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Minimally invasive cardiac surgery
78
Heart, Lung and Circulation 2009;18:65–88
Abstracts of the ASCTS Annual Scientific Meeting 2007
ABSTRACTS
TAG PRIZE ENTRANTS 26 Long-term quality of life in octogenarians after cardiac surgery Scott Graham, Hugh Cullen, John L. Knight, Robert A. Baker Cardiac and Thoracic Surgery, Flinders Medical Centre and Flinders University, Adelaide, Australia Introduction: Coronary and valvular heart disease are common conditions with substantial morbidity and mortality. The number of elderly people in the Australian population is rapidly increasing, with 25–40% of octogenarians suffering from symptomatic cardiovascular disease [1]. As such, cardiac surgeons are asked to consider those of advanced age for surgery at an increasing frequency. The survival outcomes of surgery in octogenarians have been shown to be good [2]. Information on the long-term quality of life of octogenarian patients is lacking. The aim of this study was to obtain data on the quality of life in octogenarian patients who had cardiac surgery. Methods: The surgical cohort included patients who were 80–89 years of age at operation, having cardiac surgery between 1992 and 2003 at Flinders Medical Centre, Flinders Private Hospital and Ashford Community Hospital. We identified 632 patients of whom 321 were alive at the beginning of this study. Survival status was determined using National Death Index data from the Australian Institute of Health Welfare. From this group, 161 interviews (50.1% of survivors) were successfully performed. Followup information was obtained from medical records and a structured telephone questionnaire. Results: Operative mortality was 6.5% for all-comers. Survival rate for hospital survivors at 5-years after surgery was 66.6%. The mean time to interview was 5.5 years. Respondents were asked to rate their current overall health; 47.2% rated their current health as “very good” or better, with 48.1% believing that their health was “better now” in comparison to their health at the time of their surgery; 76.4% had experienced some chest pain, whilst 45.0% had experienced some breathlessness since their operation. Questions targeted at physical ability identified 53.4% of patients who could walk a distance of half a mile unaided. With respect to resource utilisation, 26.8% were entirely independent with activities of daily living. When assistance was required, the main areas of need were mobilisation away from home (26.0%) and taking a bath or shower (17.7%). Importantly, 96.2% of patients believed that their cardiac surgery had been worthwhile (75.9% strongly agreed). Discussion: Our study supports the performance of cardiac surgery in octogenarians. Favorable findings were demonstrated with respect to resource utilisation, despite the advanced age of participants and their disease burden. Favourable quality of life was obtained by the majority of patients. This study shows a satisfactory long-term outcome and quality of life in patients who have cardiac surgery during their ninth decade of life. Further research
establishing predictors of good quality of life outcomes in this age group are required.
Reference [1] Akins CW, Daggett WM, Vlahakes GJ, et al. Ann Thorac Surg 1997;64:606–14. [2] Hewitt TD, Santa Maria PL, Alvarez JM. ANZ J Surg 2003;73:749–54.
