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Minimally invasive valve surgery
AsiaPacificHeartJ
1997;6( 1)
Cardiothoracic
mobilisation and coagulation of the perforating vessels. By employing this technique, mean procurement and wound closure time has been dramatically decreased to 15 min, significantly decreasing total operative time. In contrast to standard techniques, calcium antagonists are only used for gentle hydrostatic dilatation during pedicle preparation. Milrinone is not used postoperatively. This technique has been used in 52 patients (mean age, 57 years; range, 35-71) with 52 arterial conduits being used. This has contributed to achieving total or subtotal arterial revascularisation of noninfarcted myocardium in all patients. The mean follow-up time is 4.2 months (range, 3 weeks to 9 months). There have been no postoperative deaths, documented vasospastic events, Q wave infarcts or recurrent symptoms of angina in this patient population. Postoperatively, 7 (13%) patients developed a low systemic vascular resistance requiring inotropes, 8 (15%) developed atrial fibrillation, and 1 (2%) developed renal impairment. 1 (2%) patient developed cardiac tamponade due to bleeding from a distal anastomosis requiring re-operation. Wound complications have been minimal with 1 wound haematoma requiring reoperation, 6 (11%) minor wound infections and 9 (17%) transient dysaesthesias in the sensory distribution of the superficial radial nerve. There have been no reports of hand claudication or loss of hand function. Our experience with this new technique has been favourable and is being successfully used in CABG surgery.
Abstracts
approach. The overall tissue trauma can be reduced with a lo-14 cm horizontal tram-sternal incision through the third intercostal space for the aortic valve or with a lo-14 cm right parastemal incision and third or fourth costal cartilage resection for mitral/tricuspid valve. The great vessels are cannulated directly (usual) or via the external iliac vessels. Specific cannulae distinctly facilitate the procedure. It appears possible to carry out isolated or combined aortic, mitral and tricuspid valve surgery using standard valve techniques. The advantages appear to be: reduced tissue trauma less wound pain shortened intensive care and postsurgery hospital stay a more rapid rehabilitation recovery phase and return to work a safe procedure with no more risk of compromise to patient welfare compared to conventional techniques. Results from small recent series of patients highlight the possible advantages of this minimally invasive surgical approach.
Minimally Invasive Mitral Valve Replacement In The Dog: Use Of Carbon Dioxide To Reduce Intracardiac Air
Acute Early Thrombosis Of Coronary Artery Bypass Grafts Related To Aprothinin
W.S. Peters, J.A. Smith, A. Preovolos, M. Rabinov, M.R. Buckland, F.L. Rosenfeldt Cardiac Surgical Research Unit, Baker Medical Research Institute, and Departments of Cardiothoracic Surgery and Anaesthesia, Alfred Health Care Group, Melbourne, Victoria, Australia
M.A.J. Newman, H. Chandraratna, J.M. Alvarez Sir Charles Gairdner Hospital, Perth, WA, Australia Three cases of acute early thrombosis of CABG are reported. All 3 patients were small females undergoing firsttime CABG who received moderate doses of aprotinin. All patients had acute severe haemodynamic collapse approximately 45-60 min after reversal of heparin. All had evidence of acute ischaemia due to graft thrombosis. The first 2 patients died. One had a postmortem showing acute thrombosis of the saphenous vein/coronary artery anastomosis. The third patient had thrombus at 3 of 4 distal anastomoses, including 1 internal mammary anastomosis, and both proximal aorta-saphenous anastomoses. Thrombus was removed and the anastomoses redone, and this patient survived. This early severe thrombosis at technically normal anastomoses indicates a hypercoagulable state, probably related to aprotinin. The literature on aprotinin and graft occlusion is reviewed. Although aprotinin reduces blood loss after CABG, its routine use must be questioned.
