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Peripheral cannulation for cardiopulmonary bypass in resection of renal cell carcinomas with level 3 tumour thrombus
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Abstracts
Background: Tracheostomy has traditionally been used as a means of facilitated mechanical ventilation in patients requiring respiratory management following cardiac surgery. However in the clinical setting, the advantages of tracheostomy have been questioned by concerns surrounding evidence of its association with increased risk of deep sternal wound infections (DSWI). The present study sought to evaluate retrospectively our experience with post-sternotomy tracheostomy among cardiac surgery patients and association with DSWI. Methods: Between July 2003 and June 2013, 11,795 patients underwent open cardiac surgery via sternotomy in our department. Among these, 225 underwent post-sternotomy tracheostomy. Data were obtained by reviewing and analysing the Cardiac Surgical and Cardiac Intensive Care Unit databases for adult cardiac patients. Results: Out of the 11,795 sternotomy patients analysed, 225 (1.9%) underwent tracheostomy. The overall mortality rate for post-sternotomy tracheostomy patients was 21.3%. DSWI developed in 23 patients (10.2%) of the tracheostomy group. Seven of these 23 patients had DSWI after tracheostomy, with 3 patients after early tracheostomy (<10 days) and 4 patients after late tracheostomy (>10 days). DSWI was significantly higher in tracheostomy versus no-tracheostomy patients (10.2% vs 0.48%; p<0.001). DSWI was also associated with higher mortality rates compared to non-DSWI patients (11.4% vs 2.3%; p<0.001). Conclusions: The present study demonstrated that tracheostomy was an independent risk factor for post-sternotomy DSWI, and that DSWI was a predictor of mortality. For tracheostomy patients, CABG procedures and longer durations of tracheostomy were strong predictors of DSWI. Across all sternotomy patients, tracheostomy, diabetes, urgency status and transfusions were significant risk factors for DSWI. As such, the decision for tracheostomy post-sternotomy should be carefully considered on a case by case basis. http://dx.doi.org/10.1016/j.hlc.2014.12.105 Robotic-assisted hybrid coronary revascularisation. A systematic review Yi-Chin Tsai 1*, Kevin Phan 2,3, Jessie J. Zhou 2, Steven Phan 3, Tristan D. Yan 2,4 1
The Prince Charles Hospital, Chermside, Australia The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia 3 Sydney Medical School, Sydney, Australia 4 Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia * Corresponding author. 2
Background Hybrid coronary revascularisation (HCR) for multi-vessel coronary artery disease combines surgical bypass grafting for the left anterior descending (LAD) coronary artery and percutaneous coronary intervention (PCI) for non-LAD coronary arteries. While minimally invasive coronary bypass grafting is the common preferred approach for HCR, recent technological advances have meant that graft harvesting can be done using a robotic-assisted approach with a daVinci telemanipulator. The present systematic
review was conducted to assess the available evidence on robotic-assisted HCR. Methods A comprehensive search from six electronic databases was performed for studies reporting outcomes for robotic-assisted hybrid coronary revascularization. Results Eight studies were identified from six electronic databases amenable for qualitative assessment and quantitative meta-analysis. There were no in-hospital deaths reported. Pooled myocardial infarction rates was 1.2% (range 0-3.7%), pooled strokes was 0.8% (range: 0-1.7%), freedom from intervention was 92.5% (range 70.4-100%), and freedom from angina was 92.9% (range 74.3-100%). LITA patency ranged from 89-100%, while hospital stay ranged from 48.1 days. Conclusions Current evidence suggests that roboticassisted HCR can be performed with acceptable mortality and complication rates, when patients are carefully selected and operated on by expert cardiovascular teams. Future comparative and randomised studies are required to provide long-term definitive assessment of this innovative surgical technique for coronary intervention. http://dx.doi.org/10.1016/j.hlc.2014.12.106 Peripheral cannulation for cardiopulmonary bypass in resection of renal cell carcinomas with level 3 tumour thrombus Robert B. Xu, MBBS *, Sameer Thakur, MBBS, Kim Pese, FRACS, James Edwards, FRACS * Corresponding author. In renal cell carcinomas with tumour thrombus involving the intrahepatic vena cava or above (Level 3+), the urologist will often require the assistance of a cardiothoracic surgeon to establish cardiopulmonary bypass to safely perform a cavotomy for complete resection – this is traditionally through a sternotomy and central cannulation approach. We present 2 cases of patients with Level 3 tumour thrombus involvement, in whom resection was performed with bypass established through peripheral cannulation, thus avoiding the added morbidity of a sternotomy. Renal cell carcinomas are often clinically silent, and present only when the disease is already locally advanced. Despite advances in immunotherapy, radiotherapy and RF ablation, surgical resection remains the mainstay of potential curative treatment. RCCs are highly vascular, and often invade the venous system, creating tumour thrombus within the renal vein or inferior vena cava. When there is Level 3+ tumour thrombus involvement, cardiopulmonary bypass is an option to allow the urologist to perform a safe a cavotomy for complete resection in a relatively bloodless field. Traditionally, this has been performed through sternotomy with central cannulation. Some authors report techniques where CPB can be avoided, however they are not widely practiced and reviews have not shown any significant difference in morbidity or 90-day mortality. http://dx.doi.org/10.1016/j.hlc.2014.12.107
