surgery, transesophageal echocardiography (TEE) is needed for guidance
of central venous cannula in establishing peripheral cardiopulmonary bypass (CPB). Undoubtedly, anesthesiologist
plays a more important role in robotic cardiac surgery than in
any other surgeries [8].
Surgical procedures performed in cardiac surgery with
the da Vinci Surgical System are as follows:
1. Left and right internal mammary artery harvest with
– Totally endoscopic coronary artery bypass (TECAB)
– Minimally invasive direct coronary artery bypass
(MIDCAB)
– Hybrid procedure (coronary artery bypass and stent
placement)
2. Totally endoscopic ASD/VSD closure
3. Totally endoscopic mitral valve repair or replacement
4. Other atrial procedures – tricuspid valve repair, myxoma
resection etc.
5. Atrial fibrillation ablation, left ventricular lead implantation
2.2
Preoperative Visit
The prime goals of preoperative evaluation and therapy for
patients before robotic cardiac surgery like other cardiac surgical procedures are to quantify and reduce intraoperative
risks to patients during and after surgery. Preoperative evaluation and therapy enable the anesthesiologist to review the
patient’s history and results of the preoperative examination,
and explain the techniques of anesthesia and monitoring to
the patient. The physical examination ensures that airway
and chest anatomy should be suitable for insertion of a
double-lumen tube to facilitate OLV. Thus, a patient who has
documented difficulty with intubation, major scoliosis, or
emphysematous chest may be identified in the preoperative
clinic as unsuitable for this type of surgery. Awake intubation
may be indicated in difficult airway in order to keep the
patient breathing spontaneously. Preoperative pulmonary
function test, arterial blood gases, and chest X-ray and computed tomographic scan are evaluated; these may provide
information to predict whether the patient is suitable for
prolonged OLV. On the other hand, preoperative evaluation
and communication with the surgical team are necessary
for determining the methods and techniques appropriate for
induction, maintenance of anesthesia, airway management,
and monitoring.
The anesthesiologist should tell the patient to continue the
necessary medications up to the morning of surgery, e.g. the
antihypertensive and antianginal medications, and particularly beta-blockers, which should be continued throughout
the perioperative period to decrease myocardial irritability
and maintain a slow heart rate. The patients should withhold
the morning dose of insulin and oral hypoglycemic medications on the day of the surgery. The anesthesiologist should
confirm that the patient does not take aspirin and clopidogrel
for at least 5–7 days prior to the surgery, unless the surgeon
has specified otherwise [9, 10]. Electrolytes such as potassium and magnesium should be checked preoperatively and
should be within normal range prior to anesthesia.
2.3
Patient Selection
Aside from understanding the standard contraindications to
cardiac surgical intervention, patient selection for robotic
cardiac surgery involves a history and physical exam heavily
weighted on uncovering factors affecting external and internal thoracic structures. The primary difference between
robotic cardiac surgery and sternotomy cardiac surgery is the
requirement for prolonged OLV and induced tension pneumothorax. Anesthesiologists should consider the physiologic
responses of the patient to robotic cardiac surgery such as
hemodynamics, gas exchange, ventilation-perfusion distribution, and echocardiographic or TEE examinations. Until
recently, primarily ASA I to II patients have been considered
for robotic cardiac surgery. Whether robotic cardiac surgery
is suitable for patients with a compromised physical status
has been an anesthesiologist consideration. To correctly
establish the risks for these “sicker” patients, a more detailed
knowledge of the physiologic changes associated with the
procedure is indicated.
Patients with severe chronic obstructive pulmonary disease (COPD) or asthma or major emphysematous bullae will
be poor candidates to tolerate the hypercapnia, potential
hypoxemia, and barotraumas resulting from OLV and CO2
pneumothorax. More details are suggested that patients with
significant comorbidity, such as compromised pulmonary
function tests, resting hypercapnia (>50 mmHg) and hypoxemia (PaO2 <65 mmHg on room air), those requiring additional cardiac procedures, left ventricular ejection fraction
<40 %, and dense pleural or pericardial adhesions limiting
visibility, are not considered for robotic surgery [11].
Cardiac status is even more important to patients undergoing
2
Anesthesia for Robotic Cardiac Surgery
the robotic mitral valve surgery, because with long-standing
diseases, patients may develop moderate, even severe
cardiac malfunction and high pulmonary arterial pressure
during surgery. As a result, patients may become very vulnerable because of OLV, CO2 pneumothorax and CPB.
Mishra et al. [12] gave the suggestion of patient selection for
TECAB as follows. Patients with significant comorbidity
such as compromised pulmonary function, those that require
additional cardiac procedures, LVEF <30 %, associated ventricular or aortic aneurysm surgery, or significant peripheral
vascular disease precluding femoral CPB procedures, were
not considered for robotic surgery. Other preoperative exclusion criteria included body mass index >35.0 kg · m−2,
decompensated congestive heart failure (NYHA class III–
IV), acute pulmonary edema, uncontrolled hypertension,
and any coagulopathy, or history of acute myocardial infarction within 30 days [12].
Usually, in patients with COPD, pulmonary function
should be optimized with the aid of bronchodilators, steroids
and physiotherapy. Buggeskov and colleagues [13] found
that the patients with COPD may be impaired by hypoxemia
and systemic inflammatory response during the CPB. For
smokers, it is necessary to stop smoking for at least 2 weeks.
It was demonstrated that arterial oxygen tension showed significant reduction in heavy smokers in comparison with nonsmokers during OLV [14]. Because of the relatively small
number of da Vinci Surgical Systems deployed for cardiac
Fig. 2.1 Properly positioned left
double-lumen endobronchial tube
is confirmed by a fiberoptic
bronchoscope
17
surgery to this date, we can assume that as more
procedures will be performed using robotic technique and
the anesthesiologists will become more familiar with the use
of the robotic equipment, it can be expected that there will be
more changes in patient-selection criteria.
2.4
OLV and CO2 Insufflation
OLV can be established with several methods The simplest
method of providing OLV is to intubate double-lumen endotracheal tube, such as Robertshaw tube, Carlens, White,
Bryce-Smith, etc. All have two lumina, one terminating in
the trachea and the other in the mainstem bronchus. Left
Robertshaw tube is most widely used. The advantage of
double-lumen endotracheal tube is that it is easy to apply for
suction and/or CPAP to either lung. In addition, there are
three kinds of single-lumen endotracheal tube with a built-in
bronchial blocker. These are achieved by using an Arndt
Blocker (wire-guided), a Univent tube, or a Fogarty catheter.
Bronchial blockers have been used to establish OLV by using
a balloon catheter inflated to occlude the bronchus of the
lung being operated on.
Tube patency and position should be checked (Fig. 2.1).
Secretions may be blocking the tube lumen. Looking at the
capnograph trace, if it is changed, it could be concluded as a
general rule that the tube has been moved. Even if you have
18
G. Wang and C. Gao
One-lung CPAP device
Right angle connector
Adjustable settings
(5−20 cm H2O)
Clamp to nonventilated lung
(not supplied)
15 mm adaptor
Anesthesia breathing
circuit
To nonventilated lung
Endobronchial tube
To ventilated lung
Fig. 2.2 Application of CPAP to the non-ventilated lung
carefully tied it in place, movement may occur during
manipulation by surgeons and TEE. Bronchoscopy will confirm this and allow the tube to be repositioned.
OLV is initiated prior to insertion of trocar to prevent lung
injury. Respiratory changes may occur during the OLV and
the CO2 insufflation. Firstly, ventilation-perfusion relationship may be altered by the modified lateral decubitus position in the anesthetized patient during two-lung ventilation.
Perfusion is normally distributed preferentially to dependent
regions of the lung because of the hydrostatic gradient
imposed by gravity to the benefit of the overall ventilation to
perfusion ratio (V/Q) maintained. Nevertheless, general
anesthesia, neuromuscular blockade, and mechanical ventilation increase V/Q mismatch. Secondly, intrapleural CO2
insufflation positive pressure constricts the lung, reducing
compliance, functional residual capacity (FRC) and tidal
volume. OLV may cause further damage to ventilatory conditions by limiting the ventilation of the nondependent lung
and create an obligatory right-to-left transpulmonary shunt
through the nondependent lung [5, 15, 16]. Last, hypercapnia may occur during OLV and pneumothorax, partly due to
CO2 absorption across the pleura, and partly because of a
mechanical constriction on the pulmonary parenchyma,
reducing tidal volume, FRC, total lung capacity and pulmonary compliance [6, 17, 18]. Because of the above changes,
it is not uncommon for a patient to desaturate during OLV. If
this happens, the first thing needed is to give the patient a
larger breath by hand with sustained pressure at the end of
the breath, or applying positive end expiratory pressure
(PEEP) to the ventilated lung. That may help to prevent the
small airways from closing. Usually 5 cm H2O is enough to
keep the saturation up without pushing the peak inspiratory
pressure too high (above 40 cm H2O). In fact, if PEEP is too
high, blood is diverted to the collapsed lung and the shunt is
increased, which will worsen the hypoxemia. Meanwhile, it
needs to sure that the patient’s blood pressure has not dropped
because dropping of blood pressure may also be the cause of
desaturation.
If severe hypoxemia occurs or airway pressure increases
significantly, double-lumen endotracheal tube position
should be checked at once with fiberoptic bronchoscope to
ensure its proper placement. Add continuous positive airway pressure (CPAP 5–10 cm H2O, 5 L/min) to collapsed
lung may help to reduce shunt, divert blood to the ventilated
lung effectively and to improve oxygenation (Fig. 2.2).
When necessary, reinflating the collapsed lung to return to
two-lung ventilation temporarily is always an option.
Medication to decreased intrapulmonary shunt due to the
collapsed lung include using almitrine (12 μg/kg/min for
10 min followed by 4 μg/kg/min) [19] and inhaled nitric
oxide that enhance hypoxic pulmonary vasoconstriction
(HPV) [20].
It must be noted that pressure of 5–10 cm H2O will not
immediately inflate an already collapsed and atelectatic lung
and it may not be very helpful to increase oxygenation right
away. Therefore, it is necessary to reinflate the lung with
higher airway pressure and then use CPAP to keep lung at a
constant level of inflation. High frequency jet ventilation is
2
Anesthesia for Robotic Cardiac Surgery
another method and keeps the lung almost immobile helping
with operating conditions [21].
Currently, the definition of permissive hypercapnia has
been approved by more and more clinicians. The literature
generally agrees that CO2 should be allowed to rise while
reducing tidal volume and minute ventilation in order to
prevent alveolar overdistention or the propagation of lung
injury [22, 23]. The use of excessive airway pressures may
increase pulmonary vascular resistance in the dependent
lung and increase flow through the nondependent lung.
Therefore, the lungs should be protected against high airway pressures during OLV with intrapleural CO2 insufflation, by carefully balancing tidal volume, respiratory rate,
minute ventilation and PETCO2 [17, 23–26]. In clinical conditions, PETCO2 that shows the tendency to increase during
the course of the OLV and CO2 pneumothorax and sometimes is higher than the normal range, is nevertheless always
within the ranges foreseen for moderate permissive hypercapnia [22].
During OLV, arterial oxygenation may markedly decrease
because of an increased intrapulmonary shunt due to the collapsed lung. Therefore, it is necessary to increase FiO2 to
over 0.5 during OLV and CO2 pneumothorax. The increase
of FiO2 is the principal measure allowing an adequate oxygenation. Hypoxic pulmonary vasoconstriction (HPV), a
physiologic defense mechanism that serves to divert blood
away from poorly ventilated lung regions, is a second way to
maintain oxygenation during OLV by restricting pulmonary
blood flow to the nondependent lung. OLV management
should be reduced to the minimum in any clinical conditions
that might directly vasodilate hypoxically constricted lung
vessels, such as the presence of infection, vasodilator drug
infusion and the use of certain anesthetics (Table 2.1) [12,
27, 28]. Intravenous anesthesia does not influence HPV,
while isoflurane, desflurane and sevoflurane have been
shown to have less effect on HPV than halothane. To limit
their effects on oxygenation, inhalation agents should be
used at minimal concentration or less [17, 25]. Also, the
intraoperative hypoxia can be reduced by delivering lowflow oxygen to the nondependent lung through a doublelumen bronchial tube or a bronchial blocker with a distal port
[15, 27].
CO2 insufflation causes significant circulatory perturbations, alone or in combination with OLV. Cardiovascular
function is impaired proportionally to intrathoracic CO2
pressure [29]. An excessive positive pressure results in significant hemodynamic compromise which reduces preload,
stroke volume, cardiac index, mean arterial pressure and
reflex tachycardia [16, 30, 31]. Therefore, in early stage, the
intrapleural pressure is monitored directly via an 18-gauge
IV cannula and pressure transducer to avoid excessive pressure generation [10]. Nevertheless, slow increase of the
intrathoracic CO2 pressure, limitation of CO2 insufflating
19
Table 2.1 Anesthesiology interventions that modify HPV (Reproduced
with permission from Nagendran et al. [28])
Decrease HPV
Dextran volume replacement
Halothane
Halothane and verapamil
Nifedipine
Alkalosis (respiratory or metabolic)
Nitroprusside
Hypothermia
Pregnancy
Increase HPV
Lateral decubitus position
Thoracic epidural anesthesia
Propofol
Lidocaine
High-frequency positive pressure ventilation
Neutral to HPV
Propofol
Enflurane
Isoflurane
Fentanyl
pressure, and cardiovascular function optimization (by fluid
administration or possible use of inotropic agents) are effective to minimize the hemodynamic changes with only a
slight reduction in the preload, but without any major effects
on cardiac output and mean arterial pressures [25, 30, 32]. So
the hemodynamic compromise is generally well tolerated by
the patients with normal cardiac function. A correct way is
that the intrapleural insufflation is always performed in
stages and the desired intrathoracic pressure should never be
attained in less than 1 min.
A recent study on adult thoracoscopy compares OLV
with intrapleural CO2 insufflation in respect of the hemodynamic and respiratory effects. The investigation shows a
reduction in cardiac index due to intrapleural insufflation
that is statistically greater than that provoked by OLV,
while the variations in the oxygenation index are statistically greater during OLV with respect to intrapleural insufflation [33]. In one word, intrapleural CO2 insufflation
brings about hemodynamic changes characterized by a fall
in systolic and diastolic blood pressure greater than in
OLV. On the other hand, respiratory endangerment arises
due to a greater rise in PETCO2 in patients undergoing OLV
than in those where more intrapleural insufflation is
applied [34].
In patients with preoperative pulmonary abnormalities,
PETCO2 is statistically higher both during OLV and after
pleural cavity deflation. The restrictive, obstructive and
mixed ventilatory defects need careful ventilatory strategies. In such cases high intraoperative airway pressure
should be avoided and a small increase in PETCO2 is preferable [35].
20
G. Wang and C. Gao
Table 2.2 Hemodynamic changes after induction of anesthesia with hypnotics [39]
HR
MBP
SVR
PAP
PVR
PAO
RAP
CI
SV
LVSWI
dP/dt
Diazepam
−9 ± 13 %
0–19 %
−22 ± 13 %
0–10 %
0–19 %
Unchanged
Unchanged
Unchanged
0−8 %
0–36 %
Unchanged
Droperidol
Unchanged
0–10 %
−5–15 %
Unchanged
Unchanged
+25 ± 50 %
Unchanged
Unchanged
0–10 %
Unchanged
–
Etomidatea
−5 ± 10 %
0–17 %
−10 ± 14 %
−9 ± 8 %
−18 ± 6 %
Unchanged
Unchanged
−20 ± 14 %
0–20 %
0–33 %
0–18 %
Ketamine
0–59 %
0 ± 40 %
0 ± 33 %
+44 ± 47 %
0 ± 33 %
Unchanged
+15 ± 33 %
0 ± 42 %
0–21 %
0 ± 27 %
Unchanged
Lorazepam
Unchanged
−7–20 %
−10–35 %
–
Unchanged
–
Unchanged
0 ± 16 %
Unchanged
–
–
Midazolam
−14 ± 12 %
−12–26 %
0–20 %
Unchanged
Unchanged
0–25 %
Unchanged
0–25 %
0–18 %
−28–42 %
0–12 %
Propofol
−10 ± 10 %
−10–40 %
−15–25 %
0–10 %
0–10 %
Unchanged
0–10 %
−10–30 %
−10–25 %
−10–20 %
Decreased
CI cardiac index, dP/dt first derivative of pressure measured over time, HR heart rate, LVSWI left ventricular stroke work index, MBP mean blood
pressure, PAP pulmonary artery pressure, PVR pulmonary vascular resistance, PAO pulmonary artery occluded pressures, RAP right atrial pressure, SV stroke volume, SVR systemic vascular resistance
a
The larger deviations are in patients with valvular disease
2.5
Induction and Maintenance
of Anesthesia
The hemodynamics stability should be taken into consideration in cardiac anesthetic selection (Table 2.2). Today cardiac anesthesia is still based on fentanyl or sufentanil, in
combination with etomidate, midazolam, and muscle relaxats for induction and trachea intubation with a double-lumen
endotracheal tube. Longer acting muscle relaxants i.e. pancuronium or pipecuronium may subsequently be supplemented to ensure patient paralysis after port placement
[36, 37], because patient movement with robotic arms in situ
may be devastating [38].
There is no single strategy to be recommended for maintenance of anesthesia; hypnotics (midazolam or propofol), opioids and volatile anesthetics are used in different combinations.
The dose and selection of anesthetic agents must provide
adequate anesthesia and analgesia during induction and surgery, and attenuate the hemodynamic responses to laryngoscopy and surgery. For robotic cardiac surgery, dosages and
the type of the drugs that are to be used depend on the desire
of ‘fast-track’ – extubation in the operating room or, more
commonly, several hours after arrival in the ICU (Table 2.3).
High-dose opioids based anesthetic management of the
cardiac surgical patients, with more stable hemodynamics
providing a long-term mechanical ventilation, has been supplanted by protocols using low-dose fentanyl, sufentanil, or
alfentanil [41, 42], to facilitate early extubation. Sufentanil is
used in combination with midazolam, propofol and inhaled
anesthetics to provide more stable hemodynamics when it is
compared with fentanyl-based anesthetic protocols.
Sufentanil has a half-life of about 20–40 min and allows
patients to awaken within hours of completion of the operation. Remifentanil is a short-acting, esterase-metabolized
without any active metabolites, rapidonset μ-opioid receptor
agonist, with a context-sensitive half-life of 3–5 min that
Table 2.3 Recommended induction doses [40]
Drug
Induction dose
Hypnotics
Propofol
1–2 mg/kg
Thiopental
2–4 mg/kg
Etomidate
0.15–0.3 mg/kg
Opioids
Fentanyl
3–10 μg/kg
Sufentanil
0.1–1 μg/kg
Remifentanil
0.1–0.75 μg/kg/min or bolus 0.5–1 μg/kg
Muscle relaxants
Cisatracurium
70–100 μg/kg
Vecuronium
70–100 μg/kg
Pancuronium
70–100 μg/kg
Rocuronium
0.3–1.2 mg/kg
Succinylcholine
1–2 mg/kg
Maintenance of anesthesia in critically ill patients
Sedative/hypnotic agent
Propofol
20–100 μg/kg/min
Lorazepam
2–4 mg (25–50 μg/kg)
Diazepam
4–8 mg (50–100 μg/kg)
Midazolam
0.25–0.5 μg/kg/min
An opioid infusion
Remifentanil
0.05–0.1 μg/kg/min
Fentanyl
0.03–0.1 μg/kg/min
Sufentanil
0.01 μg/kg/min
Dexedetomidine
0.5–1 μg/kg/h
may be beneficial in shorter operations and in elderly patients
[43–45]. It provides stable hemodynamics in high-risk cardiac surgical patients. Remifentanil-propofol combination is
usually selected for patients who can be extubated promptly
after surgery. Thus, propofol has not been shown to increase
overall hospital costs [46].
Midazolam has been shown to have an average elimination half-life of 10.6 h in patients recovering from cardiac
2
Anesthesia for Robotic Cardiac Surgery
surgery [47]. Although early extubation can be achieved in
patients receiving midazolam throughout surgery, most
groups limit its use to the pre-bypass period. Propofol providing stable hemodynamics at the recommended doses of
infusion 2–4 mg/kg/h and continue it in the ICU [4, 8].
Propofol decreases systemic blood pressure and systemic
vascular resistance because of its strong vasodilator properties. The major advantage of using propofol is the early extubation leading to shortening the length of stay in ICU. When
the patient is stable, propofol is turned off and the patient is
allowed to awaken [48].
Cason et al. [49] first described the term anesthetic preconditioning in 1997, by showing protective effect of isoflurane applied shortly before ischemia. Since then numbers of
experimental studies revealed the cardioprotective efficacy
of volatile anesthetics [50]. Agents commonly used include
isoflurane, enflurane, desflurane, and sevoflurane, which are
generally given during CPB to maintain anesthesia and
reduce blood pressure, and allow to decrease the doses of
intravenous medications. Desflurane and sevoflurane have
less lipid solubility with a rapid onset of action and are
quickly reversible, allowing for early extubation. A recent
meta-analysis the choice of desflurane and sevoflurane
results in better outcome in terms of mortality and cardiac
morbidity in cardiac surgical patients [51]. Although the
exact mechanism of preconditioning of volatile anesthetics
is not yet known, the cardiac depressant effects that reduces
myocardial oxygen demand, were demonstrated to have
direct cardioprotective effects [50]. Nitrous oxide is contraindicated because it reduces the amount of oxygen that can
be delivered and may also increase pulmonary arterial
pressures.
Muscle relaxants are given throughout the operation to
minimize patient movement and suppress shivering during
hypothermia. Pancuronium offsetting the bradycardia effect
of high-dose opioids has been the prefered neuromuscular
blocker, however it has also been shown to have potential to
produce a tachycardia causing myocardial ischemia during
induction. In contrast, vecuronium and pipecuronium have
very few hemodynamic effects. Rocuronium is a short-acting
neuromuscular blocker with a rapid onset of action and
vagolytic properties. It provides more adequate conditions
especially for fast track anesthesia due to its less residual
blockade and shorter time to extubation [52]. Atracurium
does not undergo renal elimination and is the best agent to be
used in patient with renal insufficiency [53].
2.6
Anesthetic Technique
In robotic cardiac surgery, anesthesiologist should be versed
in cardiac and thoracic anesthesia and familiar with the skills
required for TEE and nonsternotomy CPB. Strategies of
respiratory management are the key point of anesthesia
21
involving OLV and CO2 pneumothorax. However, OLV and
CO2 pneumothorax can be the cause of hemodynamic instability and should be closely monitored. CO2 insufflation in
the chest cavity will lead to an increase in peak airway pressure, particularly during OLV. Usually, double lumen tube is
mostly used for OLV and should be replaced by a single
lumen tube following surgery. However, care must be taken
that swelling of the glottis and pharynx resulting from intubation and TEE might make reintubation difficult. In a few
cases in which the airway is deemed to be difficult, Univent
tube or bronchial blocker should be used, and optimal position is achieved with the use of a fiberoptic bronchoscope
[54]. Although they do not allow CPAP or suction to the collapsed lung, they do not need to be replaced at the end of
surgery. They may be placed more easily in patients who are
difficult to intubate or who have a small glottis opening,
which often would not accommodate the large double lumen
tube.
TEE guidance of cannula during peripheral cardiopulmonary bypass is crucial to success. Femoral-Femoral bypass is
the most commonly used technique. Complications from
arterial cannulation are reduced when TEE is used to confirm
the location of the arterial wire within the aorta. Venous cannulae must also be guided into the inferior vena cava and into
the superior vena cava [55]. Also, the surgeons now rely
almost exclusively on high-quality intraoperative TEE imaging to plan mitral valve repair. A saline test is performed
intraoperatively to confirm the echocardiographic findings,
and occasionally measure the valve segments directly [56].
Because the side cart is close to the patient’s head, there
is limited access to the patient’s airway and neck.
Anesthesiologist and the bed-side assistant must be guarded
against patient-robot collision during surgery, which is
defined as a limitation in the free movement of the robot’s
telemanipulated arms by interference with the patient’s body
[57]. After the robot is engaged, the patient’s body position
cannot be changed. The surgical team should be capable of
rapidly disengaging the robotic device if an airway or anesthesia emergency arises. An optimal surgical position is that
the patients are placed in an incomplete side-up position at a
30° angle right or a left lateral decubitus position. Positioning
the arm of the elevated side along the side with gentle elbow
flexion has reduced conflict with robotic arms and decreased
risks of a brachial plexopathy. It is important to take care of
avoidance of unnecessary stretching of the elevated side arm
because it can produce damage to the brachial plexus.
A recent case report [58] described a brachial plexus injury
in an 18-year-old male after robot-assisted thoracoscopic
thymectomy. In this report the left upper limb was in slight
hyperabduction. In some centers, the arm of the elevated side
is hanged above the head. The elevated arm should be protected by using a sling resting device [59].
Before the arm of the robot is in the chest cavity,
a complete lung collapse must be maintained throughout the
22
procedure. Robotic surgery with the da Vinci Surgical
System does not allow for changes in patient position on the
operating table once the robot has been docked. Close
communication between the surgeon and anesthesiologist
in relation to the positioning and functioning of the robot is
mandatory.
As the heart is limited by the minithoracotomy approach,
cardiac defibrillation must be provided by means not requiring direct epicardial contact. External defibrillator pads are
placed on the back and the opposite chest wall. Successful
termination of ventricular fibrillation (VF) by electrical defibrillation is dependent on the delivery of sufficient electrical
current through the heart to depolarize a critical mass of
myocardial tissue [60–62]. Transmyocardial current is
directly related to the energy delivered, and inversely related
to transthoracic electrical impedance (TTI) [63]. Because air
and CO2 in the chest act as electrical insulators, they can
increase both TTI and defibrillation thresholds [64]. There
are other proofs, pneumothorax has been linked to repeated
failed defibrillation and increased energy requirements during induced VF with implantable cardioverter-defibrillator
placement [65–67]. In these cases, resolution of pneumothorax results in improvement in defibrillation thresholds.
Hatton et al. [68] reported a case of multiple failed defibrillation attempts during robot-assisted LIMA harvest during
OLV that VF might be resulted from inadvertent pericardial
application of electrocautery. The 4th time of external defibrillation attempt with resumption of two-lung ventilation
and decompression of the iatrogenic pneumothorax, the
patient was successfully defibrillated.
The bulk of the robot is positioned over the abdomen and
chest. Although the incidence of airway or serious cardiovascular events are no greater in robot-assisted surgery, if they
do occur, the position of the robot will interfere with effective cardiopulmonary resuscitation and airway interventions
[69]. The theatre team should practice an emergency drill for
the removal of the robotic cart.
The successful use of the robot to assist in surgery depends
upon excellent communication among all members of the
theatre team. The surgeon sits behind a console, away from
the site of operation, but must communicate effectively with
both anesthetic staff and his operative assistant at the
patient’s bedside. The special care must be taken to ensure
that transfer of information is precise and clear. This is aided
by the addition of audio speakers to the video tower that
transmits the operating surgeon’s voice.
The postoperative course is usually uneventful. On arrival
in the cardiac surgery ICU, all patients remain sedated (usually with propofol) until hemodynamics become completely
stable and with minimal blood drainage. The incidence of
complications is low. Blood transfusion is not normally
required as intraoperative blood loss is very low, but significant hemorrhage may be insidious and the patient should be
G. Wang and C. Gao
carefully monitored in the immediate postoperative period.
Postoperative analgesic considerations are similar to those
corresponding non-robotic operations.
2.7
Anesthesia Consideration of Robotic
Assisted CABG on Beating Heart
For robotic assisted CABG on beating heart, fast-track anesthesia with early extubation appears to be normal, which can
involve either extubation immediately at the conclusion of
surgery or within a few hours of arrival in the ICU. The goal
of minimally invasive coronary artery bypass grafting is to
perform the entire anastomosis endoscopically and avoid
CPB. The result is to reduce postoperative morbidity, length
of hospital stay, and overall cost. Advances and experience
in beating heart surgery have aided this approach.
The first closed-chest CABG surgery with the aid of
robotic instruments was performed on human in June 1998
[70]. Thereafter, the technique of robotic assisted CABG has
achieved perfection. Technical advances in minimally invasive surgery have enabled CABG to be performed through
very small ports. Sternotomy alone carries a finite risk of
morbidity from an inflammatory response, but it is less than
that of exposure to cardiopulmonary bypass [71, 72]. Robotic
assisted CABG on beating heart (off-pump) includes two
kinds of surgeries: TECAB and MIDCAB in which the left
internal mammary artery (LIMA) is harvested robotically
and direct anastomosis through a small left anterior thoracotomy incision (6 cm) [73–75]. Although the anesthetic
concerns in managing robotic assisted CABG operation are
similar to those of any patient requiring surgical revascularization, this surgical technique requires greater communication and coordination between the surgical team and the
anesthesiologist. The anesthesiologist in this setting must
provide both hemodynamic stability and relative bradycardia. Because the minithoracotomy incision permits only limited access to the heart, the anesthesiologist must give early
warning of impending cardiovascular collapse and the need
for emergent institution of CPB. So a perfusionist should
always be prepared in the operating room in the event of the
need for CPB.
Performance of the distal anastomosis involves the use
of a myocardial stabilizer designed to isolate a small segment of myocardium with the relevant coronary artery, and
proximal and distal silastic sutures to control back-bleeding
[10]. Intracoronary shunts are often used to facilitate anastomosis and maintain distal perfusion, particularly to the
target vessel that the myocardium perfusion still depends
on. But putting the intracoronary shunt into the target vessel
is not easy in TECAB surgery and it may disturb the anastomosis with continuous suture or U-clip. Alternatively, it
can be done to provide ischemic preconditioning to assess
2
Anesthesia for Robotic Cardiac Surgery
the possibility of not using intracoronary shunt during the
anastomosis, a 5 min test occlusion of the LAD is conducted before coronary arteriotomy [76]. If this is well tolerated, the LIMA to LAD anastomosis is completed without
CPB. If signs of ventricular dysfunction appear, median
sternotomy may be performed, and the patient can be placed
on CPB, or alternatively, femoral-femoral CPB may be
initiated.
In our institution, the details of anesthesia are as follows
[4, 8]. Patients are prepared and draped as for conventional
cardiac surgery, permitting sternotomy in case of need. All
cardiac medications should be continued up to the day of
surgery. Patient monitoring consists of standard electrocardiogram leads II and V5 and a right radial artery catheter
placed under local anesthesia before induction. Intubation is
performed with a left-sided double-lumen endotracheal tube
and correct placement is confirmed by both auscultation and
fiberoptic bronchoscopy. After intubation, a pulmonary
artery catheter is placed in the right internal jugular vein
(RIJV). A two-lumen central venous catheter is also placed
in the RIJV in all patients. TEE probe is placed after all central catheters are inserted. This anesthetic protocol permits
patients to be entered into an early extubation and fast-track
recovery protocol. Postoperative analgesia is administered
with intravenous sufentanil.
It is important that throughout the operation the heart rate
remains slow and stable. The combined use of nitroglycerin
and beta-blockade minimizes the possibility of myocardial
ischemia during the period of vascular occlusion. If systemic
hypotension occurs as a consequence of the procedure or
from the anti-ischemia therapies, small amounts of phenylephrine or norepinephrine are administered to transiently
augment vascular tone and restore systemic pressure. The
effects of drug administration on the cardiac index, pulmonary artery pressures, and ventricular function as assessed by
TEE are closely monitored. Usually, CO2 insufflation and
OLV increase central venous pressure and pulmonary artery
pressure by a small amount [77].
For the multivessel revascularization indication, both
internal thoracic arteries (ITA) may be used for grafting of
the LAD, diagonal branch, right circumflex, and right coronary artery. Bilateral ITA grafting is feasible but appears to
be very challenging and time consuming. Such a procedure
should be accepted only for very special indications [78]. For
harvesting both ITA, insufflation of the left hemithorax is
sufficient to expose the right internal mammary artery
because of the leftward position of the heart and the improved
angle of sight. If the right side pleural is broken, both sides
of intrapleural CO2 positive pressure may cause further
damage to ventilatory conditions by limiting the ventilation
of the right lung and increased CO2 absorption across
the pleura, and this may result in hypercapnia and tachycardia more easily. To control heart rate slower and stable is
23
difficult in the situation. Most patients studied tolerate
bilateral pneumothorax well for periods less than 1 h [79].
Graft patency is usually evaluated intra-operatively using
direct measurement of blood flow by means of a Doppler
flow meter. The blood flow measured is thus dependent on
systemic blood pressure and distal coronary run-off.
2.8
Anesthesia Considerations
of Minimally Invasive Mitral Valve
Surgery with da Vinci Surgical System
Technological innovations are improving minimally invasive mitral valve surgery as da Vinci Surgical System
becomes a feasible, safe and effective option in mitral valve
surgery [80, 81]. It is claimed that the robotic mitral valve
repair and replacement allow complete anatomic correction
of all categories of leaflet prolapses, enhance visualization of
the valve which can afford a high mitral valve repair rate,
offer excellent freedom from adverse events, decrease ventilation time and length of stay [82, 83], and have excellent
early-term and mid-term results [84].
The preoperative considerations required for anesthesiologists is to evaluate and estimate the cardiac and lung functions of the patients, as well as the change of pathophysiology
of heart, the tolerance to OLV and CO2 pneumothorax, and
the effect of CPB. All these need adapt the prudent strategy
to manipulation of the infusion, use of inotropic and reasonable ventilation management in order to maintain the stable
of hemodynamic and effective deal with hypoxemia. From
the induction of anesthesia to start the CPB, it is crucial to
maintain stable hemodynamic and oxygenation. An understanding and an appreciation of pathophysiologic changes
associated with mitral stenosis and mitral insufficiency form
the foundation of anesthetic management in this kind of
patients. With long-standing mitral valve disease, the elevated left atrium pressure leads to passive increases in pulmonary arterial and venous pressure. During surgery the CO2
pneumothorax is needed which may artificially create a positive intrathoracic pressure and results in relative hypovolemia by reduce the venous return. In addition, most patients
with valve heart disease have increased dependency and sensitivity to ventricular preload. The adequate intravascular
fluid is not only benefit to keep heart rate in an optimal range
but also to maintain the cardiac preload. Tachycardia has detrimental effects on mitral stenosis because of the decreased
time for diastolic filling. For mitral insufficiency patients,
especially with ventricular distention, the inotropic (dopamine or epinephrine) is often used to maintain a stable hemodynamic condition.
Hypoxemia may occur during OLV, especially in
the post-CPB phases. The following factors may contribute
to Hypoxemia. Firstly, left OLV is more harmful to
24
oxygenation. Slinger et al. [85] found that the side of
position to be one of the important factor in predicting
hypoxemia during OLV, which may be relevant to the fact
that the right lung is larger than the left one. A recently
study also found that, while ventilating with an FiO2 of 1,
mean arterial oxygen tension was approximately 280 mmHg
on the left-sided as compared with approximately
170 mmHg on the right-sides thoracic operation during
OLV [86]. Secondly, the airway is narrowed because of the
use of double-lumen endotracheal tube, prolonging alveolar
emptying time. Some alveoli are over inflated and damaged
because of the high inspiratory pressures during OLV resulting in alveolar edema [38]. Fortunately, the hypoxic pulmonary vasoconstriction (HPV) is beneficial to reduce the
perfusion of the nonventilation lung and improving oxygenation [87]. It is demonstrated that the level of tidal volume
during OLV could be maintained just as that during twolung ventilation without positive end-expiratory pressure,
targeting normalization of CO2 [88, 89]. Thereby, it is reasonable to keep the tidal volume as in two-lung ventilation
and regulate the respiratory rate (10–15 bpm) to maintain
the PETCO2 in 40 mmHg.
The TEE is crucial for proper placement of the catheter,
such as the femoral venous (IVC) and internal jugular
venous (SVC), and the transthoracic aortic root cannulation in robotic mitral valve surgery. The TEE can not only
contribute to complete de-airing of the cardiac chambers
before coming off CBP so that coronary air embolism and
subsequent right or left ventricular dysfunction are minimized, but also help to assess the quality of the mitral valve
procedure and the status of aortic valve. The CO2 insufflation is adopted, which has the advantage of creating high
carbon dioxide levels in the left cardiac chambers, potentially reducing the risk of air embolism. It is claimed that
the neurologic deficits could result from inadequate deairing or retained particulate embolus from the operative
field [90]. Therefore, to ensure removal of all source of
potential embolus, the surgeon should be very careful with
broken sutures and other debris encountered during the
procedure.
It is found that the nodal arrhythmia frequently appear
after termination of CPB. The potential cause of the phenomenon is not explicit. The thin muscular wall of the right
atrium possesses less resistance to mechanical shift and ischemia injury resulting from OLV and intrathoracic CO2 positive pressure, and that eventually leads to dysfunction of
sinoatrial node. A similar situation has been that OLV can
add strain on the right ventricle in patients with preexisting
dysfunction leading to decompensation, and the persistent
hypoxemia during OLV will increase sympathetic tone and
can lead to arrhythmia promotion [91]. Sometimes, the nodal
arrhythmia is harmful to maintaining of the circulatory stability, so cardiac pacemaker may be needed temporarily.
G. Wang and C. Gao
Fortunately, in our series, most patients automatically
regained sinus rhythm at 30–60 min after CPB is stopped.
Since CPB is typically associated with hemodilution, hypothermia, and nonpulsatile blood flow, the cross-sectional
area and the flow profile of the cerebral vessels may not
remain constant during hypothermic CPB [92]. The conditions of hypothermic CPB may potentially damage the cerebral blood flow when the peripheral CPB is established
through the femoral arterial and venous. So it is worth stressing that the ventilation should restart as early as possible
before weaning off the CPB, especially when the perfusion
volume is being reduced.
We observed that hypoxemia mostly occurred after terminating CPB during OLV [4], at this point surgeons are
engaged with identifying and controlling any bleeding. The
following factors may be responsible for hypoxemia: (1)
Blood contact with artificial surfaces during CPB that may
provoke systemic cytokine-mediated inflammatory, lung
ischemia and reperfusion injury with increases in immunologic mediators and CPB-induced non-physiologic laminar
perfusion, are considered reasons for postoperative hypoxemia [93, 94]. These injuries mostly lead to a postoperative
pulmonary interstitial edema and abnormal gas exchange.
(2) The intrapulmonary shunting through the collapsed nondependent lung and ventilation/perfusion mismatch in the
dependent lung can become most serious after terminating
CPB. Other studies also found similar results that terminating CPB during OLV significantly impaired oxygenation and
may expose patients to critical low oxygen for a period of
time [during OLV significantly decreased PaO2/FiO2 from
50.8 (12.1) kPa after induction to 24.1 (14.9) kPa], after
returning to double lung ventilation PaO2/FiO2 significantly
increased to near baseline values [95]. (3) Some studies
proved that neutralization of heparin with protamine is
inducing activation of the classic pathway complement system, action which is correlated with postoperative pulmonary shunt fraction [96, 97]. Therefore, it is intelligent to
deliver oxygen intermittently to the collapsed lung to
improve oxygenation in terms of SpO2 lower than 90 % with
100 % of FiO2. If this method does not improve oxygenation,
it would be effective to use continuous positive airway pressure (CPAP) (5–10 cm H2O) to the non-independent lung by
expanding the nonventilation lung and keeping it expanded
during prolonged OLV for prevention and treatment of
hypoxemia [98]. It is suggested that routine CPAP not only
can improve oxygenation but also be beneficial in reducing
to the nonventilated lung [99]. In addition, increasing PEEP
up to 10 cm H2O may be needed throughout the operation to
achieve adequate oxygenation. However, when above methods are not improving oxygenation, the anesthesiologist
should ask the surgeon to stop the hemostasis and temporarily restore two lung ventilation until SpO2 returns to the normal range.
