Systematic review of beating heart surgery with the Octopus Tissue Stabilizer

Innovative use of the octopus stabilizer in the excision of a cardiac hydatid cyst

Hydatid disease is caused through Echinococcus granulosus infection. Hydatid disease remains endemic in developing countries. The majority of cases involve the lungs or liver. We report the case of a patient diagnosed with concurrent mediastinal and cardiac cysts. In this patient, the Octopus IV cardiac stabilizer was used to rotate the heart after the excision of the mediastinal cyst, enabling the excision of a cyst adherent to left ventricle through a single median sternotomy incision. To date, there have been no reports of the application of the Octopus IV cardiac stabilizer in such a way.

The use of minimally invasive videoscopic technique in large vessel and cardiac surgery. Does the potentially increased difficulty bring benefits to the patient?

We present the clinical case of a 63-year-old patient who underwent in the Department of Cardiac Surgery implantation of an aorto-bifemoral graft prosthesis and coronary artery bypass revascularization with application of less invasive off-pump technique. Graft selection (arterial grafts, venous grafts) is very important during qualification for coronary artery bypass revascularization. Minimally invasive saphenous vein harvesting was performed during the presented case. The endoscopic technique of vein harvesting is a relatively rarely applied technique during myocardial revascularization surgery. The concept of minimally invasive videoscopic technique is presented. There is a discussion on why the team decided to prolong duration of the case consisting of two major operations performed simultaneously. Minimally invasive videoscopic technique may have a significant positive impact on postoperative outcome in a selected group of patients.

Off-pump coronary artery surgery with the Coronéo Cor-Vasc stabilizing device: clinical experience of 141 patients

OBJECTIVES

Numerous devices have been successfully introduced in off-pump coronary artery bypass graft (OPCABG) surgery, most of them being disposable tools based on suction stabilization. Coronéo Cor-Vasc is a reusable system combining suction positioning with compression stabilization. The purpose of this study was to analyze our experience in OPCABG with the Cor-Vasc system.

METHODS

Between March 2001 and May 2008, 141 patients (age = 71.1 +/- 7.5 years) underwent OPCABG surgery using the Cor-Vasc system, representing 6.3% of the case volume of isolated coronary artery bypass graft surgery in the same period. Eighty-eight patients (62.4%) underwent surgery on an urgent basis. In 95 patients (67.4%), the OPCABG option was selected after finding a diseased ascending aorta at intraoperative epiaortic ultrasound.

RESULTS

Among 334 anastomoses (mean = 2.4 +/- 1 per patient), 242 (95 patients) were fashioned with bilateral and 54 (46 patients) with single internal thoracic artery, respectively. In 89.4 and 73% of patients, a complete and a total arterial myocardial revascularization was achieved, respectively. There were two strokes (1.4%) and two myocardial infarctions (1.4%). Two patients died in the hospital (1.4%). Median ICU and in-hospital length of stay were 31.2 h and 10 days, respectively.

CONCLUSION

In our experience, the use of the Cor-Vasc system, including the device-learning curve, was associated with low mortality and morbidity indexes in an aged population with a high risk of stroke. The system appeared to be sufficiently versatile and potentially cost-effective when compared with disposable devices.

ASERNIP-S: international trend setting

The Australian Safety and Efficacy Register of New Interventional Procedures--Surgical (ASERNIP-S) came into being 10 years ago to provide health technology assessments specifically tailored towards new surgical techniques and technologies. It was and remains the only organisation in the world to focus on this area of research. Most funding has been provided by the Australian Government Department of Health, and assessments have helped inform the introduction of new surgical techniques into Australia. ASERNIP-S is a project of the Royal Australasian College of Surgeons. The ASERNIP-S program employs a diverse range of methods including systematic reviews, technology overviews, assessments of new and emerging surgical technologies identified by horizon scanning, and audit. Support and guidance for the program is provided by Fellows of the Royal Australasian College of Surgeons. ASERNIP-S works closely with consumers to produce health technology assessments and audits, as well as consumer information to keep patients fully informed of research. Since its inception, the ASERNIP-S program has developed a strong international profile through the production of over 60 reports on evidence-based surgery, surgical technologies and audit. The work undertaken by ASERNIP-S has evolved from assessments of the safety and efficacy of procedures to include guidance on policies and surgical training programs. ASERNIP-S needs to secure funding so that it can continue to play an integral role in the improvement of quality of care both in Australia and internationally.