Abstracts
Background: Tracheostomy has traditionally been used as a means of facilitated mechanical ventilation in patients requiring respiratory management following cardiac surgery. However in the clinical setting, the advantages of tracheostomy have been questioned by concerns surrounding evidence of its association with increased risk of deep sternal wound infections (DSWI). The present study sought to evaluate retrospectively our experience with post-sternotomy tracheostomy among cardiac surgery patients and association with DSWI. Methods: Between July 2003 and June 2013, 11,795 patients underwent open cardiac surgery via sternotomy in our department. Among these, 225 underwent post-sternotomy tracheostomy. Data were obtained by reviewing and analysing the Cardiac Surgical and Cardiac Intensive Care Unit databases for adult cardiac patients. Results: Out of the 11,795 sternotomy patients analysed, 225 (1.9%) underwent tracheostomy. The overall mortality rate for post-sternotomy tracheostomy patients was 21.3%. DSWI developed in 23 patients (10.2%) of the tracheostomy group. Seven of these 23 patients had DSWI after tracheostomy, with 3 patients after early tracheostomy (<10 days) and 4 patients after late tracheostomy (>10 days). DSWI was significantly higher in tracheostomy versus no-tracheostomy patients (10.2% vs 0.48%; p<0.001). DSWI was also associated with higher mortality rates compared to non-DSWI patients (11.4% vs 2.3%; p<0.001). Conclusions: The present study demonstrated that tracheostomy was an independent risk factor for post-sternotomy DSWI, and that DSWI was a predictor of mortality. For tracheostomy patients, CABG procedures and longer durations of tracheostomy were strong predictors of DSWI. Across all sternotomy patients, tracheostomy, diabetes, urgency status and transfusions were significant risk factors for DSWI. As such, the decision for tracheostomy post-sternotomy should be carefully considered on a case by case basis. http://dx.doi.org/10.1016/j.hlc.2014.12.105 Robotic-assisted hybrid coronary revascularisation. A systematic review Yi-Chin Tsai 1*, Kevin Phan 2,3, Jessie J. Zhou 2, Steven Phan 3, Tristan D. Yan 2,4 1
The Prince Charles Hospital, Chermside, Australia The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia 3 Sydney Medical School, Sydney, Australia 4 Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia * Corresponding author. 2
Background Hybrid coronary revascularisation (HCR) for multi-vessel coronary artery disease combines surgical bypass grafting for the left anterior descending (LAD) coronary artery and percutaneous coronary intervention (PCI) for non-LAD coronary arteries. While minimally invasive coronary bypass grafting is the common preferred approach for HCR, recent technological advances have meant that graft harvesting can be done using a robotic-assisted approach with a daVinci telemanipulator. The present systematic
review was conducted to assess the available evidence on robotic-assisted HCR. Methods A comprehensive search from six electronic databases was performed for studies reporting outcomes for robotic-assisted hybrid coronary revascularization. Results Eight studies were identified from six electronic databases amenable for qualitative assessment and quantitative meta-analysis. There were no in-hospital deaths reported. Pooled myocardial infarction rates was 1.2% (range 0-3.7%), pooled strokes was 0.8% (range: 0-1.7%), freedom from intervention was 92.5% (range 70.4-100%), and freedom from angina was 92.9% (range 74.3-100%). LITA patency ranged from 89-100%, while hospital stay ranged from 48.1 days. Conclusions Current evidence suggests that roboticassisted HCR can be performed with acceptable mortality and complication rates, when patients are carefully selected and operated on by expert cardiovascular teams. Future comparative and randomised studies are required to provide long-term definitive assessment of this innovative surgical technique for coronary intervention. http://dx.doi.org/10.1016/j.hlc.2014.12.106 Peripheral cannulation for cardiopulmonary bypass in resection of renal cell carcinomas with level 3 tumour thrombus Robert B. Xu, MBBS *, Sameer Thakur, MBBS, Kim Pese, FRACS, James Edwards, FRACS * Corresponding author. In renal cell carcinomas with tumour thrombus involving the intrahepatic vena cava or above (Level 3+), the urologist will often require the assistance of a cardiothoracic surgeon to establish cardiopulmonary bypass to safely perform a cavotomy for complete resection – this is traditionally through a sternotomy and central cannulation approach. We present 2 cases of patients with Level 3 tumour thrombus involvement, in whom resection was performed with bypass established through peripheral cannulation, thus avoiding the added morbidity of a sternotomy. Renal cell carcinomas are often clinically silent, and present only when the disease is already locally advanced. Despite advances in immunotherapy, radiotherapy and RF ablation, surgical resection remains the mainstay of potential curative treatment. RCCs are highly vascular, and often invade the venous system, creating tumour thrombus within the renal vein or inferior vena cava. When there is Level 3+ tumour thrombus involvement, cardiopulmonary bypass is an option to allow the urologist to perform a safe a cavotomy for complete resection in a relatively bloodless field. Traditionally, this has been performed through sternotomy with central cannulation. Some authors report techniques where CPB can be avoided, however they are not widely practiced and reviews have not shown any significant difference in morbidity or 90-day mortality. http://dx.doi.org/10.1016/j.hlc.2014.12.107