2
Anesthesia for Robotic Cardiac Surgery
2.9
Monitoring of Cardiovascular System
Standard perioperative monitoring includes pulse oximetry,
electrocardiogram (ECG), PETCO2, invasive blood pressure
measurement, temperature and urine output. The ECG often
involves using leads II and V5 and using automated
ST-segment monitoring. Visual inspection of the ECG on the
monitor has low sensitivity in diagnosing ischemic changes.
Modern ECG monitors can provide automatic ST segment
analysis for the detection of ischemia, which depends on the
computer’s ability to accurately set the isoelectric and J-point
reference points.
Before induction of general anesthesia and after local
anesthesia, a radial arterial cannula is inserted into the radial
artery for blood sampling and pressure monitoring. If an
endoaortic occlusion device is used, bilateral radial arterial
catheters are required to monitor correct balloon placement.
Patient risk factors and comorbid conditions often necessitate real-time, beat-to-beat assessment of arterial perfusion
pressure and arterial blood gases. Furthermore, during nonpulsatile CPB, intraarterial catheter allows continuous monitoring of arterial blood pressure and interval blood gas
sampling. We suggest pulse oximeter and arterial blood pressure monitoring in the contralateral arm to the surgical
approach.
A central venous catheter is a reasonable consideration as
a monitor of central venous pressure. Central venous catheters, in addition to monitoring CVP, provide portals for volume replacement, pharmacologic therapy, and insertion of
other invasive monitors such as pulmonary artery (PA) catheter. CVP monitoring has its limitations as at times it becomes
erratic due to compression of the major vessels and heart
itself by robotic instruments. The values should be noted
when there are no obvious compressions of major vessels or
heart directly. Moreover, trends may be more important than
single values. Also pneumothorax increases the CVP by
about 6–8 mmHg. Therefore, it is reasonable to administer
fluid to maintain the urine output of more than 0.5 ml/kg/h
during the perioperative period, although randomized studies
are lacking at this time to confirm this statement [100]. Thus,
urine output should be measured to aid in fluid management
during long procedures.
PA catheter is usually introduced percutaneously via the
RIJV into the pulmonary artery by pressure tracing, because
the RIJV provides ease of approach and optimal distance
from the operative field. It is used to measure CVP, PAP,
PCWP, and CO. Most centers report routine use of PA catheters. In some cases an endopulmonary vent catheter is
placed by the anesthesiologist to function as an indirect left
atrial drainage catheter.
Because OLV and pneumothorax could decrease lung
volumes, impair ventilation, and increase CO2 absorption,
airway pressures, ventilatory volumes, capnography,
25
compliance, and arterial blood gas monitoring can be very
crucial.
Bispectral (BIS) analysis to monitor depth of anesthesia
can be used to titrate and minimize the amount of medication
required to maintain adequate anesthesia (aiming for a target
value of less than 60) while preventing awareness to assist in
fast-tracking patients [101, 102]. This is useful during bypass
when hemodilution increases the effective volume of distribution and may necessitate redosing of anesthetic medications. Near-infrared spectral analysis aids in ensuring
adequate brain protection and leg perfusion with alternative
cannulation strategies [103].
After induction of anesthesia, a TEE probe is introduced
into the esophagus. Use of TEE is indicated for positioning
of percutaneous arterial, venous, and coronary sinus catheters in robotic operations.
2.10
Establishment of Peripheral
Cardiopulmonary Bypass
With the development of the da Vinci Surgical System,
robotic cardiac surgery could be performed safely with modified perfusion management. Modified perfusion technology
including smaller arterial and venous cannulae, transthoracic
clamp, endoaortic balloon clamping devices and assisted
venous drainage has facilitated peripheral CPB greatly [104].
Ultrasound guided RIJV access now is a recommended
practice (Figs. 2.3 and 2.4) and TEE is critical for assessment
of venous cannula positioning, retrograde cardioplegia cannula position (if used), and intra-aortic balloon occlusion
device positioning (if used). Femoral-Femoral bypass is the
most commonly used technique. Complications from arterial
cannulation are reduced when TEE is used to confirm the
location of the arterial wire within the aorta. Femoral arterial
cannula is positioned using a modified Seldinger guidewire
technique under TEE guidance. The axillary artery cannulation may be more appropriate for patients with peripheral
atherosclerosis [105]. Vascular injuries from femoral cannulation include arterial occlusion, localized arterial injuries,
and aortic dissections. Major aortic dissection is rare, but
devastating, and occurs in 1–2 % of patients [106–109]. To
avoid these complications, preoperative screening for
peripheral vascular disease may include noninvasive
plethsmography, computed tomography, or selective
angiography.
Venous cannulae must also be guided up the superior
vena cava (SVC) and into the inferior vena cava (IVC). Care
must be exercised to prevent the cannulae from crossing the
atrial septum, which may result in poor venous return, an
obscured surgical field and possible perforation of the left
atrium. There are two techniques for endovenous drainage cannula. One is administration of Carpentier Bicaval
G. Wang and C. Gao
26
Fig. 2.3 Ultrasonic guidance catheter placement in RIJV
Fig. 2.5 A 16-gauge conduct catheter placed in the RIJV by the
anesthesiologist
Puncture point
2
RIJV
RCA
Fig. 2.4 Ultrasound imaging of the RIJV, anterior and lateral to the
right carotid artery (RCA)
femoral cannula in the right femoral vein. Another is venous
drainage consisted of a single-stage venous drainage cannula in the right femoral vein and a smaller cannula positioned in the RIJV by the anesthesiologist (Figs. 2.5 and
2.6). The latter is used for SVC drainage during CPB. These
two methods of venous drainage cannulation require guide
by the TEE.
A 15F–17F wire-bound Biomedicus cannula (Medtronic
Inc, MI, USA) is inserted into the RIJV using the Seldinger
technique and positioned at the atrial/SVC junction after systemic heparization to obtain an activated clotting time (ACT)
>480 s. The femoral vein cannula size is determined by the
patient’s body surface area and circulatory requirements.
The correct position of the cannulae is checked by TEE.
Jugular venous cannula (JVC) and femoral venous cannula
(FVC) are joined to each other with a ‘Y’ connector, which
makes up the venous inlet to the CPB circuit.
Fig. 2.6 The conduct catheter in the RIJV replaced with SVC drainage
cannula by surgeon
The long, relatively small venous cannula may result in
impaired venous drainage. If the cannula is not snared, blood
may enter the right ventricle, be pumped through the lungs
and into the systemic arterial tree, resulting in shunting if the
lungs are not ventilated. Although arterial blood gases drawn
from the patient will show desaturation, those from the CPB
circuit will not. If the SVC is snared, then blood will pool
into the venous system causing a rise in jugular venous pressure and a reduction in cerebral perfusion pressure. This
may be dramatic with jugular pressures of 40 mmHg and
systemic pressures of only 50–60 mmHg resulting in cerebral perfusion pressures of only 10–20 mmHg. To recognize
this occurrence, SVC pressures should be monitored during
CPB [110].
In peripheral CPB, access for direct insertion of largebore cannula is not feasible. For this reason, gravity-assisted
2
Anesthesia for Robotic Cardiac Surgery
venous drainage is often inadequate [111]. This can lead to
poor surgical visualization and distention of the myocardium
leading to poor patient outcomes [112]. So it is almost necessary to use the assisted drainage in peripheral CPB.
Assisted drainage improves siphoning of venous blood
return flow to the CPB machine. A variety of methods can be
used to improve assisted venous drainage, but, most commonly, kinetic-assisted (KAVD), Vacuum-assisted venous
drainage (VAVD) and roller-assisted venous drainage are
used [104, 113]. Cirri et al. [114] compared the vacuumassisted drainage and kinetic-assisted drainage with centrifugal pump in respect of hemolysis on CPB. They found an
increase in hemoglobinuria and a decreased platelet count in
the vacuum-assisted drainage group, and concluded that the
red cell and platelet damage were reduced when the kineticassist mode of venous drainage was used. The major disadvantage associated with kinetic-assisted venous drainage
was the entrainment of macrobubbles in the venous line,
requiring manual clearing of the centrifugal pump. When
VAVD was clinically applied for the first time, many problems were encountered. Some initial cases resulted in inadvertent air emboli to the patient [115]. With the use of a
vacuum regulator (the Hamlet Box), Munster et al. [112]
showed that VAVD could be used in a safe manner. Up to
now, vacuum-assisted venous drainage is the popular practice in most centers although kinetic-assisted venous drainage has been shown to be physiologically superior.
VAVD utilizes a standard vacuum suction source connected to a hard-shell venous reservoir, which creates suction in the entire drainage system and increases venous
return. It requires close regulation of the vacuum source to
avoid negative pressure variations; excessive VAVD can
cause trauma to the blood components in addition to cracking or imploding of the venous reservoir. Regulators must be
used to maintain precise vacuum pressures. Moreover, positive and negative pressure relief valves must be incorporated
into the reservoir to prevent overpressure and depression
(implosion), and to ensure consistent extracorporeal flow
rates [116].
On commencement, partial CPB is initiated using gravity
drainage, then VAVD is started and its speed is increased
progressively to reach the maximum active venous return,
and venous return augmented by applying a monitored negative pressure of approximately 40 mmHg. Pressures
>70 mmHg can cause the chattering phenomenon with
incomplete blood drainage by the venous cannulae. The
blood can be sucked by the pulmonary artery vent, which has
a pressure relief valve that prevents excessive negative pressure. The amount of blood aspirated through this vent is an
indicator of optimal venous cannula positioning, with flows
<100 ml/min indicating complete CPB support [111].
LaPietra et al. [117] examined the potential for the transmission of air emboli with VAVD or KAVD. They concluded
27
that a centrifugal pump had air-handling disadvantages when
used for KAVD alone, but when used as an arterial pump in
combination with VAVD it resulted in fewer emboli post
arterial filter. So, the standard of practice for most centers is
VAVD [118]. In vitro studies suggest that air embolization
during CPB may be increased when blood entering the
venous reservoir is turbulent, such as is found during low
blood volume levels of the reservoir and high pump flow
rates [119, 120]. VAVD at 40 mmHg does not significantly
increase gaseous microemboli activity when compared with
gravity siphon venous drainage at 4 L/min flow rates [121].
When used with appropriate care, VAVD does not appear to
significantly increase air microemboli and is not associated
with an increased neurological risk following valvular surgery [122, 123]. VAVD at 40 mmHg is a safe, simple, and
effective technique in cases of minimally invasive cardiac
surgery; when used with appropriate care, it does not appear
to significantly increase air microemboli and is not associated with increased neurological risks following valvular
surgery [111].
Air removal is particularly difficult in robotic cardiac surgery. The cardiac apex cannot be elevated, and difficulty
exists in manipulating the heart. The intracardiac air tends to
be retained along dorsal interventricular septum and right
pulmonary veins [38]. Use of CO2 insufflation into the hemithorax tends to displace any air from the exposed areas of the
heart and this is supplemented by hand ventilation to expel
air from the pulmonary veins.
Weaning off CPB is done after resume of double-lung
ventilation and under TEE guidance following standard
practices as for the type of surgery with conventional CPB.
The femoral artery and vein are closed primarily, and the
RIJV line is removed and pressure is held.
2.11
Aortic Occlusion and Cardioplegia
Protection of the myocardium from prolonged cross-clamp
and bypass times can be performed using transthoracic aortic
clamp (Fig. 2.7), or using the endoaortic balloon occlusion
(Fig. 2.8). The transthoracic aortic cross-clamp (Chitwood
clamp) is passed through an incision in the right axilla and
applied to the ascending aorta, and care should be taken not
to injure the pulmonary artery or the left atrial appendage
[124]. Standard antegrade cold blood cardioplegia solution
provides reliable myocardial protection. The transthoracic
clamp has been shown to be less expensive, and decrease
operating time with fewer complications than the endoaortic
balloon method [125, 126]. We have had no aortic injuries
from the transthoracic clamp in over 400 cases. This method
has resulted in great success with no ensuing complications
[127]. Nevertheless, for most ASD repair operations, we use
the technique of beating heart without cross-clamping the
28
Fig. 2.7 The transthoracic aortic cross-clamp
Fig. 2.8 The endoaortic balloon occlusion catheter system
aorta. It is shown that to perform on-pump ASD repairs
on the beating heart without cross-clamping the aorta is
feasible, safe, and effective [128].
Alternatively, the endoaortic catheter system includes a
17F or 21F Remote Access Perfusion catheter (Fig. 2.8)
with an aortic occlusion balloon, and it functions as an aortic cross clamp and antegrade cardioplegia delivery, and for
active suctioning and deairing at the termination of CPB.
The major advantage of this system is for redoing operations [110]. The endoaortic clamp inflated to a pressure of
greater than 300 mmHg usually provides complete occlusion of the aorta [129] and antegrade cardioplegia is delivered. The aortic cannula is positioned in the ascending
aorta, 2 cm above the aortic valve, with TEE guidance. The
endoaortic balloon is inflated with a volume equal to the
G. Wang and C. Gao
diameter of the sinotubular junction of the aorta. Residual
flow around the balloon can be seen and monitored with
color flow on TEE. Pump flows may need to be reduced
during cross clamping for both transthoracic and endoaortic, for proper placement and prevention of damage to the
aorta.
The endoaortic balloon catheter may be exchanged, if it
for example ruptures accidentally, which may happen especially in mitral surgery when placing sutures in the mitral
ring. When this happens, the endoaortic balloon clamp
immediately becomes insufficient. The balloon may be
replaced. The balloon itself is less stable because it has to be
re-positioned more often and requires an experienced surgeon for re-positioning [130].
The migration of the occlusion balloon can lead to
obstruction of the innominate artery, causing cerebral hypoperfusion and neurological injury. The use of bilateral radial
arterial lines is useful in detecting the migration of the occlusion balloon toward the innominate artery. Occasionally the
balloon may migrate proximally obstructing the coronary
arteries, causing myocardial dysfunction [131]. Proximal
migration of the balloon can be seen most easily with TEE,
preventing balloon herniation through the aortic valve.
Usually balloon migration does not lead to aortic valve dysfunction. The aortic root pressure should be maintained
below the systemic arterial blood pressure to avoid balloon
movement. Venting the heart properly and limiting cardioplegic flow are two strategies to avoid balloon migration.
Use of the endoaortic balloon catheter should be avoided in
heavily atherosclerotic aorta for fear of migration and embolization of plaque.
Reichenspurner et al. [125] demonstrated increased morbidity, total operative and crossclamp times, and cost for the
endoaortic balloon versus the transthoracic clamp. Aortic
dissection is more common with the endoaortic balloon technique [132]. Early detection of aortic dissection by increased
line pressure monitored by the perfusionist, a dissection
membrane seen in echocardiography, or the surgeon’s direct
vision, should always lead to immediate weaning from CPB
and conversion to median sternotomy [130]. Improvements
in design and use of the TEE for placement have reduced the
complication rates for this device. Hypothermic ventricular
fibrillation can be used when aortic access is limited, such as
in reoperations.
Deairing can be a problem with minimally invasive cardiac surgery. The flooding of CO2 into the surgical field has
resulted in a decrease in air emboli [133, 134]. Suction on the
aortic root cannula and TEE confirmation may also help to
minimize emboli.
As the necessary accompaniment, the anesthesiologist
places an endopulmonary vent and endocoronary sinus catheter for retrograde cardioplegia through the RIJV [135–137]
(Fig. 2.9). The endopulmonary vent catheter allows passive
2
Anesthesia for Robotic Cardiac Surgery
29
Endoaortic clamp
Endocoronary
sinus catheter
Endopulmonary
vent
Endovenous
drainage cannula
Fig. 2.9 Diagrammatic representation of heartport endocoronary sinus
catheter, endoaortic clamp, endopulmonary vent and endovenous drainage cannula
venting of the pulmonary artery at approximately 50 ml/min.
On inflating the endocoronary sinus catheter balloon a previously right atrial trace is changed to a right ventricular trace
[38]. The use of a pulmonary vent catheter and an endocoronary sinus catheter is routinely but not mandatory. The cannulation of endocoronary sinus catheter for retrograde
cardioplegia is the most complex manipulation that requires
guide by the TEE and C-arm X-ray.
2.12
Summary
• The status of endoscopic approaches is clear, but its future
development is not predicted clearly. The da Vinci
Surgical System as a new technology is being accepted by
more and more surgeons. In the field of cardiac surgery,
the administration of the da Vinci Surgical System possesses some particularity required to make more changes
accordingly. Nifong and Chitwood [124] have reported in
their editorial views regarding anesthesia and robotics:
that a team approach with expertise in these procedures
involving nurses, anesthesiologists, and surgeons with an
interest in robotic procedures is required. Therefore, the
learning and training are necessary for the operation team
enabling the robotic cardiac surgery to be routinely
achieved with standard methods. In Kernstine’s report
[138], one among the recommendations to improve efficiency is the “use of an experienced anesthesiologist who
can efficiently intubate and manage single-lung ventilation and hemodynamically support the patient during the
procedure.” Finally, to summarize the clinical application
and results of robotic cardiac surgery in recent years,
using the opinion of Lehr et al. [56]: Early results of
robotic cardiac surgical procedures are encouraging with
evidence demonstrating fewer blood transfusions, shorter
hospital stay, faster return to preoperative function levels,
and improved quality of life compared with those having
a sternotomy.
• Robotic mitral valve repair and total endoscopic coronary
artery bypass surgery have become standardized procedures at specialized centers.
• Success of a robotic program is highly dependent on
the skill sets, experience, and dedication of the entire
team.
• Stepwise progression of robotic technology and procedure development will continue to make robotic operations simpler and more efficient.
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2
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3
Intraoperative Transesophageal
Echocardiography in Robotic
Cardiac Surgery
Yao Wang and Changqing Gao
Abstract
Robotic cardiac surgery is a new surgical technique that uses small incisions. Previous
studies have proved that intraoperative transesophageal echocardiography (TEE) plays an
important role in conventional cardiac surgery with a median sternotomy incision.
Intraoperative TEE is also useful in robotic cardiac surgery. Intraoperative TEE allows us:
(1) to confirm the preoperative diagnosis before CPB; (2) to guide correct placement of the
cannulae in the IVC, SVC, and AAO during establishment of peripheral CPB; (3) and to
assess immediately the surgical results after weaning from CPB. Therefore, intraoperative
TEE is a valuable adjunct in robotic cardiac surgery.
3.1
Introduction
Conventional cardiac surgery operations have been
performed through a median sternotomy, which provides
extensive exposure of the operative field and allows ample
access to all cardiac structures and proximal great vessels.
During the early days of minimally invasive cardiac surgery, attempts to operate through small incisions were
hindered by the absence of appropriate accessory technology, such as cardiopulmonary bypass, vascular cannulation, visualization systems, and instrumentation. Advances
in closed-chest cardiopulmonary bypass, myocardial protection, improved intracardiac visualization, and robotic
telemanipulation, have hastened the shift toward minimally invasive endoscopic cardiac surgery. Currently,
complex mitral valve surgery, atrial septal defect repair,
and atrial masses removal can be performed through small
incisions using robotic assistance. Previous reports have
demonstrated the importance of intraoperative transesophageal echocardiography (TEE) for conventional cardiac
Y. Wang, MD • C. Gao, MD (*)
Department of Cardiovascular Surgery,
PLA General Hospital, No. 28 Fuxing Road,
Beijing 100853, People’s Republic of China
e-mail: gaochq301@yahoo.com
surgery operations [1–5]. Intraoperative TEE has also
gained wide acceptance for the management of patients
undergoing robotic cardiac surgery [6–9]. This chapter
will document the role of intraoperative TEE in robotic
MV surgery, atrial septal defect repair, and atrial mass
removal.
3.2
Intraoperative Transesophageal
Echocardiography in Robotic Mitral
Valve Surgery
Mitral valve (MV) surgery has advanced dramatically over
the past decades [10–13]. Conventional MV surgery has
been performed through a median sternotomy, which provides extensive exposure of the operative field. Minimally
invasive MV surgery has been used with technical advances
in cardiopulmonary perfusion, valve exposure, myocardial
preservation, instrumentation, and robotic telemanipulation
[10–12, 14–17]. Currently, complex MV repair or replacement can be performed through port incisions with the use of
robotic assistance [18, 19].
Previous reports have demonstrated the importance of
intraoperative TEE for conventional MV surgery [20, 21],
and recent data are available on the value of intraoperative
TEE in robotic MV surgery [6, 7]. Intraoperative TEE is a
valuable adjunct in robotic MV surgery.
C. Gao (ed.), Robotic Cardiac Surgery,
DOI 10.1007/978-94-007-7660-9_3, © Springer Science+Business Media Dordrecht 2014
33
34
Y. Wang and C. Gao
a
b
Fig. 3.1 TEE differentiation of degenerative MV disease: (a) Barlow’s
disease with posterior leaflet prolapse (arrow): both leaflets are thick,
bulky, and billowing (arrow); (b) Fibroelastic deficiency with P2 pro-
3.2.1
TEE Examination Before CPB
Establishment
After induction of anesthesia, a left-sided double-lumen
endotracheal intubation and cannulation of the right internal
jugular vein, the TEE probe is inserted into the mid
esophagus.
Before CPB, a systematic TEE examination is performed:
(1) to analyze MV anatomy according to Carpentier’s pathophysiologic triad, which consists of valve etiology (i.e., the
cause of the disease), valve lesions resulting from the disease, and valve dysfunction resulting from the lesions [22];
(2) to identify the precise localization of the leaflet dysfunction according to segmental valve analysis [23]; and (3) to
evaluate the severity of the hemodynamic consequences
according to published guideline [24, 25].
3.2.1.1 Analysis of the MV Pathology
Etiology
The determination of the etiology of MV disease is important because it helps to predict the proper surgical intervention (valve repair or replacement) and expect complexity of
the operation [26]. MV can be affected by numerous diseases
and is the primary target in degenerative valve disease, rheumatic valve disease, and other uncommon diseases [26].
TEE is the gold standard for diagnosis and differentiation
of degenerative MV disease [27]. Two main forms of degenerative MV disease (Barlow’s disease and fibroelastic deficiency) have unique differentiating characteristics on
echocardiography [28]. Barlow’s disease is characterized by
(1) excess leaflet tissue with large billowing and thickened
leaflets; (2) prolapse of multiple leaflet segments that are
usually involved; (3) chordae tendinae that tends to be thickened; (4) chordae elongation which is the most common
lapse (arrow): both leaflets are thin and do not have billowing. A ruptured chord (arrow) is visible. AO aorta, LA left atrium, LV left ventricle,
RA right atrium, RV right ventricle
cause of prolapse; and (5) large annular size. In contrast,
fibroelastic deficiency is characterized by (1) thin valve
leaflets that do not show redundancy or billowing; (2) a
single prolapsing segment; (3) occasional visible ruptured
chordae; and (4) annular dilation that is less pronounced than
that in Barlow’s disease [28] (Fig. 3.1).
TEE can provide anatomic information on patients with
rheumatic valve disease [26]. Mitral stenosis (MS) is the
most frequent complication of rheumatic valve disease [26].
Commissural fusion is an important feature to distinguish
rheumatic from degenerative MS [25]. Commissural fusion
can be assessed from the short-axis view of MV. Commissures
are better visualized using real-time or live 3D TEE [29]
(Fig. 3.2).
Valvular Lesions
The valve lesions are critical data that a surgeon needs in
order to define the best therapeutic strategy. In addition, the
valve lesions may have great effect on the potential benefits
of surgical intervention [27]. Any of the diseases previously
mentioned can cause one or several lesions, which may affect
one or several components of MV apparatus: the annulus, the
leaflet, the chordae, the papillary muscles, and the ventricular wall.
TEE can accurately assess MV lesions in patients with
degenerative MV disease [30]. The following definitions are
used: leaflet prolapse is defined as “any portion of the MV
that moved above the mitral annulus during systole” [30];
leaflet billowing as “excess leaflet tissue protrudes into the
atrium during systole with the free edge of the leaflets remaining in apposition below the plane of the MV annulus” [31];
chordae elongation as “the free edge of the leaflet is above the
annular plane” [32]; chordae rupture as “the presence of free
and highly mobile, linear echoes is associated with flail mitral
leaflet” [33] (Fig. 3.3); annular dilatation as “the ratio of
3
Intraoperative Transesophageal Echocardiography in Robotic Cardiac Surgery
a
35
b
Fig. 3.2 Live 3D TEE shows commissures of the MV: (a) Commissures viewed from the left atrium; (b) Commissures viewed from the left
ventricle. AO aorta, LAA left atrial appendage, MV mitral valve
a
b
c
d
Fig. 3.3 TEE assessment of MV lesions: (a) leaflet prolapse; (b) leaflet billowing; (c) chordae elongation; (d) chordae rupture. AO aorta, LAA left
atrial appendage, LA left atrium, LV left ventricle, RA right atrium, RV right ventricle
36
Fig. 3.4 Live 3D TEE shows the typical rheumatic MS: a “fish mouth”
configuration
annulus to anterior leaflet is greater than 1.3 or when the
diameter of the annulus is greater than 35 mm” [34].
TEE can also accurately assess the valve and subvalvular
apparatus in patients with MS due to rheumatic valve disease
[26]. The pathological process of rheumatic MS causes commissural fusion, leaflet thickening and calcification, chordal
fusion, or a combination of these processes [25]. Commissural
fusion can be assessed from the short axis view of the MV;
leaflet thickening from the mid esophageal long axis view;
chordal fusion from the mid esophageal long-axis and fourchamber views. The typical rheumatic MS has a funnel
shape and a small central orifice with a “fish mouth” configuration, which could be best visualized with live 3D TEE
(Fig. 3.4).
The Type of Dysfunction
Assessing the type of dysfunction in MV disease is important for the surgeon to identify the lesions causing the
dysfunction [31]. In normal motion of the leaflet, MV
regurgitation is due to either leaflet perforation or abnormal leaflet coaptation. MV prolapse may be due to either
chordae rupture or elongation. Restricted leaflet motion
is seen in rheumatic MV disease or ischemic
cardiomopathy.
TEE is the principal diagnostic tool for the accurate evaluation of the dysfunction of the MV [23]. The “functional
approach” of valvular disease is based on analysis of the
motion of the leaflets by TEE and visual inspection during
the operation [23]. Three functional types are described
depending upon whether the motion of the leaflets is normal
(type I), increased (typed II), or restricted (type III) (Fig. 3.5).
Restricted leaflet motion may occur mainly during the opening of the valve (type IIIa) or during valve closure (type IIIb)
[31]. Types I and II valve dysfunctions result in valve regurgitation whereas type III may result in valve regurgitation,
stenosis, or both (Fig. 3.5).
Y. Wang and C. Gao
3.2.1.2 Identification of the Precise Localization
of Leaflet Dysfunction
The functional classification of MV disease is refined by the
addition of the “Segmental Analysis” which allows precise
localization of the leaflet dysfunction [23]. In segmental
valve analysis, the valvular apparatus is separated into eight
segments. The three scallops of the posterior leaflet are
identified as P1 (anterior scallop), P2 (middle scallop), and
P3 (posterior scallop). The three corresponding segments of
the anterior leaflet are termed as: A1 (anterior part), A2
(middle part), and A3 (posterior part). The remaining two
segments are the anterior commissure and the posterior
commissure [23].
MV is examined with TEE by using four mid-esophageal
views (the mid-esophageal four-chamber view, the commissural view, the two-chamber view, and the long-axis view)
[35] and the transgastric basal short-axis view [36]
(Fig. 3.6).
The transgastric basal short-axis view is obtained at a
multiplane angle of 0°–20° by anteflexing and withdrawing
the probe at the level of the base of LV. The view provides the
MV short axis view, with P3 being the closest to the apex of
the sector [36].
The recent development of a fully sampled matrix-array
TEE transducer (Philips Medical Systems, Andover, MA)
allows excellent real-time imaging of MV in three dimensions [37] (Fig. 3.7).
3.2.1.3 Evaluation of the Severity of the
Hemodynamic Consequences
Assessing the severity of hemodynamic consequences is an
important complement to functional valve analysis, and it is
essential for clinical decision-making [24, 25].
The severity of MS is assessed according to published
guidelines [25]. Routine evaluation of MS severity should
combine measurements of mean gradient and MV area using
planimetry and the T1/2 method. In case of discrepancy, the
result of planimetry is the reference measurement, except
with poor acoustic windows. MV stenosis is graded as being
mild, moderate, and severe.
The severity of MV regurgitation is assessed according to
published guidelines [24]. A comprehensive approach to the
evaluation of the severity of MV regurgitation is required
which integrates multiple parameters. Specific signs related
to MV anatomy (regurgitant jet area, vena contracta width,
flow convergence, pulmonary vein flow) along with supportive signs (pulmonary vein flow, peak mitral E velocity, and
regurgitation jet profile) constitute the basic features of an
integrated assessment. These specific signs include color
flow jet area, mitral inflow, jet density, jet contour, pulmonary vein flow, and quantitative parameters regarding regurgitant volume, regurgitant fraction and effective regurgitant
orifice area [24]. MV regurgitation is graded as being mild,
moderate, and severe [24].
3
Intraoperative Transesophageal Echocardiography in Robotic Cardiac Surgery
37
a
b
c
Fig. 3.5 TEE evaluation of the dysfunction of the MV (left) and hemodynamics (right): (a) type I; (b) type II; (c) type IIIa; AAO ascending aorta,
LA left atrium, LV left ventricle, RA right atrium, RV right ventricle
3.2.2
TEE-Guided Cannulation
of Peripheral CPB
Conventional cardiac surgery has been performed via median
sternotomy, which provides optimal access to all cardiac
structures and the great vessels and allows central cannulation for CPB under direct vision. To perform robotic cardiac
procedures through small port sites, peripheral vessel cannulation for CPB has been used. [6]. TEE may provide direct
visualization of the target vessels, guidewire and cannulae
[38]. TEE may be useful in guiding successful placement of
the cannulae in the inferior vena cava (IVC), superior vena
cava (SVC), and ascending aorta (AAO) in the establishment
of peripheral CPB during robotic cardiac surgery [8].
38
Y. Wang and C. Gao
a
b
c
d
Fig. 3.6 The mid-esophageal mitral valve views: (a) the mid-esophageal four-chamber view; (b) the commissural view; (c) the two-chamber
view; (d) the long-axis view. AO aorta, LAA left atrial appendage, LA left atrium, LV left ventricle, RA right atrium, RV right ventricle
a
b
Fig. 3.7 Live 3D imaging of the en face view of the mitral valve from the left atrial perspective (a) and left ventricle perspective (b) at enddiastole. AO aorta
3
Intraoperative Transesophageal Echocardiography in Robotic Cardiac Surgery
a
b
c
d
39
Fig. 3.8 TEE-Guided Cannulation of the Inferior Vena Cava: (a) the
intrahepatic IVC view; (b) TEE shows the guidewire in the IVC; (c)
TEE shows the guidewire in the RA; (d) TEE shows the cannula in the
IVC. HV hepatic vein, IVC inferior vena cava, LA left atrium, LV left
ventricle, RA right atrium
3.2.2.1 TEE-Guided Cannulation
of the Inferior Vena Cava (IVC)
The intrahepatic IVC view (70°–90°) and the mid-esophageal
bicaval view (80°–110°) [36] are obtained in turn. A guidewire is inserted through a cutdown into the right femoral
vein. Under TEE guidance, the guidewire is advanced into
the IVC and then into the right atrium (RA) sequentially, and
a femoral venous cannula (Medtronic, Inc, Minneapolis,
MN, USA) is inserted over the guidewire with the distal end
of the cannula parallel to the IVC wall and its distal tip positioned at or above the IVC/RA junction (Fig. 3.8). The
guidewire is then removed.
the cannula is removed, and an arterial cannula (Medtronic,
Inc, Minneapolis, MN, USA) is inserted over the guidewire
with the distal end of the cannula parallel to the SVC wall
and its distal tip positioned at or above the SVC/RA junction
(Fig. 3.9). The guidewire is then removed.
3.2.2.2 TEE-Guided Annulation
of the Superior Vena Cava (SVC)
The mid esophageal bicaval view (80°–110°) is obtained
[36]. Under TEE guidance, the guidewire is advanced into
RA via the cannula in the right internal jugular vein and then
3.2.2.3 TEE-Guided Cannulation
of the Ascending Aorta (AAO)
The mid-esophageal aortic valve long-axis view (120°–160°)
is obtained [36]. After cross clamping of the AAO, an angiocath (a cannula adapted for antegrade administration of cardioplegic solution) (Becton Dickinson Infusion Therapy
Systems Inc., Sandy Utah) is inserted into the AAO via the
fourth intercostal space, with its distal tip located in the aortic root under TEE guidance. Color flow imaging is used to
indicate whether the angiocath is following the appropriate
course (Fig. 3.10), and rapid flush of the cardioplegic solution is used to identify the tip of the angiocath (Fig. 3.10).
40
a
Y. Wang and C. Gao
b
Fig. 3.9 TEE-guided cannulation of the superior vena cava: (a) TEE shows the guidewire in the SVC; (b) TEE shows the cannula in the SVC. LA
left atrium, LV left ventricle, RA right atrium, SVC superior vena cava
a
b
c
d
Fig. 3.10 TEE-guided cannulation of the ascending aorta: (a) TEE
shows an angiocath inserted into the AAO; (b) Rapid flush of the cardioplegic solution identifies the tip of the angiocath; (c) Color flow
imaging indicates the course of the angiocath; (d) Surgical view shows
the angiocath inserted into the AAO. AAO ascending aorta, LA left
atrium, LV left ventricle, AV aortic valve
3
Intraoperative Transesophageal Echocardiography in Robotic Cardiac Surgery
3.2.3
TEE Examination After Pump-Off
41
a
3.2.3.1 Assessment of the Mitral
Valve After Repair
Immediately after weaning from CPB, TEE is performed to
assess the results of MV repair, and to assess for residual MV
regurgitation, restriction of MV opening with stenosis, and
systolic anterior motion of the leaflets of the MV.
Residual MV Regurgitation
Confirming the absence of significant residual MV regurgitation is the most critical aspect of postoperative valve analysis
by TEE [35]. Immediate repair results by TEE are essential in
determining whether reintervention is warranted. Residual
MV regurgitation evaluated by TEE should be attempted as
much as possible to create representative loading conditions
with volume or vasopressors to fully assess the adequacy of the
MV repair immediately after the patient is weaned from CPB,
because insufficient preload and low ventricular pressure will
result in underestimation of residual MV regurgitation [39,
40]. Appropriate volume loading, and hemodynamic manipulations are necessary to adequately evaluate the repaired MV.
The depth of coaptation should be documented and be at
least 5 mm in a two-dimensional long-axis view to ensure
adequacy of coaptation [39].
Mitral Stenosis (MS)
Acute MS following MV repair is a rare but severe complication, and it is more likely to be seen with the Alfieri edge-toedge repair, commissuroplasty, and small annuloplasty ring
[41, 42]. Intraoperative TEE can be utilized to diagnose iatrogenic MS immediately after MV repair. Continuous-wave
Doppler gradients displaying a mean gradient greater than
7 mmHg or peak gradient greater than 17 mmHg is suggestive
of clinically relevant MS after MV repair [41].
Systolic Anterior Motion (SAM)
SAM of MV leaflets causes obstruction of dynamic left
ventricular outflow tract (LVOT) which is a known complication of MV repair that may necessitate immediate
additional surgical intervention [43–45]. TEE may demonstrate a characteristic systolic anterior motion of the MV into
the LVOT. Doppler echocardiography is used to determine
the peak gradient. Peak gradient across the LVOT is increased
from baseline as a result of dynamic LVOT obstruction.
When SAM occurs after MV repair, hemodynamic maneuvers must be attempted before the results are declared inadequate. SAM can be resolved with volume loading, increased
afterload, and withdrawal of inotropic agents [45].
Aortic Valve Leaflet Injury
The leaflets of the aortic valve may be inadvertently injured
during percutaneous cannulation of the angiocath in the
ascending aorta in the establishment of peripheral CPB. TEE
b
c
Fig. 3.11 TEE shows perforated aortic valve with regurgitation: (a)
discontinuity is noted in the RCC (arrow); (b) an accentric jet of AR
through this region on color flow imaging; (c) after repair of the RCC,
there is no residual AR
can provide high-resolution images of the aortic valve and is
helpful in determining the mechanism and cause of the injury
immediately after CPB. Discontinuity in the leaflet of the
aortic valve with an accentric jet of aortic regurgitation noted
by TEE alerts the surgeon to perforated aortic valve
(Fig. 3.11).
42
Y. Wang and C. Gao
a
b
c
d
Fig. 3.12 Bileaflet mechanical valve (upper) and bioprosthetic valve (lower) in mitral position. TEE shows the opening (left) and closure (right)
of the leaflets of the prosthetic valve (arrows). AO aorta, LA left atrium, LV left ventricle, RV right ventricle
3.2.3.2 Assessment of the Mitral
Valve After Replacement
Immediately after MV replacement, TEE is performed to
verify normal leaflet or motion of occluders and to detect
technical problems such as paravalvular regurgitation and
left ventricular outflow tract obstruction.
Confirmation of the Leaflet Motion
The opening and closure of the leaflets of the prosthetic
valve in the MV position can be confirmed by TEE. Leaflet
motion is best visualized using the 2D TEE mid-esophageal
long-axis views and live 3D-TEE en face view of the MV.
In 2D-TEE mid-esophageal long-axis views, the two
mechanical leaflets are open, producing two parallel linear
shadows within a circular annulus, and close symmetrically
to a tilt angle of 85°–90° (Fig. 3.12). In the live-3D TEE en
face view of MV, the leaflets motion of mechanical and
bioprosthetic valves are better visualized (Fig. 3.13).
Confirmation of the Absence
of Paravalvular Regurgitation
TEE demonstrates small characteristic regurgitant jets
during leaflet closure. Closure backflow is the reversal of
flow required for closure of the valve. In contrast, leakage
backflow occurs after closure of mechanical valves and originates from the hinges and the regions of coaptation between
the occluders and the valve ring. Physiologic regurgitation
jets are small and short in duration. Mild transvalvular or
paravalvular regurgitation can often be detected by TEE
immediately after implantation. Small, insignificant transvalvular or paravalvular leaks are commonly observed
immediately after CPB (Fig. 3.14), and should not be a
cause for concern [46].
Pathologic paravalvular regurgitation is caused by incomplete fixation of the prosthetic sewing ring to the native
annulus or dehiscence of the sewing ring. Paravalvular regurgitant jets detected by TEE originate from the outside of the
3
Intraoperative Transesophageal Echocardiography in Robotic Cardiac Surgery
a
b
c
d
43
Fig. 3.13 Bileaflet mechanical valve (upper) and bioprosthetic valve
(lower) in mitral position. Live-3D TEE en face view of the MV from
the left atrial perspective (upper) and from the left ventricle perspective
(lower) shows the opening (left) and closing (right) of the leaflets of the
prosthetic valve (arrows). AO aorta
sewing ring, and characteristically produce eccentric jets that
track along the walls of the left atrium [47]. Intraoperative
TEE is useful for detecting pathologic paravalvular regurgitation. Precise characterization of the location and severity of
paravalvular regurgitation jets detected by TEE immediately
after MV replacement may be useful for guiding decisions
for surgical intervention [47].