doi:10.1016/j.hlc.2008.11.036 27 Minimally invasive cardiac surgery K.S. Rathore, M. Worthington, R. Stuklis, J. Edwards Department of Cardiothoracic Surgery, Royal Adelaide Hospital, Adelaide, SA, United States Introduction: Minimally Invasive Cardiac Surgery (MICS) is an exciting new technology introduced about a decade ago but because of perceived difficulty has not been adopted widely. At the Royal Adelaide and Wakefield Hospitals in Adelaide we are in the third year of our MICS program. Initially the da Vinci Robotic system was employed but, as in other institutions, was abandoned in favour of direct access surgery using long shafted instruments. Particular stimulus was provided by our visits to Prof. Mohr’s group in Leipzig, Germany. As with all new technology and surgical techniques we have conducted a rigorous and ongoing audit. In this paper we present our results. Material and methods: Included are all the patients who had minimally invasive surgery from September 2006 onwards without the da Vinci system. Operations included are isolated mitral valve disease, intracavitory tumours; redo surgery and tricuspid valve disease. Demographic data, preoperative echocardiography, catheterisation data, operative findings and post-operative follow up data was all collected prospectively. Results: There were 65 patients, the majority were male (40), with a mean age of 60.58 ± 2.45 years and weight of 80.12 ± 4.32 kg. The majority of patients had degenerative disease with 58 having regurgitant pathology. Sixty patients had mitral valve surgery (52 were repaired, 8 were replaced). Left atrial myxoma excision were performed in 4 cases and tricuspid valve replacement in 1 patient. Associated procedures were cryoablation (8), ventricular septal defect closure (1), patent foramen ovale closure (1). Five cases had previous median sternotomy. These 5 patients were done without aortic cross clamp and beating heart. Two in hospital mortalities occurred with 1 stroke and 1 permanent pacemaker insertion. Ventilation time was 8.2 ± 1.52 h, ICU stay was 1.85 ± 1.12 days. Six patients had post-operative atrial fibrillation. They all had low pain score and can be mobilised very early. There were no wound infections. Blood transfusion was rare. Pre discharge echocardiography showed 1 with moderate MR and 5 with mild MR. No patient required redo valve repair.
Discussion: Although we are in very early stages of our program, minimally invasive cardiac surgery is producing encouraging results. With time we believe it will become the standard of care in particular for mitral valve surgery. doi:10.1016/j.hlc.2008.11.037 28 Towards development of a novel bio-engineered vascular bypass conduit Michael J. Byrom, Steven Wise, Martin K.C. Ng, Paul G. Bannon, Anthony Weiss The Baird Institute, Sydney, Australia Introduction: Vascular bypass grafting for ischaemic heart disease (IHD) and peripheral vascular disease (PVD) requires a conduit resistant to stenosis and occlusion by thrombosis and neo-intimal hyperplasia. Autologous grafts namely saphenous vein for PVD as well as internal mammary and radial arteries for IHD remain the most widely used conduits for surgical revascularisation but suffer from limited availability, variable quality and size, and complications of surgical harvest [1]. Synthetic materials are frequently used for treatment of PVD but remain limited to high flow/low resistance conditions because of poor elasticity, low compliance, and thrombogenicity of synthetic surfaces [2]. We have developed a method for the construction of novel bio-engineered vascular bypass conduits using human elastin, and present the results of studies to assess their physical characteristics and biocompatibility. Methods: Recombinant human tropoelastin was used to create elastin and elastin-copolymer conduit material which was then subjected to in vitro tests of physical performance and bio-compatibility. This included the construction of a pulsatile flow circuit to simulate perfusion conditions in the human peripheral arterial circulation, utilising a Harvard pulsatile blood pump with variable rate and stroke volume together with a compliance chamber and variable outflow resistance. Vascular bypass conduits were then created (6 mm internal diameter) to be assessed in the circuit. Results: The synthetic conduit material was highly compliant and achieved tensile strength approaching human aorta. Bio-compatibility tests demonstrated enhanced endothelialisation and low thrombogenicity. The flow circuit was able to achieve a range of physiological arterial flow and pressures, allowing the performance of the vascular bypass conduits to be assessed under these conditions. Discussion: We are able to use recombinant human tropoelastin to develop novel vascular bypass conduit material. Early results demonstrate encouraging physical performance and bio-compatibility. Further modification aims to produce conduits for in vivo assessment in an animal model.
Abstracts of the ASCTS Annual Scientific Meeting 2007
79
Reference [1] Ishii Y, Kronengold RT, Virmani R, Rivera EA, Goldman SM, Prechtel EJ, et al. Novel bioengineered small calibre vascular graft with excellent one-month patency. Ann Thorac Surg 2007;83:517–25. [2] Hoenig MR, Campbell GR, Rolfe BE, Campbell JH. Tissueengineered blood vessels: alternative to autologous grafts? Arterioscler Thromb Vasc Biol 2005;25:1128–34.