Current Status of Off-Pump Coronary Artery Bypass Surgery

The expanding indications for angioplasty coupled with the successful short and mid-term results of randomized controlled trials of drug-eluting stents have already had an unquestionable impact on the practice of coronary revascularization operations. However, coronary artery bypass grafting remains a major mode of therapy for coronary artery disease. It is likely that surgery will continue to be preferred for more complex subsets and that surgeons will have to continue to maintain good results in patients with more complex problems. Concerns regarding morbidity associated with conventional surgical myocardial revascularization on cardiopulmonary bypass have led to a resurgence of interest in off-pump bypass surgery during the last decade, with the expectation that it would be safer if cardiopulmonary bypass could be avoided. This review summarizes the impact of off-pump bypass surgery in reducing the morbidity and mortality associated with conventional coronary artery bypass on cardiopulmonary bypass by evaluating the current best-available evidence from randomized controlled trials and meta-analyses comparing off-pump surgery with conventional bypass grafting.

Effects of Pericardial Lidocaine on Hemodynamic Parameters and Responses in Dogs Anesthetized With Midazolam and Fentanyl

OBJECTIVE

Tachycardia during anesthesia should be avoided, especially during off-pump coronary artery bypass graft surgery. Decreasing heart rate without reducing cardiac contractility is an ideal goal. To achieve this, the authors attempted to block the cardiac nerves by pericardial administration of local anesthetic.

DESIGN

A prospective study.

SETTING

A laboratory.

PARTICIPANTS

Anesthetized, mechanically ventilated dogs (n = 69).

INTERVENTIONS

The pericardial space was infused with 2.5 or 5 mL of 1% lidocaine, 5 mL of 2% lidocaine, or normal saline solution. The hemodynamic changes and the cardiac responses to atropine or isoproterenol were measured during cardiac nerve blockade. To examine the inhibitory action of pericardial lidocaine on arrhythmias, an electrical fibrillator was installed. Furthermore, the blood level of lidocaine was measured.

MEASUREMENTS AND MAIN RESULTS

Pericardial injection of lidocaine significantly decreased heart rate without a change in stroke volume. Under pericardial lidocaine, the tachycardia response to isoproterenol was similar to that observed without pericardial lidocaine, but response to atropine was significantly reduced. Pericardial lidocaine increased the voltage thresholds for inducing arrhythmias and ventricular fibrillation. Intravenous injection of lidocaine elevated the plasma concentration of lidocaine immediately, whereas the plasma concentration peaked at 10 minutes after pericardial administration.

CONCLUSIONS

Pericardial lidocaine (1) decreased heart rate without affecting stroke volume, (2) preserved the tachycardiac response to isoproterenol but completely blocked the response to atropine, and (3) increased the voltage thresholds for arrhythmias and ventricular fibrillation induced by an electrical fibrillator. These results suggest that pericardial lidocaine may be useful for controlling heart rate during off-pump coronary artery bypass graft surgery.

Dissecting Sub-Epicardial Haematoma: A Rare Complication with the Use of Octopus™ Suction Mechanical Stabiliser

Mechanical heart stabilisers are the most important method of anastomotic field immobilisation in off pump coronary artery bypass (OPCAB) surgery. The new generations of stabilisers are small, versatile and relatively free of complications. We report a patient who developed a dissecting sub-epicardial haematoma following OPCAB using the OCTOPUS 3.0 (Medtronic Inc., Minneapolis, USA) suction stabiliser, which manifested as myocardial ischaemia two hours after surgery. It is a rare but potentially lethal complication that has only once before been reported in literature.

Deep pericardial suture vs apical suction for off-pump bypass grafting

Hemodynamic changes during heart luxation and stabilization are major problems in off-pump coronary artery bypass surgery. The hemodynamic effects of an apical suction device were compared with those of the classic posterior pericardial suture in 45 patients with multivessel coronary disease undergoing off-pump coronary artery bypass. Mean age was 63.78 +/- 8.11 years; 31 patients were male and 14 were female. Transesophageal Doppler echocardiography was used for hemodynamic monitoring. All hemodynamic parameters were significantly better when the apical suction device was used to position the heart for anastomoses on the posterior descending and circumflex arteries.