LVOT image after MV replacement and to estimate the
LVOT pressure gradient [50].
Dynamic Left Ventricular Outflow Tract (LVOT)
Obstruction
Dynamic LVOT obstruction is an uncommon, but is a recognized complication of MV replacement. [48] The valve
sparing or chordal sparing technique used in MV replacement, may cause residual MV leaflet or chordal apparatus
remaining in the LVOT, and result in LVOT obstruction
[48, 49]. In addition, LVOT obstruction may also resulted
from a porcine bioprosthesis in the mitral position with a
strut impinging LVOT [50]. TEE can provide a means for
Atrial septal defect (ASD) is one of the most common adult
congenital heart defects. ASD types include: secundum
ASD, primum ASD, superior sinus venosus defect, inferior
sinus venosus defect, and unroofed coronary sinus [51].
Currently, ASD repair can be performed through port incisions with robotic assistance [52]. Previous studies have
shown that intraoperative TEE was valuable in the perioperative care of patients with congenital heart defects [4].
Intraoperative TEE is also a valuable adjunct in robotic ASD
repair.
3.3
Intraoperative Transesophageal
Echocardiography in Robotic
Atrial Septal Defect Repair
44
Y. Wang and C. Gao
3.3.1.1 Confirmation of the Preoperative
Diagnosis
TEE is the primary diagnostic imaging modality for ASD
[53] (Fig. 3.15). TEE may be necessary to adequately
visualize the atrial septum, because it provides exact
localization and sizing of the ASD [54, 55]. The septum is
thin and may not be visualized if the septum is parallel to
the echocardiographic beam. To ensure proper visualization
of the septum, the echocardiographic beam should be
perpendicular to the septum. The shunt of blood that occurs
with ASD can be evaluated with color-flow Doppler imaging [56] (Fig. 3.16).
a
3.3.1.2 Ruling Out the Presence
of Associated Lesions
ASD can be associated with additional malformations,
including anomalous pulmonary venous connection, persistent left SVC, pulmonary valve stenosis, and mitral
valve prolapse [51]. TEE may be necessary to identify the
lesions.
b
3.3.2
During the Establishment
of CPB
Follow the same steps as previously discussed in
Sect. 3.2.2.
c
3.3.3
TEE Examination After
Weaning from CPB
Immediately following CPB, a thorough intraoperative TEE
exam must also be performed (1) to assess the adequacy of
the surgical repair; and (2) to rule out the complications of
the surgical repair.
Fig. 3.14 Mild transvalvular (upper) and paravalvular regurgitantion
(middle) of mechanical and mild paravalvular regurgitation of bioprosthetic (lower) valve in the MV position, detected by TEE immediately
after CPB. AO aorta, LA left atrium, LV left ventricle
3.3.1
TEE Examination Before CPB
Prebypass TEE examination is performed: (1) to confirm the
preoperative diagnosis; (2) to rule out the presence of associated lesions that may have a direct impact on surgical
procedure.
3.3.3.1 Assessment of the Adequacy
of the Surgical Repair
The contributions of post-CPB TEE include assessment of
the adequacy of the surgical repair (Fig. 3.16), evaluation of
postrepair atrioventricular valve competence, and evaluation
of ventricular function [57]. TEE may also reliably provide
for immediate detection of suboptimal surgical repairs and
significant postoperative residue [57], potentially improving
the efficacy of the surgical repair.
3.3.3.2 Ruling Out Complications
of Surgical Repair
Post-CPB TEE examination may also be particularly
important since repair of these defects, using a patch may
involve the pulmonary veins, obstruct the IVC, or may not
completely close the defect. In each of these instances,
diagnosis should immediately be made by intraoperative
TEE.
3
Intraoperative Transesophageal Echocardiography in Robotic Cardiac Surgery
a
45
b
Fig. 3.15 TEE in the mid-esophageal bicaval view demonstrating ASD: (a) secundum ASD; (b) superior sinus venosus defect. ASD atrial septal
defect, LA left atrium, RA right atrium, SVC superior vena cava
a
b
Fig. 3.16 Pre- and post-bypass TEE in patients with ASD: (a) colorflow Doppler imaging shows the shunt of blood that occurs with ASD;
(b) there is no residual shunt at atrial level post ASD repair. ASD atrial
septal defect, IAS interatrial septum, LA left atrium, RA right atrium,
SVC superior vena cava
3.4
examination is important for the planning of incision and
excision techniques.
Intraoperative Transesophageal
Echocardiography in Robotic Atrial
Masses Removal
Surgical removal of an intracardiac mass is the treatment of
choice in many instances [58]. Currently, atrial mass removal
can be performed through port incisions with robotic assistance [59]. Previous studies have shown that intraoperative
TEE was useful toward a successful outcome during surgical
removal of intracardiac masses [60]. Intraoperative TEE is a
valuable adjunct in robotic atrial mass removal.
3.4.1
3.4.1.1 Confirmation of the Preoperative
Diagnosis
TEE gives a clear image and anatomical definition of the atrial
mass [60]. TEE can characterize the location, size, shape,
and mobility of the tumor [61]. Typical TEE displays characteristics of myxoma as having a rounded shape, smooth margins, and lack of laminated appearance (Fig. 3.17). Caution
should be applied to appropriate patient selection because
malignant tumors are unlikely to be removed with minimally
invasive approaches [62].
TEE Examination Before CPB
Prebypass TEE examination is performed to confirm the
preoperative diagnosis, and to provide information about
the attachment site of atrial masses. The pre-CPB TEE
3.4.1.2 Providing Information About the
Attachment Site of Atrial Masses
TEE may provide a definitive site of attachment (stalk) of the
atrial masses, which is most frequently from the fossa ovalis
46
Y. Wang and C. Gao
a
b
c
d
Fig. 3.17 Pre- and post-bypass TEE in patients with LA myxoma:
(left) pre-bypass TEE demonstrating the myxoma attached to the
interatrial septum (upper) and the root of the anterior leaflet of the
of the interatrial septum [61]. The tumor’s site of attachment
may have important implications for involvement of adjacent, and indirectly involved structures including the valve.
In addition, identifying the location and extent of right atrial
myxomas may be important for guiding the appropriate percutaneous cannulation of the IVC and SVC.
3.4.2
TEE Examination During CPB
Establishment
Follow the same steps as previously discussed in Sect. 3.2.2.
3.4.3
TEE Examination After Weaning
from CPB
Following resection of the mass, post-CPB TEE is necessary
to evaluate the completeness of surgical removal and to
assure that the interatrial septum is intact (Fig. 3.16).
mitral valve (lower) via a narrow stalk (arrows); (right) post-bypass
TEE confirming complete resection of the myxoma. AO aorta, IAS
interatrial septum, LA left atrium, LV left ventricle, RA right atrium
Conclusion
Intraoperative TEE is especially useful in robotic cardiac
surgery. Intraoperative TEE allows surgeons: (1) to confirm the preoperative diagnosis before CPB; (2) to guide
correct placement of the cannulae in the IVC, SVC, and
AAO during establishment of peripheral CPB; (3) and to
assess immediately the surgical results after weaning
from CPB. Therefore, intraoperative TEE is a valuable
adjunct in robotic cardiac surgery.
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4
Peripheral Cardiopulmonary Bypass
Establishment for Robotic Cardiac
Surgery
Cangsong Xiao and Changqing Gao
Abstract
Conventional cardiac surgery is performed via median sternotomy and central cardiopulmonary bypass (CPB) is performed through cannulation on ascending aorta and superior
vena cava and inferior vena cava. Robotic surgical technology has provided port-access
which has made peripheral CPB endoaortic balloon occluders possible. Establishment of
peripheral CPB has been an important step for robotic cardiac surgery. The standard procedures of peripheral CPB establishment include right internal jugular cannulation and femoral artery and vein cannulation. This chapter describes the peripheral CPB technique which
has been used routinely for totally robotic cardiac surgery using da Vinci Surgical System
at the Chinese PLA General Hospital.
Conventional cardiac surgery is performed via median
sternotomy and central cardiopulmonary bypass (CPB) is
performed through cannulation on ascending aorta and
superior vena cava (IVC) and inferior vena cava (SVC).
With the evolution of minimally invasive cardiac surgery,
especially totally robotic cardiac surgery [1–3], very limited skin incisions make central CPB extremely difficult or
even impossible and peripheral CPB becomes mandatory.
Port-access technology for peripheral CPB with endoaortic
balloon occluders was reported applicable and strongly
advocated for minimally invasive and robotic mitral surgery by some authors [4–7]. However, this technique has
such disadvantage as migration of the occluding balloon
resulting in inadvertently occlusion of cephalic artery and
subsequently compromising of cerebral blood flow.
Therefore, peripheral CPB establishment through internal
jugular vein and femoral artery and vein and direct aortic
cross clamping via intercostal space by Chitwood clamp is
more reasonable to avoid this disadvantage. Moreover,
C. Xiao, MD • C. Gao, MD (*)
Department of Cardiovascular Surgery,
PLA General Hospital, No. 28 Fuxing Road,
Beijing 100853, People’s Republic of China
e-mail: gaochq301@yahoo.com
Reichenspurner and colleagues demonstrated increased
morbidity, cost, and operative/cross-clamp times when the
endoballoon technique was used for mitral valve surgery
[8]. The standard procedures of peripheral CPB establishment include right internal jugular cannulation and femoral
artery and vein cannulation. Aorta is cross-clamped with
Chitwood clamp through 4th intercostal space. Myocardial
preservation is achieved by antegrade delivery of cardioplegia via angio-catheter inserted into ascending aorta, mostly
through 2nd intercostal space.
4.1
Pre-operative Preparation
for Establishment of Peripheral CPB
Preoperative evaluations of candidates for robotic cardiac surgery include heart lesions suitable for robotic correction, general conditions of patients as well as peripheral arteries and
veins. Regarding the peripheral CPB setup, much attention is
paid to ECHO examination of right internal jugular vein and
bilateral femoral arteries and veins. For young patients, ECHO
is of adequacy for thorough investigation of peripheral vessels. For patients older than 60 years, 3-D CTA is necessary
for further evaluation of iliac-femoral artery and abdominal
aorta to exclude the patient with significant atherosclerotic
stenosis or tortuosity of the arteries (Fig. 4.1). For patients
C. Gao (ed.), Robotic Cardiac Surgery,
DOI 10.1007/978-94-007-7660-9_4, © Springer Science+Business Media Dordrecht 2014
49
50
C. Xiao and C. Gao
Fig. 4.1 3-D CTA of iliac-femoral artery and abdominal aorta
older than 50 years, coronary angiogram is routinely conducted. For patients younger than 50 years with risk factors of
atherosclerosis, CTA is used to evaluate coronary artery
(Fig. 4.2). The right femoral artery and vein are preferred for
cannulation, therefore, right femoral artery is not used for
angiography to avoid local hematoma which may complicate
the cannulation. For cases of previous history of abdominal
surgery, such as kidney surgery, magnetic resonance imaging
(MRI) is probably necessary for watching out if IVC stenosis
was created.
4.2
Preparation of Conduits
of Peripheral CPB
The CPB conduits are specially designed for the peripheral
CPB establishment at the PLA General Hospital. Venous
conduit has two bifurcations, one is much shorter than the
other so that these two conduits can be comfortably placed
on the table after cannulation (Fig. 4.3).
Proper size of cannula for femoral artery and vein cannulation is selected according to the weight and height of the
patient. The surgeon’s experience is also of much importance
for cannula selection. So far, 15 F cannula is routinely used for
internal jugular cannulation at the PLA General Hospital, and
Fig. 4.2 3-D CTA of coronary artery
Connected to IVC
Connected to SVC
Fig. 4.3 Venous conduits placed on table
the outflow is sufficient. For femoral vein cannulation, 23 F
cannula is most frequently used. 21 F cannula is adequate for
arterial inflow for patients with weight of about 80 kg. The
lightest weight of the patient receiving robotic heart surgery
performed at the PLA General Hospital was 29 kg, and the
arterial cannula size was 17 F.
4
Peripheral Cardiopulmonary Bypass Establishment for Robotic Cardiac Surgery
a
51
b
Fig. 4.4 Internal jugular cannula with guidance of ECHO. (a) To puncture the internal jugular vein under guidance of ECHO; (b) The EECHO view
a
b
15G
Fig. 4.5 A 15G angio-catheter is pre-positioned 10 mm above clavicle (a) and heparin is infused (b)
4.3
Techniques for Peripheral
CPB Establishment
Intraoperative transesophageal echocardiography (TEE)
plays a very important role in venous cannulation for peripheral CPB set up. The precise positioning of the internal
jugular vein cannula and femoral vein cannula, which are
both advanced into right atrium, must be guided by TEE.
After general anesthesia and double-lumen endotracheal
intubation, a 15 gauge angio-catheter is inserted and secured
in advance by anesthesiologist with the guidance of ECHO
(Fig. 4.4) and heparin is infused inside the catheter
(Fig. 4.5). The puncture site of skin for angio-catheter is
just 10 mm above the clavicle. The puncture site of internal
jugular vein should be guided by ECHO and be just at the
anterior middle portion of the vein, which is important for
subsequent smooth advancement of a 15 F cannula. Another
7 F double lumen catheter is also introduced more cephalically (Fig. 4.6).
4.4
Exposure of Femoral Artery and Vein
The patient is positioned as described above, and followed
by sterilization and draping. A 2-cm transverse right groin
incision just above the crease is made to expose the femoral
artery and vein. The two vessels are dissected just below,
rather than above, the femoral canal. This maneuver can
avoid injury of structures within femoral canal, and may not
decrease the strength of the abdominal wall because the
plane of dissection is just at the inferior edge, instead of
within, the femoral canal (Fig. 4.7). A purse string with 5/0
52
C. Xiao and C. Gao
a
b
Fig. 4.6 Another 7 F double lumen catheter is inserted cephalically
a
b
c
Femoral V
Femoral A
Fig. 4.7 Exposure of femoral artery and vein. (a) The skin mark of incision; (b) The dissection plane at the inferior edge of abdominal wall; (c)
The dissected right femoral artery and vein
4
Peripheral Cardiopulmonary Bypass Establishment for Robotic Cardiac Surgery
a
53
b
c
Fig. 4.8 (a) A purse string suture on the right femoral vein; (b and c) Two snares around right femoral artery and vein
polypropylene suture is placed at the anterior wall of the
femoral vein. Two snares are placed around the femoral
artery and vein respectively (Fig. 4.8).
4.5
Femoral Artery Cannulation
After systemic heparinization (300 IU/kg), the femoral arterial is clamped with two fine clamps, between which transverse arteriotomy was made and the arterial cannula is inserted
using the Seldinger guidewire method. The guidewire, which
has been inserted within the cannula in advance, is firstly
introduced into femoral artery. The guidewire should be
passed into the artery smoothly without any resistance.
Arterial cannula insertion along the guidewire is followed.
Assistant should hold the end of the cannula tightly to facilitate
the insertion of the tip of the cannula. The surgeon holds the
tape and the cannula is carefully advanced into the artery for
at least 10 cm deep along the guidewire. Femoral artery is then
snared and the guidewire is withdrawn and the cannula is
clamped by the assistant. Blood is allowed to squirt for deairing and good blood flow is checked. Cannula is connected
to the arterial conduit of CPB and secured with two sutures
(Fig. 4.9).
4.6
Femoral Vein Cannulation
into the Right Atrium
Just after completion of arterial cannulation, TEE probe has
already been standing by and focusing on the IVC to guide
the venous cannula positioning. The two snares around
54
C. Xiao and C. Gao
a
b
c
d
e
f
g
h
Fig. 4.9 (a–h) Femoral artery cannulation using Seldinger guidewire
method. (a) The clamp for femoral artery occlusion; (b) The right femoral artery was occluded; (c) The end of femoral catheter; (d) The assistant hold the end of the cannula to facilitate the insertion of the tip of the
cannula; (e) The cannula is advanced into the femoral artery; (f)
Deairing and check the blood flow; (g) The cannula was connected to
the arterial conduit of CPB; (h) The cannula was secured with two
sutures
4
Peripheral Cardiopulmonary Bypass Establishment for Robotic Cardiac Surgery
a
b
c
d
e
f
55
Fig. 4.10 Femoral vein cannulation using Seldinger guidewire method.
(a) A small incision was made on femoral vein; (b) The incision was
dilated; (c) The guidewire was inserted into the femoral vein; (d) The
cannula was inserted into femoral vein along the guidewire; (e) The
cannula was connected to the vein conduit of CPB; (f) The tip of femoral vein cannula
femoral vein are pulled slightly and a small incision is created within the purse string suture. The small incision is
dilated by mosquito clamp to facilitate venous cannula
entrance. Seldinger guidewire is then advanced into right
atrium under the guidance of TEE followed by venous cannula insertion. The venous cannula tip is positioned at the
middle portion of right atrium. Care must be taken to clearly
visualize the cannula passing through the SVC and into right
atrium. The cannula is clamped and subsequently connected
to venous conduit of CPB. Before the clamp is released, the
other end of bifurcated venous conduit of CPB must be
clamped to prevent bleeding (Fig. 4.10).
4.7
Right Internal Jugular Cannulation
into Right Atrium
After femoral vein is cannulated, right internal jugular vein cannulation is followed. Seldinger guidewire is firstly advanced
into right atrium through the pre-positioned angio-catheter. The
56
C. Xiao and C. Gao
a
b
c
d
e
f
Fig. 4.11 (a–f) Right internal jugular vein cannulation into right atrium
using Seldinger guidewire method. (a) The 15G angio-catheter was prepositioned; (b) The guidewire was inserted into the catheter; (c) The
dilating sheaths with different diameter are respectively passed through
the guidewire; (d) The cannula was inserted into jugular vein along the
guidewire; (e) The cannula was secured; (f) The secured vein cannula
angio-catheter is withdrawn and the guidewire is left in place.
The assistant presses the jugular vein with left hand to prevent
bleeding and hold the guidewire with thumb and pointing finger
of left hand to prevent inadvertently pulling out the guidewire.
The skin is incised with blade and dilated with tip of mosquito
clamp. Two dilating sheaths with different diameter are respectively passed through the guidewire and into SVC to make a
channel along the guidewire to facilitate the passage of a 15 F
cannula. After the second dilating sheath is withdrawn and
guidewire is still in place, the cannula was passed along the
guidewire and into right atrium guided by TEE. The assistant
should hold the end of the cannula to help the surgeon easily
pass the tip of the cannula across the entering site of the vein and
into right atrium. The cannula is connected to another venous
conduit and secured (Fig. 4.11). At this moment, the peripheral
CPB establishment for robotic cardiac surgery is completed.
4
Peripheral Cardiopulmonary Bypass Establishment for Robotic Cardiac Surgery
a
57
b
Fig. 4.12 (a) Chitwood clamp is introduced through the 4th intercostal space adjacent to the inferior edge of working port; (b) The inferior jaw
of clamp must not bite the pulmonary trunk and right pulmonary artery
4.8
Techniques for Antegrade
Cardioplegia Delivery
a
12G
Chitwood clamp is used through the 4th intercostal space
adjacent to the inferior part of working port. The bed side
surgeon must hold the shaft of Chitwood clamp tightly with
both hands and slowly let the clamp go forward. After perfusion flow is decreased and blood pressure is lowed by perfusionist, jaws of Chitwood clamp is opened very carefully
under guidance of console surgeon. The inferior jaw must
not bite the pulmonary trunk and right pulmonary artery in
case of injury (Fig. 4.12).
14G angio-catheter is routinely used for cardioplegia
delivery at the PLA General Hospital. A side hole on the
catheter, 4 mm away from the tip, is created by a scrubbing
nurse (Fig. 4.13). The catheter is often obliquely advanced
through the 2nd intercostal space, about 3 cm lateral to the
stay suture catheter. Then cardioplegia is delivered to irrigate
the catheter to flush away the residuals inside the needle to
prevent embolism (Fig. 4.14). Console surgeon slightly hold
the catheter and puncture the ascending aorta and the bedside
surgeon must meticulously cooperate. After the tip of the
catheter has crossed aortic wall for about 1 cm, the inside
needle is withdrawn by the bedside surgeon. At the essential
moment as the catheter proceeds the tip of catheter must by
carefully visualized by TEE. Proper location of the tip is
always near the posterior wall of aorta (Fig. 4.15). The catheter is fixed by sutures on the chest wall. Attention should be
taken so as to avoid the risks of injuring the aortic wall or
valve because the catheter tip is too close to the aortic wall.
Inadvertent forward displacement of the catheter during surgery is also risky.
Cross clamping of aorta should always be cautious like in
open chest cardiac surgery. Prior to clamping, perfusing flow
is decreased and the aorta is slowly clamped. Cardioplegia
delivery is constantly monitored by TEE (Fig. 4.16). Again,
the tip of catheter must be confirmed inside the aorta.
14G
15G
b
c
Fig. 4.13 (a) 14G angio-catheter is used for cardioplegia delivery; (b)
A side hole on the catheter; (c) 4 mm away from the tip, is showed
58
C. Xiao and C. Gao
a
b
Fig. 4.14 (a) The catheter is advanced through the 2nd intercostal space, 3 cm lateral to the staying suture catheter; (b) Cardioplegia is delivered
to irrigate the catheter to flush away the debris inside the needle
a
b
Fig. 4.15 (a) Catheter goes through anterior wall of ascending aorta; (b) Proper location of its tip, always near the posterior wall of aorta, is monitored by TEE
Sometimes aortic regurgitation may be detected by TEE and
the depth of catheter should be adjusted and regurgitation
can be corrected.
After all the procedures are completed and heart incision
is closed, clamp is slowly released and the heart beat
resumed. The catheter delivering cardioplegia is used for
deairing. Surgical outcome is checked by TEE. A purse
string by a mattressed Gortex suture is placed around the
aortic puncture site. At the same time of decreasing perfusing flow, the catheter is pulled out of aorta and the purse
suture is tied (Fig. 4.17). Cardiopulmonary bypass is weaned
off as usual.
4.9
De-cannulation After
Conclusion of CPB
After conclusion of CPB, surgical results are evaluated by
TEE. Protamine is administered and the ACT is titrated to
baseline value and de-cannulation is followed. Femoral
venous cannula is always withdrawn firstly. The purse string
suture is held slightly when the cannula is pulled out to prevent bleeding and then tied. Care must be taken in decannulation. The conduit connected to the right internal
jugular vein cannula should be clamped in case of bleeding
before withdrawing the femoral venous cannula. Femoral
4
Peripheral Cardiopulmonary Bypass Establishment for Robotic Cardiac Surgery
a
59
b
Fig. 4.16 (a) Aorta is cautiously clamped; (b) Cardioplegia delivery is constantly monitored by TEE and aortic valve competency is verified
a
b
c
Fig. 4.17 Before CPB is weaned off, catheter delivering cardioplegia is withdrawn and a mattressed Gortex suture is used for hemostasis. (a) The
pure string suture is placed around the catheter; (b) The suture is tied using pusher by the assistant; (c) The tied kont
60
C. Xiao and C. Gao
arterial cannula must be removed always with great caution.
The distal snare is released and the artery is clamped with a
fine clamp. The proximal snare is released but the snare tape
is kept in place and another clamp is placed in advance. After
these preparation, the proximal snare tape is held slightly
and the cannula is slowly pulled out and the artery is
immediately clamped. The proper site of the two clamps may
be adjusted for more space to facilitate subsequent repair of
the artery. The width of arterial wall of both side of arteriotomy should be adequate for suturing. The proximal edge of
the arteriotomy is always much larger than the distal one
because of cannulation and the posterior wall may be injured,
which will make the approximation of both edge technically
demanding. A 6/0 polypropylene running suture is placed
evenly to approximate the two edges of arteriotomy. The
suture should not be frapped too tight to avoid artery stenosis. Right internal jugular vein cannula is pulled out and
puncture site of vein is compressed for at least ten minutes
for hemostasis and skin incision is sutured.
4.10
Results
So far, 640 cases of totally robotic has been successfully
performed at the PLA General Hospital [9–11], which
include 297 cases of peripheral cardiopulmonary bypass.
Only one adult patient with Marfan syndrome was converted to sternotomy because of failure of venous cannulation due to lower part of IVC or bilateral common iliac vein
stenosis. Postoperative thrombotic complication at the site
of peripheral cannulation occurred in five patients at an earlier time after the operation. Three patients suffered from
femoral vein thrombus formation which was resolved by
warfarin. Two patients had femoral artery thrombus which
was resolved by re-exploration for thrombus clearance. We
think that the cause for thrombus was the compression of
the cannulation site for prevention of bleeding in previous
cases. We realized afterwards that this compression of cannulation site was unnecessary and abandoned such practice.
With this learning curve, we started giving 100 mg aspirin
routinely to patients for 3 months after the operation to prevent thrombotic complications. In all cases, antegrade
delivery of cardioplegia via 14G agiocatheter provides optimal myocardial protection. With the aortic cross clamping
technique well applied, no pulmonary artery may be
injured.
References
1. Modi P, Rodriguez E, Chitwood WR. Robot assisted cardiac surgery. Interact Cardiovasc Thorac Surg. 2009;9(3):500–5.
2. Kypson AP, Chitwood WR. The use of robotics in cardiovascular
surgery. Future Cardiol. 2005;1(4):61–7.
3. Chitwood WR. Current status of endoscopic and robotic mitral
valve surgery. Ann Thorac Surg. 2005;79:S2248–53.
4. Vanermen H, Farhat F, Wellens F, et al. Minimally invasive video
assisted mitral valve surgery: from Port-Access towards a totally
endoscopic procedure. J Card Surg. 2000;15:51.
5. Vanermen H, Wellens F, De Geest R, et al. Video-assisted PortAccess mitral valve surgery: from debut to routine surgery. Will
Trocar-Port-Access cardiac surgery ultimately lead to robotic cardiac surgery? Semin Thorac Cardiovasc Surg. 1999;11:223.
6. Murphy D, Miller JS, Langford DA, Snyder AB. Endoscopic
robotic mitral valve surgery. J Thorac Cardiovasc Surg. 2006;132:
776.
7. Colvin SB, Galloway AC, Ribakove G, et al. Port-Access mitral
valve surgery: summary of results. J Card Surg. 1998;13:286.
8. Reichenspurner H, Detter C, Deuse T, et al. Video and roboticassisted minimally invasive mitral valve surgery: a comparison of
the Port-Access and transthoracic clamp techniques. Ann Thorac
Surg. 2005;79:485; discussion 490.
9. Gao C, Yang M, Wang G, et al. Totally robotic resection of myxoma and atrial septal defect repair. Interact Cardiovasc Thorac
Surg. 2008;7(6):947–50.
10. Gao C, Yang M, Wang G, Wang J, Xiao C, Wu Y, Li J. Totally
endoscopic robotic atrial septal defect repair on the beating heart.
Heart Surg Forum. 2010;13(3):E155–8.
11. Gao C, Yang M, Wang G, et al. Totally endoscopic robotic ventricular septal defect repair. Innovations (Phila). 2010;5(4):278–80.
5
Robotic Surgery in Congenital
Heart Diseases
Changqing Gao and Ming Yang
Abstract
Surgical techniques to reduce postoperative recovery time and improve the cosmetic results
have been achieved through limited incisions. In the late 1990s, as a result of technical
innovation in peripheral cardiopulmonary bypass (CPB) technology combined with the
possibility of endoaortic clamping, remote cardiac arrest became feasible and thus enabled
small access and thoracoscopic surgery. Conventional thoracoscopic instruments have limited degrees of freedom, which hampers performance of complex maneuvers that involve
tissue reconstruction, such as suturing and tying knots, particularly under tension. Robotic
surgical instruments have the dexterity required for these complex maneuvers and, therefore, hold the promise of facilitating truly thoracoscopic repair of cardiac defects even in
children. Application of robotic approaches for open heart procedures now still is confined
to operations where much of the intracardiac repair is performed through the right atrium,
such as closure of atrial or ventricular septal defects, atrioventricular canal defects, atrioventricular valve repair/replacement. This chapter describes the robotic surgical system
employed in the congenital heart disease in adult.
5.1
Robotic Atrial Septal Defects
Repair in Adults
For atrial septal defect (ASD) in adults, surgical repair has
been performed for more than 50 years. Lewis and Taufic
performed the first successful ASD closure in 1953 [1]. Since
then standard surgical closure of an ASD via sternotomy or
thoracotomy has been a safe and effective procedure with
low morbidity and mortality [2, 3]. Currently, there is a
growing interest in minimally invasive approaches in all
fields of cardiac surgery. The ASD closure traditionally conducted via median sternotomy has been recently forwarded
by progressively advanced minimally invasive technology.
In parallel, closure of small ostium secundum and patent
foramen ovale types of ASD by different percutaneous
catheter techniques have been developed by interventional
C. Gao, MD (*) • M. Yang, MD
Department of Cardiovascular Surgery, PLA General Hospital,
No. 28 Fuxing Road, Beijing 100853, People’s Republic of China
e-mail: gaochq301@yahoo.com
cardiologists [4, 5]. The catheter procedure avoids operative
trauma and reduces hospital stay, although it is associated
with occasional major complications [6]. The success rate in
the transcatheter approach depends on the size and shape of
the defect. Therefore, surgery will undoubtedly continue to
be an option for the treatment. With the development of portaccess technology for peripheral cardiopulmonary bypass
(CPB) induction and the use of a transthoracic clamp, skin
incision could be further reduced [7–9]. The recent clinical
introduction of robotically assisted surgery finally enables
totally endoscopic procedures through ports.
Robotic systems comprised of miniaturized surgical
instruments with multiple degrees of motion, coupled with a
dual camera endoscope providing true three-dimensional
high-magnification visualization that had greatly propelled
this field. With the assistant of robotic surgical system, the
surgeon can perform complex intracardiac procedures such
as ASD closure, coronary artery bypass and mitral valve
repair or replacement through smaller incisions. Since
Torracca and colleagues [10] reported a small series of
patients undergoing robotic ASD repair in 2001, other
C. Gao (ed.), Robotic Cardiac Surgery,
DOI 10.1007/978-94-007-7660-9_5, © Springer Science+Business Media Dordrecht 2014
61
62
C. Gao and M. Yang
Fig. 5.2 Intraoperative TEE check
Fig. 5.1 Checking the intubation depth using bronchofiberscope
authors [11–13] subsequently report their experiences.
The first case of ASD repair in China was performed
robotically on January 15, 2007 at the PLA General Hospital
[14]. The group of robotic ASD repairs enrolled the most
cases that supplement this experience at beginning.
5.1.1
Anesthesia, Patient Position
and CPB Establishment
Anesthesia is induced using a standard technique with a leftsided double-lumen endotracheal intubation for single-lung
ventilation. And the flexible bronchofiberscope is used to
identify the proper intubation depth (Fig. 5.1). The transesophageal echocardiography (TEE) probe is inserted
(Fig. 5.2) to evaluate the position of the venous cannulas.
Both a central venous catheter and a 15-F or 17-F venous
drainage cannula are placed percutaneously into the right
internal jugular vein (Figs. 5.3 and 5.4). External defibrillator patches are placed to subtend the maximum cardiac mass.
Each patient is positioned with the right side of the chest
elevated approximately 30° and with the right arm tucked at
the side (Fig. 5.5). After systemic heparinization (300 IU/
kg), the femoral arterial (18–20 F) and venous cannulations
(21–23 F) are performed through a 2-cm transverse right
groin incision (Fig. 5.6) by using the Seldinger guide wire
Fig. 5.3 Puncture the internal jugular vein under TEE guidance
Fig. 5.4 Central venous catheter and internal venous drainage cannula
5
Robotic Surgery in Congenital Heart Diseases
63
Fig. 5.5 The patient position
Fig. 5.7 Right internal jugular vein cannulation
Fig. 5.6 Femoral arterial and venous cannulations
method and TEE guidance. Bicaval venous drainage is instituted through the jugular and femoral/inferior vena cava cannulas (Fig. 5.7) [14].
5.1.2
Surgical Technique
on Arrested Heart [14]
5.1.2.1 Robotic ASD Closure on Arrested Heart
After exclusion of the right lung, a 12-mm endoscopic trocar
is placed into the right thoracic cavity through the fourth
intercostal space (ICS), lateral to the nipple. The pleural
space is insufflated with carbon dioxide at a maximum pressure of 8–10 mmHg, usually 6 mmHg, and the 30° endoscopic camera is inserted. A 1.5–2.0 cm incision is used as a
working port in the same ICS for the patient-side surgeon.
Additionally two 8-mm port incisions are made in the second
and sixth ICS to allow insertion of the left and right instrument arms. The right instrument arm generally is positioned
4–6 cm lateral to the working port in the sixth ICS. The left
instrument arm is positioned medial and cephalad to the right
arm in the second or third ICS. The fourth arm trocar is
placed in the midclavicular line in the 4th or 5th ICS [14],
dependent on the patient’s rib direction and ICS. Two 16 F
Angiocatheters are inserted in the 6th and 4th ICS laterally
respectively for the placement of pericardial stay sutures
(Figs. 5.8 and 5.9).
CPB is initiated with kinetically assisted bicaval venous.
The intrathoracic part of the operation began robotically
with pericardiotomy and placement of pericardial stay
sutures. The pericardium is opened longitudinally 1.5 cm
anteriorly to the phrenic nerve (Fig. 5.10). The incision is
extended superiorly to expose the superior vena cava and
then extended inferiorly to the diaphragm to visualize the
inferior vena cava. The pericardium stay sutures are placed
64
C. Gao and M. Yang
Fig. 5.8 Ports position
Fig. 5.11 The pericardium stay suture
Fig. 5.9 Setup of the da Vinci Surgical System
Fig. 5.12 The stay suture on the left superior side of pericardium to
expose the aorta
Fig. 5.10 The pericardium was opened anteriorly to the phrenic nerve
on the right side of pericardium to rotate the heart for optimal exposure of the atrium (Fig. 5.11). And the 3rd pericardium stay suture is placed on the left superior side of
pericardium through anterior chest (16 Ga Angio) to expose
the aorta (Fig. 5.12).
The space between the vena cavae and the pulmonary
veins are dissected clear (Figs. 5.13 and 5.14). And the linear tapes are placed around the inferior and superior vena
cavae (Figs. 5.15 and 5.16). The aortic occlusion is performed with a Chitwood cross-clamp via the midaxillary
line in the fourth ICS (Figs. 5.17 and 5.18). Antegrade cold
blood cardioplegic solution is administered directly through
the anterior chest (the second ICS) with a 14 Ga Angiocatheter
(Figs. 5.19 and 5.20).
5
Robotic Surgery in Congenital Heart Diseases
65
Fig. 5.16 The tape around the superior vena cavae
Fig. 5.13 Dissected the space between superior vena cava and right
superior pulmonary vein
Fig. 5.14 Dissected the space between inferior vena cava and right
inferior pulmonary vein
Fig. 5.17 The extracorporeal position of Chitwood clamp
Fig. 5.18 The Chitwood cross-clamp
Fig. 5.15 The tape around the inferior vena cavae
66
Fig. 5.19 14 Ga angiocatheter is inserted into the aorta
C. Gao and M. Yang
Fig. 5.21 The right atrium is opened
Fig. 5.22 The atrial retractor is introduced into right atrium
Fig. 5.20 Administration cold blood cardioplegic solution through the
angiocatheter
After snaring of the superior and inferior vena cavae, the
right atrium is opened (Fig. 5.21). The atrial retractor is
introduced into the right atrium through the fourth robotic
arm to expose the atrial septal defect (Fig. 5.22). Cardiotomy
suction is passed through the working port by the patientside surgeon. After thorough exploration, ASD is closed
directly using 4-0 Gore-Tex running suture or autologous
pericardial patching, depending on the size and location of
ASD (Figs. 5.23 and 5.24). The knot tying is performed
extracorporeally by patient-side surgeon using a knot pusher.
And the atrial leakage is identified before closing right
atrium. If the moderate to severe tricuspid valve regurgitation is diagnosed, the retractor is removed to expose the tricuspid valve and ring. The tricuspid valve plasty is performed
using De Vaga technique. The result of tricuspid valve plasty
Fig. 5.23 Closing the ASD using running suture
5
Robotic Surgery in Congenital Heart Diseases
67
Fig. 5.24 Closing the ASD using autologous pericardial patch
Fig. 5.26 Evaluating the plasty result
Fig. 5.25 Tricuspid valve plasty using De Vaga technique
is evaluated (Figs. 5.25 and 5.26). The right atrium is closed
with double-layer 4-0 Gore-Tex running suture (Fig. 5.27).
The deairing is done through the cardioplegia Angiocatheter.
Then the aortic puncture site is closed using 4-0 Gore-Tex
(Fig. 5.28). After adequate hemostasis achieved, the robotic
arms are removed and a chest tube is inserted through right
arm porthole. The right femoral artery is reconstructed after
removing of the cannulas.
5.1.2.2 Robotic ASD Repair on Beating Heart
For ASD closure on beating heart, the aortic occlusion and
cardioplegic solution administration can be avoided [15].
Under mild hypothermic conditions (rectal temperature,
34–35 °C), CPB full flow is maintained with mean systemic
pressure more than 60 mmHg. To avoid air embolism, carbon dioxide with 6–8 mmHg is insufflated continuously into
the chest for air displacement. On beating heart, a right
atriotomy is performed under SVC and IVC snared with
same techniques mentioned above, and ASD is exposed with
atrial retractor by the 4th arm. A small suction catheter is
placed in the right atrium, not in the left atrium through the
Fig. 5.27 The right atrium is closed with double-layer running suture
Fig. 5.28 Aortic puncture site is closed
68
Fig. 5.29 The right atrium is opened on beating heart under SVC and
IVC snared
Fig. 5.30 The atrial retractor is introduced into the right atrium
Fig. 5.31 ASD is exposed with the aid of atrial retractor
working port. The direct closure with running suture or
autologous pericardium patching can be used (Figs. 5.29,
5.30, 5.31, 5.32, and 5.33). As the inter-atrial septum is
closed, the lung is briefly inflated, and the inter-atrial suture
line is secured when there is no evidence of retained air in the
left atrium.
C. Gao and M. Yang
Fig. 5.32 The autologous pericardium patch is used for ASD closure
Fig. 5.33 Secured suture line when there is no evidence of retained air
in the left atrium
Advantages of this method include avoidance of ischemiareperfusion injury, performance of surgery in a more physiological state of the heart, decreased use of inotropic
medications, and shorter hospital stay [16]. In addition,
proximal aortic arteriosclerosis is the source of macro- and
microemboli at the time of placement and release of the aortic cross-clamp. Potential concerns related to this technique
may include performance of surgery in a relatively bloodfilled field, limited surgical precision due to difficult exposure, risk of air embolization, and limited ability to perform
very large ASD closure procedure on beating heart [16].
