Minimally invasive compared to conventional approach for coronary artery bypass grafting improves outcome

Comparison of postoperative pain and quality of life between left anterior thoracotomy and median sternotomy off-pump coronary artery bypass surgery in multivessel coronary revascularization: a retrospective study of a case series of 356 consecutive patients

BACKGROUND

This study compared post-operative pain and quality of life (QoL) between left anterior thoracotomy (LAT) and median sternotomy (MS) in off-pump coronary artery bypass grafting (OPCAB). LAT is a less invasive alternative to MS for the treatment of advanced coronary artery disease.

METHODS

This retrospective study analysed 356 patients who underwent OPCAB for multivessel revascularization between January 2018 and April 2023. Patients were divided into LAT (n = 169) and MS (n = 187) groups. Postoperative pain was measured using a Visual Analog Scale (VAS). QoL was assessed using the Short Form-36 (SF-36) questionnaire preoperatively and postoperatively.

RESULTS

Patients with LAT had significantly lower pain scores on postoperative days 1, 3, and 7 (p < 0.001) than those with MS. LAT was associated with shorter ICU and hospital stay (p = 0.011 and p < 0.001, respectively). The QoL scores for physical domains were higher in the LAT group at 1 and 3 months post-surgery (p < 0.01). No significant differences were observed in the mental health domains between groups.

CONCLUSIONS

LAT for multivessel OPCAB is associated with reduced postoperative pain, shorter hospital stay, and improved early QoL, particularly in physical domains, compared to MS. These findings suggest that LAT is a preferable option for suitable patients, promoting faster recovery and better early postoperative outcomes.

Remimazolam Use in Cardiac Anesthesia: A Narrative Review

Remimazolam, a novel ultra-short-acting intravenous benzodiazepine, has garnered recent attention for its use as a general anesthetic. This narrative review aims to summarize and analyze the available literature on the effects of remimazolam use in cardiac surgical patients, including its effects on hemodynamics, safety in patients with baseline myocardial dysfunction, and impact on postoperative management including time to emergence and extubation. Finally, there is discussion regarding potential drawbacks of adopting remimazolam as a routine anesthetic for cardiac surgery.

Anesthesia for Minimal Invasive Cardiac Surgery: The Bonn Heart Center Protocol

The development and adoption of minimally invasive techniques has revolutionized various surgical disciplines and has also been introduced into cardiac surgery, offering patients less invasive options with reduced trauma and faster recovery time compared to traditional open-heart procedures with sternotomy. This article provides a comprehensive overview of the anesthesiologic management for minimally invasive cardiac surgery (MICS), focusing on preoperative assessment, intraoperative anesthesia techniques, and postoperative care protocols. Anesthesia induction and airway management strategies are tailored to each patient's needs, with meticulous attention to maintaining hemodynamic stability and ensuring adequate ventilation. Intraoperative monitoring, including transesophageal echocardiography (TEE), processed EEG monitoring, and near-infrared spectroscopy (NIRS), facilitates real-time assessment of cardiac and cerebral perfusion, as well as function, optimizing patient safety and improving outcomes. The peripheral cannulation techniques for cardiopulmonary bypass (CPB) initiation are described, highlighting the importance of cannula placement to minimize tissue as well as vessel trauma and optimize perfusion. This article also discusses specific MICS procedures, detailing anesthetic considerations and surgical techniques. The perioperative care of patients undergoing MICS requires a multidisciplinary approach including surgeons, perfusionists, and anesthesiologists adhering to standardized treatment protocols and pathways. By leveraging advanced monitoring techniques and tailored anesthetic protocols, clinicians can optimize patient outcomes and promote early extubation and enhanced recovery.

Persistent and acute postoperative pain after cardiac surgery with anterolateral thoracotomy or median sternotomy: A prospective observational study

OBJECTIVE

The primary objective of this study was to compare the association between cardiac surgical approach (thoracotomy vs. sternotomy) and incidence of persistent postoperative pain at 3 months. Secondary objectives were the incidence and intensity of persistent pain at 6 and 12 months, acute postoperative pain, analgesic requirement and its side effects.

DESIGN

Single-center, prospective, observational study. Recruitment between December 2017 and August 2018.

SETTING

Perioperative care at university-affiliated tertiary care centre.

PATIENTS

202 adults scheduled for cardiac surgery. Patients with chronic pain or behavioural disorder were excluded.

INTERVENTIONS

Thoracotomy (n = 106) and sternotomy (n = 96).

MEASUREMENTS

Pain scores and pain medication requirements from extubation until hospital discharge. Persistent postoperative pain was assessed using a telephone questionnaire.