Midterm Results of Off-Pump Coronary Artery Bypass Surgery in 136 Patients: An Angiographic Control Study

BACKGROUND

Off-pump coronary artery bypass surgery may provide an alternative form of surgical revascularization by avoiding the complications of cardiopulmonary bypass (CPB). This study summarizes the midterm results of 136 off-pump bypass surgery patients.

METHODS

Between January 2000 and March 2002, out of 178 surgical myocardial revascularizations, 136 (76.4%) were off-pump bypass surgery. Complete revascularization was done and especially arterial grafts were used. All patients were followed clinically and with treadmill test for 2 years. Average control angiography was performed at the end of 2-year follow-up.

RESULTS

Of all the patients, 56.7% were male and the mean age of the patients was 63.6 +/- 7.4 years. A total of 481 anastomoses were performed-136 (28.27%) to the left anterior descending artery (LAD), 135 (28.07%) to the circumflex coronary artery (Cx) branches, 102 (21.20%) to the right coronary artery (RCA), 108 (22.46%) to the Di. The mean graft number was 3.46. We used 96.6% of patients' left internal mammarian artery (LITA), 29.2% radial artery (RA), 4.4% right internal thoracic artery (RITA), and 100% saphenous vein. There were ischemic changes within 12 patients. All ischemic changes came back to normal within 4 and 18 hours, postoperatively. Mean extubation time was 5.36 +/- 2.23 hours, mean stay in intensive care unit was 17.53 +/- 3.15 hours, mean hospital stay was 5.03 +/- 1.29 days. The LITA patency was 99.25%, RA patency was 97.84%, RITA patency was 100%, and saphenous vein patency was 91.79% with control angiography.

CONCLUSION

Off-pump coronary artery bypass graft (CABG) is efficient procedure with lower index of mortality, morbidity, ICU stay, hospital stay, good wound healing, early socialization, and results in lower costs.

Impact of Off-Pump Coronary Artery Bypass Surgery on Postoperative Bleeding: Current Best Available Evidence

Cardiopulmonary bypass (CPB) is a prerequisite for open-heart surgery, and is a procedure routinely used. CPB exposes blood to artificial surfaces, to mechanical trauma from the pump, to alterations in temperature, and to dilution with fluids, whole blood, plasma products, and drugs, and leads to the activation of platelets, coagulation, and fibrinolysis. Coagulopathy during cardiac surgery with CPB results in impairment in hemostasis and subsequently higher morbidity and mortality. Recent advances in surgical techniques and postoperative management have aimed at reducing postoperative morbidity and mortality. Off-pump coronary artery bypass (OPCAB) surgery is one such advance that attempts to avoid the deleterious effects of extracorporeal circulation by performing myocardial revascularization without CPB. Emerging evidence from several randomized controlled trials (RCTs) as well as large registries such as the Society of Thoracic Surgeons (STS) database suggests that OPCAB reduces the postoperative morbidity and mortality. This review article attempts to evaluate the current best available evidence from RCTs on the impact of OPCAB on postoperative bleeding and transfusion requirements.

Acute effects of suction retraction on atrial hemodynamics and histology

OBJECTIVES

In minimally invasive and robotic mitral valve surgery, a blade retractor is used to elevate the left atrial roof, which often distorts tissue and impairs visualization. We tested the hemodynamic and histologic changes of intra-atrial suction, using a new suction retractor that may improve stabilization and visualization.

METHODS

Swine were divided into 3 equal (n = 4) groups: blade retractor, suction retractor, and arrested heart control. Left atrial ultrasonic crystals were used to record ejection fractions. After cardioplegic arrest, the atrium was opened and sampled for preretractor histology. Retractors remained in place for 1 hour, followed by postretractor histologic sampling. Controls were crossclamped for an equivalent time and postarrest histologic data obtained. Animals were weaned from bypass, data were collected for 4 hours, and postsacrifice atrial histologic samples were obtained.

RESULTS

The main effect due to treatment was not statistically significant ( P = .52) between the 3 groups, with the 4-hour average ejection fraction for blade retractor, suction retractor, and control being statistically equivalent at 33.3% +/- 8.3, 35.3% +/- 12.1, and 40.8% +/- 9.9 (mean +/- standard deviation), respectively. Histology showed equivalent amounts of myocyte fragmentation, interstitial edema, eosinophilia, and wavy fibers between blade retraction and suction retraction, while the latter showed slightly increased amounts of hemorrhage.