In fact, the operations can be performed without difficulty
because the atrial retractor through 4th arm and small suction
catheter from the working port could provide adequate visualization of the operative field. In addition, the concomitant
surgery of tricuspid valve repair is easily performed. In our
study, the complications related to beating heart ASD repair
are not observed, such as, strokes or residual atrial septal
defect due to dehiscence of the atrial suture line.
For the prevention of air embolism, each patient is positioned with the right chest elevated approximately 30°.
Furthermore, the left atrium is kept full without suction in it
5
69
Robotic Surgery in Congenital Heart Diseases
during operation, and throughout the procedure carbon
dioxide with 6–8 mmHg is insufflated continuously into the
chest for air displacement. De-airing of left atrium at the end
of the procedure is easily done.
Based on this knowledge, it seems reasonable to perform
robotic beating-heart ASD closure surgery with on-pump
beating heart conditions. This technique is simple and it
shortens the duration of CPB and total operation. Besides,
this technique does not increase the risk of central nervous
system (CNS) injury. It is not possible to determine with certainty whether minor neuron-cognitive disorders due to
microembolization occur. The neurocognitive evaluation is
an important aspect that needs to be further investigated.
Possible contraindications to robotic beating-heart ASD
repair may include the presence of mobile vegetations in
patients with infective endocaditis or large left atrial thrombi,
due to the risk of embolization. Inadequate experience of
console surgeon certainly is contraindication to beating heart
surgery.
5.1.3
Postoperative Management
Postoperation patients are monitored at the intensive care
unit (ICU) and discharged to an intermediate care unit as
soon as hemodynamics and spontaneous respiration has
become adequately stabilized. Chest drains are removed
when drainage reaches less than 50 ml/12 h. All patients
undergo transthoracic echocardiography immediately before
discharge from hospital and at 3 months after the procedure.
5.1.4
Surgical Results and Learning Curves
Totally endoscopic ASD closure remains a highly complex
procedure, the performance of which requires experience with
several non-routine operative steps, such as remote access
perfusion and robotic cardiac surgery [17]. Moreover anesthesia management of those patients has additional non-routine
steps as prerequisites, such as single-lung ventilation and
advanced TEE for patient monitoring during remote access
cardiopulmonary bypass (CPB) [13]. According to the previous literatures published, the robotic ASD closure is a more
time-consuming operation compared with procedures in sternotomy, which requires long CPB and aortic occlusion time
[10–13]. However, from our experience, we feel that robotic
surgery is not time-consuming operation after overcoming the
learning curve. The learning curves and operation times play
a major role for the acceptance of such a program [13].
Between January 2007 and January 2013, 147 consecutive patients (99 female and 48 male) underwent ASD closure with da Vinci S or Si Surgical System at the PLA
General Hospital. The mean age of the patients was 35.8
Table 5.1 The baseline characteristics of robotic ASD closure at the
PLA General Hospital (01/2007 –01/2013)
Variables
Total number of patients
Gender
Male (%)
Female (%)
Age (year)
Weight (kg)
Height (cm)
Pathology
Atrial septal defect II, n (%)
Patent foramen ovale, n (%)
Median to sever tricuspid
valve regurgitation, n (%)
Median to sever pulmonary
hypertension, n (%)
Atrial septal aneurysm, n (%)
Diameter of defect (cm)
Left ventricular ejection
fraction (%)
Arrest
Beating
Both
heart group heart group groups
54
93
147
16(29.6)
38(70.3)
35.2 ± 13.1
58.3 ± 10.0
162.6 ± 8.0
32(34.4)
61(65.6)
36.4 ± 13.3
61.7 ± 12.1
163.0 ± 8.2
48(32.7)
99(67.3)
35.8 ± 12.3
59.2 ± 13.6
162.7 ± 9.2
52(96.3)
2(3.7)
4(7.4)
91(97.8)
2(2.2)
8(8.6)
143(97.3)
4(2.7)
12(8.1)
6(11.1)
9(9.7)
15(10.2)
4(7.4)
2.8 ± 1.6
64.3 ± 7.1
2(2.2)
2.7 ± 1.8
65.8 ± 8.4
6(4.1)
2.7 ± 2.0
65.3 ± 6.4
Table 5.2 Results of robotic ASD closure at the PLA General Hospital
(01/2007–01/2013)
Variables
Procedure, n
Direct closure, n (%)
Patch closure, n (%)
Combined with tricuspid valve plasty, n
(%)
Operation time (min)
Cardiopulmonary bypass time (min)
Cross clamp time (min)
Mechanical ventilation time (h)
ICU duration (h)
Drainage volume (ml)
Length of stay (d)
Arrest heart
group
54
38(70.4)
16(29.6)
4(7.4)
Beating heart
group
93
34(36.6)
59(63.4)
8(8.6)
287.4 ± 58.7
103.5 ± 27.5
43.0 ± 10.2
4.9 ± 2.4
29.4 ± 7.8
107.8 ± 32.4
12.1 ± 4.5
207.9 ± 62.3*
61.9 ± 17.0*
0
4.7 ± 1.5
27.9 ± 3.8
92.4 ± 36.7
11.2 ± 3.2
*p < 0.05
years old (12–65 years), and ostium secundum ASD was
confirmed echocardiographically on all patients. Patients
were excluded if they could not tolerate single-lung ventilation or peripheral CPB, or otherwise were considered poor
candidates for a thoracoscopic approach. Fifty-four cases
were completed on arrest heart (arrest heart group) from
January 2007 to December 2008, and 93 cases on beating
heart (beating heart group) from December 2008 to January
2013 (Table.5.1).
Anesthesia and surgical techniques were described above.
The direct closure of ASD was performed in 72 cases, and
autologous pericardial patching in 75 cases, and 8 patients
accepted ASD repair combined with tricuspid valve repair
(Table 5.2). TEE confirmed complete closure and tricuspid
C. Gao and M. Yang
70
500.0
125.0
400.0
CPB time (min)
Operation time (min)
150.0
300.0
100.0
75.0
50.0
200.0
0.0
10.0
20.0
30.0
40.0
50.0
0.0
60.0
10.0
20.0
Case number
valve plasty in all cases. Reoperations and intraoperative
conversions to alternate procedures were not needed.
Mortality and serious complications were not encountered.
In the arrest heart group, the median operating room time
was 301.6 min (260–390 min), the median CPB time was
99.2 min (62–154 min), and the median cross-clamp time
was 43.0 min (21–62 min). Every five patients were a group,
then the mean operating room time, CPB time and crossclamp time were calculated and the coefficient of variation
of each group was estimated. The operation, CPB and crossclamp time were stable if the two consecutive groups’ differences of coefficient of variation were smaller than 0.05.
Learning curves were assessed by means of regression analysis with logarithmic curve fit. The operation time was stable
after 30 cases and decreased with the increase of the case
number (Fig. 5.34).
The tendency of CPB time had the same pattern as the
operating room time (Fig. 5.35). Significant learning curves
were noted for cross-clamp time of arrest heart group:
y(min) = 69.63 − 8.70 ln(x) ⟮r2 = 0.525; P < 0.01) (Fig. 5.36).
In beating heart group, the median operating room time
was 254.7 min (range, 120–330 min), and the median
CPB time was 61.9 min (range, 40–94 min). The operating room time of beating heart group was stable after
five cases, and the significant learning curve was noted: y
(min) = 355.51 − 56.29 ln(x) ⟮r2 = 0.581; P < 0.01) (Fig. 5.37).
The CPB time decreased as case number increased
(Fig. 5.38).
No statistic differences in median ventilation time, ICU
stay, drainage volume, and length hospital of stay were
shown between two groups. No perioperative neurologic
event was recorded and no residual ASD was detected on
intraoperative TEE and on postoperative TEE performed
before discharge. All the patients were discharged, and
40.0
50.0
60.0
Fig. 5.35 The linear correlations of CPB time with case number
(r2 = 0.349, p = 0.000)
70.0
60.0
Cross–clamp time (min)
Fig. 5.34 The linear correlations of operation time with case number
(r2 = 0.104, p = 0.017)
30.0
Case number
50.0
40.0
30.0
20.0
0.0
10.0
20.0
30.0
40.0
50.0
60.0
Case number
Fig. 5.36 The learning curve of cross-clamp time in arrest heart group
(y(min) = 69.63 − 8.70 ln(x); r2 = 0.525, p = 0.000)
cosmetic results are excellent (Figs. 5.39, 5.40, 5.41, 5.42,
5.43, and 5.44).
In our study, there were no incision conversions either to
a thoracotomy or to a median sternotomy. These patients
benefit from minimal musculoskeletal trauma, zero transfusion, and early discharge. We believe that ASD closure using
da Vinci Surgical System, is feasible, safe and simple with
excellent surgical results either on arrest heart or beating
heart.
5.1.5
Summary
During the past decade, improvements in instruments, endoscopes, as well as patients demand have resulted in a
5
71
Robotic Surgery in Congenital Heart Diseases
Operation time (min)
400.0
300.0
200.0
100.0
0
20
40
60
Case number
80
100
Fig. 5.37 The learning curve of operating room time in beating heart
group (y (min) = 355.51 − 56.29 ln(x); r2 = 0.581, p = 0.000)
Fig. 5.39 Postoperative view of conventional sternotomy
100.0
90.0
CPB time (min)
80.0
70.0
60.0
50.0
40.0
30.0
0
20
40
60
Case number
80
100
Fig. 5.38 The linear correlations of CPB time with case number
(r2 = 0.246, p = 0.000)
substantial increase in minimally invasive cardiac surgical
procedures being performed [17]. Endoscopic instrumentation, with only four degrees of freedom, significantly reduces
the dexterity needed for delicate cardiac surgical procedures,
and the loss of depth perception by using two-dimensional
video monitor further increases operative difficulty [17].
With the advances in closed-chest cardiopulmonary bypass,
micro instruments and computer telemanipulation, the
robotic surgical system have been developed to facilitate the
surgeons’ hand motion in limited closed chest operating
spaces [18]. Computerized surgical robotic systems have
been developed very rapidly in the past few years. The most
common robotic applications in cardiac surgery are for
mitral valve repair and endoscopic coronary artery bypass
Fig. 5.40 One week after robotic ASD closure
grafting. Argenziano et al. demonstrated that ASD in adults
could be closed safely and effectively using totally endoscopic robotic approaches with a median cross-clamp time
of 32 min [12]. Gao et al. reported first ASD repair surgery
using da Vinci S Surgical System for in China in January,
2007, and subsequently, 54 ASD cases were completed on
arrested heart. Since 2008, Gao and his team developed the
techniques of beating-heart ASD repair without crossclamping the aorta and had excellent results [15].
Although transcatheter closure of ASD using an occluder
has recently been presented as an alternative, it is considered
difficult in practice for implantation for defects greater than
72
C. Gao and M. Yang
Fig. 5.41 One month after robotic ASD closure in a female patient
Fig. 5.43 Three months after robotic ASD closure
Fig. 5.42 One month after robotic ASD closure in a male patient
30-mm in diameter or defects without sufficient amount of
septal tissue. In addition, the long-term outcomes of occluder
implantation remain to be clarified [19, 20]. Unlike transcatheter treatment, robotic surgery allows for closure of ASD
of all types, including primum type or sinus venous defects,
Fig. 5.44 Six months after robotic ASD closure
5
Robotic Surgery in Congenital Heart Diseases
73
as well as closure of multiple defects. Some ASD cases may
be complicated by tricuspid regurgitation, however, robotic
surgery provides a solution to these problems.
Few reports have so far investigated the feasibility of
robotic surgery for treating pediatric ASD, particularly in
infants [21] because the femoral cannulation is the big
issue.
In conclusion, the robotic ASD closure can be safely
implemented on arrest or beating heart, and is especially
suitable for patients whose defects are greater than 30-mm in
diameter, defects without sufficient amount of septal tissue
for occluder implantation, or defects complicated by
tricuspid regurgitation.
5.2
Ventricular Septal Defect Repair
Fig. 5.45 The exposed VSD
Recent advances in robotic instrumentation have facilitated
totally endoscopic intracardiac procedures. However, due to
relative complexity of ventricular septal defect (VSD) anatomy, totally endoscopic robotic VSD repair has not been
reported in the literatures except those reported by our
institution.
5.2.1
Indications of VSD for Surgery
Adults with small restrictive VSDs who are asymptomatic
often require no surgical intervention and should receive
endocarditis prophylaxis as necessary. In general, if Op:Os
ratio is >1.5:1 and the calculated pulmonary vascular resistance is under 6 U/m2, surgical closure of a VSD can be performed safely and is recommended. The development of a
double-chambered right ventricle with outflow obstruction is
also an indication for surgical intervention. The occurrence
of infective endocarditis in an adult with a restrictive VSD is
rare but compelling indication for repair of the defect [22].
5.2.2
Anesthesia, Patient Position
and CPB Establishment
The anesthesia, position of patient and CPB establishment
are the same as those previously described for atrial septal
defect repair in Sect. 5.1.
5.2.3
Surgical Technique [23]
The CPB is initiated with kinetically assisted bicaval venous.
The intrathoracic part of the operation began robotically
with pericardiotomy and placement of pericardial stay
sutures. The pericardium is opened longitudinally 1.5 cm
anteriorly to the phrenic nerve (Fig. 5.10). The incision is
extended superiorly to expose the superior vena cava and
then extended inferiorly to the diaphragm to visualize the
inferior vena cava. The pericardium stay sutures are placed
on the right side of pericardium to rotate the heart for optimal exposure of the atrium (Fig. 5.11). And the 3rd pericardium stay suture is placed on the left superior side of
pericardium through anterior chest (16 Ga Angio) to expose
the aorta (Fig. 5.12).
The space between the vena cavae and the pulmonary
veins are dissected clear (Figs. 5.13 and 5.14). And the linear tapes are placed around the inferior and superior vena
cavae (Figs. 5.15 and 5.16). The aortic occlusion is performed with a Chitwood cross-clamp via the midaxillary
line in the fourth ICS (Figs. 5.17 and 5.18). Antegrade cold
blood cardioplegic solution is administered directly through
the anterior chest (the 2nd ICS) with a 14 Ga Angiocatheter
(Fig. 5.19).
After snaring of the superior and inferior vena cavae, the
right atrium is opened. The atrial retractor is applied through
the fourth robotic arm. VSD is exposed through the tricuspid
valve annulus (Fig. 5.45). Visualization of the perimembranous VSD edges is excellent with the assistance of valve
hook. The membranous aneurysm is opened and the basal
part of ventricular septal defect is exposed (Figs. 5.46 and
5.47). The defect is closed with interrupted sutures (Fig. 5.48)
or Dacron patch (Fig. 5.49). The knot tying is performed
extracorporeally by patient-side surgeon using a shafted knot
pusher. The aortic clamp is released when the patient is
rewarming. The tricuspid valve is repaired (Fig. 5.50) when
no leakage and atrioventricular block are identified. The
right atriotomy is closed using double-layer continuous 4-0
polytetrafluoroethylene running sutures. Then the patient is
weaned from cardiopulmonary bypass.
74
Fig. 5.46 The membranous aneurysm is opened
C. Gao and M. Yang
Fig. 5.49 VSD closure with Dacron patch
Fig. 5.50 The tricuspid valve is repaired
Fig. 5.47 The basal part of VSD is exposed
5.2.4
Fig. 5.48 VSD closure with interrupted sutures
Surgical Results and Learning Curves
From 2009 to 2012, 20 patients with VSD, 11 female and 9
male, were operated on with “da Vinci S” or “da Vinci Si”
Surgical System. Ages ranged from 16 to 45 years with an
average of 29.0 ± 9.5 years. The echocardiography demonstrates the average diameter of perimembranous ventricular
septal defect was (6.1 ± 2.8) mm, and a patent foramen ovale
was found in one patient (Table 5.3).
The VSD closure was secured with interrupted mattress
sutures in 17 patients and patch closure in 3 patients
(Table 5.4.). All cases were accomplished successfully without complications. The mean operation time was 225.0 ± 34.8
(180–300) min. And the mean CPB time was 94.3 ± 26.3 (70–
140) min; the mean cross-clamp time was 39.1 ± 12.9 (22 to
75) min. The postoperative TEE demonstrated intact ventricular septum. The mean hospital stay was 5 days. No residuary
shunt was detected in an average of 14 months follow-up.
5
Robotic Surgery in Congenital Heart Diseases
75
Table 5.3 The baseline characteristics of robotic VSD closure at the
PLA General Hospital (01/2009–01/2013)
20
120.00
CPB time (min)
Variables
Total number of patients
Gender
Male (%)
Female (%)
Age (year)
Weight (kg)
Height (cm)
Diameter of defect (mm)
Left ventricular ejection fraction (%)
140.00
9(45 %)
11(55 %)
29.0 ± 9.5
56.3 ± 8.2
160.7 ± 7.3
6.1 ± 2.8
66.9 ± 8.3
80.00
60.00
0.00
Table 5.4 Results of robotic perimembranous VSD repair
20
17(85 %)
3(15 %)
225.0 ± 34.8
94.3 ± 26.3
39.1 ± 12.9
4.6 ± 3.3
91.8 ± 60.8
5.0 ± 2.1
Operation time (min)
20.00
70.00
280.00
260.00
60.00
50.00
40.00
30.00
20.00
0.00
240.00
5.00
10.00
15.00
Case number
20.00
Fig. 5.53 The linear correlations of cross-clamp time with case number (r2 = 0.19, p = 0.046)
220.00
5.00
10.00
15.00
Case number
20.00
Fig. 5.51 The learning curve of operating time of VSD closure
(y(min) = 258.25 − 16.18 ln(x); r2 = 0.221, p = 0.037)
Significant learning curve was noted for operation time: y
(min) = 258.25−16.18 ln(x) ⟮r2 = 0.221; P<0.05) (Fig. 5.51).
The CPB and cross-clamp time decreased as the case number
increased (Figs. 5.51, 5.52, and 5.53).
5.2.5
10.00
15.00
Case number
80.00
300.00
200.00
0.00
5.00
Fig. 5.52 The linear correlations of CPB time with case number
(r2 = 0.14, p = 0.039)
Cross–clamp time (min)
Variables
Procedure, n
Direct closure, n (%)
Patch closure, n (%)
Operation time (min)
Cardiopulmonary bypass time (min)
Cross clamp time (min)
Mechanical ventilation time (h)
Drainage volume (ml)
Length of stay (d)
100.00
Summary
VSD closure can be completed through a conventional
median sternotomy with low morbidity, relatively low cost,
and excellent long-term results. However, patients are reluctant to undergo an operation because of the long incision in
the midline of the chest. The incision leaves an unsightly scar
that may be a source of persistent psychological disturbances
and permanent dissatisfaction. Although the transcatheter
closure of VSD has been used in some centers, the success
rate of the procedure is low, and recurrence of the intracardiac shunt and the occluder dislodgment have been reported
frequently.
With the advent of computer-assisted robotic surgery,
another option is offered for VSD closure without opening
the chest. After over 300 cases of robotic cardiac surgery
at the PLA General Hospital, Prof. Changqing Gao completed the first case of totally endoscopic robotic VSD
repair on an adult patient using da Vinci robot in the world
on the 22nd October 2009 [23]. We believe that the
76
C. Gao and M. Yang
Fig. 5.55 One month after robotic VSD closure
5.3
Fig. 5.54 One week after robotic VSD closure
possibility of closing all type of VSD regardless of the
size and location could be realistic. The excellent exposure of whole VSD edges in the surgical field is paramount
for successful VSD repair. In this group, the excellent
visualization for VSD repair is achieved through the tricuspid valve annulus using dynamic atrial retractor to
elevate the anterior leaflet of the tricuspid valve. Although
in one case, the edges of the defect are a little difficult to
be visualized because of multiple attachments of the septal defect to the edges of the defect, the visualization is
well acceptable for repairing under the assistance of valve
hook. In addition, the defect is carefully examined to
establish that all edges can be seen well, and reached
before repair is started. Our experience shows that the closure of VSD can be completed with a patch for a large one
or direct suture for a small one without difficulties after a
learning curve. The lack of a thoracotomy or a sternotomy
should allow for a faster recovery and should quicken the
patient’s return to a normal life style with excellent cosmetic result (Figs. 5.54, 5.55, and 5.56). The results are
encouraging, however, a large study would be needed to
confirm this concept.
Partial Atrioventricular
Septal Defect Repair
Atrioventricular septal defects encompass a spectrum of
lesions that are caused by maldevelopment of the endocardial cushions. Abnormalities of atrioventricular valve form
and function and interatrial and interventricular communications may results.
5.3.1
Ostium Primum Defect
with a Cleft Mitral Valve
A 33-year-old female patient was admitted due to heart murmurs for 6 years. An ostium primum defect (2.5 × 3.0 cm)
with a cleft mitral valve was confirmed (Fig. 5.57a), and
moderate mitral valve regurgitation was revealed echocardiographically (Fig. 5.57b). The right atrium of the patient
was enlarged and cardiac function was in class II (NYHA).
The systolic heart murmur in the apex could be auscultated
in physical examination. Electrocardiography showed sinus
rhythm and left anterior branch block. Routine chest radiography revealed normal cardiothoracic ratio with mildly exaggerated bronchovascular markings.
After inducing of general anesthesia, the intubation for
single-lung ventilation and TEE were administrated. The
right side of the chest was slightly elevated at 30o. Femoral
arterial (18 F) and venous cannulation (23 F) was performed through a 2 cm transverse right groin incision with
Seldinger guidewire method. And the cannulation was
5
Robotic Surgery in Congenital Heart Diseases
77
Fig. 5.56 Three months after robotic VSD closure, the surgical incision viewed from the front and right side
a
b
Fig. 5.57 Preoperative echocardiography showed ostium primum defect (a) and mitral valve regurgitation (b)
performed in the right internal jugular venous (15 F) under
TEE guidance. Cardiopulmonary bypass was initiated with
kinetically assisted bicaval venous drainage. The da Vinci
Si camera and instrument arms were inserted in the right
chest. A 2.0-cm incision was used as the working port in
the fourth intercostals space of right chest. The aortic
occlusion was performed with a Chitwood crossclamp via
the midaxillary line in the fourth ICS. Antegrade cold HTK
solution was administered directly through the anterior
chest (second ICS) with a 14Ga Angiocatheter. Carbon
dioxide was insufflated continuously into the operative
field for air replacement.
After lung deflation, the pericardium was opened and stay
sutures were placed on the right side of pericardium to rotate
the heart for optimal exposure of the left atrium. A right
atrium incision was made and the atrial retractor was applied.
A partial atrioventricular septal defect with estimated dimensions of 2.5 × 3.0 cm was found (Fig. 5.58), and the mitral
valve cleft with a normal mitral annulus was also found
(Fig. 5.59a). Repair of the mitral valve cleft proceeded by
precise placement of simple Gortex sutures in the cleft,
beginning at its base and moving centrally until the first set
of chordal attachment was approached (Fig. 5.59b). The
valve was then tested again with saline solution. Absolutely
78
C. Gao and M. Yang
Fig. 5.58 The 2.5 × 3.0-cm partial atrioventricular septal defect
a
b
Fig. 5.59 The 0.2-cm cleft in A2 segment (a), and the cleft was repaired using interrupted suture (b)
alignment of the cleft in all its dimensions was of critical
importance. The interatrial communication was then closed
with a patch. The patch was placed with interrupted suture
technique, beginning at the base of the mitral cleft
(Fig. 5.60a). The suture line continued to the surgeon’s right,
where the critical area of the conduction system and the coronary sinus were located. The edge of the patch was sutured
superficially to the mitral valve tissue that was adherent to
the underlying ventricular septal crest. Suture depth was
critical, as the proximal conduction bundles traveled along
the underlying crest of the ventricular septum at this level. As
the suture line approached the inferiormost extent of the ventricular septal crest, it should be directed well to the right
ventricular side of the crest, using the available tissue from
the right-side atrialventricular valve inferior leaflet. As the
annulus was approached, the suture line undergoes transition
from atrioventricular valve tissue to the atrial free wall.
The patch repair allowed the coronary sinus to drain to the
right atrium (Fig. 5.60b).
The sinus rhythm was observed on the electrocardiogram
monitor after release of the aortic cross-clamp. The right
atriotomy was closed using double-layer continuous 4-0
Gortex running sutures. The bypass weaned from CPB after
the patient was rewarmed. The ports were closed and the
femoral vessels were decannulated. The total operative time
was 320 min; total bypass time and ischemic time was 165
and 126 min respectively. The patient was ventilated for 6 h.
The postoperative course was uneventful and the patient was
discharged from the hospital on the eighth postoperative day
with excellent results (Fig. 5.61a, b). And the ECG showed
sinus rhythm, right bundle branch block and first-degree
atrioventricular block.
5
Robotic Surgery in Congenital Heart Diseases
79
a
b
Fig. 5.60 The interrupted suture line was placed on the tricuspid valve side (a), and the continued line was placed inferiorly on the atrial wall,
then under the lip of the coronary sinus and back to the edge of the ostium primum defect (b)
a
b
Fig. 5.61 Postoperative echocardiography showed the patch closure of the defect (a) and good mitral valve function (b)
80
5.4
C. Gao and M. Yang
Summary
In the mid-1990s, cardiac surgeons recognized the significant advantages of minimizing surgical trauma by reducing
incision size. A series of clinic reports demonstrate that
robotic atrial septal defect repair is safe and has excellent
results [10–15]. However, total robotic partial atrioventricular septal defect repair combined with mitral valve repair has
not been reported in the literatures to our knowledge.
After 500 cases of robotic cardiac surgery, including 120
cases of ASD and 20 cases of VSD repair surgery, we performed the totally robotic partial atrioventricular septal
defect repair.
In terms of ostium primum defect with a cleft mitral
valve, author’s understanding is as follows: excellent
exposure is the key to successful operation. The robotic surgical system provides us with a satisfying surgical field of
right atrium, tricuspid and mitral valve. With the assistance
of the dynamic atrial retractor by the fourth arm, ostium primum defect can be perfectly identified through the right
atrium incision. Robotic surgical system enables surgeons to
perform complex repairs using optimized, high-definition
visualization and fine dexterity [24, 25].
When an ostium primum interatrial defect is present with
a left mitral valve, the approach is exclusively through a right
atrial incision. The mitral valve is addressed first, looking
through the atrial defect. Repair of the mitral valve cleft proceeds by precise placement of simple Gortex sutures in the
cleft, beginning at its base and moving centrally until the first
set of chordal attachment are approached. The valve is then
tested again with saline. If central coaptation is adequate, the
repair is complete. Absolute alignment of the cleft in all its
dimensions is of critical importance. The interatrial communication is then closed with a patch. The patch is placed with
a running suture technique using Gortex suture, beginning at
the base of the mitral cleft. The suture line continues to the
surgeon’s right, where the critical area of the conduction system and the coronary sinus are located. The edge of the patch
is sutured superficially to the mitral valve tissue that is adherent to the underlying ventricular septal crest. Suture depth is
critical, as the proximal conduction bundles travel along the
underlying crest of the ventricular septum at this level. As the
suture line approaches the inferiormost extent of the ventricular septal crest, it should be directed well to right ventricular side of the crest, using the available tissue from the
right-side atrialventricular valve inferior leaflet. As the annulus is approached, the suture line undergoes transition from
atrioventricular valve tissue to the atrial free wall. The patch
repair allows the coronary sinus to drain to the right atrium.
We believe that robotic surgery for partial atrioventricular
septal defect should be feasible and safe with good cosmetic
outcomes for selected patients [26].
References
1. Lewis FJ, Taufic M. Closure of atrial septal defects with the aid of
hypothermia: experimental accomplishments and the report of the
one successful case. Surgery. 1953;33:52.
2. Murphy JG, Gersh BJ, McGoon MD, et al. Long-term outcomes
after surgical repair of isolated atrial septal defect. Follow-up at 27
to 32 years. N Engl J Med. 1990;323:1645–50.
3. Minale C. Atrial septal defect closure through a thoracotomy. Ann
Thorac Surg. 1997;63:913–4.
4. Rao PS, Sideris EB, Hausdorf G, et al. International experience
with secundum atrial septal defect occlusion by the buttoned device.
Am Heart J. 1994;128:1022–35.
5. Ewert P, Berger F, Daehnert I, et al. Transcatheter closure of atrial
septal without fluoroscopy. Feasibility of new method. Circulation.
2000;101:847–9.
6. Webb G, Gatzoulis MA. Atrial septal defects in the adult: recent
progress and overview. Circulation. 2006;114:1645–53.
7. Izzat MB, Yim AP, El-Zufari MH. Limited access atrial septal
defect closure and the evolution of minimally invasive surgery. Ann
Thorac Cardiovasc Surg. 1998;4:56–8.
8. Galloway AC, Shemin RJ, Glower DD, et al. First report of
the port-access international registry. Ann Thorac Surg. 1999;
67:51–8.
9. Chitwood Jr WR, Elbeery JR, Moran JF. Minimally invasive mitral
valve repair using transthoracic aortic occlusion. Ann Thorac Surg.
1997;63:1477–9.
10. Torracca L, Ismeno G, Alfieri O. Totally endoscopic computerenhanced atrial septal defect closure in six patients. Ann Thorac
Surg. 2001;72(4):1354–7.
11. Wimmer-Greinecker G, Dogan S, Aybek T, et al. Totally
endoscopic atrial septal repair in adults with computer-enhanced
telemanipulation. J Thorac Cardiovasc Surg. 2003;126(2):
465–8.
12. Argenziano M, Oz MC, Kohmoto T, et al. Totally endoscopic atrial
septal defect repair with robotic assistance. Circulation. 2003;108
Suppl 1:II191–4.
13. Bonaros N, Schachner T, Oehlinger A, et al. Robotically assisted
totally endoscopic atrial septal defect repair: insights from operative times, learning curves, and clinical outcome. Ann Thorac Surg.
2006;82(2):687–93.
14. Gao C, Yang M, Wang G, et al. Totally robotic resection of myxoma and atrial septal defect repair. Interact Cardiovasc Thorac
Surg. 2008;7(6):947–50.
15. Gao C, Yang M, Wang G, Wang J, Xiao C, Wu Y, Li J. Totally
endoscopic robotic atrial septal defect repair on the beating heart.
Heart Surg Forum. 2010;13(3):E155–8.
16. Salerno TA, Suarez M, Panos AL, Macedo FI, Alba J, Brown M,
Ricci M. Results of beating heart mitral valve surgery via the transseptal approach. Rev Bras Cir Cardiovasc. 2009;24(1):4–10.
17. Modi P, Rodriguez E, Chitwood WR. Robot assisted cardiac
surgery. Interact Cardiovasc Thorac Surg. 2009;9(3):500–5.
18. Kypson AP, Chitwood WR. The use of robotics in cardiovascular
surgery. Future Cardiol. 2005;1(4):61–7.
19. Rosas M, Zabal C, Garcia-Montes J, et al. Transcatheter versus surgical closure of secundum atrial septal defect in adults: impact of
age at intervention: a concurrent matched comparative study.
Congenit Heart Dis. 2007;2(3):148–55.
20. Bijulal S, Sivasankaran S, Ajitkumar VK. An unusual thrombotic
complication during percutaneous closure of atrial septal defect.
J Invasive Cardiol. 2009;21(2):83–5.
21. Baird CW, Stamou SC, Skipper E, et al. Total endoscopic repair of
a pediatric atrial septal defect using the da Vinci robot and hypothermic fibrillation. Interact Cardiovasc Thorac Surg. 2007;6(6):
828–9.
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22. Cohn L. Cardiac surgery in the adult. 4th ed. New York: McGrawHill Professional; 2011.
23. Gao C, Yang M, Wang G, et al. Totally endoscopic robotic ventricular septal defect repair. Innovations (Phila). 2010;5(4):278–80.
24. Chitwood WR. Current status of endoscopic and robotic mitral
valve surgery. Ann Thorac Surg. 2005;79:S2248–53.
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25. Yang M, Gao C, Wang G, et al. Robotic-assisted endoscopic atrial
septal defect closure: analysis of 115 cases in a single center. Zhong
Nan Da Xue Xue Bao Yi Xue Ban. 2012;32(7):915–8.
26. Gao C, Yang M, Wang G, et al. Totally endoscopic robotic ventricular septal defect repair in the adult. J Thorac Cardiovasc Surg.
2012;144:1404–7.
6
Totally Robotic Myxoma Excision
Changqing Gao and Ming Yang
Abstract
A median sternotomy approach with ascending aortic and bicaval cannulation is usually
employed. In recent years, minimally invasive approaches are being applied with increasing
frequency in all areas of cardiac surgery, and also in surgery for cardiac tumors.
Over the past few years, computerized surgical robotic systems have been developed
very rapidly. The da Vinci surgical robot has assisted the surgeon’s work using telemanipulation through a master-controller activation principle with a 3-D intracardiac camera. In
2005, Murphy and associates reported the initial successful experience with left atrial myxoma excision with the da Vinci Surgical System. Subsequently, the largest series of robotic
resection of atrial myxomas with no operative deaths or strokes was reported by Gao et al.
at the PLA General Hospital in Beijing, China in 2010. In this chapter, robotic resection of
atrial myxoma will be discussed.
Traditionally, left atrial myxomas have been resected by median sternotomy with cardiopulmonary bypass. Recent advances in robotic instrumentation have facilitated endoscopic
intracardiac procedure. The initial successful robotic resection of left atrial myxoma was
reported in 2005, and the largest case series was reported by Dr. Changqing Gao (Gao C) at
the PLA General Hospital, Beijing, China in 2011. The experience of robotic myxoma
resection is still limited. This chapter is to discuss a surgical approach for ideal and safe
resection of atrial myxoma using the da Vinci Surgical System. The robotic myxoma resection is technically feasible in all stable and selective patients without the fear of inadequate
intraoperative exposure. Results in this limited number of selected patients are satisfactory,
but more experience and longer follow-up are still needed before this can be recommended
as a standard approach.
Neoplasms of the heart can be divided into primary cardiac
tumors arising in the heart and secondary cardiac tumors that
have metastasized to the heart. Primary cardiac tumors are
uncommon and represent only 5–10 % of all neoplasms of
the heart and pericardium. Primary cardiac tumors can be
further stratified into benign and malignant tumors.
Approximately 80 % of primary cardiac tumors are benign.
Approximately 50 % of the benign tumors are myxomas
C. Gao, MD (*) • M. Yang, MD
Department of Cardiovascular Surgery, PLA General Hospital,
No. 28 Fuxing Road, Beijing 100853, People’s Republic of China
e-mail: gaochq301@yahoo.com
[1–4]. Myxomas occur in any chamber of the heart but have
a special predilection for the left atrium, in which approximately 75 % originate. The next most frequent site is the
right atrium, where 10–20 % are found. Surgical resection is
the only effective therapeutic option for patients with cardiac
myxoma and should not be delayed because death from
obstruction to flow within the heart or embolization may
occur in as many as 8 % of patients awaiting operation [5, 6].
A median sternotomy approach with ascending aortic and
bicaval cannulation is usually employed. In recent years, the
minimally invasive approaches are being applied with
increasing frequency in all areas of cardiac surgery, which
include cardiac tumors. But minimally invasive surgical
C. Gao (ed.), Robotic Cardiac Surgery,
DOI 10.1007/978-94-007-7660-9_6, © Springer Science+Business Media Dordrecht 2014
83
84
C. Gao and M. Yang
Fig. 6.1 The pericardium is opened longitudinally anteriorly to the
phrenic nerve
experience in treatment of cardiac tumors is quite limited.
Approaches include right parasternal or partial sternotomy
exposure with standard cardioplegic techniques [7], right
submammary incision with femoral-femoral bypass and
nonclamped ventricular fibrillation [8], and the right submammary port access method with antegrade cardioplegia
and ascending aortic balloon occlusion [9, 10].
Over the past few years, computerized surgical robotic
systems have been developed very rapidly. The da Vinci surgical robot has assisted the surgeon’s work using telemanipulation through a master-controller activation principle
with a 3-D intracardiac camera. In 2005, Murphy and associates [11] reported the initial successful experience with
left atrial myxoma excision with the da Vinci Surgical
System. Subsequently, the largest series of robotic resection
of atrial myxomas with no operative deaths or strokes was
reported by Dr. Changqing Gao et al. at the PLA General
Hospital in Beijing, China in 2010 [10]. In this chapter, the
largest series of robotic resection of atrial myxoma will be
discussed.
6.1
Fig. 6.2 Vertical stay sutures placed on the right side of pericardium
Fig. 6.3 Stay suture on the left superior side of pericardium to expose
the ascending aorta
Anesthesia, Patient Position
and CPB Establishment
The anesthesia, da Vinci Surgical System setup and CPB
establishment are as previously described for atrial septal
defect repair in Chap. 5.
Fig. 6.4 The Chitwood cross-clamp is put in the ascending aorta
6.2
Surgical Technique
The initial preparation is the same as ASD repair, and
after the da Vinci Surgical System is docked, the operation
starts. The pericardium is opened longitudinally anteriorly to
the phrenic nerve (Fig. 6.1). The incision is extended superiorly to expose the aorta. Then the vertical stay sutures are
placed low on the pericardium on the right side (Fig. 6.2) and
the left superior side (Fig. 6.3) to rotate the heart for optimal
exposure of the atrium and aorta.
The aortic is occluded with a Chitwood cross-clamp in
the fourth ICS via the midaxillary line (Fig. 6.4). Antegrade
cold blood cardioplegic solution is administered directly
through the anterior chest (the 2nd ICS) with a 14-F angiocatheter (Figs. 6.5 and 6.6).
6
Totally Robotic Myxoma Excision
Fig. 6.5 The 14-F angiocatheter is punctured into the thoracic cavity
on the second ICS in the anterior chest
85
Fig. 6.8 Exposing the left atrial myxoma with atrial retractor
Fig. 6.6 The 14-F angiocatheter is punctured into the aorta for cardioplegic solution administration
Fig. 6.9 The papillar myxoma in the left atrium
Fig. 6.7 The left atriotomy anterior to the pulmonary veins for the left
atrial myxoma
A left atriotomy anterior to the pulmonary veins is performed (Fig. 6.7) and exposure of left atrial myxomas is
maximized with the atrial retractor (Figs. 6.8, 6.9, and 6.10).
For left atrial tumors, the vena cavae are not taped, allowing an increased mobility and exposing the left atrial cavity.
Fig. 6.10 The villous myxoma in the left atrium
86
C. Gao and M. Yang
Fig. 6.11 Total excision by dissecting a plane through the atrial muscle at the point of attachment
Fig. 6.13 The attachment of myxoma after total excision
Fig. 6.12 Total excision of left myxoma
The left atriotomy can be extended behind both cavae for
greater exposure. Total excision is achieved by dissecting a
plane through the atrial muscle at the point of attachment
(Figs. 6.11 and 6.12).
The subendocardial defects are also directly closed
with 4-0 polytetrafluoroethylene running suture without
pericardial patches (Figs. 6.13 and 6.14). The atrial septal defects originated from the resection can be repaired
with autologous pericardial patches with 4-0 polytetrafluoroethylene running suture. Four right atrial myxomas
are completely resected from the beating heart with the
superior and inferior venae cavae snared avoiding the
aorta clamp and cardioplegia administration (Figs. 6.15
and 6.16).
Right atrial myxomas pose special venous cannulation
problems. Intraoperative echocardiography may be of
benefit in allowing safe cannulation. Robotic surgery is
constantly safer for right atrial myxomas than sternotomy
because of cannulation of the jugular or femoral vein.