doi:10.1016/j.hlc.2008.11.038 29 Epicardial high intensity focused ultrasound cardiac ablation for treatment of atrial fibrillation Sergei Mitnovetski, Aubrey Adrian Pick
Almeida, Julian
Smith,
Department of Cardiothoracic Surgery, Monash Medical Centre, Melbourne, Australia Introduction: The increased risk of complications and death associated with atrial fibrillation (AF) is well established. The available alternatives to an effective but complex Cox maze procedure for treatment of AF include radiofrequency, microwave, laser, cryotherapy and ultrasound ablation. The purpose of this study was to evaluate the efficacy and safety profile of the High Intensity Focused Ultrasound (HIFU) cardiac ablation for management of AF. Methods: Twelve patients underwent epicardial HIFU treatment for AF using Epicor cardiac ablation system (St. Jude Medical) between August 2006 and August 2007 at the Monash Medical Centre. The procedure was performed on the beating heart before the concomitant cardiac procedures. After dissection, 3-phase energy was delivered around the pulmonary veins for 10 min. Additional lesions were created if deemed necessary. Clinical assessment and serial electrocardiography (ECG) were used to determine the postoperative heart rhythm. Results: There were 10 men and 2 women in this group of patients with the mean age of 70 (range from 50 to 84). Duration of AF before surgery ranged from 3 months to 14 years with 10 out of 12 patients having permanent AF and 2 paroxysmal AF. Five patients had concomitant CABG surgery, 3 had AVR, 2 MV repair and 2 patients had combined valve and CABG surgery. There were no deaths directly related to the procedure. One patient with myelodysplastic syndrome died of septic complications. One patient was cardioverted on day 10 after surgery. At one week after surgery 7 out of 12 patients were in sinus rhythm (58%) and at 3 month follow up 8 out of 10 patients were in SR (80%). Discussion: Epicardial HIFU ablation is a viable alternative to Cox maze procedure for management of AF. The procedure does not require cardiopulmonary bypass and in those undergoing concomitant surgery does not increase cross-clamp or CPB times. Although the results of this study using Epicor cardiac ablation for AF are satisfactory, according to the other studies further increase in
ABSTRACTS
Heart, Lung and Circulation 2009;18:65–88
Heart, Lung and Circulation 2009;18:65–88
Abstracts of the ASCTS Annual Scientific Meeting 2007
ABSTRACTS
TAG PRIZE ENTRANTS 26 Long-term quality of life in octogenarians after cardiac surgery Scott Graham, Hugh Cullen, John L. Knight, Robert A. Baker Cardiac and Thoracic Surgery, Flinders Medical Centre and Flinders University, Adelaide, Australia Introduction: Coronary and valvular heart disease are common conditions with substantial morbidity and mortality. The number of elderly people in the Australian population is rapidly increasing, with 25–40% of octogenarians suffering from symptomatic cardiovascular disease [1]. As such, cardiac surgeons are asked to consider those of advanced age for surgery at an increasing frequency. The survival outcomes of surgery in octogenarians have been shown to be good [2]. Information on the long-term quality of life of octogenarian patients is lacking. The aim of this study was to obtain data on the quality of life in octogenarian patients who had cardiac surgery. Methods: The surgical cohort included patients who were 80–89 years of age at operation, having cardiac surgery between 1992 and 2003 at Flinders Medical Centre, Flinders Private Hospital and Ashford Community Hospital. We identified 632 patients of whom 321 were alive at the beginning of this study. Survival status was determined using National Death Index data from the Australian Institute of Health Welfare. From this group, 161 interviews (50.1% of survivors) were successfully performed. Followup information was obtained from medical records and a structured telephone questionnaire. Results: Operative mortality was 6.5% for all-comers. Survival rate for hospital survivors at 5-years after surgery was 66.6%. The mean time to interview was 5.5 years. Respondents were asked to rate their current overall health; 47.2% rated their current health as “very good” or better, with 48.1% believing that their health was “better now” in comparison to their health at the time of their surgery; 76.4% had experienced some chest pain, whilst 45.0% had experienced some breathlessness since their operation. Questions targeted at physical ability identified 53.4% of patients who could walk a distance of half a mile unaided. With respect to resource utilisation, 26.8% were entirely independent with activities of daily living. When assistance was required, the main areas of need were mobilisation away from home (26.0%) and taking a bath or shower (17.7%). Importantly, 96.2% of patients believed that their cardiac surgery had been worthwhile (75.9% strongly agreed). Discussion: Our study supports the performance of cardiac surgery in octogenarians. Favorable findings were demonstrated with respect to resource utilisation, despite the advanced age of participants and their disease burden. Favourable quality of life was obtained by the majority of patients. This study shows a satisfactory long-term outcome and quality of life in patients who have cardiac surgery during their ninth decade of life. Further research
establishing predictors of good quality of life outcomes in this age group are required.