MAIN RESULTS

Incidence and intensity of pain was not significantly different between thoracotomy or sternotomy either in the short- or in the long-term follow-up. Incidence of persistent postoperative pain showed no differences between groups (30.2 vs 22.9% at 3 months (p = 0.297), 10.4 vs 7.3% at 6 months (p = 0.364) and 7.5 vs 7.3% at 12 months (p = 0.518) in thoracotomy and sternotomy group). A significant decrease of pain incidence was observed between 3 and 6 months (p < 0.001) but not between 6 and 12 months (p = 0.259) in both groups. ANOVA of repeated measures adjusted for confounding variable showed a decrease of acute pain intensity over time (p = 0.001) with no difference between groups (p = 0.145). Acute pain medication requirements were not different between the groups (p = 0.237 for piritramide and p = 0.743 for oxycodone) with no difference in their side effects.

CONCLUSIONS

Our study showed no difference in short- or long-term pain in patients undergoing anterolateral thoracotomy or median sternotomy. Both groups showed a decrease in persistent postoperative pain incidence between 3 and 6 months without any significant changes at 12 months.

ICU Nurses-An Impact Factor on Patient Turnover in Cardiac Surgery in Western Denmark?

OBJECTIVE

The aim of this study was to describe changes in performance indicators such as length of stay [LOS] in the intensive care unit [ICU] and ventilation time, during the last six years in an attempt to identify associations between patient and systemic performance indicators, including the impact of nurse turnover.

DESIGN

A retrospective study of prospectively registered data (2013-2018). Propensity- score matching was performed to establish comparable groups.

SETTING

Three Danish university hospitals.

PARTICIPANTS

The study included a total of 12,404 adult cardiac surgical patients registered in the Western Denmark Heart Registry. The cohort was divided into an "early" group (2013-2016) and a "late" group (2017-2018).

INTERVENTIONS

An analysis of dynamics in patient indicators and systemic performance indicators, including the impact from selected performance parameters and nurse turnover.

MEASUREMENTS AND MAIN RESULTS

Comorbidity, calculated from the European System for Cardiac Operative Risk Evaluation, and the mean age were stable in the study period. Strong predictors of long LOS in the ICU included postoperative use of inotropes, re-exploration surgery, high postoperative drainage, and the "late" time group. Time parameters (relative risks) were all significantly longer in the "late" time group": ventilation time 1.21 (1.05-1.39), length of stay ICU 1.28 (1.11-1.48), and in-hospital time 1.36 (1.19-1.57). ICU nurse turnover increased from four (2013-2014) to 52 (2017-2018).

CONCLUSION

No single patient factor, such as age or comorbidity, could explain the decrease in patient turnover in the ICU. In the same period, the turnover of ICU nurses increased. Patient turnover is complex and affected by a mix of patient and systemic performance factors.

Development of a Novel Heart Positioner for Minimally Invasive Coronary Surgery

PURPOSE

We developed a heart positioner, the Tentacles NEO, specifically designed for minimally invasive coronary artery bypass grafting (MICS-CABG).

DESCRIPTION

The device has 3 flexible suction tubes, with a suction cup at the tip of each tube. The suction tubes can be detached from the device body, allowing them to be manipulated in any direction through a small incision around the small thoracotomy. When the device displaces the heart, the suction cup moves behind the chest wall and does not crowd the operative field.

EVALUATION

Although the sideways suction force of the new device was as strong as that of the original device, Tentacles, the longitudinal and perpendicular force exerted was approximately 80% of the original device. Nevertheless, the new device could safely and favorably displace the heart in a pig model and even during off-pump CABG via sternotomy. During MICS-CABG, the device was able to displace the heart without crowding the operative field.

CONCLUSIONS

The new heart positioner, Tentacles NEO, is a useful and practical heart positioner suitable for MICS-CABG.

Postoperative complications associated with coronary artery bypass graft surgery and their therapeutic interventions

Coronary artery disease is one of the commonest surgery demanding cardiovascular diseases. Coronary artery bypass graft surgery is practiced all over the world for the treatment of coronary artery disease. Systemic trauma during the surgery is associated with a wide range of complications, some of which are fatal. Preoperative risk factors such as age, previous illness and obesity are common predictors of these adverse events. Advances in therapeutic medicine have allowed timely treatment of these adverse events and co-morbidities. This review summarizes some of the most occurring complications associated with coronary artery bypass graft and corresponding treatment options.

The Major Decrease in Resource Utilization in Recent Decades Seems Guided by Demographic Changes: Fast Tracking-Real Concept or Demographics

OBJECTIVE

To identify dynamics of associations and potential areas for optimization of patient turnover between various patient profile and comorbidity indicators and selected system performance indicators such as ventilation time, length of stay in the intensive care unit, and in-hospital stay.

DESIGN

Retrospective study of prospectively registered data (2000-2017).

SETTING

Three university hospitals.

PARTICIPANTS

The study comprised 38,100 adult cardiac surgical patients registered in the Western Denmark Heart Registry.

INTERVENTIONS

Analysis of dynamics in patient indicators and system performance indicators, including effect on the selected performance parameters.