The tricuspid valve and the right atrium should be
inspected carefully in patients with right atrial myxoma,
with or without familial myxoma. Regardless of the
Fig. 6.14 Suturing the subendocardial defects
Fig. 6.15 The right atrial myxoma is resected on the beating heart
surgical approach, the ideal resection compasses the
tumor and a portion of the cardiac wall or interatrial septum to which it is attached. It is controversial whether
6
Totally Robotic Myxoma Excision
Fig. 6.16 The right atrial myxoma is exposed with the aid of atrial
retractor
87
Fig. 6.18 The closed cardioplegia site
Fig. 6.19 The pre-operative TEE shows the left atrial myxoma
Fig. 6.17 The cardioplegia site is closed with extracorporeal knot
tying
excision of full-thickness wall is necessary or excision of
only an endocardial attachment is sufficient to prevent
recurrence. Our policy is to resect full thickness whenever possible. However, only partial-thickness resection
of the area of tumor attachment has been performed when
anatomically necessary without a noted increase in recurrence rate [12]. Every care should be taken to remove the
tumor without fragmentation. When the tumor is removed
from the field, the area should be liberally irrigated, suctioned, and inspected.
The atrial is closed with running sutures after total resection. For excision in arrested heart, after crossclamp release
and meticulous intracardiac deairing by angiocatheter of
antegrade cold blood cardioplegic solution, the patient is
weaned from CPB. After removal of the cardioplegia angiocatheter, the cardioplegia site is closed with extracorporeal
knot tying through the working port (Figs. 6.17 and 6.18),
and then chest tubes are inserted. The surgical result and
integrity of the septal closure are confirmed by TEE
(Figs. 6.19 and 6.20).
Fig. 6.20 The surgical resection and integrity of the septal closure are
confirmed by TEE
6.3
Postoperative Management
After the operation, patients are monitored at the ICU and
discharged to an intermediate care unit as soon as hemodynamics and spontaneous respiration have been adequately
88
C. Gao and M. Yang
Table 6.1 The clinical data of robotic atrial myxoma resection
Table 6.2 The results of robotic atrial myxoma resection
Variables
Total number of patients
Gender
Male (%)
Female (%)
Age (year)
Weight (kg)
Height (cm)
Attachment sites
Interatrial septum, n (%)
Posterocaudal wall, n (%)
Root of the anterior leaflet
of mitral valve, n (%)
Left atrial roof, n (%)
Right atrium, n (%)
Shape
Spherical/encapsulated, n (%)
Villous, n (%)
Diameter of myxoma (mm)
Left ventricular ejection fraction (%)
Combined intracardiac diseases
Sever mitral valve regurgitation
Patent foramen ovale
Variables
Procedure, n
Through a left atriotomy, n (%)
Through an oblique right
atriotomy, n (%)
On beating heart, n (%)
Combined with mitral valve
repair, n (%)
Combined with mitral patent
foramen ovale closure, n (%)
Operation time (min)
Cardiopulmonary bypass time (min)
Cross clamp time (min)
Mechanical ventilation time (h)
Drainage volume (mL)
Length of stay (days)
45
12 (32.5 %)
33 (67.5 %)
47.0 ± 14.1
62.3 ± 11.8
162.0 ± 6.8
31 (77.5 %)
2 (5 %)
2 (5 %)
1 (2.5 %)
4 (10 %)
22 (55 %)
18 (45 %)
43 × 52
68.9 ± 8.1
2
1
1
stabilized. Chest drains are removed when drainage reaches
less than 50 mL/12 h. All patients undergo transthoracic
echocardiography immediately before discharge from hospital and at 3 months after the procedure.
6.4
Surgical Experience
and Learning Curves
Between July 2007 and May 2013, robotic myxoma resection with da Vinci S or Si Surgical System was performed on
45 consecutive patients at the authors’ hospital. Twelve
patients were male and 33 female. The mean age was
47.0 ± 14.1 years old (ranging from 13 to 66). Two patients
had preoperative cerebral infarction. The mean tumor size
was 43 × 52 mm (14 × 19–44 × 74 mm). Four tumors were
found in the right atrium and 36 tumors were found in the left
atrium, of which 31 tumors arose from the interatrial septum,
2 from the posterocaudal wall, 2 from the root of the anterior
leaflet of the mitral valve, and 1 from the left atrial roof. One
left atrial myxoma was combined with severe mitral valve
regurgitation. One patient was diagnosed with left atrial
myxoma and patent foramen ovale (Table 6.1).
In 34 patients, the tumors were explored through a left
atriotomy anterior to the pulmonary veins and were exercised by dissecting a plane through the atrial muscle at the
point of attachment. In the first two patients, the tumors were
explored and exercised through an oblique right atriotomy.
45
34 (85 %)
2 (5 %)
4 (10 %)
1 (2.5 %)
1 (2.5 %)
288.1 ± 41.4
90.9 ± 29.1
46.4 ± 16.3
4.7 ± 3.2
101.8 ± 58.8
4.6 ± 2.1
Four right atrial myxomas were resected on the beating heart
(Table 6.2). The da Vinci instrument arms were inserted
through three 0.8 cm trocar incisions at the right side of the
chest. Via four port incisions and a 1.5–2 cm working port,
all the procedures were completed with da Vinci S or da
Vinci Si robot. The mean operation time, cardiopulmonary
bypass (CBP) time and cross clamp time were calculated.
And the learning curves were assessed by means of regression analysis with logarithmic curve fit. Follow-up was conducted with echocardiography which was used as the
diagnostic tool.
All cases turned out to be successful. One formal artery
arterial embolism was observed on the 5th postoperative day
and was cured through embolectomy. Two patients required
combined cardiac surgery: one mitral valve repair, and one
patent foramen ovale closure.
The mean operation time was 288.1 ± 41.4 (180–390)
min, and the mean CPB time was 90.9 ± 29.1 (62–156) min,
the mean cross-clamp time was 46.4 ± 16.3 (24–97) min.
Significant learning curves were noted for operating time,
CPB time and cross-clamp time (Figs. 6.21, 6.22 and 6.23).
And the operating time was stable after 20 cases. All the
patients were discharged with excellent cosmetic results
(Figs. 6.24 and 6.25). No patients were lost to follow-up, and
the mean follow-up was 24 ± 14 months. There were no
deaths during hospitalization or at follow-up. No patient
required reoperation for recurrence postoperatively.
6.5
Summary
Cardiac myxoma is a benign gelatinous growth composed of
primitive connective tissue cells and stroma resembling mesenchyme, which is usually pedunculated and arises from the
interatrial septum, near the fossa ovalis [13]. Grossly, about
6
Totally Robotic Myxoma Excision
89
100.00
Cross−clamp time (min)
Operation time (min)
400.00
300.00
200.00
100.00
0.00
80.00
60.00
40.00
10.00
20.00
Case number
30.00
40.00
Fig. 6.21 The learning curve of operation time (y(min) = 366.6 − 37.9
ln(x); r2 = 0.346, p = 0.000)
20.00
0.00
10.00
20.00
Case number
30.00
40.00
Fig. 6.23 The learning curve of cross-clamp time (y(min) = 70.5 − 11.2
ln(x); r2 = 0.64, p = 0.00 0)
CPB time (min)
150.00
125.00
100.00
75.00
50.00
0.00
10.00
30.00
20.00
Case number
40.00
Fig. 6.22 The learning curve of CPB time (y(min) = 136.2 − 20.1 ln(x);
r2 = 0.53, p = 0.000)
two-thirds of myxomas are round or oval tumors with a
smooth or slightly lobulated surface (Figs. 6.26 and 6.27).
Most are polypoid, relatively compact, pedunculated and
mobile. Embolism is a major feature of cardiac myxomas,
with systemic embolism occurring in 30–45 % of patients
with a left atrial tumor.
In 2005, Murphy and associates [11] reported the initial
successful experience with left atrial myxoma excision with
the da Vinci Surgical System. To date, other approaches for
better exposure and ideal resection of left or right atrial
myxomas with the da Vinci S Surgical System have not
been reported. The surgical principles of myxoma excision
include exposure of the attachment point of the tumor which
allows excision of adequate tissue margins, removal of the
Fig. 6.24 The port incision view after robotic myxoma resection for 1
week
tumor without fragmentation, reconstruction of atrial wall
defects, and the ability to inspect the cardiac chambers for
other tumors [13]. Exposure of left atrial myxomas is maximized by principles from mitral valve repair surgery with
atrial retractors when the right side of the heart to rotate up
and the left side of the heart to rotate down. Therefore, stay
sutures are placed low on the pericardium on the right side.
This rotates the heart for optimal exposure of the left atrium.
For left atrial tumors, the superior vena cava is extensively
mobilized as is the inferior vena cava–right atrial junction,
allowing an increased mobility and exposure of the left
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C. Gao and M. Yang
Fig. 6.27 The oval myxoma with a smooth or slightly lobulated
surface
Fig. 6.25 The excellent cosmetic results after robotic myxoma resection for 1 month
Fig. 6.26 The lathy myxoma
atrial cavity. Left atrial myxomas could be approached by
an incision through the anterior wall of the left atrium anterior to the right pulmonary veins. This incision could be
extended behind both cavae for greater exposure [12]. Right
atrial myxomas could be resected directly through the right
atrial incision from the beating heart without an aortic cross
clamp [10].
The atrial retractor is an excellent device for atrial exposure through the fourth arm. This device offers superior identification of the tumor attachment points to those that have
been achieved in patients in whom the surgical approach has
been via median sternotomy [10].
Furthermore, left atrial myxomas can be approached more
easily by the left atrial approach than the right; thus the stalk
can be easily found and total excision can be achieved by
dissecting a plane through the atrial muscle at the point of
attachment with magnification [10]. Left atrial myxomas
were resected in 34 of our 40 patients through left atrial
approach.
Regardless of the surgical approach, the ideal resection
encompasses the tumor and a portion of the cardiac wall or
interatrial septum to which it is attached [12]. It has been
controversial whether excision of full-thickness wall or only
the endocardial attachment is sufficient to prevent recurrence. Our policy is to resect full thickness whenever possible. When the stalk of myxoma originates in the septum, we
try to resect the stalk together with full septum, and the septum is then repaired. Actis Dato [14], McCarthy and their
associates [15] reported that only partial thickness resection
of the area of tumor attachment was performed when anatomically necessary without a noted increase in recurrence
rate [12]. In our study, we found that some stalks of myxoma
were loosely attached to the endocardium, which could be
easily resected robotically because of the 10× magnification. When the stalk of myxoma was not completely
resected, we cauterized the stalk of the myxoma to prevent
recurrence [10].
Chitwood’s aortic clamp technique [16] is safe, simple,
and economical compared with the remote access perfusion
6
Totally Robotic Myxoma Excision
cannula with endoaortic balloon. In our series, aortic occlusion is completed with the Chitwood crossclamp via the
fourth ICS in the midaxillary line. Cardioplegic solution
administered antegradely directly through the anterior chest
wall is feasible and safe [17]. Therefore, the working port
could become smaller. In our series, the robotic system
could be operated safely and efficiently, causing no operative deaths or conversions resulting from a system malfunction. Only two patients had temporary atrial fibrillation.
Mean length of hospital stay was shorter than that with conventional surgical repair. These patients benefited from minimal trauma, early discharge, and excellent cosmesis [10].
We conclude that robotic myxoma resection is technically
feasible and could be applied as a routine access in all stable
and selective patients without the fear of inadequate intraoperative exposure. Surgical results are excellent. It is important
to remember that the use of a minimally invasive technique
must not compromise complete surgical excision. Results in
this limited number of selected patients are satisfactory, but
more experience and longer follow-up are still needed before
this can be recommended as a standard approach.
6.6
Case Report
6.6.1
Totally Robotic Left Atrial Myxoma
Excision Associated Mitral Valve Plasty
An 18-year-old female patient was admitted because of progressive post-exercise despnea in the previous 5 months.
On echocardiographic examination, a mass measuring
6.4 × 3.8 cm was discovered attached to the middle part of
interatrial septum (Fig. 6.28a). The mass showed no signs
of calcification or breakdown. Simultaneously, echo revealed
a 0.2 cm cleft between A2 and A3 segment and the dilated
mitral annulus, which led to severe mitral valve regurgitation (Fig. 6.28b). The patient had a NYHA III heart function and enlarged left atrium. The systolic heart murmur
in the apex could be auscultated in clinical examination.
Electrocardiography showed sinus tachycardia. Routine
chest radiography revealed normal cardiothoracic ratio
with mildly exaggerated bronchovascular markings. All
laboratory tests were in normal ranges.
After general anesthesia, the intubation for single-lung
ventilation and transesophageal echocardiography (TEE)
were established. The right side of the chest was slightly
elevated at 30°. Femoral arterial (17 F) and venous cannulation (21 F) were performed through a 2-cm transverse right
groin incision cutdown with Seldinger guidewire method
and TEE guidance. Cardiopulmonary bypass (CPB) was initiated with kinetically assisted bicaval venous drainage. The
da Vinci S camera and instrument arms were inserted through
91
a
b
Fig. 6.28 Preoperative echocardiography shows left atrial myxoma
(a) and mitral valve regurgitation (b)
1-cm ports in the right chest. 3 cm below the camera port, a
2.5-cm incision was used as the working port in the fourth
intercostals space (ICS) of right chest. The aortic occlusion
was performed with a Chitwood cross clamp via the midaxillary line in the fourth ICS. Antegrade cold blood cardioplegic solution was administered directly through the anterior
chest (second ICS) with a 14 F angiocatheter. Carbon dioxide was insufflated continuously into the operative field for
air replacement.
After lung deflation, the pericardium was opened and the
stay sutures were placed on the right side of pericardium to
rotate the heart for optimal exposure of the left atrium. A longitudinal incision, posterior to Waterstone’s groove was
made and the atrial retractor was applied. Exposure revealed
a mass soft, gelatinous, reddish brown, oval in shape, smooth
surface with estimated dimensions of 6.4 × 3.8 cm, attached
to the interatrial septum (Fig. 6.29a). The mass had neither
calcified deposits nor areas of hemorrhage or necrosis.
A meticulous dissection was made to ensure complete resection without any residues. The tumor was deposited into an
Endopouch Retriever and extracted via the working port.
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C. Gao and M. Yang
provided. The postoperative course was uneventful and the
patient was discharged from the hospital on the eighth postoperative day without any complications.
References
b
Fig. 6.29 Resection of myxoma at the point of attachment (a) and the
good result of mitral valve repair (b)
The mitral valve was inspected and examined revealing a
0.5-cm cleft between A2 and A3 segment and an enlarged
mitral annulus. The two leaflets were reapproximated using
interrupted suture (Fig. 6.29b), and a Cosgrove-Edwards
annuloplasty band was implanted. And the left atriotomy
was closed using double-layer continuous 4-0 polytetrafluoroethylene running sutures. Standard postoperative care was
1. Prichard RW. Tumors of the heart: review of the subject and report
of one hundred and fifty cases. Arch Pathol. 1951;51:98–128.
2. Gerbode F, Keith WJ, Hill JD. Surgical management of tumors of
the heart. Surgery. 1967;61:94–101.
3. McAllister HA, Fenoglio Jr JJ. Tumors of the cardiovascular system. In: Rubinstein L, editor. Atlas of tumor pathology, Series
Ishington. Washington, DC: Armed Forces Institute of Pathology;
1978.
4. Silverman NA. Primary cardiac tumors. Ann Surg. 1980;91:127.
5. Sutton D, Al-Kutoubi MA, Lipkin DP. Left atrial myxoma diagnosed by computerized tomography. Br J Radiol. 1982;55:80.
6. Symbas PN, Hatcher Jr CR, Gravanis MB. Myxoma of the heart:
clinical and experimental observations. Ann Surg. 1976;183:470.
7. Ravikumar E, Pawar N, Gnanamuthu R, et al. Minimal access
approach for surgical management of cardiac tumors. Ann Thorac
Surg. 2000;70:1077.
8. Ko PJ, Chang CH, Lin PJ, et al. Video-assisted minimal access in
excision of left atrial myxoma. Ann Thorac Surg. 1998;66:1301.
9. Gulbins H, Reichenspurner H, Wintersperger BJ. Minimally invasive extirpation of a left-ventricular myxoma. Thorac Cardiovasc
Surg. 1999;47:129.
10. Gao C, Yang M, Wang G, et al. Excision of atrial myxoma using
robotic technology. J Thorac Cardiovasc Surg. 2010;139:1282–5.
11. Murphy DA, Miller JS, Langford DA, Snyder AB. Robot-assisted
endoscopic excision of left atrial myxomas. J Thorac Cardiovasc
Surg. 2005;130:596.597.
12. Cohn L. Cardiac surgery in the adult. 4th ed. New York: McGrawHill Professional; 2011.
13. Schroeyers P, Vermeulen Y, Wellens F, De Geest R, Degrieck I, Van
Praet F, et al. Video-assisted port-access surgery for radical myxoma resection. Acta Chir Belg. 2002;102:131–3.
14. Actis Dato GM, de Benedictus M, Actis Dato Jr A, Ricci A,
Sommarival L, De Paulis R. Long-term follow-up of cardiac myxoma (7–31 years). J Cardiovasc Surg (Torino). 1993;34:41–3.
15. McCarthy PM, Piehler JM, Schaff HV, Pluth JR, Orszulak TA,
Vidaillet Jr HJ, et al. The significance of multiple, recurrent, and
“complex” cardiac myxomas. J Thorac Cardiovasc Surg. 1986;91:
389–96.
16. Chitwood WR, Elbeery JR, Moran JM. Minimally invasive mitral
valve repair: using a mini-thoracotomy and transthoracic aortic
occlusion. Ann Thorac Surg. 1997;62:1477–9.
17. Gao C, Yang M, Wang G, Wang J. Totally robotic resection of myxoma and atrial septal defect repair. Interact Cardiovasc Thorac
Surg. 2008;7:947–50.
7
Robotic Mitral Valve Surgery
Changqing Gao and Ming Yang
Abstract
Mitral valve repair surgery has advanced markedly over the past 25 years with excellent
long-term outcomes. And the significant advances in surgical optics, instrumentation, and
perfusion technology have allowed surgeons to perform mitral valve surgery using progressively smaller incisions. Due to its excellent therapeutic results, minimally invasive mitral
valve surgery has become a standard of care at quite some specialized centers worldwide.
The da Vinci robotic surgical system, an embodiment of minimally invasive surgical tools,
was introduced to mitral valve surgery in 1998. And Chitwood further refined the endoscopic approach, taking advantage of the da Vinci robotic surgical system and its advanced
robotic technology to repair complex mitral valve pathology through port incisions using
optimized, high-definition visualization and fine dexterity. The excellent clinical outcomes
are built on the foundation of stepwise improvement in surgeon’s techniques with a gradual
learning curve. This chapter covers robotic mitral valve repair and replacement.
Mitral valve surgery has conventionally been performed
through the median sternotomy with conventional cardiopulmonary bypass. Due to its more complex nature and requirement of cardiopulmonary, cardiac surgery lagged far behind
other surgical fields in the development of minimal access
methods until 1995. After closed-chest cardiopulmonary
bypass and cardioplegic arrest were practiced, reduction of
incision size became possible. The valve surgery through
small incision has become a standard practice at many clinical centers. Loulmet and Carpentier [1] classified minimally
invasive cardiac surgery into four levels: direct-vision
approaches (Level I), video-assisted procedures (Level II
and III), and the robotic valve operations (Level IV).
C. Gao, MD (*) • M. Yang, MD
Department of Cardiovascular Surgery, PLA General Hospital,
No. 28 Fuxing Road, Beijing 100853, People’s Republic of China
e-mail: gaochq301@yahoo.com
7.1
Level I: Direct-Vision
and Mini-Incision
Initially, minimally invasive cardiac valve surgery was
based on modifications of previously used incisions and performed under direct vision. Alternative incisions to expose
the mitral valve, including partial sternotomies, parasternal
incisions and mini-thoracotomies, are the initial approaches
to repair the mitral valve while optimizing cosmesis.
Cosgrove, Cohn, Gundry and Arom [2–5] showed that mitral
valve operations could be done with incisions other than a
median sternotomy with low surgical mortality (1–3 %) and
morbidity. In early 1996, the Stanford group [6, 7] performed
the first mini-incision mitral valve surgery (MIMVS) using
intra-aortic balloon occlusion (Port access) and cardioplegia. By December 1998, Cosgrove had done 250 minimally
invasive mitral valve operations using either a ministernotomy or parasternal incision with no mortality [8]. In fact,
the annulus of the mitral valve is nearly in the sagittal plane
of the body, making a right mini-thoracotomy the optimal
approach to the valve. This approach provides a direct
enface view of the mitral valve, although the distance to the
mitral valve is further.
C. Gao (ed.), Robotic Cardiac Surgery,
DOI 10.1007/978-94-007-7660-9_7, © Springer Science+Business Media Dordrecht 2014
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C. Gao and M. Yang
These encouraging results confirmed the feasibility and
safety of these techniques and further advanced the next
level of “minimally invasiveness”.
vision could transpose surgical manipulations from outside
the chest wall to deep within cardiac chambers.
7.4
7.2
Level II: Video-Assisted
and Microincisions
The radical endoscopic surgical techniques initiated a
wave of new surgical approaches in general, orthopedic,
urologic, and gynecologic procedures and became routine
operations in the 1990s. In contrast, fine vascular anastomotic and complex reparative procedures are the centerpieces of cardiac surgery. Because of the difficulty in
acquiring the fine video-assisted dexterity needed for
these operations, cardiac surgeons are reluctant to explore
the benefits of operative video assistance. Microincisions
are considered as 4–6 cm skin incisions, and video assistance indicates that 50–70 % of the operation is done
while viewing the operative field from a monitor. Video
assistance is used at first for closed-chest internal mammary artery harvests and congenital heart operations
[9–11]. In early 1996, Carpentier performed the first video
assisted mitral valve repair through a minithoracotomy
using hypothermic ventricular fibrillation [12]. Shortly
thereafter, Chitwood performed the first video-assisted
mitral valve replacement through a minithoracotomy,
using a percutaneous transthoracic aortic clamp and retrograde cardioplegia [13, 14]. Video technology is helpful
for replacement and simple repair operations. However,
complex reconstructions are still approached under direct
vision [14].
7.3
Level III: Video-Directed
and Port Incisions
In 1997, Mohr [15] used the AESOP 3000 (Computer
Motion, Santa Barbara, CA) voice-activated camera robot in
minimally invasive videoscopic mitral valve surgery for the
first time. With this device, a voice-controlled robotic arm
allows hands-free camera manipulation. Camera motion has
been shown to be much smoother, more predictable, and
requires less lens cleaning than during manual direction.
Image stability during complex surgical maneuvers remains
crucial. The addition of three-dimensional visualization,
robotic camera control, and instrument tip articulation are
the next essential steps toward a totally endoscopic mitral
operation where wrist-like instruments and three-dimensional
Level IV: Video-Directed
and Robotic Instruments
Innovations in computer-assisted robotic mitral surgery
have rapidly taken place. In June 1998, Carpentier [16] did
the first true robotic mitral valve operation using an early
prototype of da Vinci Surgical System. The “micro-wrist”
permits intra atrial instrument articulation with the seven
degrees of freedom offered by the human wrist. The surgeon operates from a master console using three-dimensional vision to affect simultaneous, filtered, and scaled
movements in a robotic slave that drives intracardiac articulated instruments. To date, Chitwood et al. [17] have rich
experience with robotic mitral valve repairs, and have independently shown that da Vinci is very effective, even for
performing complex bileaflet repairs.
7.5
Robotic Mitral Valve Repair
Mitral valve repair is favored over replacement in most
instances of mitral regurgitation owing to preserved left
ventricular function and geometry, a decreased risk of
thromboembolism and improved survival [18]. Although
classically performed via median sternotomy, isolated
mitral valve repair is now frequently performed via minimally invasive access, such as hemisternotomy or right
thoracotomy often with videoscopic or robotic assistance
[18]. With three-dimensional camera and its magnifying
capability, robotic system can provide good exposure for
mitral valve repair and replacement in a least invasive
approach. Excellent view leads to easy and accurate assessment of valve pathology and a high rate of successful valve
repairs or replacement. In 1998, Carpentier [16] performed
the first complete robotic mitral valve repair using da Vinci
Surgical System. In 2000, Chitwood performed the first
complete da Vinci mitral valve repair in North America
[19]. And the East Carolina University subsequently participated in the phase I and phase II [17] US Food and
Drug Administration (FDA) trials. Now the experience of
East Carolina University includes over 540 cases of
patients from 2000 to 2010. Since 2007 at the PLA General
Hospital in Beijing, Gao and his team have performed over
550 cases of robotic cardiac operations, which include 100
cases of mitral valve surgery using the da Vinci S or Si
Surgical System.
7
Robotic Mitral Valve Surgery
95
Fig. 7.1 The patient position
7.5.1
Patient Selection
Strict inclusion and exclusion criteria for patient selection
should be followed in robotic mitral valve repair. In our
experience, all patients had isolated mitral insufficiency or
stenosis without other valvular disease or coronary artery
disease requiring operative intervention. Patients with previous right thoracotomy were excluded. Patients with
severely calcified mitral annulus were not candidates.
Decalcification requires further instrument development as
well as a reliable means to evacuate any calcium that may
fall into the left ventricle. Patients with mitral valve stenosis treatable by commissurotomy would be suitable candidates for robotic repair. Improved visualization of the
valve and subvalvular apparatus along with the tiny blade
inserted into the robotic instrument would compliment
comissurotomy. Patients with poor lung function shall
undergo pulmonary testing to ascertain whether they could
tolerate single-lung ventilation or not. And the cardiopulmonary bypass (CPB) will be instituted earlier for intrathoracic surgical preparation if the patient has a poor lung
function.
Fig. 7.2 The positions of ports
cavity through the incision made at 2–3 cm lateral to the
nipple in the fourth intercostal space (ICS). A 1.5 cm incision is used as a working port in the same ICS for the
patient-side surgeon. Additionally two 8-mm port incisions
are made in the second and sixth ICS to allow insertion of
the right and left instrument arms. The right instrument arm
generally is positioned 4–6 cm lateral to the working port in
the sixth ICS. The left instrument arm is positioned medial
and cephalad to the right arm in the second or third ICS.
The fourth arm trocar is placed in the midclavicular line in
the fifth ICS (Fig. 7.2). And the surgical system is set-up
(Fig. 7.3). Cardiopulmonary bypass is established using
femoral arterial inflow and kinetic venous drainage using
the femoral vein (21–23 Fr cannula) and right internal jugular vein (15–17 Fr cannula) in each case. The cannulations
in right femoral artery, vein (Fig. 7.4) and right internal
jugular vein are completed under the guidance of TEE.
7.5.3
7.5.2
Anesthesia, Patient Position
and CPB Establishment
Patients are anesthetized and positioned, as described for
robotic atrial septal defect repair in Chap. 5 with the right
chest elevated to 30°–40°. The transesophageal echocardiography (TEE) probe is inserted to evaluate the position
of the venous cannulas and surgical results. And the external defibrillator patches are placed to subtend the maximum
cardiac mass (Fig. 7.1). After exclusion of the right lung, a
12-mm endoscopic trocar is placed into the right thoracic
Surgical Technique
The anterior pericardium is opened longitudinally to the
phrenic nerve. The incision is extended superiorly to expose
the aorta. The vertical pericardium staying sutures are placed
on the right side and left superior side of pericardium for
exposure, and two right side staying sutures should be as far
as possible for nice exposure. The aorta is occluded with
Chitwood cross-clamp via the fourth intercostal space in the
midaxillary line. Care must be taken to avoid injury to the
right pulmonary artery, the left atrial appendage, or the left
main coronary artery. We have never used the endoballoon as
an occluder since we started with robotic surgery. Antegrade
96
a
C. Gao and M. Yang
b
Atrial retractor
port
Angiocatheter
port
Nipple
Camera
Left arm
port
Right arm port
Chitwood damp
Working port
Fig. 7.3 The robotic mitral valve repair operative field. (a) System set-up; (b) Sketch map. From Siwek and Reynolds (21Reproduced with permission from Siwek and Reynolds [21)
a
c
b
Fig. 7.4 Cannulation of the femoral artery and vein. (a) Making a
2-cm incision in the right groin crease; (b) Exposure of the femoral
artery and vein; (c) Placing purse string suture on the vein; (d) Circling
the vessels; (e) Arterial cannulas inserted over a guidewire; (f) Vein
cannulas inserted over a guidewire; (g) Cannulation completed
7
Robotic Mitral Valve Surgery
97
d
e
f
g
Fig. 7.4 (continued)
Fig. 7.5 The Chitwood cross-clamp and antegrade cardioplegia
administered
Fig. 7.6 The small left atriotomy
cold blood cardioplegia is administered directly through
anterior chest on the second or third intercostal space with
14 F angiocatheter (Fig. 7.5). Carbon dioxide is insufflated
continuously into the operative field for deairing. The interatrial groove is dissected. Then a small left atriotomy is
performed medial to the right superior pulmonary vein with
extension toward the SVC and inferiorly behind the IVC
(Fig. 7.6). The atrial septum is retracted with left atrial
endowrist retractor (Fig. 7.7) to visualize the mitral valve.
The mitral valve and appurtenants are inspected using a
98
C. Gao and M. Yang
Fig. 7.7 The left atrial retractor is used to expose the mitral valve
Fig. 7.9 Resecting the prolapse P2 segment
Fig. 7.8 The mitral valve and appurtenants are inspected using a valve
hook
Fig. 7.10 Residual leaflet edges are reapproximated
valve hook (Fig. 7.8). A left inferior pulmonary vein sump
scavenges residual left atrial blood.
Valve function is tested by cold saline injections. The
table surgeon exchanges the various microtipped instruments. Standard reconstructive methods have been used in
all da Vinci mitral valve repairs. Posterior leaflet prolapse
is treated by either quadrangular or trapezoidal resection
of diseased chordal leaflet segment (Fig. 7.9). Residual
leaflet edges are re-approximated with 4-0 GoreTex interrupted sutures or nitinol U-clips (Coalescent Inc.,
Sunnyvale, CA) (Fig. 7.10). Water injection test is performed again to identify that no mitral valve regurgitation
occurs.
Remodeling the annulus by ring annuloplasty after mitral
valve repair is essential to a complete and long-lasting repair.
The size of annulus is measured (Fig. 7.11). The flexible
annuloplasty band (Cosgrove Edwards, Edwards
Lifesciences, Irvine, CA) is secured between the fibrous
trigones using running sutures or nitinol U-clips. Bites
should be deep with the needle entering the annulus, then
into the left ventricular cavity, and then coming out on the
atrial side again.
Fig. 7.11 Measuring the annulus
For the running suture technique (Fig. 7.12), three 2-0
braided polyester sutures are used to secure the annuloplasty ring as follows [20]: After the ring is introduced into
the left atrium, the first suture (16 cm in length) is passed
through the ring, through the right trigone, and then back
7
Robotic Mitral Valve Surgery
99
a
b
c
d
Fig. 7.12 The running annuloplasty suture technique. (a) First suture
is tied at the right trigone and run clockwise. (b) Second suture is tied
at the mid-portion of the annulus and the tail is tied to the first suture.
through the ring. The suture is then tied down and runs
clockwise to the midportion of the ring (Fig. 7.12a). The
second suture (14 cm in length) is then passed through the
ring, through the midportion of the annulus, and then back
through the ring. This second suture is tied down, and the
tail is used to secure the first suture (Fig. 7.12b). The second suture then runs clockwise to the left trigone
(Fig. 7.12c). The third suture (9 cm in length) is passed
through the ring, through the left trigone, and then back
through the ring. This third suture is tied down, and the tail
is used to secure the second suture (Fig. 7.13d). Another
technique is the 2-suture method that we have used. The
technique is as follows: The first suture is used as described
above. The second suture is passed through the ring,
through the left trigone. The suture is then tied down and
runs anticlockwise to the midportion of the ring. Then, the
two sutures are tied together at the midpoint of the ring
(Fig. 7.13).
(c) Second suture runs clockwise. (d) Third suture is tied at the left trigone and the tail is tied to the second suture (Reproduced with permission from Tomislav et al. [20])
Fig. 7.13 The ring is secured using the running suture technique
The flexible band can be secured using nitinol U-clips
(Figs. 7.14 and 7.15). These clips are placed through the annulus
like conventional sutures (Fig. 7.14a), with each arm then placed
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C. Gao and M. Yang
b
d
e
Fig. 7.14 Annuloplasty band is secured with nitinol U-clips using the
da Vinci system. (a) The clips are placed through the annula. (b) The
clips are released using robotic needle holders. (c) The U-clip arm is
laid over the band. (d) The secured clip against the tissues. (e) The
annuloplasty band is secured using U-clip
through the band. The locking mechanism, which deploys the
clip, is released using robotic needle holders (Fig. 7.14b). Nitinol
retains a preformed shape securing the annuloplasty band tightly
against the tissues. The U-clip arms are carefully laid over the
annuloplasty band to secure it firmly (Fig. 7.14c).
The congenital clefts in anterior leaflet of the mitral valve
can cause severe mitral valve insufficiency that requires
surgical correction. The robotic repair can be easily used
for isolated anterior cleft repair. After inspection of the
intracardiac anatomy (Fig. 7.16), the cleft in the mitral valve
is repaired using multiple interrupted 4-0 GoreTex suture
(Fig. 7.17). The mitral valve function is tested by the cold
saline injections (Fig. 7.18). In the presence of annular dilation, the repair is buttressed by an annuloplasty. The ring
implanted can be completed using the method described
above (Fig. 7.19).
GoreTex neo-chordae placement is greatly facilitated
by a robotic approach due to excellent exposure and
7
Robotic Mitral Valve Surgery
101
Fig. 7.15 Completed repair using nitinol U-clips to secure the annuloplasty band
Fig. 7.18 The mitral valve function I is tested by the cold saline
injections
Fig. 7.16 The cleft is inspected
Fig. 7.19 The ring is secured using running sutures
Fig. 7.17 The cleft is repaired using multiple interrupted 4-0 GorTex
suture
magnified view of the subvalvular apparatus. The minimal
distortion of the valve provided by the lateral approach
enhances the ability to judge and adjust chordae length.
Through inspection with mitral valve apparatus, the ruptured chordae is identified (Fig. 7.20). 4-0 GoreTex buttressed with two pledgets are placed through the head of
the papillary muscle (Fig. 7.21). Both ends of the suture
are then brought through the leading edge of the leaflet
(Fig. 7.22). The suture length is then adjusted and the
suture is held with a robotic instrument while the patient
side surgeon assistant ties the suture (Fig. 7.23). The surgeon firmly holds the suture and let the assistant tie against
the robotic instrument to prevent the knot from slipping
and making the new chordae too short [21].
102
C. Gao and M. Yang
a
b
Fig. 7.20 The ruptured chordae of mitral valve. (a) Ruptured chordae in A3 area of anterior leaflet; (b) Ruptured chordae in A2 area of anterior
leaflet
Fig. 7.21 4-0 GoreTex
buttressed with two pledgets are
placed through the head of the
papillary muscle. (a) Screenshot;
(b) Sketch map
a
The left atriotomy is closed with running sutures after the
satisfactory mitral valve plasty using water injection test. Before
the crossclamp release, the left atrium is meticulously deaired
with antegrade cold blood cardioplegic solution through the
angiocatheter, and after removal of the cardioplegia angiocatheter, the cardioplegia site is closed with extracorporeal knot
tying through the working port, and then patient is weaned from
CPB. The surgical results are confirmed by TEE (Fig. 7.24). and
then chest tubes are inserted, and da Vinci was undocked finally.
7.5.4
Postoperative Management
Postoperatively patients are monitored as usual at the ICU,
and discharged to an intermediate care unit as soon as their
b
hemodynamics and spontaneous respiration have been adequately stabilized. Chest drains are removed when drainage
reaches less than 50 mL/12 h. All patients undergo transthoracic echocardiography immediately before discharge from
hospital and at 3 months after the operation.
7.5.5
Surgical Experience
and Learning Curves
Between January 2007 and May 2013, 70 consecutive
patients (49 male and 21 female) underwent mitral valve
repair with da Vinci S or da Vinci Si Surgical System at PLA
General Hospital. Mean age of the patients was 45.2 years
(from 14 to 62 years). All the patients had isolated mitral
7
Robotic Mitral Valve Surgery
a
103
b
Fig. 7.22 The sutures are brought through the leading edge of the leaflet. (a) Screenshot; (b) Sketch map. From Siwek and Reynolds (Reproduced
with permission from Siwek and Reynolds [21])
a
b
Fig. 7.23 (a) The suture firmly held is tied against the instrument to prevent the knot from slipping and making the new chordae too short. (b)
Sketch map. From Siwek and Reynolds (Reproduced with permission from Siwek and Reynolds [21])
a
b
Fig. 7.24 TEE is used to evaluate the surgical result. (a) Pre-operation, severe mitral valve regurgitation; (b) Post-operative echo
C. Gao and M. Yang
104
Table 7.1 Preoperative echocardiographic mitral valve characteristics
(n = 90)
n
71
37
8
2
14
1
2
2
1
3
14
4
3
2
3
2
Operation time (min)
Variables
Posterior leaflet
P2 prolapse
P2 prolapse with ruptured chordae tendineae
P2 prolapse and P2 perforation
P3 prolapse with ruptured chordae tendineae
P3 prolapse and P3 perforation
P1 prolapse with ruptured chordae tendineae
P1 prolapse with P1 perforation
P1 prolapse and P3 perforation
P1 and P2 prolapse
Anterior leaflet
A3 prolapse with ruptured chordae tendineae
A3 leaflet cleft
A2 leaflet cleft
Cleft between A2 and A3 leaflet
Cleft between A1 and A2 leaflet
500.00
400.00
300.00
200.00
100.00
0.00
20.00
40.00
60.00
Case number
80.00
100.00
Fig. 7.25 The learning curve of operation time for robotic mitral valve
plasty (y(min) = 392.5 − 25.1 ln(x); r2 = 0.167, p = 0.000)
300.00
Table 7.2 Type of mitral valve procedures (n = 90)
n
67
3
2
6
4
8
250.00
CPB time (min)
Procedures
Posterior leaflet resection + annuloplasty ring
Posterior leaflet resection
Annuloplasty ring
Artificial chordae + annuloplasty ring
Anterior leaflet repair
Anterior leaflet repair + annuloplasty ring
200.00
150.00
100.00
50.00
0.00
20.00
60.00
40.00
Case number
80.00
100.00
Fig. 7.26 The learning curve of CPB time for robotic mitral valve
plasty (y(min) = 184.3 − 18.4 ln(x); r2 = 0.184, p = 0.000)
200.00
Aortic ocllusion time (min)
valve regurgitation. Patients were excluded if they could not
tolerate single-lung ventilation or peripheral CPB, or otherwise were considered as poor candidates for a thoracoscopic
approach (Table 7.1).
Repair techniques included quadrangular resections,
sliding-plasties, neochord insertion, and annuloplasties. See
Table 7.2 for the surgical procedures. There were no
device-related and procedure-related complications.