CONCLUSIONS

Atrial endocardial suction retraction appears to be safe with no acute changes in the left atrial ejection fraction or significant acute histologic differences, compared to blade retraction. Furthermore, intra-atrial suction may be applicable to procedures other than minimally invasive and robotic mitral valve repair for providing improved stabilization.

Haemodynamic effects of a milrinone infusion without a bolus in patients undergoing off-pump coronary artery bypass graft surgery

The haemodynamic effects of a continuous infusion of milrinone without an initial bolus dose were evaluated in patients undergoing off-pump coronary artery bypass graft surgery. After internal mammary artery harvest, milrinone 0.5 microg.min(-1).kg(-1) (29 patients) or a normal saline infusion (33 patients) was started and continued until all graft anastomoses were completed. Haemodynamic variables were recorded before application of the tissue stabiliser, at 1, 3, 5 and 10 min after the application of the stabiliser, and after its removal. The administration of a milrinone infusion was associated with a smaller decrease in cardiac output and mixed venous oxygen saturation during all the coronary artery anastomoses, with no severe complications and a decreased dose of norepinephrine infused to maintain systemic arterial pressure.

Novadaq SPY: intraoperative quality assessment in off-pump coronary artery bypass grafting

OBJECTIVES

Off-pump coronary artery bypass grafting may decrease operative morbidity when compared to on-pump bypass grafting; however, it is technically demanding and thus quality control is essential. This study assesses the clinical feasibility of a new, indocyanine green (ICG)-based imaging system (SPY; Novadaq Technologies; Toronto, ON, Canada) to monitor the quality of anastomoses and grafts in off-pump revascularization.

SETTING

Thirty-eight consecutive patients undergoing nonemergent coronary artery bypass grafting without the use of extracorporeal circulation at two Swiss cardiac surgery clinics were included. On completion of bypass grafts, the quality of the grafts was assessed using the ICG-based imaging system. The imaging device comprises an 806-nm laser light source that is used to cause ICG to fluoresce and a near infrared-sensitive charged couple device videocamera that is used to capture the fluorescence images. ICG was administered through the central venous line, and images were acquired during the first pass of the ICG through the field of view. Graft flow (qualitative) and the quality of the grafts and anastomoses were assessed intraoperatively.

RESULTS

Between March 2002 and September 2002, a total of 38 patients (26 men and 12 women; mean +/- SD age, 64.6 +/- 10.5 years; body mass index, 27.1 +/- 2.9) underwent surgery and imaging at two institutions. One hundred seven of 124 grafts (45 arteries and 62 veins) were analyzed. Seventeen grafts could not be assessed due to difficulties in positioning. The imaging system was easy to handle, and no adverse reactions to ICG were observed. Four of the 107 grafts imaged required revision (three anastomotic constrictions and one graft dissection). Each imaging sequence required approximately 1.25 to 2.5 mg of ICG. The images were equivalent to angiography without the need for radiographs and catheter insertion. In addition, the course of coronaries that would otherwise be difficult to locate in obese patients could be detected using the imaging system. Biochemical and ECG data demonstrated an absence of intraoperative or postoperative myocardial damage, and no liver enzyme elevation or renal dysfunction.

CONCLUSIONS

This study supports the clinical utility of a ICG-based imaging system for the assessment of the quality of bypass grafts, which appears to be safe and simple to use.

Off-pump long onlay bypass grafting using left internal mammary artery for diffusely diseased coronary artery

Surgical treatment of a diffusely diseased coronary artery has been considered a relative contraindication for off-pump coronary artery bypass grafting. To our knowledge, long onlay-patch grafting with off-pump coronary artery bypass grafting has not been described. Two sets of Octopus 3 tissue stabilizers were placed longitudinally along the target coronary artery. This allowed us to perform surgical angioplasty and bypass grafting without cardiopulmonary bypass support (double Octopus technique). We report our early experience with off-pump long onlay bypass grafting in patients with a diffusely diseased coronary artery using double Octopus tissue stabilizers. Diffusely diseased coronary artery; off-pump coronary artery bypass grafting; coronary artery reconstruction; coronary artery bypass grafting; onlay patch anastomosis