Reference [1] Akins CW, Daggett WM, Vlahakes GJ, et al. Ann Thorac Surg 1997;64:606–14. [2] Hewitt TD, Santa Maria PL, Alvarez JM. ANZ J Surg 2003;73:749–54.
doi:10.1016/j.hlc.2008.11.036 27 Minimally invasive cardiac surgery K.S. Rathore, M. Worthington, R. Stuklis, J. Edwards Department of Cardiothoracic Surgery, Royal Adelaide Hospital, Adelaide, SA, United States Introduction: Minimally Invasive Cardiac Surgery (MICS) is an exciting new technology introduced about a decade ago but because of perceived difficulty has not been adopted widely. At the Royal Adelaide and Wakefield Hospitals in Adelaide we are in the third year of our MICS program. Initially the da Vinci Robotic system was employed but, as in other institutions, was abandoned in favour of direct access surgery using long shafted instruments. Particular stimulus was provided by our visits to Prof. Mohr’s group in Leipzig, Germany. As with all new technology and surgical techniques we have conducted a rigorous and ongoing audit. In this paper we present our results. Material and methods: Included are all the patients who had minimally invasive surgery from September 2006 onwards without the da Vinci system. Operations included are isolated mitral valve disease, intracavitory tumours; redo surgery and tricuspid valve disease. Demographic data, preoperative echocardiography, catheterisation data, operative findings and post-operative follow up data was all collected prospectively. Results: There were 65 patients, the majority were male (40), with a mean age of 60.58 ± 2.45 years and weight of 80.12 ± 4.32 kg. The majority of patients had degenerative disease with 58 having regurgitant pathology. Sixty patients had mitral valve surgery (52 were repaired, 8 were replaced). Left atrial myxoma excision were performed in 4 cases and tricuspid valve replacement in 1 patient. Associated procedures were cryoablation (8), ventricular septal defect closure (1), patent foramen ovale closure (1). Five cases had previous median sternotomy. These 5 patients were done without aortic cross clamp and beating heart. Two in hospital mortalities occurred with 1 stroke and 1 permanent pacemaker insertion. Ventilation time was 8.2 ± 1.52 h, ICU stay was 1.85 ± 1.12 days. Six patients had post-operative atrial fibrillation. They all had low pain score and can be mobilised very early. There were no wound infections. Blood transfusion was rare. Pre discharge echocardiography showed 1 with moderate MR and 5 with mild MR. No patient required redo valve repair.