The median operation time was 296.2 min (ranging from
200 to 490 min), the median CPB time was 130 min (ranging
from 70 to 152 min), and the median cross-clamp time was
87.9 min (ranging from 47 to 122 min). Every 5 patients were a
group. Then mean operation time, CPB time and cross-clamp
time were calculated, and the coefficient of variation of each
group was estimated. The learning curves of operation, CPB
and cross-clamp time were assessed by means of regression
analysis with logarithmic curve fit. The operation time decreased
as the case number increased (Figs. 7.25, 7.26, and 7.27).
Postoperative echocardiograms showed that 88 patients
(97.8 %) had no mitral regurgitation, only two patients
(2.2 %) demonstrated trivial mitral regurgitation. The
length of hospital stay for all patients was 5–8 days. All the
patients were discharged, and the cosmetic results were
excellent (Fig. 7.28).
150.00
100.00
50.00
0.00
20.00
60.00
40.00
Case number
80.00
100.00
Fig. 7.27 The linear correlations of cross-clamp time with case
number (r2 = 0.064, p = 0.035)
7
Robotic Mitral Valve Surgery
105
b
a
Fig. 7.28 One year after robotic mitral valve repair, the surgical incision viewed from the front (a) and right side (b)
7.5.6
Summary
Virtually any mitral valve pathologic problem can be
addressed via an endoscopic robotic approach. The relative
contraindications are previous right chest surgery, obesity,
and severe mitral annular calcification [21]. Robotic instruments such as the left atrial retractor and simple mitral valve
repair techniques including the running annuloplasty suture
technique have greatly simplified robotic mitral repair and
facilitated complex repairs while resulting in shorter operative time and maintaining excellent results. However, despite
enthusiasm for robotic mitral valve plasty, caution cannot be
overemphasized because that the final success still needs to
be measured through comparison with conventional
approach. Surgeons performing totally robotic mitral valve
repair should be very experienced in the standard approach
and diligent in evaluating the results to ensure the highest
quality of valve surgery [22].
Fig. 7.29 The soft retractor in working port can provide more space
for delivering the prosthetic valve
7.6.2
7.6
Robotic Mitral Valve Placement
7.6.1
Anesthesia, Patient Position
and CPB Establishment
The da Vinci Surgical System setup and CPB is established
as previously described for robotic mitral valve repair in
Chap. 4. The patient will require one-lung ventilation for a
significant period of time, necessitating the use of doublelumen tube technique. The use of TEE is indicated for the
position of femoral cannulation (Fig. 7.29). The working
port incision for a 15-mm soft rubber port or tissue retractor
is placed in the fourth ICS.
Surgical Technique
The camera cannula was placed in the right side, 2–3 cm lateral to the nipple in the fourth ICS. A 2.5- to 3.0-cm incision
was used as a working port in the same ICS for the patientside surgeon. The soft tissue retractor was inserted into this
port, and no other rib retractor was used (Fig. 7.29). The da
Vinci instrument arms were inserted through three 8-mm trocar incisions in the right side of the chest. The right instrument arm was generally poisoned lateral to the working port
in the sixth ICS. The left instrument arm was positioned
medially and cephalad to the working port in the second ICS.
The fourth trocar arm was placed in the midclavicular line in
the fifth ICS. All resection and suturing of the mitral valve
and atrial closure were completed with the da Vinci S robot.
106
Fig. 7.30 The Chitwood clamp is introduced to avoid injury to the
right pulmonary artery, the left atrial appendage, or the left main coronary artery
C. Gao and M. Yang
Fig. 7.32 The short atriotomy is made with extension toward the SVC
and inferiorly behind the IVC
LA appendage
Aortic valve
AV node
Circumflex artery
Fig. 7.31 The interatrial groove is dissected
Fig. 7.33 Inspection of the mitral valve structure with the aid of left
atrial retractor
Cardiopulmonary bypass was initiated with kinetically
assisted bicaval venous drainage. The aorta was occluded with
a Chitwood crossclamp (Scanlan International, Minneapolis,
MN) using the midaxillary line in the fourth ICS (Fig. 7.30).
Antegrade cold blood cardioplegic solution was administered
directly through the anterior chest (the second ICS) with a 14 F
angiocatheter, by which deairing was conducted, and repeat
doses could be given when necessary. TEE was used routinely
to monitor the position of the angiocatheter and assist with
deairing. Carbon dioxide was insufflated continuously into the
operative field for air displacement. The left atrium was then
opened parallel to the interatrial septum (Figs. 7.31 and 7.32).
All MVRs were performed using standard techniques. The diseased mitral valve was completely excised, and the posterior
leaflets were preserved whenever possible (Figs. 7.33 and
7.35). Figure 7.34 shows the proximity of important cardiac
structures. Appropriate sizing was performed, and everting,
double-armed, mattress sutures with Teflon pledgets were
placed counterclockwise from the 11-o’clock position. Every
stitch was fixed sequentially outside with a small hemostat.
Fig. 7.34 Location of important structures surrounding the mitral
annulus (From Cohn [1])
Usually 10–12 sutures were needed (Figs. 7.36 and 7.37). Once
the sutures were placed in the prosthesis sewing ring outside
the chest, the prosthesis was lowered into the chest and
7
Robotic Mitral Valve Surgery
Fig. 7.35 The anterior leaflet is removed with preserving partial posterior leaflet
Fig. 7.36 Sutures are then placed anticlockwise from the 11 o’clock
point
Fig. 7.37 The interrupted sutures with pledget are well placed
positioned, and the knots were tied using the knot pusher
through the incision (Figs. 7.38, 7.39, 7.40, 7.41, 7.42, and
7.43). The atriotomy was closed with 4-0 polytetrafluoroethylene running suture (W. L. Gore & Associates, Flagstaff, AZ).
Before the Chitwood crossclamp was released, meticulous
intracardiac de-airing was conducted through the angiocatheter
107
Fig. 7.38 The interrupted sutures are extracorporeally placed in order
Fig. 7.39 The patient-side surgeon places the sutures to the mechanical or tissue valve extracorporeally
Fig. 7.40 The valve prosthesis is introduced into the left atrium
through the working port
of cardioplegia, and then the aorta was unclamped. The patient
was weaned from cardiopulmonary bypass, and the cardioplegia site was closed with an extracorporeal knot tied through the
working port, and chest tubes were inserted. The prosthesis
function was confirmed by TEE [23].
108
C. Gao and M. Yang
Fig. 7.41 The patient-side surgeon ties the sutures using knot-pusher
Fig. 7.42 The patient-side surgeon ties sutures using Cor-Knot
(Lsisolution, Victory-mendon, New York, US)
7.6.3
Surgical Experience
and Learning Curves
The most common surgical approach to the mitral valve
requires the surgeon to saw open the breastbone and spread
the edges apart to gain direct access to the heart. Although
this approach provides excellent access to the heart, the
resulting wound requires several months to heal completely,
which causes extended recovery period for patients and substantial activity restrictions, and patients can be subjected to
serious complications such as infection, breakdown, and
even death [23].
In contrast, robotic cardiac surgery can extend the ability
of the surgeon toward new challenges, performing MVR
using a 3-cm working port without rib resection and retraction, albeit with the potential danger of performing suboptimal surgery because of learning curves. After more than 500
cases of various types of robotic cardiac surgery, we believe
that the da Vinci Surgical system can be considered the best
surgical solution to the philosophic approach of minimally
invasive cardiac surgery [23].
The 3-D digital vision system enables natural depth perception with high-power magnification [18]. A perfect view
was obtained of all cardiac chambers, the mitral valve, and
the subvalvular apparatus, especially in patients with a small
left atrium. Although many reports have described the excellent results of robotically assisted mitral valve repair using
the da Vinci Surgical system, few data are available on
robotically assisted MVR. All our patients had satisfactory
clinical outcomes, as demonstrated by the complete echocardiographic follow-up. No late thromboembolic complications or paravalvular leaks developed. Intraoperative
contamination must be considered when performing extrathoracic knots and introducing the prosthetic ring through
the narrow working port, although no cases of either native
or prosthetic mitral valve endocarditis were identified during
follow-up in our patients [23].
The suture techniques for robotic MVR are very different
from those in the open technique. For all mechanical and
bioprosthetic valves, we used everting, double-armed mattress sutures with Teflon pledgets counterclockwise from the
11-o’clock position to prevent any possibility of subannular
obstruction of the valve leaflets by protruding tissue and to
prevent one suture from crossing with another. Every stitch
was fixed sequentially outside with a small hemostat
(Figs. 7.37 and 7.38) [23].
Usually 10–12 sutures were needed (Fig. 7.43). Once the
sutures were placed sequentially in the prosthesis sewing
ring outside the chest, the prosthesis was lowered into the
chest and positioned, and the knots were tied with the knot
pusher through the incision. When the knots are tied with the
knot pusher, the console surgeon must confirm the knot
tightness one by one. And in the case of a knot not being
tight, the knot tightness requires robotic assistance. Recently,
we started using the Cor-Knot (LSI Solution, Victor, NY) to
tie the knots during robotic MVR (Fig. 7.42). This has
resulted in a shorter operative time, and the preliminary
results have been satisfactory [23].
It is believed that any new surgical approach requires a
learning curve, and robotic cardiac surgery is no exception.
We believe that robotic cardiac surgery requires real teamwork and surgeons must overcome a substantial learning
curve. Our learning curve is showed graphically in Figs. 7.44
and 7.45. The mean crossclamp time was significantly shortened with surgical experience as denoted by the number of
operations. Our learning curve was truncated because the
console surgeon simultaneously had performed a large volume of various types of other robotic cardiac surgeries with
the same team over a relatively short period [23].
Furthermore, since we started our robotic surgical program, our robotic team members have remained the same.
Our experience has demonstrated that with a well-trained
7
109
Robotic Mitral Valve Surgery
a
b
Fig. 7.43 The mitral valve replacement is completed. (a) The mechanical valve; (b) The tissue valve
200.00
CPB time (min)
175.00
150.00
125.00
100.00
0.00
10.00
20.00
Case number
30.00
40.00
Fig. 7.44 The learning curve of CPB time for robotic mitral valve
replacement (y(min) = 172.1 − 18.9 ln(x); r2 = 0.539, p = 0.000)
160.00
Aortic occlusion time (min)
robotic team and after a substantial learning curve, optimal
results can be achieved with robotic surgery [5–9, 23].
In conclusion, the present results suggest that robotically assisted MVR is safe for patients with isolated
mitral valve stenosis. The 3-D digital vision system provides a perfect view of the mitral valve and the subvalvular apparatus in patients in whom limited exposure
prohibits direct vision. This technique also provides the
unique opportunity for junior surgeons to observe experienced surgeons at work, shorten their learning curve and
avoid mistakes [23].
We conducted a retrospective review on 40 patients
who underwent totally robotic mitral replacement with
the da Vinci S or Si robotic system from November 2008
to May 2013. Mean age of the patients was 47 ± 10 years
(from 32 to 66 years old). Eighteen patients were female
and 22 were male. All patients had isolated mitral valve
disease. Preoperative echo showed mitral stenosis combined with regurgitation in 11 patients and mitral stenosis
in 29 patients. All patients had a preserved left ventricular
ejection fraction. Moderate annular calcification alone did
not preclude patients from undergoing a robotically
approach.
The mitral procedure was completed endoscopically in all
the patients, including 30 mechanical prosthetic valves and
ten tissue valve replacements. These procedures did not
mandate intraoperative conversion to alternate techniques
and caused no surgery-related hospital deaths.
The median operation time was 320 min (from 140 to
405 min), the median CPB time was 127.5 min (from 89 to
198 min), and the median cross-clamp time was 87.9 min
(from 47 to 151 min). The learning curves of operation,
CPB and cross-clamp time were assessed by means of
regression analysis with logarithmic curve fit. The CPB and
cross-clamp time decreased as the case number increases
(Figs. 7.44 and 7.45).
140.00
120.00
100.00
80.00
60.00
0.00
10.00
20.00
30.00
Case number
40.00
Fig. 7.45 The learning curve of cross-clamp time for robotic mitral
valve replacement (y(min) = 132.2 − 17.4 ln(x); r2 = 0.717, p = 0.000)
110
7.6.4
C. Gao and M. Yang
Summary
Robotic technology can be used in mitral valve replacement
safely and effectively. The robotic system allows excellent
visualization of the valve and permits dexterity [23]. The
placement of wrist-like articulations at the end of the instrument moves the pivoting action to the plane of mitral annulus.
This improves dexterity in tight spaces and allows ambidextrous suture placement. From the learning curve, we can see
that operation time decreases as case number increases. No
doubt this change is related to improved setup and deployment times, team cooperation, and surgeon experience.
This new science is a trek not a destination. In this era of
outcomes-based medicines, surgical scientists must continue
to evaluate robotics and all new technologies critically.
Despite enthusiasm, caution can never be overemphasized.
Surgeons must be careful because indices of operative safety,
speed or recovery, level of discomfort, procedure cost, and
long-term operative quality have yet to be defined.
Conventional valve operations still enjoy long-term success
with ever-decreasing morbidity and mortality, and remain
the excellent control group for robotic mitral valve surgery.
References
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invasive cardiac surgery via ministernotomy. Ann Thorac Surg.
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12. Carpentier A, Loulmet D, Carpentier A, et al. Open heart operation
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13. Chitwood WR, Elbeery JR, Chapman WHH, et al. Videoassisted
minimally invasive mitral valve surgery: the “micro-mitral” operation. J Thorac Cardiovasc Surg. 1997;113:413–4.
14. Chitwood WR, Elbeery JR, Moran JM. Minimally invasive mitral
valve repair: using a mini-thoracotomy and transthoracic aortic
occlusion. Ann Thorac Surg. 1997;63:1477–9.
15. Falk V, Walter T, Autschbach R, et al. Robot-assisted minimally
invasive solo mitral valve operation. J Thorac Cardiovasc Surg.
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16. Carpentier A, Loulmet D, Aupecle B, et al. Computer assisted
open-heart surgery. First case operated on with success. C R Acad
Sci III. 1998;321:437–42.
17. Nifong LW, Chitwood WR, Pappas PS, et al. Robotic mitral valve
surgery: a United States multicenter trial. J Thorac Cardiovasc
Surg. 2005;129:1395.
18. Anderson CA, Chitwood WR. Advances in mitral valve repair.
Future Cardiol. 2009;5(5):511–6.
19. Chitwood WR, Nifong L, Elbeery JR, et al. Robotic mitral valve
repair: trapezoidal resection and prosthetic annuloplasty with da
Vinci surgical system. J Thorac Cardiovasc Surg. 2000;120:
1171–2.
20. Tomislav M, Craig MJ, Gillinov M, et al. A novel running annuloplasty suture technique for robotically assisted mitral valve repair.
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21. Siwek LG, Reynolds B. Totally robotic mitral valve repair. Oper
Tech Thorac Cardiovasc Surg. 2007;12:235–49.
22. Jan DS, Suyong AM, Chon L. Minimally-invasive valve surgery.
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8
Robotic Coronary Bypass Graft
on Beating Heart
Changqing Gao and Ming Yang
Abstract
The ultimate goal of minimally invasive CABG is to perform the entire anastomosis in a
closed chest, to avoid the deleterious effect of CPB and to minimize the incision and surgical trauma. We think that totally endoscopic coronary artery bypass (TECAB) on beating
heart has brought minimally invasive CABG close to this goal.
Since the first report of totally endoscopic CABG using da Vinci Surgical System
(Intuitive Surgical, Sunnyvale, CA, USA) in 1999, the robotic technology has been applied
to the closed-chest CABG on arrested or beating heart for more than 10 years. Despite this
successful milestone, only a limited number of TECAB operations have been carried out
worldwide.
We started to perform the robotic CABG on beating heart using da Vinci Surgical
System in 2008. In this chapter, we will describe in detail our experience in minimally
invasive direct coronary artery bypass (MIDCAB) on beating heart through minithoracotomy, totally endoscopic coronary artery bypass (TECAB) on beating heart, and the hybrid
revascularization.
8.1
Robotic Internal Thoracic
Arteries Harvesting
The ultimate goal of minimally invasive coronary artery
bypass graft (CABG) is to perform the entire anastomosis in
a closed chest, to avoid the deleterious effects of cardiopulmonary bypass (CPB) and to minimize the incision and surgical trauma. The superiority of left internal thoracic artery
(LITA) as a conduit has been well established for long-term
patency and event-free survival. Remarkable development
has been made in the robotic surgical technology to reduce
surgical trauma and to improve the postoperative course.
Loulmet [1] reported the first totally robotic coronary artery
bypass grafting on arrested heart in 1999.
C. Gao, MD (*) • M. Yang, MD
Department of Cardiovascular Surgery, PLA General Hospital,
No. 28 Fuxing Road, Beijing 100853, People’s Republic of China
e-mail: gaochq301@yahoo.com
The initial clinical step for programs wishing to develop a
robotic coronary surgery program is internal thoracic artery
(ITA) takedown. Both pedicle and skeletonized harvesting
techniques can be applied, with the latter offering better graft
length and easier graft handling. The advantages of ITA skeletonization are reported to include early high blood flow, a
longer conduit, and less bleeding than pedicle ITA grafts [2].
Longer conduits are needed for complete endoscopic arterial
revascularization. The feasibility and safety of ITA skeletonizing using da Vinci robotic system have been reported [3, 4].
8.1.1
Anesthesia and Patient Position
The patient is positioned supine on the left edge of the operating room (Fig. 8.1). After routine induction of anesthesia,
double-lumen intubation is carried out for single right lung
ventilation. The placement of the double lumen endotracheal
tube is aided by bronchoscopy. Single lung ventilation is an
important step of operation for adequate visualization during
the mobilization of ITAs.
C. Gao (ed.), Robotic Cardiac Surgery,
DOI 10.1007/978-94-007-7660-9_8, © Springer Science+Business Media Dordrecht 2014
111
112
Fig. 8.1 Patient positioned on left edge of OR table
C. Gao and M. Yang
Fig. 8.3 Ports placement for LITA harvesting
8.1.2
Fig. 8.2 The external defibrillator pads on chest
Standard hemodynamic monitoring is used with a radial
arterial line for systemic blood pressure monitoring. A central venous line or a pulmonary artery catheter can be used
for central access of the cardiac monitoring. CO2 insufflation
at a pressure of 8–10 mmHg is used in the left pleural space
to help with exposure. Special consideration has to be given
to hemodynamic effects related to the insufflation as the
increased pressure of CO2 may cause tamponade physiology
and affect hemodynamics. Single lung ventilation can also
cause hypoxemia and hypercarbia which hence may make
the patient unstable.
External defibrillator patches are placed on the chest
(Fig. 8.2) and the patient is positioned supine with the left
chest elevated to 30° with the aid of a small bolster under
the left chest. The operative side arm with protective padding is hung loosely and supported by a sheet. In the female
patient, the breast is positioned medially after sterile skin
preparation, and is secured by an adhesive sheet during the
draping.
Surgical Technique
The port sites are marked on the patients skin (Fig. 8.3)
before the incision is made. The camera port mark is on a
transverse line midway between the suprasternal notch and
the xiphoid process. The elevation of the camera port is
located about 3 cm lateral of the midclavicular line (MCL),
any place from 4 to 6 cm medial of the anterior axillary line
(AAL) depending on the body habitus. This location is typically at the 4th or 5th ICS but depends on the body habitus
and the length of the sternum. The location of the left
instrument port is about the breadth of four fingers from the
camera mark at about the same elevation, and always in the
seventh ICS. The right instrument port is about the breadth
of four fingers from the camera port at about the same elevation, and always in the third ICS. The three ports are in
the almost same line. However, our experience is that left
port should be little lower in order to prevent collisions.
After deflation of the left lung, a camera port is inserted
through the middle incision and carbon dioxide insufflation
is initialed and maintained at an average of 6–8 mmHg,
which may be increased to 12 mmHg as long as patients are
able to maintain satisfactory hemodynamic status. A 30
degree-angle upward camera is inserted, and the thoracic
cavity, the location and course of the LITA are examined.
The left and the right instrument ports are inserted
(Fig. 8.4). The surgical cart with 4 arms is brought in and
docked to the camera and the instrument arm ports
(Fig. 8.5).
After access to the left pleura space, a 30° upward endoscope is inserted to the camera port by the patient-side surgeon. The entire mediastinum is inspected. CO2 is insufflated
for adequate visualization and working space for hemodynamic tolerance. The required dose of CO2 is nominally
8 mmHg (usually 8–10, 12–15 mmHg maximum for fatty
8
Robotic Coronary Bypass Graft on Beating Heart
113
Fig. 8.4 Ports placement for LITA harvesting
Fig. 8.6 Dissecting the pleura parietalis, fascia and muscles covering
the LITA
Fig. 8.5 The da Vinci S Surgical System set up
mediastinum). LITA location and adhesions are carefully
examined before surgery. The LITA is identified and pulsation can be observed. Both pedicle and skeletonized harvesting techniques can be applied. The skeletonized harvesting
technique is similar to that used in open surgery or
endoscopy.
First, the pleura parietalis, fascia and muscles covering
the LITA are transected along the entire length (Fig. 8.6).
This allows exposure of the vessel regardless of the amount
of fat or muscle covering the mammary artery. The skeletonized LITA is dissected from the lateral edge medially using
blunt dissection and short bursts of low power monopolar
cautery to mobilize the anterior attachments (Fig. 8.7). Small
intercostal branches are ligated with monopolar energy in a
painting stroke then transected (Fig. 8.8). Large intercostal
branches are clipped for hemostasis (Fig. 8.9). The entire
length of LITA is dissected from the first intercostal branch
to the diaphragm. Starting at about the 3rd ICS, short
Fig. 8.7 The skeletonized LITA harvesting is performed using low
power cautery
segments of periarterial connective tissue are left attached to
help stabilize the ITA when the surgeon prepares the end for
anastomosis.
The right ITA (RITA) can be harvested through the same
approach for the LITA harvesting. After the instruments are
inserted into the robotic ports, the anterior mediastinum is
dissected and the instruments gain accesses to the right
pleural space (Fig. 8.10). The RITA is identified. The pedicle or skeletonized harvesting technique is similar to that
used in robotic LITA harvesting (Figs. 8.11, 8.12, 8.13, and
8.14). For RIMA to be the right coronary bypass graft, the
RITA can also be robotically harvested using right chest
approach, just the opposite to the left chest approach
(Figs. 8.15 and 8.16).
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Fig. 8.8 The small branch is ligated with monopolar energy
Fig. 8.11 Opening the right pleural cavity for exposing the RITA
Fig. 8.9 Large intercostal branches are clipped for hemostasis
Fig. 8.12 RITA is identified
Fig. 8.10 The anterior mediastinum is dissected
Fig. 8.13 RITA is harvested in skeletonized fashion
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70.00
Harvesting time (min)
60.00
50.00
40.00
30.00
20.00
10.00
0.00
50.00
100.00
150.00
200.00
Case number
Fig. 8.14 The double ITAs are harvested
Fig. 8.17 The learning curve of ITAs harvest (y(min) = 57.8 − 5.5
ln(x); r2 = 0.342, p = 0.000)
8.1.3
Fig. 8.15 The surgical system set-up of right approach for RITA harvesting
Fig. 8.16 RITA is robotically harvested in a right approach
The Surgical Experience
and Learning Curves
There is an initial learning curve with the technique of
robotic-assisted endoscopic ITAs harvest. From April
2007 to May 2013, 220 patients accepted totally robotic
coronary bypass on beating heart (BH-TECAB, 100 cases)
or robotic minimally invasive coronary bypass on beating
heart (MIDCAB, 120 cases). The mean age was 58.9 ± 10.1
(33–78) years. ITA was harvested robotically in all cases
successfully without damage leading to abandon, including
LITAs, RITAs and double-ITAs harvesting with da Vinci
S or Si system. The mean harvesting time was 30.8 ± 8.7
(16–52) min. A significant learning curve (Fig. 8.17)
for harvesting time was noted: y(min) = 57.8 − 5.5
ln(x); (r2 = 0.342; P < 0.01)
The development of robotic surgical devices is a prerequisite for performing TECAB. However, TECAB is a highly
complex procedure consisting of several but not routinely
performed surgical steps, which requires a modular and step
approach [5]. An important step of this procedure is the
robotic ITA harvesting.
For the patients undergoing robotic harvesting, the preoperative three-dimensional computer tomography images are
needed to be taken to evaluate the quality of the target ITA.
The robotic-enhanced IMA takedown is a prerequisite for
TECAB or MIDCAB operations and can be safely implemented. With a noted learning curve, the surgeon will harvest the target ITA in an acceptably shorter time. In this study
the harvesting time stayed stable after about 30 cases and
decreased as case number increased. The harvesting time
was reduced to an acceptable duration between 25 and
30 min. Long preparation time at the beginning may be
explained by the complexity of this new system and the lack
of clinical experience of the operation team [6].
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Bolotin and associates [7] reported robotic LITA harvesting
speed in a range of 39–48 min when using the dog model.
Learning curves and long preparation time at the beginning of
implementation had also been described by Falk and associates
[8] and Reuthebuch and coworkers [9]. The Falk group presented a LITA takedown time of about 40 min after 50 cases.
The Reuthebuch study noted that after the learning curve, a target LITA harvesting speed in the 35 min range could be achieved.
In conclusion, robotic-enhanced IMA takedown can be
safely implemented, and is prerequisite for TECAB operations. After overcoming learning curve, IMA takedown can
be performed in an acceptable time. Demographics and chest
size do not seem to influence ITA harvesting time. The rate
of LITA injuries is comparable with the rate reported for conventional thoracoscopic harvesting [6].
8.2
pericardium. The small left anterior thoracotomy incision
(about 4 cm) may be made in the fourth or fifth intercostal
space (Fig. 8.21). And the left pleural cavity is entered
and a retractor is placed in the incision (Fig. 8.22). The distal
end of the artery is then prepared for anastomosis. LAD is
Minimally Invasive Direct Coronary
Artery Bypass Grafting (MIDCAB)
After LITA is completely mobilized, the pericardium is
incised robotically, anterior to the left phrenic nerve and the
small pericardial branches are carefully cauterized
(Fig. 8.18). This helps in clearing the operative field and also
proper placing of ITA. Then the left anterior descending
artery (LAD) or the target vessels are identified (Fig. 8.19)
and the corresponding anterior intercostal space is identified
to confirm the proper placement of the small left anterior
thoracotomy incision, usually 4 cm long in the 4th ICS. After
systemic heparinization, with an activated clotting time
(ACT) goal of 350 s, the LITA is dissected distally. The distal
end of the artery is parked on the pericardium using a hemoclip (Fig. 8.20). If RITA is to be used for anastomosis, it is
harvested prior to LITA harvest. RITA is harvested in its full
length as a skeletonized conduit as described above in
Fig. 8.16. If a free RITA is to be used for composite grafting,
it is dissected at its origin, and the free RITA is parked on the
Fig. 8.19 Identifying the target vessel
Fig. 8.20 ITA is parked on the pericardium using a hemoclip
Fig. 8.18 The pericardium is opened
Fig. 8.21 A small left anterior thoracotomy incision may be made in
the fourth or fifth intercostal space
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Fig. 8.22 The retractor and cardiac stabilizer are used to expose the
target vessel
Fig. 8.24 LITA is anastomosed to the LAD
Fig. 8.23 LITA is anastomosed to the LAD in the end to side fashion,
using a continuous 7-0 Prolene suture
stabilized with a cardiac stabilizer and LITA is anastomosed
to LAD manually in the end to side fashion, using a continuous 7-0 Prolene suture (Fig. 8.23). The in situ LITA is always
used as grafting to the LAD (Fig. 8.24), or sequentially to
diagonal branch (Fig. 8.25). The LAD along with composite
RITA can be used to the lateral wall grafts. In some instances,
in situ RITA can be anastomosed to the LAD, and in situ
LITA to the lateral wall vessels. All composite grafts are
anastomosed prior to the coronary grafting.
8.2.1
Surgical Experience
and Learning Curves
One hundred and twenty (86 male and 34 female) patients
of the study group underwent MIDCAB. The mean age was
58.9 years (38–77 years), the mean weight was 70.6 kg
Fig. 8.25 LITA is sequentially anastomosed to LAD and diagonal
branch
(44–100 kg). The mean height was 165.9 cm (153–178 cm).
The mean left ventricular ejection fraction was 63.7 %
(44–72 %) and the mean diameter of left ventricle was
44.8 mm (35–57 mm).
The mean operating-room time was 240.8 min
(180–300 min) and the mean operating time was 182.9 min
(160–200 min). The mean ITA harvesting time was
33.4 min (16–45 min) (Fig. 8.26).
Double ITA harvesting (for “Y” type or sequence graft)
was performed in three patients (Fig. 8.27). Right ITA harvesting was performed on five patients (Poor LITA quality was
found in one patient. RITA to right coronary graft was performed on two patients and RITA to LAD graft on two
patients.). RITA to RCA graft was performed on two patients
(Fig. 8.28), LITA to diagonal branch graft on two patients,
(Fig. 8.29), RITA to LAD graft on one patient (Fig. 8.30),
sequential graft on four patients (Fig. 8.31), RITA to LAD and
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Fig. 8.26 The MIDCAB incision after operation
Fig. 8.28 RITA is anastomosed to the RCA
Fig. 8.27 “Y” type graft for LAD and diagonal branch using composite graft
Fig. 8.29 LITA to diagonal branch graft
LITA to diagonal branch graft on two patients, (Fig. 8.32).
LITA to LAD graft was performed on the rest of the patients
(Fig. 8.33).
The mean graft flow was 21.3 ± 12.6 (15–56) ml/min. The
graft patency was followed up by 64-MSCTA, and the
patency rate was 97.1 %. The mean follow-up time was 13.1
(1–70) months. All patients had excellent cosmetic results
(Figs. 8.34 and 8.35).
8.3
Totally Endoscopic Coronary Artery
Bypass Grafting (TECAB)
Conventional coronary artery bypass grafting provides complete revascularization with excellent long-term results for
various clear-cut indications with a major favorable impact
on the patient outcome and recurrence of adverse cardiac
events. The success of catheter-based techniques for treating
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119
Fig. 8.30 RITA is anastomosed to the LAD
Fig. 8.32 LITA is anastomosed to diagonal branch and the RITA to
LAD
ischemic coronary syndromes, combined with the shift
toward less invasive approaches, has renewed interest in
minimally invasive approach. The current tendency is to perform operations through smaller and smaller incisions to
reduce hospital stay and to hasten postoperative recovery.
After the introduction of robotic telemanipulators, TECAB
became feasible in the late 1990s. Didier Loulmet [1] performed the first TECAB procedure on arrested heart in 1999,
and subsequently several investigators reported TECAB on
beating heart [10, 11]. However, only a limited number of
cases have been performed worldwide.
8.3.1
Fig. 8.31 LITA is used in sequential graft
Surgical Technique
TECAB surgery on beating heart begins with satisfactory
single lung ventilation of the patient, and patient positioning
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Fig. 8.35 Three months after the surgery with well-healed incisions
Fig. 8.33 LITA is anastomosed to LAD
Fig. 8.36 The patient in a supine position with the left chest elevated 30°
Fig. 8.34 A MIDCAB patient, 1 month after the surgery
on the operating room table allows adequate access to the
anatomy. After routine induction of anesthesia, doublelumen intubation is carried out for single right lung ventilation. External defibrillator patches are placed on the chest,
and the patient is positioned supine with the left chest
elevated 30° with the aid of a small bolster under the left
chest (Fig. 8.36). The operative side arm with protective padding hung loosely is supported by a sheet. In female patients,
the breast is positioned medially, and after sterile skin preparation, is secured by an adhesive sheet during the draping.
Three 0.8–1.0-cm incisions are made in the 3rd, 5th, and
7th intercostal spaces (ICS) 2–3 cm medial to the anterior
axillary line (Fig. 8.37). After deflation of the left lung,
a camera port is inserted through the middle incision and
Fig. 8.37 The ports placement for LITA harvesting before TEACB
carbon dioxide insufflation is initiated and maintained at an
average of 6–8 mmHg, which may increase to 12 mmHg as
long as patients are able to maintain satisfactory hemodynamic status. A 30° angle upward camera is inserted, and the
thoracic cavity and the location and course of the LITA are
examined. The left and the right instrument ports are inserted.
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121
Fig. 8.38 The system set-up
Fig. 8.40 LITA is fully harvested in a skeletonized fashion
Fig. 8.39 The patient side cart center column is aligned with the
patient’s neck
Fig. 8.41 Large intercostal branches are clipped using hemoclip
The surgical cart with 4 arms is brought in and docked to the
camera and the instrument arm ports (Figs. 8.38 and 8.39).
The robotic system is used to harvest the LITA completely
from the subclavian vein to the LITA bifurcation in a totally
skeletonized fashion (Fig. 8.40). Hemoclips are used for
larger branches, while cautery is used to cauterize and transect the smaller branches. The 1st and 2nd intercostal arterial
branches are usually larger, therefore, Hemoclips are used
(Fig. 8.41). In a few cases, LITA is harvested with the accompanying veins in case of close proximity of arteries and
veins. The LITA is left attached to the chest wall with the
connecting areolar tissue to prevent it from hanging over the
pericardium. The pericardial fat is removed (Fig. 8.42) and
pericardiotomy is performed (Fig. 8.43). The pericardium
over the apex of the left ventricle is left intact to prevent herniation of the heart, and the target vessel is identified using a
30 degree-angle-downward camera (Fig. 8.44).
Fig. 8.42 The pericardial fat is removed
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Fig. 8.43 The pericardiotomy is performed
Fig. 8.45 The 12 mm cannula is docked to the system
Fig. 8.44 The target vessel is identified
Fig. 8.46 Adjunctive mediastinotomy 12 mm cannula at the subcostal
level
The da Vinci S 12 mm cannula for endostabilizer is
inserted into the thoracic cavity close to the left midclavicular line at the subcostal margin (Figs. 8.45 and 8.46). The
skeletonized LITA is sprayed using papaverine solution with
a 5 Fr feeding tube (Fig. 8.47). All the anastomosis supplies
are passed into the chest through this port (Fig. 8.48). After
systemic heparinization, the distal LITA is skeletonized
completely and partially transected obliquely leaving a small
toe section attached (Fig. 8.49). 5 S18-U-Clips are put outside-in in the far side of the partial transection of the LITA
(Fig. 8.50). The LITA is fully transected and secured to the
epicardial fat to maintain the LITA location and orientation.
After the console surgeon takes active control to position the
endostabilizer at the LAD to apply epicardial tension (Fig. 8.51),
the LAD is dissected (Fig. 8.52) and occluded proximally and
distally with SaddleLoops (Fig. 8.53 and 8.54). LAD arteriotomy is created (Fig. 8.55) and anastomosed to LITA using an
interrupted parachuting technique (Fig. 8.56). First, the 5
Fig. 8.47 The skeletonized LITA is sprayed using papaverine solution
with a 5Fr feeding tube
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123
Fig. 8.48 All the anastomosis supplies are passed into the chest
through this port
Fig. 8.50 Five S18-U-Clips are put outside-in in the far side of the
partial transection of the LITA
Fig. 8.49 After systemic heparinization, the distal LITA is partially
transected obliquely leaving a small toe section attached
Fig. 8.51 EndoWrist stabilizer and ClearField irrigator positioned
onto target site
U-clips are put inside-out in the far side of LAD (Fig. 8.57), and
then three more U-clips are put in the near side (Fig. 8.58), and
ITA is parachuted onto coronary artery. The SaddleLoop
occluders are removed to check the anastomosis (Fig. 8.59).
Lidocaine is infused intravenously during pericardiotomy and
coronary anastomosis to minimize ventricular arrhythmia.
After protamine is administered, the graft flow is measured by
the Medistim transit time probe (Fig. 8.60). All the accessories
are removed from the ports, a chest tube is placed, the robotic
system is removed and all incisions are closed (Fig. 8.61).
RITA can be anastomosed to the main stem of the right
coronary artery using the same technique. RITA can also be
robotically harvested using right chest approach, just the
opposite of the left chest approach. And the anastomosis can
be completed in the same fashion as that of LITA to LAD
(Figs. 8.62, 8.63, and 8.64).
Fig. 8.52 LAD is dissected
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Fig. 8.53 The distally LAD is occluded with SaddleLoops
Fig. 8.54 LAD is totally occluded proximally and distally with
SaddleLoops
C. Gao and M. Yang
Fig. 8.56 LITA is anastomosed to LAD using an interrupted parachuting technique
Fig. 8.57 5 U-clips are put inside-out in the far side of LAD
Fig. 8.55 LAD arteriotomy is created
Fig. 8.58 Three more U-clips are put in the near side of LAD
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Robotic Coronary Bypass Graft on Beating Heart
Fig. 8.59 SaddleLoop occluders are removed to check the
anastomosis
125
Fig. 8.62 RITA is harvested in skeletonized and prepared for anastomosed to RCA
Fig. 8.63 TECAB procedure of RITA to RCA
Fig. 8.60 Graft flow is measured by the Medistim transit time probe
Fig. 8.61 The operative incisions after TECAB
Fig. 8.64 RITA is anastomosed to RCA
C. Gao and M. Yang
60.00
25
50.00
20
Anastomosis time (min)
ITA harvesting time (min)
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40.00
30.00
20.00
10
5
10.00
0
0
20
40
60
Case number
80
100
0
20
40
60
80
100
Case number
Fig. 8.65 The learning curve of ITA harvest in TECAB procedure
(y(min) = 50.1 − 4.5 ln(x); r2 = 0.185, p = 0.000)
Fig. 8.67 The learning curve of anastomosis time (y(min) = 18.3 − 2.5
ln(x); r2 = 0.285, p = 0.000)
50.00
150
40.00
400
Operation time (min)
Occlusion time (min)
15
30.00
20.00
350
300
250
10.00
200
0.00
0
20
40
60
80
100
Case number
Fig. 8.66 The learning curve of coronary
(y(min) = 38.2 − 5.5 ln(x); r2 = 0.366, p = 0.000)
8.3.2
150
0
20
40
60
80
100
Case number
occlusion
time
Surgical Experience
and Learning Curves
One hundred TECAB procedures on beating heart were
successfully completed at the PLA General Hospital.
Two patients were converted to minithoracotomy during the operation after the target vessels were identified
to be not ideal for TECAB. The average LITA harvesting time, coronary occlusion time and anastomosis time
were 34.9 ± 9.6 (18–55) min, 19.5 ± 8.4 (7–41) min and
10.0 ± 4.2 (5–21) min respectively. The mean operation
time was 150.1 ± 55.9 (120–188) min. The learning curves
Fig. 8.68 The learning curve of operation time (y(min) = 400.9 − 49.9
ln(x); r2 = 0.663, p = 0.000)
were shown graphically in Figs. 8.65, 8.66, 8.67, and 8.68.
The average graft flow was 35.8 ± 18.2 (10–103) ml/min.
The average chest drainage was 164.9 ± 83.2 (70–450) ml.
Troponin-T and creatine kinase/creatine kinase-myoglobin
(CK/CK-MB) levels were within normal range. No patient
had angina after surgery.
TECAB on beating heart has become a feasible procedure
for coronary revascularization at specialized centers.
However, proper planning and patient selection are paramount for success. Grafting strategy should never be compromised to complete revascularization. This was the first
robotic endoscopic cardiac procedure reported and remains
8
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Robotic Coronary Bypass Graft on Beating Heart
a
b
Fig. 8.69 Coronary angiography shows the sever stenosis in the proximal segment of LAD (a) and the LITA graft (b)
among the most complex robotic surgical operations.