Background: We developed a method of minimally invasive mitral valve replacement (MVR) with cardioplegia, and studied the effects of carbon dioxide (C02) in improving cardiac deairing. Methods: MVR was performed via a 5x3 cm right lateral minithoracotomy in 8 greyhounds. Peripheral cardiopulmonary bypass and an ascending aortic balloon catheter (endoaortic clamp) were used for cardioplegia and aortic root venting. In 4 dogs CO2 (2 L/min) was used in the chest to displace air. After left atrial closure, retained intracardiac gas was aspirated via the aortic vent and collected in a bubble trap. Results: Satisfactory MVR was completed in all studies. The clamp time was 64213 min (mean&SD), and all dogs were weaned from bypass with good cardiac function. In the COz group, intrathoracic CO2 was maintained between 8696% during the procedure and O.lfO.l mL of gas was collected in the bubble trap, compared to 1.3* 0.8 mL in the non-CO2 group (pcO.05). Conclusions: Peripheral bypass and cardioplegia allows MVR via a right minithoracotomy. A high intrathoracic COz concentration can reduce the amount of retained intracardiac gas. Abstracts continued on page 45
Minimally Invasive Valve Surgery Mark F. O’Brien The Prince Charles Hospital and St Andrew’s Hospital, Brisbane, Queensland, Australia Both aortic and mitral valve repair or replacement can be achieved by limited access or a minimally invasive
37
1997;6( 1)
Cardiothoracic
mobilisation and coagulation of the perforating vessels. By employing this technique, mean procurement and wound closure time has been dramatically decreased to 15 min, significantly decreasing total operative time. In contrast to standard techniques, calcium antagonists are only used for gentle hydrostatic dilatation during pedicle preparation. Milrinone is not used postoperatively. This technique has been used in 52 patients (mean age, 57 years; range, 35-71) with 52 arterial conduits being used. This has contributed to achieving total or subtotal arterial revascularisation of noninfarcted myocardium in all patients. The mean follow-up time is 4.2 months (range, 3 weeks to 9 months). There have been no postoperative deaths, documented vasospastic events, Q wave infarcts or recurrent symptoms of angina in this patient population. Postoperatively, 7 (13%) patients developed a low systemic vascular resistance requiring inotropes, 8 (15%) developed atrial fibrillation, and 1 (2%) developed renal impairment. 1 (2%) patient developed cardiac tamponade due to bleeding from a distal anastomosis requiring re-operation. Wound complications have been minimal with 1 wound haematoma requiring reoperation, 6 (11%) minor wound infections and 9 (17%) transient dysaesthesias in the sensory distribution of the superficial radial nerve. There have been no reports of hand claudication or loss of hand function. Our experience with this new technique has been favourable and is being successfully used in CABG surgery.
Abstracts
approach. The overall tissue trauma can be reduced with a lo-14 cm horizontal tram-sternal incision through the third intercostal space for the aortic valve or with a lo-14 cm right parastemal incision and third or fourth costal cartilage resection for mitral/tricuspid valve. The great vessels are cannulated directly (usual) or via the external iliac vessels. Specific cannulae distinctly facilitate the procedure. It appears possible to carry out isolated or combined aortic, mitral and tricuspid valve surgery using standard valve techniques. The advantages appear to be: reduced tissue trauma less wound pain shortened intensive care and postsurgery hospital stay a more rapid rehabilitation recovery phase and return to work a safe procedure with no more risk of compromise to patient welfare compared to conventional techniques. Results from small recent series of patients highlight the possible advantages of this minimally invasive surgical approach.
Minimally Invasive Mitral Valve Replacement In The Dog: Use Of Carbon Dioxide To Reduce Intracardiac Air
Acute Early Thrombosis Of Coronary Artery Bypass Grafts Related To Aprothinin
W.S. Peters, J.A. Smith, A. Preovolos, M. Rabinov, M.R. Buckland, F.L. Rosenfeldt Cardiac Surgical Research Unit, Baker Medical Research Institute, and Departments of Cardiothoracic Surgery and Anaesthesia, Alfred Health Care Group, Melbourne, Victoria, Australia
M.A.J. Newman, H. Chandraratna, J.M. Alvarez Sir Charles Gairdner Hospital, Perth, WA, Australia Three cases of acute early thrombosis of CABG are reported. All 3 patients were small females undergoing firsttime CABG who received moderate doses of aprotinin. All patients had acute severe haemodynamic collapse approximately 45-60 min after reversal of heparin. All had evidence of acute ischaemia due to graft thrombosis. The first 2 patients died. One had a postmortem showing acute thrombosis of the saphenous vein/coronary artery anastomosis. The third patient had thrombus at 3 of 4 distal anastomoses, including 1 internal mammary anastomosis, and both proximal aorta-saphenous anastomoses. Thrombus was removed and the anastomoses redone, and this patient survived. This early severe thrombosis at technically normal anastomoses indicates a hypercoagulable state, probably related to aprotinin. The literature on aprotinin and graft occlusion is reviewed. Although aprotinin reduces blood loss after CABG, its routine use must be questioned.
Background: We developed a method of minimally invasive mitral valve replacement (MVR) with cardioplegia, and studied the effects of carbon dioxide (C02) in improving cardiac deairing. Methods: MVR was performed via a 5x3 cm right lateral minithoracotomy in 8 greyhounds. Peripheral cardiopulmonary bypass and an ascending aortic balloon catheter (endoaortic clamp) were used for cardioplegia and aortic root venting. In 4 dogs CO2 (2 L/min) was used in the chest to displace air. After left atrial closure, retained intracardiac gas was aspirated via the aortic vent and collected in a bubble trap. Results: Satisfactory MVR was completed in all studies. The clamp time was 64213 min (mean&SD), and all dogs were weaned from bypass with good cardiac function. In the COz group, intrathoracic CO2 was maintained between 8696% during the procedure and O.lfO.l mL of gas was collected in the bubble trap, compared to 1.3* 0.8 mL in the non-CO2 group (pcO.05). Conclusions: Peripheral bypass and cardioplegia allows MVR via a right minithoracotomy. A high intrathoracic COz concentration can reduce the amount of retained intracardiac gas. Abstracts continued on page 45
Minimally Invasive Valve Surgery Mark F. O’Brien The Prince Charles Hospital and St Andrew’s Hospital, Brisbane, Queensland, Australia Both aortic and mitral valve repair or replacement can be achieved by limited access or a minimally invasive
37