Discussion: Although we are in very early stages of our program, minimally invasive cardiac surgery is producing encouraging results. With time we believe it will become the standard of care in particular for mitral valve surgery. doi:10.1016/j.hlc.2008.11.037 28 Towards development of a novel bio-engineered vascular bypass conduit Michael J. Byrom, Steven Wise, Martin K.C. Ng, Paul G. Bannon, Anthony Weiss The Baird Institute, Sydney, Australia Introduction: Vascular bypass grafting for ischaemic heart disease (IHD) and peripheral vascular disease (PVD) requires a conduit resistant to stenosis and occlusion by thrombosis and neo-intimal hyperplasia. Autologous grafts namely saphenous vein for PVD as well as internal mammary and radial arteries for IHD remain the most widely used conduits for surgical revascularisation but suffer from limited availability, variable quality and size, and complications of surgical harvest [1]. Synthetic materials are frequently used for treatment of PVD but remain limited to high flow/low resistance conditions because of poor elasticity, low compliance, and thrombogenicity of synthetic surfaces [2]. We have developed a method for the construction of novel bio-engineered vascular bypass conduits using human elastin, and present the results of studies to assess their physical characteristics and biocompatibility. Methods: Recombinant human tropoelastin was used to create elastin and elastin-copolymer conduit material which was then subjected to in vitro tests of physical performance and bio-compatibility. This included the construction of a pulsatile flow circuit to simulate perfusion conditions in the human peripheral arterial circulation, utilising a Harvard pulsatile blood pump with variable rate and stroke volume together with a compliance chamber and variable outflow resistance. Vascular bypass conduits were then created (6 mm internal diameter) to be assessed in the circuit. Results: The synthetic conduit material was highly compliant and achieved tensile strength approaching human aorta. Bio-compatibility tests demonstrated enhanced endothelialisation and low thrombogenicity. The flow circuit was able to achieve a range of physiological arterial flow and pressures, allowing the performance of the vascular bypass conduits to be assessed under these conditions. Discussion: We are able to use recombinant human tropoelastin to develop novel vascular bypass conduit material. Early results demonstrate encouraging physical performance and bio-compatibility. Further modification aims to produce conduits for in vivo assessment in an animal model.
Abstracts of the ASCTS Annual Scientific Meeting 2007
79
Reference [1] Ishii Y, Kronengold RT, Virmani R, Rivera EA, Goldman SM, Prechtel EJ, et al. Novel bioengineered small calibre vascular graft with excellent one-month patency. Ann Thorac Surg 2007;83:517–25. [2] Hoenig MR, Campbell GR, Rolfe BE, Campbell JH. Tissueengineered blood vessels: alternative to autologous grafts? Arterioscler Thromb Vasc Biol 2005;25:1128–34.
doi:10.1016/j.hlc.2008.11.038 29 Epicardial high intensity focused ultrasound cardiac ablation for treatment of atrial fibrillation Sergei Mitnovetski, Aubrey Adrian Pick
Almeida, Julian
Smith,
Department of Cardiothoracic Surgery, Monash Medical Centre, Melbourne, Australia Introduction: The increased risk of complications and death associated with atrial fibrillation (AF) is well established. The available alternatives to an effective but complex Cox maze procedure for treatment of AF include radiofrequency, microwave, laser, cryotherapy and ultrasound ablation. The purpose of this study was to evaluate the efficacy and safety profile of the High Intensity Focused Ultrasound (HIFU) cardiac ablation for management of AF. Methods: Twelve patients underwent epicardial HIFU treatment for AF using Epicor cardiac ablation system (St. Jude Medical) between August 2006 and August 2007 at the Monash Medical Centre. The procedure was performed on the beating heart before the concomitant cardiac procedures. After dissection, 3-phase energy was delivered around the pulmonary veins for 10 min. Additional lesions were created if deemed necessary. Clinical assessment and serial electrocardiography (ECG) were used to determine the postoperative heart rhythm. Results: There were 10 men and 2 women in this group of patients with the mean age of 70 (range from 50 to 84). Duration of AF before surgery ranged from 3 months to 14 years with 10 out of 12 patients having permanent AF and 2 paroxysmal AF. Five patients had concomitant CABG surgery, 3 had AVR, 2 MV repair and 2 patients had combined valve and CABG surgery. There were no deaths directly related to the procedure. One patient with myelodysplastic syndrome died of septic complications. One patient was cardioverted on day 10 after surgery. At one week after surgery 7 out of 12 patients were in sinus rhythm (58%) and at 3 month follow up 8 out of 10 patients were in SR (80%). Discussion: Epicardial HIFU ablation is a viable alternative to Cox maze procedure for management of AF. The procedure does not require cardiopulmonary bypass and in those undergoing concomitant surgery does not increase cross-clamp or CPB times. Although the results of this study using Epicor cardiac ablation for AF are satisfactory, according to the other studies further increase in
ABSTRACTS
Heart, Lung and Circulation 2009;18:65–88