TECAB has been criticized especially because of prolonged
operative times compared with open procedures.
We have to state that since the heart is not decompressed
by using CPB, space in the thoracic cavity is limited,
Therefore, CO2 pressure may be increased above the suggested value as long as the heart is filled sufficiently and contractility is not impaired; suturing of the anastomosis is the
most demanding part of TECAB on beating heart, even the
slightest movement of the target vessel impairs surgical
manipulation due to the 10× magnification. TECAB on beating heart is a safe procedure in selected patients, and produces excellent early and midterm patency of anastomosis
and surgical results.
TECAB on beating heart should be conducted by surgeons with extensive surgical experience in open techniques,
and requires a stable and well trained robotic team, and
learning curves are substantial. Since da Vinci is a surgical
tool, what kinds of surgical procedures surgeons can perform
depend on surgeons’ own experience in the operating room,
not on da Vinci!
In our study, we experienced significant learning curves
in terms of durations of operation, coronary occlusion, and
anastomosis. It is clear that intraoperative surgical challenges prolong the operative time. It therefore seems to be
very important for the surgical team to make all efforts to
avoid any surgical problems and pay very meticulous attention to every detail.
Before discharge, eight patients of the study group underwent CTA scan and the rest of the patients underwent coronary angiography. Both angiography and CTA scan showed
100 % graft patency (Figs. 8.69 and 8.70). Unexpectedly, the
angiography showed that LITA graft in the middle segment
developed a collateral branch in two patients (Fig. 8.71), however, they were asymptomatic. After discharge, all patients
were followed up by CTA scan in 3, 6 and 12 months and the
study showed 100 % graft patency. One patient had gastric
bleeding 6 months after surgery. The average follow-up time
was 18.39 ± 11.8 (1–62 months). ICU stay was 1.5 ± 0.9 (1–3)
days. No other complications were found. And all the patients
had cosmetic results (Fig. 8.72, 8.73, and 8.74).
8.4
Hybrid Coronary Revascularization
Despite decades of intense scientific clinical research, controversy still exists regarding the most appropriate therapy
for patients with multivessel coronary artery disease (CAD).
Prospective randomized studies from each of the last 3 decades
have documented the superior long-term symptom relief and
survival benefit that coronary artery bypass grafting affords
compared with both medical therapy and percutaneous coronary interventions (PCI) for multivessel CAD [12, 13].
However, PCI offers a lower level of invasiveness, a more rapid
recovery, and less short-term complications than CABG in
appropriately selected patients. It is widely accepted that the
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a
b
c
d
e
f
Fig. 8.70 CTA follow-up for TECAB. 3 months (a), 6 months (b), 1 year (c), 2 years (d), 3 years (e) and 5 years (f) after the surgery
Fig. 8.71 Angiography shows that LITA graft develops a collateral
branch
survival advantage conferred by CABG is related to the presence of a patent left internal thoracic artery graft sewn to the
left anterior descending artery [14]. Minimally invasive cardiac
surgical techniques have been perfected to perform this isolated
LITA-LAD revascularization [14]. Hybrid coronary artery
revascularization is a combination of minimally invasive coronary artery surgery and catheter based coronary intervention.
The ultimate goal of minimally invasive coronary artery bypass
grafting is to perform the entire anastomosis in a closed chest.
With the advent of robotically enhanced telemanipulation, the
latest minimally invasive techniques are now available and thus
enable true closed chest totally endoscopic procedures.
The hybrid concept is gaining renewed interest because
totally endoscopic LITA to LAD has become feasible and
placement of drug-eluting stents in non-LAD targets may be
competitive even for arterial bypass grafts. The concept of
hybrid revascularization is first discussed and applied clinically when placement of the left internal mammary artery to
the left anterior descending artery becomes feasible through
mini-thoracotomies [15, 16].
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129
Fig. 8.74 Six months after the surgery with well-healed incisions
Fig. 8.72 A male patient, 1 month after TECAB
Fig. 8.73 A female patient, 3 months after TECAB
8.4.1
Patient Selection
Inclusion criteria for the hybrid procedure are patients with
double-vessel or triple-vessel disease in whom LAD lesions
are not suitable for PCI but suitable for surgical bypass and in
whom non-LAD lesions are amenable to PCI. Selecting
patients for hybrid coronary revascularization (HCR) involves
close consultation between cardiac surgeon and interventional cardiologist. The surgeon and cardiologist must address
specific concerns regarding the suitability of coronary anatomy as well as clinical characteristics as far as the specifics of
minimally invasive LITA-LAD revascularization are concerned. Angiography should be carefully reviewed for the
suitability of LAD for surgical grafting. A large distal LAD
will provide the best incremental advantage to LITA-LAD
revascularization compared with multivessel stenting. Very
small LAD targets or obvious long intramyocardial LAD segments may pose significant technical challenges to the minimally invasive surgeon and should be approached carefully.
Total chronic occlusions of LAD can be safely approached
with minimally invasive LITA-LAD. The non-LAD targets
should be reviewed in detail for PCI options. An estimation of
both the technical considerations and the possible long-term
success of PCI should be considered. Decisions regarding the
possible aggressiveness of PCI should be based on HCR
strategy, as the presence of a patent LITA-LAD graft may
change the safety margin for the interventional cardiologist.
In general, a suitable LAD with focal proximal lesions in the
right coronary artery and/or circumflex distribution provides
the best conditions for HCR [14].
The need for single-lung ventilation and chest cavity
insufflation raises important considerations when selecting
patients for robotic CABG. Absolute exclusion criteria for
robotic CABG include patients with severe chronic obstructive pulmonary disease who cannot tolerate single-lung ventilation and patients who have had prior left chest surgery.
Patients with severe pulmonary hypertension also provide a
relative contraindication as rapid desaturation and hemodynamic change can compromise single-lung ventilation and
thoracic cavity insufflation. Actively ischemic patients also
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b
Fig. 8.75 (a) Preoperative angiography of a patient for staged-hybrid revascularization demonstrating high-grade proximal LAD lesion. (b)
Angiography on the fifth day after operation of patent LITA-LAD anastomosis at the time of staged-hybrid revascularization
a
b
Fig. 8.76 Successful percutaneous coronary intervention of the right coronary artery. (a) pre-stent. (b) post-stent
pose a challenge. Chest insufflation can exacerbate ischemia
and result in malignant arrhythmias which can be challenging to handle [14].
From April 2007 to May 2013, 35 patients with right coronary artery or circumflex coronary stenosis received stent
placement after robotic LITA to LAD surgery in staged session
[17]. The average age of the patients was 62.3 ± 12.1 years old.
Three patients were female and 32 were male. All patients
underwent preoperative computed tomographic scan of the
thorax and pulmonary function tests. Four to five days following the robotic LITA to LAD surgery, routine stent placement
was performed on these patients in the catheter lab. At same
time, angiographic confirmation of LITA-LAD graft patency
was verified (Fig. 8.75a, b) and successful PCI of the right
coronary and/or circumflex artery followed (Figs. 8.76a, b, and
8.77). No patient complained of complications.
8
Robotic Coronary Bypass Graft on Beating Heart
Fig. 8.77 CTA follow-up for hybrid coronary revascularization
8.5
Summary
Endoscopic operations have associated with nearly all surgical
disciplines over the last two decades and have become the
standard of care [18]. In cardiac surgery and specifically for
coronary artery bypass grafting, the use of minimally invasive
techniques has been a challenge for the following reasons:
First, most procedures are already complex, and endoscopic
approaches further increase the degree of complexity; second,
the cardiac surgery community has no experience in endoscopic surgery until recently; and finally, early attempts to perform CABG with the use of conventional thoracoscopic
instrumentation failed completely [18, 19]. Endoscopic instrumentation, with only four degrees of freedom, significantly
reduces the dexterity needed for delicate cardiac surgical procedures, and the loss of depth perception by using two dimensional video monitors further increases the operative difficulty.
Robotic surgery provides a solution to these problems and
represents a paradigm shift in the delivery of healthcare for
both the patient and the surgeon [20]. Mitral valve repair has
been the most common application of robotic technology in
cardiac surgery. On the basis of the success of robotic mitral
surgery, surgical telemanipulation has expanded to other cardiac procedures such as coronary revascularization.
Robotic coronary operations range from internal mammary artery harvest with a hand-sewn anastomosis,
performed either on- or off-pump through a mini-thoracotomy or median sternotomy, to totally endoscopic coronary
artery bypass grafting. The initial clinical expectation for
robotic coronary surgery was ITA takedown and completion
of CABG through sternotomy or minithoracotomy. Early
reports demonstrated the feasibility and safety of harvesting
131
IMA with the da Vinci system with harvest time 30 min
achievable once the learning curve had been negotiated [21].
In another study, by Duhaylongsod and coworkers [22], harvest time was 42–55 min. Our mean harvest time is 30.8 min,
and the time decreases as case number increases. Our experience demonstrates that thoracoscopic LITA takedown using
da Vinci telemanipulator is safe.
ITA harvest can be completed as described above. Robotic
endoscope is helpful in localizing the coronary target vessels, and also assists in identification of the correct intercostal space through which the target vessel is approached for
anastomosis, though the minithoracotomy is most commonly
performed in the fourth left intercostal space. Small thoracotomy retractors or less traumatic soft tissue retractors
enhance the exposure of the target vessel and allow the use of
standard surgical microinstrumentation for direct suturing by
hand [18]. Although MIDCAB minimizes the morbidity of a
full-sternotomy incision, concerns are about the quality of
anastomosis of LITA to LAD, LITA graft patency rates, a
steep learning curve for surgeons and the technical difficulties associated with the procedure. Now the outcomes published for robotically assisted MIDCAB show no
perioperative mortality and low complication rates [23–28].
Often these incisions can be limited to 5–8 cm and yield
excellent cosmetic results. In women, MIDCAB scars can be
easily hidden in the inframammary crease. Patient satisfaction and rapid recovery following MIDCAB have been
achieved. Preliminary studies suggested excellent long-term
patency of grafts following MIDCAB. At our center, 120
patients underwent robotic MIDCAB on beating heart with
excellent follow-up results. The study showed that the graft
patency was 97.1 % in the period of 1–54 months.
The ultimate goal of minimally invasive CABG is to perform the entire anastomosis in a closed chest, to avoid the deleterious effects of CPB and to minimize incisions and surgical
trauma. TECAB on beating heart has brought minimally invasive CABG close to this goal. TECAB is technically demanding. Several critical issues have to be emphasized for successful
surgery. Although TECAB is feasible and safe [17, 29, 30],
proper planning and patient selection are critical for success,
and grafting strategy should never be compromised to complete revascularization. Firstly, the patients’ comorbidities
should be considered. All patients with pulmonary disease
and/or poor ejection fraction should be excluded since poor
hemodynamics or low cardiac output could develop during the
procedure due to CO2 insufflation which decreases venous
return. In addition, cardiac stabilization could further decrease
cardiac output. Secondly, the location, quality, and trajectory
of the target vessel should be considered. This is more important in TECAB than in open heart surgery because the artery
sometimes can be quite difficult to be found if the vessel is
located in the fat or intramyocardial vessel. In our group, one
case was converted to MIDCAB due to intramyocardial LAD
during operation. If the vessel is calcified, it could be more
difficult to perform anastomosis robotically. Therefore, we
132
consider that diffuse calcified and intramyocardial vessels
should be exclusion criteria for TECAB procedure. Thirdly,
the diameter of the vessel is important. In OPCAB surgery, the
bigger the vessel, the easier the anastomosis and the better the
results. Totally occluded arteries are ideal target vessels since
ischemia rarely happen during vessel occlusion and the time
to perform the coronary anastomosis is not an issue [31].
However, using da Vinci Surgical System, we find that the
diameter of the vessel is not a problem for anastomosis since
a 3-D 10× magnified view and EndoWrist instruments allow
for very precise placement of the U-Clips as long as the quality of the target vessel is good. We also find that the quality of
totally occluded vessel is usually not as ideal as we expect.
Therefore, we believe that the quality of the target vessel is of
paramount importance. Suturing of the anastomosis is the
most demanding part of TECAB on beating heart because
under the 10× magnification even the slightest movement of
the target vessel could compromise surgical manipulation, and
due to lack of tactile feedback, sometimes it is difficult to
assess the quality of the vessel wall. Therefore, it could be
awkward to find the right position for placing a stitch.
Interrupted anastomosis reduces the possibility of purse
stringing of a continuous suture and helps to overcome the
lack of tactile feedback inherent with the da Vinci Surgical
System [30]. Moreover, intravascular ultrasonography has
proven that interrupted anastomosis with surgical U-Clips is
more compliant than anastomosis with running sutures [32].
We also find that big bite of U-Clips at the outside of the incision of target vessel is helpful for hemostasis. Since the heart
is not decompressed by using CPB and the space in the thoracic cavity is limited, CO2 pressure may be increased above
the suggested value up to 15 mmHg as long as the heart is
filled sufficiently and contractility is not impaired. We must
emphasize that the endostabilizer should not be compressed
too much on the heart to avoid compromising contractility.
A lighter touch rather than heavy compression can also minimize the bouncing effect of the beating heart. In addition,
ischemic preconditioning may be useful for longer anastomotic time in instances of less than 80–90 % stenosis in a large
proximal LAD. It is important to remember to rely on visual
cues. Therefore, we believe that robotic cardiac surgery should
be conducted by surgeons with extensive surgical experience
in open techniques. Optimal anesthesia will minimize occurrence of ischemia in the target coronary arteries with significant stenosis. The crucial issue of anesthesia for the surgery is
to deal with the hemodynamic compromise, hypoxia and
hypercarbia associated with single-lung ventilation, and intrathoracic insufflation of CO2 with positive pressure [33].
The results of MIDCAB procedure with harvesting of the
mammary vessel and coronary anastomosis through a minithoracotomy are established [34–36]. In our group, two cases
were converted to MIDCAB during operation. One was due
to intramyocardial LAD, in which we found intramyocardial
LAD was difficult to be anastomosed to LIMA robotically.
The other was due to diffuse calcified RCA. We anastomosed
C. Gao and M. Yang
the right IMA to the diffuse calcified RCA robotically, however, blood flow was not satisfactory. We therefore explored
the anastomosis with an infraxyphoid incision. The intraoperative exclusion or conversion was not considered as failure
of therapy as all these patients would have required an open
approach. Therefore, when necessary, we recommend conversion to a MIDCAB procedure which allows excellent
results with normal operating time.
Robotic cardiac surgery requires real teamwork and the surgeons must overcome a substantial learning curve before they
finally master TECAB. Median time for ITA harvesting and
operation is significantly shortened with surgical experience in
terms of number of operations, but IMA harvest time drops
more rapidly than anastomosis time with experience. Our
learning curve is truncated because the author, as the console
surgeon, simultaneously has performed a large volume of various kinds of other robotic cardiac surgeries with the same team
in a relatively short time [37–45], and has the experience of
over 2,000 cases of OPCAB surgery [46, 47]. Since we started
the robotic surgical program, our robotic team members have
remained the same. Our experience shows that with well
trained robotic team and after a substantial learning curve, we
could achieve optimal results for TECAB on beating heart.
In conclusion, TECAB is a safe procedure for coronary
bypass grafting in selected patients, and produces excellent
early and midterm patency of anastomosis and surgical
results. Surgeons with extensive surgical experience in open
techniques, a stable and well trained robotic team and substantial learning curves certainly ensure the perfection of
TECAB procedure.
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9
Hybrid Coronary Revascularization
Mukta C. Srivastava, Bradley Taylor,
David Zimrin, and Mark R. Vesely
Abstract
Hybrid coronary revascularization (HCR) is a treatment strategy for revascularization of
multi-vessel coronary artery disease that utilizes minimally invasive coronary artery bypass
grafting (CABG) techniques in conjunction with percutaneous coronary intervention (PCI),
integrating the advantages of both. The long-term symptom relief and survival benefit of an
internal mammary artery (IMA) graft to the left anterior descending (LAD) artery are
attained in this approach, as well as the durability of PCI with drug-eluting stents (DES) to
non-LAD targets. This chapter will review the range of minimally invasive surgical techniques that form the basis of the surgical leg of HCR, address pharmacologic issues unique
to HCR, and finally to review logistical considerations in the sequencing of each leg of
HCR, surgical and percutaneous.
Keywords
Hybrid coronary revascularization • Percutaneous coronary intervention • Minimally
invasive surgery • Totally endoscopic coronary artery bypass
9.1
Introduction
Hybrid coronary revascularization (HCR) is a treatment strategy for the revascularization of multi-vessel coronary artery
disease that utilizes minimally-invasive coronary artery bypass
grafting (CABG) techniques in conjunction with percutaneous
coronary intervention (PCI), integrating the advantages of
both. The long-term symptom relief and survival benefit of an
internal mammary artery (IMA) graft to the left anterior
descending (LAD) artery are attained in this approach, as well
as the durability of PCI with drug-eluting stents (DES) to nonLAD targets [1–6]. Furthermore, early ambulation and discharge and reduced morbidity are afforded by the
M.C. Srivastava, MD (*) • B. Taylor, MD • M.R. Vesely, MD
Division of Cardiology, University of Maryland Medical Center,
110 South Paca St., Baltimore, MD 21201, USA
e-mail: msrivast@medicine.umaryland.edu
D. Zimrin, MD
Department of Medicine, University of Maryland
School of Medicine, Baltimore, MD, USA
minimally-invasive nature of the surgical and percutaneous
interventions, which are performed without median sternotomy or institution of central by-pass [7–9]. Hybrid strategies
have also included valve replacement combined with PCI, percutaneous valve therapy and aortic de-branching procedures
combined with endovascular grafting [6].
The advent of HCR, as well as percutaneous structural
heart interventions and endovascular techniques have been an
impetus for the development of state-of-the-art hybrid operating suites that facilitate the performance of cardiac surgery
and PCI in the same procedural setting. Minimally-invasive
surgical techniques have progressed, with advanced operators
performing totally endoscopic coronary artery bypass
(TECAB). Likewise, stent technology has advanced and the
introduction of second generation DES, with lower stentthrombosis and re-stenosis rates, has made them competitive
as a revascularization approach compared with saphenous
vein grafts (SVGs) for non-LAD targets. Development in
interventional techniques and lesion modification technologies such as rotational atherectomy have also broadened the
lesion subtypes amenable to percutaneous therapy.
C. Gao (ed.), Robotic Cardiac Surgery,
DOI 10.1007/978-94-007-7660-9_9, © Springer Science+Business Media Dordrecht 2014
135
136
M.C. Srivastava et al.
A consideration unique to HCR is the sequence of surgical
and percutaneous intervention and the timing of these in
relation to one another. In this regard, there are important
implications for anti-coagulation and anti-platelet therapy,
ischemia burden during either leg of revascularization, the
ability to assess graft patency with completion angiography,
and the ability to perform rescue surgical grafting for a failed
PCI attempt. The optimal sequence of revascularization for
HCR with TECAB and PCI has not been determined.
Reports on HCR results have been published. HCR uses
minimally-invasive surgical techniques that range from
those requiring mini-thoracotomies to totally endoscopic
approaches. These results have demonstrated low mortality
rates ranging from 0–2 %, shorter intensive care unit and
hospital lengths of stay, as well superior cosmetic results and
shorter recovery times. While results are encouraging, logistical and political factors have limited widespread adoption
of the HCR approach. High-volume centers still perform
only 5 % of CABG case volume via an HCR approach.
Technical demands and learning curves associated with minimally invasive coronary artery bypass grafting techniques
also importantly contribute to limiting HCR volume [6].
This chapter are to review the range of minimally-invasive
surgical techniques that form the basis of the surgical leg of
HCR, address pharmacologic issues unique to HCR, and
finally to review logistical considerations in the sequencing
of each leg of HCR, surgical and percutaneous.
9.2
composite outcome was not significantly different (5.6 %
versus 7.0 %, respectively; p = 0.19). The overall rate of graft
patency was lower in the off-pump group however the
patency rate for left-internal mammary artery pedicle grafts
to the LAD was not significantly different (95.3 % versus
96.2 %, respectively; p = 0.48). In an analysis by Puskas
et al., off-pump CABG was found to disproportionately benefit high-risk surgical patients with an operative mortality
benefit noted in patients with a Society of Thoracic Surgeons
Predicted Risk of Mortality (PROM) greater than 2.5–3 %
[10].
9.4
In the Mid-CAB technique, LIMA to LAD revascularization
is performed via a mini-thoracotomy and utilizing off-pump
CABG technique, thereby eliminating CPB and need for
mid-line sternotomy. Decreased bleeding and infection rates
compared with off-pump CABG have also been appreciated.
Typically thoracotomy is performed in the fourth or fifth
interspace. Costal cartilage removal or disarticulation is
sometimes required for adequate visualization. Large MidCAB series have been reported in the literature with shortterm LIMA to LAD patency rates of 95–97 % [5]. The first
series of Mid-CAB LIMA to LAD revascularization combined with PCI of non-LAD vessels was reported by Angelini
et al. in 1996 [12].
Minimally Invasive LAD
Revascularization
9.5
The two components of cardiac surgery that impose significant morbidity risk are the institution of cardiopulmonary
bypass (CPB) and the sternotomy incision [10]. Minimallyinvasive surgical techniques have focused on eliminating the
need for CPB and the development of sternal-sparing
techniques.
9.3
Minimally Invasive Direct Coronary
Artery Bypass Grafting (Mid-CAB)
Off-Pump CABG
Off-pump CABG utilizes stabilizer technology to allow performance of coronary artery bypass revascularization on the
beating heart. The elimination of CPB provides the potential
advantages of reduced myocardial depression and cerebral
dysfunction and a lower incidence of pulmonary complications as well as avoidance of a generalized systemic inflammatory response [11]. These benefits are tempered by the
concern for lower overall graft patency rates, a higher incidence of peri-operative MI and less complete revascularization. In the ROOBY trial of 2,203 patients randomized to
on-pump versus off-pump CABG, the rate of the 30-day
Totally Endoscopic Coronary Artery
Bypass Grafting (TECAB)
TECAB entails thoracoscopic mobilization of the LIMA as
well as robotic LIMA to LAD anastomosis without implementing median sternotomy or thoracotomy. A consideration
for this approach is the need for single-lung ventilation and
chest cavity insufflation to develop the virtual space of the
anterior mediastinum in which the LIMA lies. The chest is
insufflated with carbon dioxide, inducing a controlled pneumothorax with cardiac displacement. Resulting hemodynamic instability, as left and right-sided filling pressures drop
and oxygenation is altered, is managed with pre-emptive volume loading and peripheral vasoconstriction. In this approach,
peripheral bypass with an intra-aortic balloon occluder for
cardioplegic arrest is instituted for arrested heart TECAB [5].
Finally, in the beating-heart TECAB approach, revascularization is performed without CPB or median sternotomy and
both the LIMA takedown and anastomosis are performed
robotically. Srivastava et al. described the largest published
series of beating-heart TECAB of 214 patients, reporting an
early graft patency, assessed by computed tomography
9
137
Hybrid Coronary Revascularization
angiography (CTA) or angiography, of 99 % and clinical
freedom from graft failure and re-intervention at a mean of
528 ± 697 days in 98.6 % of patients [13]. Gao et al. reported
TECAB on beating heart of 90 patients; the early and midterm graft patency was 98.8 %, assessed by angiography [14].
And Gao et al. report hybrid coronary revascularization by
total endoscopic robotic coronary artery bypass grafting on
beating heart and stent placement in 2009[15]. Bonatti et al.
reported an intention-to-treat intermediate-term experience of
226 patients undergoing HCR via arrested heart and beating
heart TECAB with 5-year bypass graft patency and 5-year
freedom from MACCE comparable to patients undergoing
open CABG [16].
9.6
Patient Selection
Patient selection for HCR is a collaborative effort between
the cardiac surgeon and interventional cardiologist, comprising the Heart Team approach. In this merger, the cardiac surgeon and the interventional cardiologist evaluate the clinical
and anatomical features of each patient to develop an optimal revascularization strategy. Indications and contraindications for consideration for HCR as detailed by Popma and
colleagues are listed in Tables 9.1 and 9.2 respectively [17].
Specific considerations include anatomic suitability for a
hybrid revascularization as well as clinical characteristics of
the patient. Small caliber LAD vessels or significant intramyocardial segments pose technical challenges for a minimally invasive approach. Non-LAD targets should be
reviewed for suitability of percutaneous intervention in
terms of anatomic complexity and likelihood of long-term
patency. Considerations regarding patient clinical characteristics include ability to tolerate single-lung ventilation and
the hemodynamic aberrations associated with chest cavity
insufflation. The ideal anatomy is a small cardiac silhouette
with a large left pleural space. Thus absolute exclusion criteria for minimally-invasive cardiac surgery utilizing robotic
assistance via thoracoscopic guidance include a history of
severe chronic obstructive pulmonary disease who cannot
tolerate single-lung ventilation and history of previous left
chest surgery. Patients with severe pulmonary hypertension
have a relative contraindication as rapid desaturation and
hemodynamic compromise are poorly tolerated. Importantly
actively ischemic patients can decompensate with the imposition of chest insufflation [5].
Leacche and colleagues evaluated 30-day outcomes of
patients undergoing HCR stratified by Synergy Between
Percutaneous Coronary Intervention With Taxus and Cardiac
Surgery (SYNTAX) score and the European System for
Cardiac Operative Risk Evaluation (euroSCORE). In comparison with patients undergoing conventional CABG,
patients with high SYNTAX scores (≥33) and elevated
Table 9.1 Indications for hybrid coronary revascularization
Emergency revascularization of non-LAD target with residual LAD
disease
Insufficient native vessel size or absence of venous conduits
Non-LAD lesions located in vessels not ideal for SVG long-term
patency or placement
Absence of suitable venous conduits due to prior vein stripping
High-risk co-morbidities
Adapted from Popma et al. [17]
Table 9.2 Contraindications to HCR
Clinical conditions:
Hemodynamic instability
Decompensated heart failure
Chronic lung disease with FEV1 < 50 % predicted
Coagulopathy
Malignant ventricular arrhythmias
Recent large myocardial infarction
Prior left thoracotomy
Exclusion for PCI
Exclusion for thoracoscopic LIMA-LAD grafting
Unusable or previously used LIMA
Previous thoracic surgery involving the left pleural space
Poor quality or diffusely diseased LAD
Chest wall irradiation
Left subclavian artery stenosis
Adapted from Popma et al. [17]
euroSCORES (>5) faired better with conventional CABG,
with higher bleeding complications and a higher incidence
of the composite end-point of death from any cause, stroke,
myocardial infarction and low cardiac output syndrome [18].
Thus, HCR may not be an ideal strategy for clinically highrisk patients with complex anatomy.
9.7
Anti-coagulation/Platelet Inhibition
An important consideration for HCR is the anti-coagulation
and platelet inhibition strategy as the risk of surgical bleeding has to be balanced with the risk of stent thrombosis [19].
These considerations are most relevant when HCR is performed in a same-session approach or when PCI has been
performed prior to the surgical revascularization arm.
Unfractionated heparin is the most commonly used anticoagulant for both PCI and CABG procedures as anti-coagulant
effect can be monitored by measuring activated clotting times
(ACTs) and can be reversed with protamine. Low-molecular
weight heparin is a less attractive option for cardiac surgery,
limited by its long half-life and irreversibility. Typical heparin
reversal with protamine is performed post-bypass, which can be
problematic in an HCR approach when surgical revascularization is performed after PCI, as there is a theoretical risk of
138
M.C. Srivastava et al.
stent-thrombosis with protamine administration. Interestingly,
in a series comparing same-session performed HCR without
protamine reversal versus standard off-pump CABG, less bleeding was noted in the HCR cohort [18]. This finding was attributed to lesser bleeding associated with minimally-invasive
surgical techniques. The direct thrombin inhibitor, Bivalirudin
has been evaluated as an anti-coagulation strategy in HCR with
mid-CAB with demonstrated efficacy by Kiaii and colleagues
[20]. In this series, Bivalirudin was administered intraoperatively during the mid-CAB of same-session HCR and continued
for the PCI of the revascularization. The optimal anti-coagulation
strategy has not been determined in HCR.
Anti-platelet therapy is an additional consideration during
HCR as PCI requires dual anti-platelet therapy (DAPT) with
aspirin and an oral thienopyridine such as Clopidogrel which
works at the platelet P2Y ADP receptor site. Continued DAPT
through the surgical revascularization period when PCI is performed first clearly has implications for bleeding risk. Platelet
inhibition strategy is most complex in the same-session
approach as the timing interval between both revascularization
periods is minimal. The timing of administration of a loading
dose of a thienopyridine and protamine reversal are particularly relevant. Diverse strategies have been successfully implemented without a consensus in the literature regarding the
ideal approach. Reicher and colleagues performed mid-CAB
followed by PCI without protamine reversal with Clopidogrel
loading immediately after PCI. In their series, they documented adequate platelet inhibition by 24 h by ADP-induced
aggregation [8]. Zhao and colleagues have successfully used
the strategy of administering a 300 mg loading dose of
Clopidogrel just prior to PCI followed immediately by CABG
with subsequent protamine reversal [21]. At our institution
(University of Maryland), a strategy of CABG first followed
by protamine reversal of heparin with subsequent re-heparinization and clopidogrel loading via NG tube for PCI after
CABG has been used successfully in a same-session approach.
9.8
Sequence of Revascularization
The optimal sequence of revascularization in HCR is not
arbitrary as there are advantages and disadvantages inherent
to the three potential revascularization approaches: Surgery
prior to PCI versus PCI prior to surgery versus a samesession intervention where both revascularization procedures
are performed in the same procedural setting with either procedure being performed first. Notably, patient presentation
often dictates intervention sequence.
9.8.1
CABG Prior to PCI Approach
When surgical revascularization is performed as the initial
intervention, an important advantage is that an improvement
in safety profile of subsequent PCI as typical revascularization
in the large LAD territory has been established. Furthermore,
anti-coagulant use and platelet inhibition during the interventional procedure can be optimized for PCI result rather
than tailored to avoid surgical bleeding. Completion angiography to assess graft patency can also be performed in this
approach. While the utility of completion angiography is
controversial, in an analysis by Zhao et al. of 366 patients
who underwent routine completion angiography after conventional coronary artery bypass grafting (CABG), 12 % of
grafts were found to have important angiographic defects,
with 2.8 % undergoing subsequent repair [21].
Complex lesion subsets such as bifurcation left main disease are ideally approached with CABG performed initially
as this allows for a reduction in the complexity of both the
surgical and interventional procedures as well as a significant improvement in the safety profile of subsequent PCI.
For example, a left main bifurcation lesion presents a complex target for PCI and requires double-vessel grafting if
CABG is utilized. However, both revascularization procedures are simplified by HCR. The LAD may be revascularized by placement of a single arterial graft to the LAD, a less
complex surgery than double vessel-bypass. This can then be
followed by protected left main stenting into the circumflex
vessel, a significantly lower-risk intervention than unprotected bifurcation left main stenting. Similar improvements in the complexity and safety of other complex lesion
subsets can also be realized with the CABG-first approach.
Figure 9.1 illustrates a complex trifurcation lesion revascularized via HCR.
A disadvantage inherent to this approach is the potential
for significant ischemia burden during CABG if lesions
planned for subsequent PCI subtend a large area of myocardium. Importantly, significant ischemia can result in hemodynamic instability with end-organ dysfunction, particularly
relevant with proximal RCA disease where right ventricular
and left ventricular dysfunction can complicate the intraoperative course. An additional disadvantage with this
approach is the inability to perform rescue surgical revascularization if PCI fails without embarking on a second, highrisk surgical intervention.
9.8.2
PCI Prior to CABG Approach
When HCR is performed in a staged fashion with PCI prior
to CABG, a sub-optimal interventional result can be achieved
with subsequent surgical revascularization. Additionally,
when the area of myocardium subtended by the vessel
planned for PCI is large, initial PCI reduces ischemic burden
during CABG. Conversely, initial PCI in the setting of significant un-revascularized disease, particularly in the LAD
territory, is a higher-risk procedure. By default, patients presenting with acute coronary syndromes will undergo percutaneous intervention to a culprit vessel prior to multi-vessel
revascularization.
9
Hybrid Coronary Revascularization
139
a
b
c
d
Fig. 9.1 Simplification of a complex lesion. Panel a demonstrates a
complex distal left main trifurcation lesion involving the LAD, left circumflex and ramus vessels. Panels b and c show placement of a right
internal mammary artery graft anastomosed to the LAD with a radial
artery Y-graft placed to a PDA lesion and a LIMA graft placed to the
LAD via TECAB. Panel d shows subsequent protected left main into
ramus vessel PCI (Reproduced with permission from Lee et al. [22])
A disadvantage of the PCI-first approach is that it requires
that CABG be performed on dual anti-platelet therapy while
imposing limitations on the interventionalist for choice and
duration of anti-coagulant therapy. Additionally, there is a
theoretically increased risk of stent-thrombosis from platelet
activation when protamine is administered during cardiac
surgery. This risk is thought to be more prominent in the offpump versus on-pump setting [6].
patient comfort need to be balanced with financial
considerations such as hospital LOS. In the same-session
approach, complete revascularization is performed in one
procedural setting, shortening the interval between each
revascularization period, which are still performed independently. The risk of bleeding due to anti-coagulation for
PCI in the immediate post-operative period and the potential for acute in-stent thrombosis due to performing PCI in
the post-operative inflammatory state are still relevant. The
primary benefit of this approach is complete revascularization in one procedural setting while maintaining the ability
to perform completion angiography and approach complex
lesion subsets in the environment of a surgically-equipped
hybrid operating suite. A shorter length of stay would be
expected with this approach.
9.8.3
Same-Session Revascularization
Approach
The ideal duration of time between surgical and percutaneous intervention remains indeterminate, as safety and
140
There is likely no arbitrarily superior sequence of
revascularization in HCR. Individualized selection for each
strategy based on patient presentation and anatomical considerations is likely the most effective way to determine the
order of interventions. Patients presenting with acute myocardial infarctions will typically undergo PCI first. Patients
with type C lesions with a high potential for PCI failure will
be better suited for a PCI first approach as well, as rescue
surgical revascularization can be performed at the time of
CABG. Conversely, patients with complex lesions, particularly in the left main territory, are better suited for a CABG
first approach as this would allow for performance of PCI in
a protected environment. A simultaneous procedure is satisfying in that it provides one-stop revascularization but creates logistical challenges involving personnel, equipment
and anticoagulant/platelet inhibition strategies that must be
carefully considered.
Conclusion
HCR is an approach for coronary revascularization that
optimizes treatment modalities for particular lesion subsets
and may afford the best long term patency, while maintaining the survival benefit of the LIMA graft and minimizing
morbidity. The Heart Team approach merges the insight
and skill-sets of both the cardiac surgeon and the interventional cardiologist to allow for optimized revascularization
based on the coronary anatomy and clinical characteristics
of the patient. The limitations of this approach include the
availability of hybrid operating suites and the advanced
technologies and skill sets required for the performance of
HCR. Additionally, specific features of the approach such
as optimal anti-coagulation strategies and sequence of
revascularization remain to be elucidated.
M.C. Srivastava et al.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
References
1. The VA Coronary Artery Bypass Surgery Cooperative Study
Group. Eighteen-year follow-up in the Veterans Affairs Cooperative
Study of Coronary Artery Bypass Surgery for stable angina.
Circulation. 1992;86:121–30.
2. European Coronary Surgery Study Group. Long-term results of
prospective randomized study of coronary artery bypass surgery in
stable angina pectoris. Lancet. 1982;2:1173–80.
3. Rogers W, Coggin C, Gersh B, et al. Ten-year follow-up of quality
of life in patients randomized to receive medical therapy or coronary artery bypass graft surgery. The Coronary Artery Surgery
Study (CASS). Circulation. 1990;82:1647–58.
4. The Bypass Angioplasty Revascularization Investigation (BARI)
Investigators. Comparison of coronary bypass surgery with
19.
20.
21.
22.
angioplasty in patients with multi-vessel disease. N Engl J Med.
1996;335:217–25.
Narasimhan S, Srinivas V, DeRose J. Hybrid coronary revascularization: a review. Cardiol Rev. 2011;19:101–7.
Byrne J, Leacche M, Vaughan D, et al. Hybrid cardiovascular procedures. J Am Coll Cardiol Intv. 2008;1:459–68.
Bonatti J, Lehr E, Vesely M, et al. Hybrid coronary revascularization: which patients? When? How? Curr Opin Cardiol. 2010;25:
568–74.
Reicher B, Poston R, Mehra M, et al. Simultaneous “hybrid” percutaneous coronary intervention and minimally invasive surgical
bypass grafting: feasibility, safety, and clinical outcomes. Am Heart
J. 2008;155:661–7.
Katz M, Van Praet F, de Canniere D, et al. Integrated coronary
revascularization: percutaneous coronary intervention plus robotic
totally endoscopic coronary artery bypass. Circulation. 2006;
114(Suppl I):I473–6.
Puskas J, Thourani V, Kilgo P, et al. Off-pump coronary artery
bypass disproportionately benefits high-risk patients. Ann Thorac
Surg. 2009;88:1142–7.
Shroyer A, Grover F, Hattler B. On-pump versus off-pump coronary artery bypass surgery. N Engl J Med. 2009;361:1827–37.
Angelini G, Wilde P, Selerno A, et al. Integrated left small thoracotomy and angioplasty for multi-vessel coronary artery revascularization. Lancet. 1996;347:757–8.
Srivastava S, Gadasalli S, Agusala M, et al. Beating heart totally
endoscopic coronary artery bypass. Ann Thorac Surg. 2010;89:
1873–9.
Gao C, Yang M, Wu Y, Wang G, et al. Early and midterm results of
totally endoscopic coronary artery bypass grafting on the beating
heart. J Thorac Cardiovasc Surg. 2011;142:843–9.
Gao C, Yang M, Wang G, et al. Hybrid coronary revascularization by endoscopic robotic coronary artery bypass grafting on
beating heart and stent placement. Ann Thorac Surg. 2009;87:
737–41.
Bonatti J, Zimrin D, Lehr E, et al. Hybrid coronary revascularization using robotic totally endoscopic surgery: perioperative outcomes and 5-year results. Ann Thorac Surg. 2012;94:1920–6.
Popma J, Nathan S, Hagberg R. Hybrid myocardial revascularization: an integrated approach to coronary revascularization. Catheter
Cardiovasc Interv. 2010;75:S28–34.
Leacche M, Byre J, Solenkova N, et al. Comparison of 30-day outcomes of coronary artery bypass grafting surgery versus hybrid
coronary revascularization stratified by SYNTAX and euroSCORE.
J Thorac Cardiovasc Surg. 2013;145(4):1–9.
Zimrin D, Bonatti J, Vesely M, et al. Hybrid coronary revascularization: an overview of options for anticoagulation and platelet
inhibition. Heart Surg Forum. 2010;13(6):E405–8.
Kiaii B, McClure R, Stewart P, et al. Simultaneous integrated coronary artery revascularization with long-term angiographic followup. J Thorac Cardiovasc Surg. 2008;136:702–8.
Zhao D, Leacche M, Balguer J, et al. Routine intra-operative completion angiography after coronary artery bypass grafting and
1-stop hybrid revascularization: results from a fully integrated
hybrid catheterization laboratory/operating room. J Am Coll
Cardiol. 2009;53(3):232–41.