MEASUREMENTS AND MAIN RESULTS

Comorbidity, calculated from EuroSCORE, decreased from 2.5 ± 2.2 to 1.5 ± 2.0 (p < 0.001), whereas the average age of patients increased from 65.1 ± 9.9 years to 67.6 ± 10.8 years (p < 0.001). Median ventilation time decreased from 380 to 275 minutes (p < 0.0001). The mean length of stay in the intensive care unit demonstrated a statistically significant decrease from 35.1 hours between 2000 to 2002 to 31.8 hours between 2015 to 2017 (p = 0.004), and the median time was unchanged at 22.0 hours throughout the observation period. The median in-hospital stay decreased from 6.5 to 5.1 days (p < 0.001) and the mean in-hospital stay from 8.7 days (2003-2005) to 7.0 days (2015-2017; p < 0.001). Logistic regression analysis of performance factors showed a statistically significant negative independent effect on most comorbidity and surgical factors.

CONCLUSION

The increase in performance parameters appears to be highly associated with decreased comorbidities and fast-tracking protocols and may only offer limited effect in additional patient turnover.

A minimally invasive robotic surgery approach to perform totally endoscopic coronary artery bypass on beating hearts

The currently available robotic systems rely on rigid heart stabilizers to perform totally endoscopic coronary artery bypass (TECAB) surgery on beating hearts. Although such stabilizers facilitate the anastomosis procedure by immobilizing the heart and holding the surgery site steady, they can cause damage to the heart tissue and rupture of the capillary vessels, due to applying relatively large pressures on the epicardium. In this paper, we propose an advanced robotic approach to perform TECAB on a beating heart with minimal invasiveness. The idea comes from the fact that the main pulsations of the heart occur as excursions in normal direction, i.e., perpendicular to the heart surface. We devise a 1-DOF flexible heart stabilizer which eliminates the lateral movements of the heart, and a 1-DOF compensator mechanism which follows the heart trajectory in the normal direction, thus canceling the relative motion between the surgical tool and the heart surface. In fact, we bring a compromise between two radical approaches of operating on a completely immobilized beating heart with no heart motion compensation, and operating on a freely beating heart with full compensation of heart motion, considering the invasiveness of the first and the technical challenges of the second approach. We propose operating on a partially stabilized beating heart with unidirectional compensation of the heart motion; the flexible stabilizer would exert much less holding force to the heart tissue and the robotic system with unidirectional compensator would be technically feasible. In the proposed approach, a motion sensor mounted on the stabilizer measures the heart excursion data and sends it into a control unit. A predictive controller uses this data to generate an automated trajectory. The slave robots follow this trajectory, which is superimposed on the surgeon's tele-operation commands received from a master console. Finally, the tool-activation units in the slave robots actuate the articulated laparoscopic tools to perform the anastomosis procedure. The evaluation of the hypothesis showed that our solution for the robotic TECAB on beating heart is both practical and cost effective. We showed in an in-vivo study that the flexible stabilizer can effectively restrict the heart lateral movements, while allowing for its normal excursion. We found readily available linear motors which could afford the high forces, speeds and accelerations required for following the heart trajectory. Finally, we showed that the tool-activation unit is capable of providing the maneuverability and workspace required for the most challenging task of CABG procedure, i.e., anastomosis suturing.

Intraoperative Implantation of Temporary Endocardial Pacing Catheter During Thoracoscopic Redo Tricuspid Surgery

BACKGROUND

The placement of a temporary epicardial pacing wire is a challenge during a minimally invasive redo cardiac operation. The aim of this study is to assess the application of temporary endocardial pacing in patients who underwent minimally invasive redo tricuspid surgery.

METHODS

Perioperative data of consecutive patients who underwent thoracoscopic redo tricuspid surgery were collected. All the tricuspid surgeries and combined procedures were performed under peripheral cardiopulmonary bypass without aortic cross-clamping. A sheath was introduced into the right jugular vein beside the percutaneous superior vena cava cannula and a temporary endocardial pacing catheter was guided into the right ventricle via the sheath prior to the right atrial closure. The pacemaker was connected and run as needed during or after operation.

RESULTS

A total of 33 patients who underwent thoracoscopic redo tricuspid surgery were enrolled. Symptomatic tricuspid valve regurgitation (93.9%) and tricuspid valvular prosthesis obstruction (6.1%) after previous cardiac operations were noted as indications for a redo surgery. The mean time from previous cardiac operation to this time redo surgery was 13.3±6.4years. Isolated tricuspid valve replacement was performed in 18 patients (54.5%) and tricuspid valve plasty combined with or without mitral valve replacement was performed in 15 patients (45.5%). A temporary endocardial pacing catheter was successfully placed in the right ventricle for all patients with good sensing and pacing. No temporary pacing related complications occurred from insertion to removal of pacing catheter in the patients.

CONCLUSIONS

This application of temporary endocardial pacing provided a safe and effective substitute for epicardial pacing in patients who underwent minimally invasive redo tricuspid surgery.