Lee JD, Vesely MR, Zimrin D, Bonatti J. Advanced hybrid coronary revascularization with robotic totally endoscopic triple bypass
surgery and left main percutaneous intervention. J Thorac
Cardiovasc Surg. 2012;144(4):986–7.
Robotic Left Ventricular Epicardial
Lead Implantation
10
Changqing Gao, Chunlei Ren, and Ming Yang
Abstract
Cardiac resynchronization therapy (CRT) has been considered to improve the patient’s
hemodynamics, functional status and survival probability for chronic heart failure (CHF)
patients. Transvenous insertion of left ventricular leads is currently the route of choice for
CRT. However, technical limitations owing to individual coronary sinus (CS) and coronary
venous anatomy result in a 10–15 % failure rate of left ventricular lead placement and effective biventricular pacing. The epicardial lead implantation may be the last alternative for
those who cannot receive or fail lead implantation through veins. Application of robotic
technology to epicardial implantation allows for high-resolution, three-dimensional vision
of the ventricular surface. The robotic approach provides assurance of accurate surgical
positioning, minimum trauma and improved outcomes.
Approximately 30 % of patients with heart failure exhibit
significant ventricular dyssynchrony secondary to alterations
in intraventricular conduction. Cardiac resynchronization
therapy (CRT) has an alternative for chronic heart failure
(CHF) patients, and has been regarded as Class I indication
for heart failure treatment in 2005 American College of
Cardiology/American Heart Association (ACC/AHA) guideline [1]. Several trials have recently demonstrated significant
improvement in ventricular function, exercise tolerance,
quality of life, and reduction in hospitalization and mortality
in patients undergoing CRT. The left ventricular (LV) lead is
implanted transvenously in the majority of cases and
advanced through the coronary sinus into a LV epicardial
vein. However, technical limitations owing to individual coronary sinus (CS) and coronary venous anatomy result in a
10–15 % failure rate of left ventricular lead placement and
effective biventricular pacing. The endovenous lead positioning can also cause many complications, such as dislocation of pacing lead, chronically enhanced pacing threshold
leading to reimplantation, and phrenic nerve stimulation.
C. Gao, MD (*) • C. Ren • M. Yang, MD
Department of Cardiovascular Surgery, PLA General Hospital,
No. 28 Fuxing Road, Beijing 100853, People’s Republic of China
e-mail: gaochq301@yahoo.com
Furthermore, major complications such as coronary sinus
perforation may occur. The epicardial lead implantation may
be the last alternative for those who cannot receive or fail
lead implantation through veins. The huge trauma by sternotomy limits the application of epicardial implantation.
This has caused interest in alternative techniques, such as a
limited thoracotomy, video-assisted thoracoscopy or robotic
approach.
10.1
Anesthesia, Patient Position
The patient is positioned supine on the left edge of the operating table. After routine induction of anesthesia, doublelumen intubation is carried out for single right lung
ventilation. Standard hemodynamic monitoring is used with
a radial arterial line for systemic blood pressure monitoring.
A central venous line or a pulmonary artery catheter can be
used for central access of the cardiac monitoring. External
defibrillator patches are placed on the chest and the patient is
positioned supine with the left chest elevated to 30° with the
aid of a small bolster under the left chest (Fig. 10.1). The
operative side arm with protective padding is hung loosely
and supported by a sheet. da Vinci Surgical System setup is
as previously described.
C. Gao (ed.), Robotic Cardiac Surgery,
DOI 10.1007/978-94-007-7660-9_10, © Springer Science+Business Media Dordrecht 2014
141
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C. Gao et al.
Fig. 10.3 The pericardium is opened posterior to the phrenic nerve
Fig. 10.1 The patient was positioned with the left chest elevated
approximately 30° and with left arm tucked at the left side
Fig. 10.4 The temporary epicardial pacing lead is sutured
Fig. 10.2 Port placement for robotic left ventricular epicardial lead
placement. The ports are placed in line in AAL and the working port in
MAL. The tip of the instrument is allowed for the access to the ventricular surface
10.2
Surgical Technique
After the expose of left chest, the endoscopic camera is
inserted via a 0.8 cm incision in the 5th intercostal space
(ICS) in anterior axillary line (AAL). The left and right
instrument arms are inserted through two 0.8-cm trocar incisions in 3rd and 7th ICS in AAL. A 2-cm incision posterior
to the camera in the 5th ICS in midaxillary line (MAL) of left
side is used as working port for the introduction of the lead
and sutures as necessary (Fig. 10.2). Carbon dioxide is continuously insufflated into the chest cavity via camera cannula
and the CO2 insufflation at a pressure of 8–10 mmHg is used
in the left pleural space to help with exposure. Special consideration has to be given to hemodynamic effects because of
the impaired heart function.
The instruments are controlled by a surgeon who sits at
the operating console away from the operative field. The
Fig. 10.5 The MEDTRONIC screw-in type epicardial pacing lead
pericardium is then opened posterior to the phrenic nerve
(Fig. 10.3), the lateral and posterior left ventricular wall
was exposed. As the patient has complete atrioventricular
block, a temporary epicardial pacing lead is sutured
(Fig. 10.4) and used as standby after it is tested working
normally. A screw-in type epicardial pacing lead (Fig. 10.5)
is introduced to the thoracic cavity through the working
port by the patient-side surgeon (Fig. 10.6) then rotated
into the lateral and posterior left ventricular wall with two
laps (Fig. 10.7).
10
Robotic Left Ventricular Epicardial Lead Implantation
The robotic arms are used to fix the lead to the left
ventricular surface by screw in fixation and the other end of
lead is brought out through the right port (Fig. 10.8). The lead
was tested for threshold, resistance, and lateness within the
native QRS complex. A transverse incision is made at the
pacemaker pocket and the previous dual chamber pacemaker
is isolated and took out (Fig. 10.9), meanwhile the temporary
pacemaker is working instead. The left ventricular epicardial
143
pacing lead, which is then tunneled to the pacemaker generator
pocket, together with the previous right ventricular lead and
the right atrial lead are all connected to the three chambers
pacemaker, and these are embedded in the pocket. After the
pacemaker is confirmed working smoothly, the pocket as well
as the chest incisions are sutured. A thoracic drainage tube
was placed and the patient was transferred to ICU.
10.3
Postoperative Management
Postoperatively patients are monitored at the ICU. Discharge
to an intermediate care unit takes place as soon as hemodynamics and spontaneous respiration have been adequately
stabilized. Chest drains are removed when drainage reaches
less than 50 mL/12 h.
10.4
Fig. 10.6 The screw-in type epicardial pacing lead is delivered by the
patient side surgeon
Summary
Prospective randomized trials have demonstrated improvements in ventricular function, exercise capacity, and quality
of life among patients undergoing ventricular resynchronization therapy via biventricular pacing [2, 3]. Transvenous
insertion of LV leads is currently the route of choice for CRT.
a
b
c
d
Fig. 10.7 The screw-in type epicardial pacing lead is rotated clockwise into the lateral posterior wall of the left ventricle from part (a) to part (d)
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C. Gao et al.
Fig. 10.8 The other end of lead is brought out then tested for threshold
and resistance
Fig. 10.10 The excellent cosmetic results after robotic left ventricular
epicardial lead implantation
Fig. 10.9 A transverse incision is made at the pacemaker pocket and
the previous dual chamber pacemaker is isolated and took out
Unfortunately, its success rate is about 75–93 %, as it is
totally dependent on the inconsistent coronary venous anatomy. And the surgical synchronizing technique, as a complement of percutaneous method for severe heart failure patients,
is still at the stage of development.
Compared with the endovenous approach, surgical synchronization treatment has its advantages such as precise
location, high successful rates of lead implantation, good
surgical results and avoidance of exposure to radiation damage, but the drawbacks of surgery, for instance, surgical
trauma, were inevitable. Besides, surgical approach of CRT
also has limitations in critical heart failure patients. Hence,
how to reduce wound is key to improving surgical synchronization treatment. With the development of minimally invasive surgical technology, some advanced medical centers has
already started the study of minimally invasive approach to
achieve CRT by epicardial lead implantation, and the initial
results were satisfactory [4, 5], especially the robotic
enhanced technology has provided a minimally invasive
approach for CHF treatment (Fig. 10.10).
By the virtues of high definition of 3D visualization, computer elimination of tremor and stable fixation and suturing
of lead, the robotic-assisted technique has provided assurance of accurate surgical positioning, minimum trauma and
improved outcomes [6–10]. The lateral and posterior basal
side of LV was easy to expose during the surgery, and surgical stimulation on these sites has been proved to have better
resynchronization effect than coronary sinus approach [11].
Besides, as the surgical field was locally magnified with high
definition, it is easy to avoid fat, fibrosis and vessel-enriched
area, and different sites can be tested in order to make sure
the epicardial lead was fixed at the most delayed site of LV
and achieve optimized synchronization result [12]. This
effective and convenient way has uncomparable advantages
compared with conventional endovenous approach by
implanting the lead through the branch of veins. Moreover,
limited incisions made by the robotic surgery enable the
patients’ quick recovery and is especially suitable for patients
with poor heart function. The initial experience has shown
the safety, feasibility and effectiveness brought by
robotic-enhanced application in epicardial lead implantation
for CHF treatment. It is proved to be an alternative to patients
failed in endovenous approach. The mid and long term
results need more cases and long-term follow-up to be
confirmed.
10
Robotic Left Ventricular Epicardial Lead Implantation
References
1. Cleland JGF, Daubert JC, Erdmann E, et al. The Cardiac
Resynchronization Heart Failure (CARE-HF) Study Investigators.
N Engl J Med. 2005;352:1539–49.
2. Cazeau S, LeClerq C, Lavergne T, et al. Effects of multisite biventricular pacing in patients with heart failure and intraventricular
conduction delay. N Engl J Med. 2001;344:873–80.
3. Abraham WT, Fischer WG, Smith AL, et al. Cardiac resynchronization
in chronic heart failure. N Engl J Med. 2002;346:1845–53.
4. Derose JJ, Balaram S, Ro C, et al. Midterm follow-up of robotic
biventricular pacing demonstrates excellent lead stability and
improved response rates. Innovations. 2006;1:105–10.
5. Atoui R, Essebag V, Wu V, et al. Biventricular pacing for end stage
heart failure: early experience in surgical vs. transvenous left ventricular lead placement. Interact Cardiovasc Thorac Surg. 2008;7:839–44.
6. Gao C, Yang M, Wang G, et al. Robotically assisted mitral valve
replacement. J Thorac Cardiovasc Surg. 2012;143(4 Suppl):S64–7.
145
7. Gao C, Yang M, Wang G, et al. Totally endoscopic robotic ventricular septal defect repair. Innovations. 2010;5(4):278–80.
8. Gao C, Yang M, Wang G, Wang JL, et al. Excision of atrial myxoma using robotic technology. J Thorac Cardiovasc Surg. 2010;
5(139):1282–5.
9. Gao C, Yang M, Wang G, et al. Totally robotic resection of myxoma and atrial septal defect repair. Interact Cardiovasc Thorac
Surg. 2008;24(3):313–6.
10. Gao C, Yang M, Wu Y, et al. Early and midterm results of totally
endoscopic coronary artery bypass grafting on the beating heart. J
Thorac Cardiovasc Surg. 2011;142(4):843–9.
11. Ansalone G, Giannantoni P, Ricci R, et al. Biventricular pacing in
heart failure: back to basics in the pathophysiology of left bundle
branch block to reduce number of nonresponders. Am J Cardiol.
2003;91:55F–61.
12. Gao C, Ren CL, Xiao CS, et al. The robotic epicardial lead implantation in cardiac resynchronization therapy. Zhonghua Wai Ke Za
Zhi. 2013;51(5):1.
Index
A
AAL. See Anterior axillary line (AAL)
Acute myocardial infarction, 17, 140
Acute pulmonary edema, 17
Adhesions, 12, 16, 113
Adult, 11, 19, 43, 60–73, 75
Airway management, 16
Airway pressure, 18, 19, 21, 24, 25
Alfentanil, 20
Alkalosis, 19
Almitrine, 18
Alveolar overdistention, 19
Analgesia, 20, 23
Anastomosis, 11, 22, 23, 111, 113, 116, 122, 123,
125–128, 130–132, 136
Anesthesia, 15–29, 34, 51, 62–63, 69, 73, 76, 84, 91, 95, 106,
111–112, 120, 132, 141–142
Anesthesiologists, 15–17, 21–26, 28, 29, 51
Anesthetics, 15, 16, 19–23, 25
Anesthetic staff, 22
Anesthetic techniques, 21–22
Angiocatheter, 51, 55–57, 63, 64, 66, 67, 73, 77, 84, 85, 87,
91, 97, 102, 106, 107
Annular dilatation, 34, 100
Annuloplasty band, 11, 92, 98, 100, 101
Annulus, 34, 36, 42, 73, 76–78, 80, 91–93, 95, 98, 99, 106, 110
Antegrade, 11, 27, 28, 39, 57–58, 60, 64, 73, 77, 84, 87, 91,
95, 97, 102, 106
Anterior axillary line (AAL), 112, 120, 142
Antianginal medications, 16
Anticlockwise direction, 107
Antihypertensive, 16
Aortic aneurysm, 17
Aortic cross clamping, 57, 60
Aortic occlusion, 27–29, 64, 67, 69, 73, 77, 91
Arndt blocker, 17
Arrested heart, 11, 63–69, 71, 87, 111, 119, 136, 137
Arterial blood gases, 16, 25, 26
Arterial cannulation, 21, 25, 53
Arteriotomy, 23, 53, 60, 122, 124
Ascending aorta, 11, 27, 28, 37, 39–41, 57, 58, 83, 84
Aspirin, 16, 60, 138
Assisted venous drainage, 25–27, 91
Asthma, 16
Atelectatic lung, 18
Atracurium, 21
Atrial fibrillation, 10, 12, 16, 91
Atrial retractor, 11, 66–68, 73, 76, 77, 80, 87, 89–91,
98, 105, 106
Atrial septal defects (ASD), 2, 11, 12, 27, 28, 33, 43–45,
61–73, 80, 84, 86, 95
closure of, 61, 63–73
Atriotomy, 12, 67, 73, 78, 85, 86, 88, 92, 97, 102, 106, 107
Atrioventricular valve repair/replacement, 73–80
Atrium, 12, 23–25, 34, 35, 37–40, 42–46, 51, 53–57, 64, 66–69,
73, 76–78, 80, 83–86, 88–91, 98, 102, 106–108
Auscultation, 23
Autologous pericardial patch(s), 12, 66–69, 86
Awake intubation, 16
B
Barlow’s disease, 34
Barotraumas, 16
Beating heart, 2, 11, 22–23, 27, 28, 67–71, 73, 86, 88, 90,
111–132, 136, 137
Bed-side assistant, 21
Benign tumors, 83
Beta-blockers, 16
Bispectral (BIS) analysis, 25
Blood drainage, 22, 27
Blood loss, 22
Blood pressure, 18–21, 23, 25, 28, 57, 112, 141
Body mass index, 17
Body position, 21
Brachial plexus injury, 21
Bradycardia, 21, 22
Brain protection, 25
Bronchial blocker, 17, 19, 21
Bronchodilators, 17
Bronchoscopy, 17, 18, 21, 23, 111
Bryce-Smith tube, 17
C
CABG. See Coronary artery bypass graft (CABG)
CAD. See Coronary artery disease (CAD)
Calcified mitral annulus, 95
Camera, 4, 6, 7, 10, 61, 63, 77, 84, 91, 94, 96, 105,
112, 120, 121, 142
port, 10, 91, 112, 120
Cannulation, 12, 21, 24–26, 29, 33, 34, 37, 39–41, 46, 50,
51, 53–60, 62, 63, 73, 76, 83, 86, 91, 95, 96, 105
Capnograph, 17, 25
Carbon dioxide (CO2), 12, 16–25, 27, 28, 63, 67, 69, 77, 91,
97, 106, 112, 120, 127, 131, 132, 136, 142
absorption, 16, 18, 23, 25
insufflation, 16–21, 23, 24, 27, 112, 131, 142
PETCO2, 19, 24, 25
pneumothorax, 16, 17, 19, 21, 23
Cardiac function, 12, 19, 76
Cardiac index (CI), 19, 20, 23
Cardiac output (CO), 16, 19, 25, 131, 134
Cardiac tumors, 10, 83, 84
C. Gao (ed.), Robotic Cardiac Surgery,
DOI 10.1007/978-94-007-7660-9, © Springer Science+Business Media Dordrecht 2014
147
148
Cardioplegia, 11, 25, 27–29, 57–60, 67, 84, 86, 87,
93, 94, 97, 102, 107
Cardiopulmonary bypass (CPB), 12, 16, 17, 21–28, 33, 34, 37–39,
41, 42, 44–46, 49–63, 67, 69–71, 73–75, 77, 84, 87–89, 91,
93, 95, 102, 104–107, 109, 111, 127, 131, 132, 136
Cardiotomy, 66
Cardiovascular function, 19
Cardiovascular surgery, 2, 10, 11, 13
Carlens, 17
Catheter, 17, 23–26, 28, 29, 51, 52, 54–59, 61, 62, 67, 68,
112, 118, 128, 130, 141
CPB (Cardiopulmonary bypass), 49–59
Central venous cannula, 16
Central venous catheter, 23, 25, 62
Chest x-ray, 16
Chitwood clamp, 11, 27, 57, 67, 106
Chitwood cross-clamp, 64, 65, 75, 77, 84, 91, 95, 97, 106, 107
Chordae, 34–36, 101–104
elongation, 34, 35
rupture, 34–36
Chronic obstructive pulmonary disease (COPD),
16, 17, 129, 137
CI. See Cardiac index (CI)
Cisatracurium, 20
Clefts, 76–80, 91, 92, 100, 101, 104
Clopidogrel, 16, 138
Coagulopathy, 17, 137
Collapsed lung, 18, 19, 21, 24
Commissurotomy, 95
Communication, 7, 8, 10, 16, 22, 76, 78, 80
Comorbidity, 16, 17, 131
Complications, 12, 15, 21, 22, 25, 27, 28, 34, 60, 61, 68, 70, 74, 92,
104, 108, 127, 130, 131, 136, 137, 141, 4143–45
Computed tomographic scan, 16, 130
Computer-enhanced instruments, 2
Congenital heart diseases, 12, 43, 61–80
Congestive heart failure, 17
Console surgeon, 57, 69, 108, 122, 132
Continuous positive airway pressure (CPAP), 17, 18, 21, 24
Contraindications, 12, 16, 69, 105, 129, 137
Controller, 4, 6, 84
Conversions, 28, 70, 91, 109, 132
COPD. See Chronic obstructive pulmonary disease (COPD)
Coronary artery bypass graft (CABG), 2, 10, 22–23, 71, 111,
116–129, 131, 135–140
Coronary artery disease (CAD), 97, 127, 135
Coronary revascularization, 2, 10, 11, 126–131, 135–144
Coronary sinus, 12, 25, 28, 29, 43, 78–80, 141, 144
Coronary surgery, 11, 111, 131
Coronary syndromes, 119, 138
Cosmetics, 12, 70, 76, 80, 88, 90, 104, 118, 127, 131, 136, 144
Cox-Maze, 12
CPAP. See Continuous positive airway pressure (CPAP)
CPB. See Cardiopulmonary bypass (CPB)
Cross-clamp time, 11, 69–71, 74, 75, 88, 89, 104, 109
D
da Vinci, 2, 4, 8–11, 15, 75, 77, 88, 91, 94, 98, 100, 102,
105, 109, 115, 122, 127, 131
(Si) surgical system, 2–8, 11, 15–17, 22–25, 29, 64, 70, 74,
77, 84, 88, 89, 94, 102, 105, 108, 132, 141
3D computed tomography angiography (CTA), 50
Defibrillation thresholds, 22
Degrees of freedom, 2, 4, 71, 94, 131
Index
Dependent lung, 18, 19, 24
Depth of anesthesia, 25
Desaturation, 18, 26, 129, 137
Desflurane, 19, 21
De Vaga technique, 66, 67
Dexedetomidine, 20
Diazepam, 20
Difficult airway, 16
Direct-vision approach, 28, 37, 93–94, 109
Double-lumen endotracheal intubation, 34, 51, 62, 120, 141
Double-lumen endotracheal tube, 17, 18, 20, 23, 24, 111
Double-lumen intubation, 111, 120, 141
Double lumen tube, 16, 21, 105
dP/dt, 20
Droperidol, 20
E
Echocardiograms, 104–105
Echocardiographic (ECHO) examination, 16, 44, 49–50, 91, 108
Elecocautery, 4, 22
Electrocardiogram (ECG), 23, 25, 78
Electrocautery, 4, 22
Electrolytes, 16
Emphysematous bullae, 16
Emphysematous chest, 16
Endoaortic balloon, 25, 27, 28, 91
Endoaortic occlusion, 11, 25
Endoscope, 2, 8, 61, 70, 112, 131
Endoscopic ITAs harvest, 115
Endoscopic trocar, 9, 63, 95
Endostabilizer, 122, 132
Endowrist, 5, 11, 97, 123, 132
Etomidate, 20
Event-free survival, 111
Excision, 12, 45, 83–92
External defibrillator pads, 22, 112
External defibrillator patche, 62, 95, 112, 120, 141
Extracorporeal, 27, 65, 87, 102, 107
Extubation, 20–23
F
Fast track, 20–23, 25
anesthesia, 21, 22
Femoral arterial cannula, 25
Femoral artery, 27, 50–54, 60, 67, 95, 96
Femoral-femoral bypass, 21, 25, 84
Femoral vein, 26, 39, 50, 51, 53–55, 60, 86, 95
Femoral venous cannula (FVC), 26, 39, 58
Fentanyl, 19, 20
Fiberoptic bronchoscope, 17, 18, 21
Fibroelastic deficiency, 34
FiO2, 19, 24
Fogarty catheter, 17
Fossa ovalis, 45, 88
Functional residual capacity (FRC), 18
FVC. See Femoral venous cannula (FVC)
G
Gas exchange, 16, 24
General anesthesia, 18, 25, 51, 76, 91
Gore-Tex running suture, 66, 67
Guidance of cannula, 21
Index
H
Half-life, 20, 137
Halothane, 19
Harvesting time, 115–117, 126
Heart rate (HR), 16, 20, 23
Hemodilution, 24, 25
Hemodynamic(s), 12, 16, 19–21, 23, 34, 36–37, 41, 69, 87,
102, 120, 129, 131, 132, 136–138, 141–143
compromise, 16, 19, 132, 137
stability, 22
Heparization, 26
High airway pressures, 19
High frequency jet ventilation, 18
High-frequency positive pressure ventilation, 19
Hospital stay, 2, 22, 29, 61, 68, 74, 90, 104, 119
HPV. See Hypoxic pulmonary vasoconstriction (HPV)
HR. See Heart rate (HR)
Hybrid coronary revascularization, 11, 127–129, 135–140
Hybrid procedure, 16, 129
Hybrid revascularization, 128, 130, 137
Hypercapnia, 16, 18, 19, 23
Hypertension, 17, 69, 129, 137
Hypnotics, 19, 20
Hypoglycemic medications, 16
Hypotension, 23
Hypothermia, 19, 21, 24
Hypothermic CPB, 24, 28, 67, 94
Hypoxemia, 112
Hypoxia, 19, 132
Hypoxic pulmonary vasoconstriction (HPV), 18, 19, 24
I
ICS. See Intercostal space (ICS)
ICU. See Intensive care unit (ICU)
Incisions, 1–3, 7, 9, 11, 15, 22, 27, 33, 43, 45, 51, 52, 55, 58,
60–63, 70, 73–77, 80, 84, 88–91, 93–96, 105, 107, 108, 111,
112, 116, 118–120, 123, 125, 129, 131, 132, 136, 142–144
Induced tension pneumothorax, 16
Induction, 16, 20–21, 23, 25, 34, 61, 111, 120, 141
Inferior vena cava (IVC), 21, 25, 37, 39, 63, 65, 66, 73, 89
Inflammatory response, 17, 22, 136
Inhalation agents, 19
Instruments, 1, 2, 4–13, 22, 25, 61, 63, 71, 77, 88, 91, 94,
95, 98, 101, 103, 105, 110, 112, 113, 120, 121, 132, 142
Insulin, 16
Intensive care unit (ICU), 20–22, 69, 70, 87, 102, 127, 143
Intercostal space (ICS), 9, 39, 57, 58, 63, 95, 97, 116,
120, 131, 142
Internal jugular vein, 23, 34, 39, 49, 51, 55, 56, 58, 60, 62, 63, 95
Internal thoracic artery (ITA), 111, 128
Interventional cardiologists, 61, 129, 137, 140
Intra-aortic balloon occlusion device, 25
Intracardiac mass, 45
Intracoronary shunts, 22, 23
Intrapleural CO2 insufflation, 18, 19, 23
Intrapleural pressure, 16, 19
Intrapulmonary shunt, 18, 19, 24
Intrathoracic CO2 pressure, 19
Intrathoracic pressure, 12, 19, 23
Intravenous anesthesia, 19
Intubation, 16, 20, 23, 34, 51, 62, 76, 91, 111, 120, 141
Intuitive surgical system, 11
Ischemia, 21, 23, 24, 68, 130, 132, 136, 138
Ischemic preconditioning, 22, 132
149
Isoflurane, 19, 21
ITA. See Internal thoracic artery (ITA)
IVC. See Inferior vena cava (IVC)
K
Ketamine, 20
Kinetic-assisted venous drainage (KAVD), 27
L
LAD. See Left anterior descending artery (LAD)
Laparoscopic surgery, 2, 3
Laryngoscopy, 20
Lateral decubitus position, 18, 19, 21
Leaflet billowing, 34, 35
Leaflet prolapse, 23, 34, 35, 98
Learning curves, 2, 60, 69–71, 74–76, 88, 89, 102–105, 108–110,
115–118, 126–127, 131, 132, 136
Left anterior descending (LAD) artery, 11, 23, 116–120, 122–124,
127–132, 135–139
Left atrial roof, 88
Left atrial tumor, 85, 89
Left internal mammary artery (LIMA), 11, 22, 132,
136, 137, 139, 140
Left ventricular ejection fraction (LVEF), 17
Left ventricular epicardial lead placement, 142
Left ventricular stroke work index (LVSWI), 20
Less-invasive, 12
Lidocaine, 19, 123
LIMA. See Left internal mammary artery (LIMA)
Lorazepam, 20
Lung capacity, 18
Lung injury, 18, 19
LVEF. See Left ventricular ejection fraction (LVEF)
LVSWI. See Left ventricular stroke work index (LVSWI)
M
Magnesium, 16
Maintenance of anesthesia, 16, 20–21
MAL. See Midaxillary line (MAL)
MCL. See Midclavicular line (MCL)
Mean arterial pressure (MBP), 19
Mechanical ventilation, 18, 20, 69, 75, 88
Median sternotomy, 10–12, 23, 28, 33, 37, 61, 70, 75, 83,
90, 93, 94, 135, 136
Microemboli, 27, 68
Microincision, 11, 94
Midaxillary line (MAL), 64, 73, 77, 84, 91, 95, 106, 142
Midazolam, 20, 21
MIDCAB. See Minimally invasive direct coronary artery bypass
(MIDCAB) Midclavicular line (MCL), 9, 63, 95, 105, 112, 122
Mini-incision, 93–94
Mini-incision mitral valve surgery (MIMVS), 93
Minimally invasive cardiac surgery, 27, 28, 33, 93, 108, 137
Minimally invasive coronary artery bypass grafting,
22, 128, 135, 136
Minimally invasive direct coronary artery bypass (MIDCAB),
11, 16, 22, 115–118, 120, 131, 132
Minimally invasive surgery, 1, 2, 13, 15, 22
Minithoracotomy, 11, 22, 93, 94, 126, 131, 132, 136
Minute ventilation, 19
Mitral insufficiency, 23, 95Mitral prolapse, 36, 44
Mitral regurgitation, 94, 104
150
Mitral stenosis (MS), 23, 34, 41, 109
Mitral valve, 2, 10, 23, 24, 35, 38, 41–44, 76–80, 88, 92–94,
97, 98, 100, 101, 104–106, 108
plasty, 91–92
repair, 2, 11, 16, 21, 23, 29, 61, 71, 80, 88, 89, 92, 94–96,
98, 102, 105, 108, 131
surgery, 11, 12, 17, 23–25, 33–43, 93–110
Monitoring, 16, 23, 25, 69, 112, 141
Mortality, 12, 21, 61, 70, 93, 110, 131, 136, 141
Multivessel CAD, 127
Muscle relaxants, 20, 21
Myocardial irritability, 16
Myocardial ischemia, 21, 23
Myocardial preservation, 33
Myocardial protection, 27, 33, 60
Myocardial stabilizer, 22
Myxoma, 2, 12, 16, 45, 46, 83–92
N
Near-infrared spectral analysis, 25
Neochord insertion, 104
Neoplasms, 83
Neuromuscular blocker/blockade, 18, 21
Nifedipine, 19
Nitric oxide, 18
Nitroglycerin, 23
Nitroprusside, 19
Nondependent lung, 18, 19
Norepinephrine, 23
NYHA class, 17, 76
O
Off-pump CABG, 136, 138
One-lung ventilation (OLV), 16–25, 105
On pump, 11, 28, 69, 136, 139
Operation time, 69, 70, 74, 75, 88, 89, 104, 109, 110, 126
Opioids, 20, 21
Ostium primum defect, 12, 76–80
Oxygenation, 18, 19, 23, 24, 136
P
PA catheters. See pulmonary artery (PA) catheters
Pancuronium, 20, 21
PAP. See Pulmonary arterial pressures (PAP)
Paravalvular regurgitation, 42–44
Partial anomalous pulmonary venous connection, 11
Partial atrioventricular septal defect, 76–80
Partial sternotomy, 84, 93
Patency, 17, 23, 111, 118, 127, 130–132, 136–138, 140
Patent ductus arteriosus, 11
Patient
cart, 4, 6–10
position, 9, 22, 62–63, 73, 84, 95, 105, 111–112, 119, 141–142
selection, 16–17, 45, 95, 126, 129–131, 137
Patient-side surgeon, 9, 63, 66, 73, 95, 101, 105, 107, 108, 112, 142,
143
PCI. See Percutaneous coronary intervention (PCI)
PCWP, 25
Peak airway pressure, 21
Peak inspiratory pressure, 18
Index
PEEP. See Positive end expiratory pressure (PEEP)
Percutaneous catheter techniques, 61
Percutaneous coronary intervention (PCI), 11, 127,
129, 130, 135–140
Perfusionist, 22, 28, 57
Pericardiotomy, 63, 73, 121–123
Pericardium stay suture, 63, 64, 73, 95
Peripheral cardiopulmonary bypass, 16, 21, 25–27, 49–61
Peripheral vessels, 37, 50
Permissive hypercapnia, 19
Phenylephrine, 23
Phrenic nerve, 63, 64, 73, 84, 95, 116, 141, 142
Physiotherapy, 17
Pipecuronium, 20, 21
Platelet-inhibition, 137, 138, 140
Pleural cavity, 19, 114, 116
Pneumothorax, 12, 16–19, 21–23, 25, 136
Polytetrafluoroethylen, 11, 73, 86, 92, 107
Port-access, 61, 84, 93
Positive end expiratory pressure (PEEP), 18, 24, 31
Postoperative analgesic, 22, 23
Postoperative course, 22, 78, 92, 111
Postoperative management, 69, 87–88, 102, 143
Postoperative period, 22
Potassium, 16
Pregnancy, 19
Preload, 19, 23, 41
Preoperative evaluation, 16, 49
Pre-operative preparation, 49–50
Preoperative visit, 16
Primary cardiac tumors, 83
Propofol, 19–22
Protamine, 24, 58, 123, 137–139
Pulmonary artery occluded pressure (PAOP), 20
Pulmonary arterial pressures (PAP), 19–21, 23, 25
Pulmonary artery (PA) catheter, 23, 25, 112, 141
Pulmonary compliance, 18, 136
Pulmonary function, 16, 17, 130
Pulmonary vascular resistance (PVR), 16, 19, 20, 73
Pulmonary veins, 27, 36, 44, 64, 65, 73, 85, 88, 90, 97, 98
Pulse oximetry, 25
PUMA, 2
PVR. See Pulmonary vascular resistance (PVR)
Q
Quadrangular resection, 11, 98, 104
R
Radial arterial cannula, 25
RAP. See Right atrial pressure (RAP)
Real-time 3D transesophageal echocardiography, 34
Recurrence, 12, 75, 87, 88, 90, 118
Regurgitation, 36, 41–44, 58, 66, 69, 73, 76, 77, 88, 91, 94, 98, 103,
104, 109
Reinflate lung, 18
Reintubation, 21
Remifentanil, 20
Remote access perfusion, 28, 69, 90
Respiratory rate, 19, 24
Retrograde cardioplegia cannula position, 25
Revascularization, 2, 10, 11, 22, 23, 111, 118, 126–131, 135–144
Index
Right atrial pressure (RAP), 20
Right atrium, 24, 34, 35, 37–40, 45, 46, 51, 53–55, 66–68, 73,
76–78, 80, 83, 86, 88
Right groin incision, 51, 62, 76, 91
Right internal jugular vein (RIJV), 23, 25–28, 34, 39, 49, 55,
56, 58, 60, 62, 63, 95
Right internal thoracic artery (RITA), 113–119, 123, 125
Right-to-left transpulmonary shunt, 18
RIJV. See Right internal jugular vein (RIJV)
RITA. See Right internal thoracic artery (RITA)
Robertshaw, 17
Robot, 2, 11–13, 21, 22, 75, 84, 88, 94, 105
Robotic assisted CABG, 22–23
Robotic assisted endoscopic minimal invasive
coronary artery bypass (MIDCAB), 11, 16, 22,
115–118, 120, 131, 132
Robotic coronary bypass graft, 10, 111–132, 137, 140
Robotic instruments, 6, 11, 22, 25, 73, 94,
95, 101, 105
Robotic mitral valve placement, 105–110
Robotic mitral valve plasty, 104, 105
Robotic mitral valve repair, 11, 23, 29, 94–96, 105
Robotic surgical system, 3, 61, 71, 80
Robotic technique, 3, 11, 13, 17, 29, 110, 131
Rocuronium, 20, 21
Running sutures, 60, 66–68, 73, 78, 80, 86, 87, 92, 98, 99,
101, 102, 107, 132
S
SaddleLoop, 122–125
Same-session revascularization, 139–140
Seldinger, 25, 26, 53–56, 62, 76, 91
Sevoflurane, 19, 21, 29
Shunt, 18, 19, 22–24, 44, 45, 74, 75
Single-lumen endotracheal tube, 17, 18, 20, 23, 24, 111
Single lumen tube, 17, 21
Single lung ventilation, 15, 29, 62, 69, 76, 91, 95, 104, 111,
112, 119, 129, 132, 136, 137
Smoking, 17
Standard procedures, 49
Stereo viewer, 4, 5
Sternotomy, 4, 5
Steroids, 17
Stroke volume (SV), 19, 20
ST-segment monitoring, 25
Subendocardial defects, 86
Submammary, 84
Subvalvular apparatus, 36, 95, 101, 108, 109
Succinylcholine, 20
Sufentanil, 20, 23
Superior pulmonary vein, 65, 97
Superior vena cava (SVC), 21, 24–26, 37, 39, 40, 44–46, 50,
53, 55, 56, 60, 63–65, 67, 68, 73, 89, 97, 98, 106
Surgical console, 4
Surgical team, 16, 21, 22, 127
Suturing, 12, 13, 60, 86, 105, 127, 131, 132, 144
SVC. See Superior vena cava (SVC)
SVR. See Systemic vascular resistance (SVR)
Systemic embolism, 89
Systemic heparinization, 26, 53, 62, 116, 122, 123
Systemic vascular resistance (SVR), 20, 21
Systolic anterior motion, 41
151
T
Tachycardia, 19, 21, 23, 91
TECAB. See Totally endoscopic coronary artery
bypass (TECAB)
TEE. See Transesophageal echocardiography (TEE)
Therapeutic, 34, 83, 93
Thoracic epidural anesthesia, 19
Thoracoscopic surgery, 3, 12
Thoracoscopy, 3, 12, 19, 21, 69, 104, 116, 131, 136, 137, 141
Thoracotomy, 11, 12, 22, 61, 70, 76, 94, 95, 116, 136, 137, 141
incision, 22, 116
Three-dimensional visualization, 4, 61, 94, 115
Tidal volume, 18, 19, 24
Totally endoscopic coronary artery bypass (TECAB),
2, 11, 15–17, 22, 115, 116, 118–129, 131, 132, 135–137, 139
Totally endoscopic procedures, 61, 128
Totally robotic cardiovascular surgical procedures, 11
Totally robotic coronary bypass on beating heart
(BH-TECAB), 115
Transesophageal echocardiography (TEE), 16, 18, 21, 23–29,
33–46, 51, 53, 55–59, 62, 63, 69, 70, 74, 76, 77, 87, 91,
95, 102, 103, 105–107
Transthoracic aortic clamp, 27, 94
Transthoracic chitwood clamp, 11
Transthoracic echocardiography, 69, 88, 102
Transthoracic electrical impedance (TTI), 22
Transvenous, 12, 141, 143
Trapezoidal resection, 98
Trauma, 15, 27, 61, 70, 80, 91, 111, 131, 141, 144
Tricuspid valve, 11, 16, 66–69, 73, 74, 76, 79, 86
Tricuspid valve plasty, 66, 67, 69
Trigone, 98, 99
Trocar, 9, 18, 63, 88, 95, 105, 142
TTI. See Transthoracic electrical impedance (TTI)
Tumors, 10, 12, 45, 46, 83–91
Two-lung ventilation, 18, 22, 24
Tying knots, 66, 73, 87, 102
U
U-clip, 11, 22, 98–101, 122–124, 132
Univent tube, 17, 21
Urine output, 25
V
Vacuum-assisted venous drainage (VAVD), 27
Vascular injuries, 25
Vasodilator, 19, 21
VAVD. See Vacuum-assisted venous drainage (VAVD)
Vecuronium, 20, 21
Venous cannulae, 21, 25, 27
Venous cannula position, 25, 27, 53
Venous drainage cannula, 26, 62
Ventilated lung, 18, 19, 24
Ventilation, 16–20, 23–25, 27, 69, 70, 75, 76, 88, 91, 111, 119,
120, 129, 132, 136, 137, 141
Ventilation-perfusion distribution, 16
Ventilation-perfusion relationship, 18
Ventilation to perfusion ratio (V/Q), 18
Ventilatory defects, 19
Ventricular fibrillation (VF), 22, 23, 28, 44, 84,
94, 141, 143
152
Ventricular septal defects, 2, 12, 73–78, 80
repair, 2, 12, 73–78, 80
Video-assisted procedure, 93, 94, 141
Video-directed instruments, 94
Vision cart, 4–7, 9
Visualization, 1, 4, 12, 23, 27, 33, 37, 44, 61, 68, 73, 76, 80,
94, 95, 110–112, 136, 144
V/Q mismatch, 18
Index
W
Working port, 9, 57, 63, 66, 68, 77, 87, 88, 91, 95, 96, 102, 105, 107,
108, 142
Z
ZEUS surgical system, 3