Surgical Outcomes of Congenital Atrial Septal Defect Using da VinciTM Surgical Robot System

Intermediate-Term Outcomes of Totally Endoscopic Atrial Septal Defect Repair on Beating Heart in Small Children

Objective: Manipulation in a narrow surgical field and risks of femoral arterial (FA) complications are difficulties when applying totally endoscopic surgery (TES) for congenital heart disease in small children. This study was conducted to investigate the feasibility of TES for atrial septal defect (ASD) repair in children weighing 13 to 20 kg. Methods: From July 2016 to July 2021, 14 patients with a mean age of 5.4 ± 2.2 years and mean weight of 15.57 ± 2.39 kg (range, 13 to 20 kg), underwent TES for ASD repair on the beating heart. FA cannulation was established through a Dacron graft. An additional FA cannula (2 to 4 Fr smaller than the expected size) was placed into the left FA in case of increasing arterial pressure. Three 5 or 5.5 mm trocars and one 12 mm port were used. The surgical field was filled with CO₂. No aortic clamp, no aortic root needle, and no snaring of the inferior vena cava were used. The mean follow-up time was 37.9 ± 12.5 months. Results: Cardiopulmonary bypass (CPB) installation time, CPB time, and operation time were 42.6 ± 16.5 min, 113.1 ± 33.1 min, and 209.6 ± 50.6 min, respectively. Total drainage volume was 125.4 ± 89.2 mL. Patients did not need analgesics on day 4 or 5 after surgery. No severe complications, including arterial complications, were recorded during follow-up. Conclusions: By optimizing the surgical field and setting the FA cannula correctly, TES for ASD closure is feasible in small children weighing between 13 and 20 kg.

Robot-Assisted Repair of Atrial Septal Defect: A Comparison of Beating and Non-Beating Heart Surgery

Background

Robot-assisted repair of atrial septal defect (ASD) can be performed under either beating-heart or non-beating-heart conditions. However, the risk of cerebral air embolism (i.e., stroke) is a concern in the beating-heart approach. This study aimed to compare the outcomes of beating- and non-beating-heart approaches in robot-assisted ASD repair.

Methods

From 2010 to 2019, a total of 45 patients (mean age, 43.4±14.6 years; range, 19–79 years) underwent ASD repair using the da Vinci robotic surgical system. Twenty-seven of these cases were performed on a beating heart (beating-heart group, n=27) and the other cases were performed on an arrested or fibrillating heart (non-beating-heart group, n=18). Cardiopulmonary bypass (CPB) was achieved via cannulation of the femoral vessels and the right internal jugular vein in all patients.

Results

Complete ASD closure was verified using intraoperative transesophageal echocardiography in all patients. Conversion to open surgery was not performed in any cases, and there were no major complications. All patients recovered from anesthesia without any immediate postoperative neurologic symptoms. In a subgroup analysis of isolated ASD patch repair (beating-heart group n=22 vs. non-beating-heart group n=5), the operation time and CPB time were shorter in the beating-heart group (234±38 vs. 253±29 minutes, p=0.133 and 113±28 vs. 143±29 minutes, p=0.034, respectively).

Conclusion

Robot-assisted ASD repair can be safely performed with the beating-heart approach. No additional risk in terms of cerebral embolism was found in the beating-heart group.

External aortic clamping versus endoaortic balloon occlusion in minimally invasive cardiac surgery: a systematic review and meta-analysis

OBJECTIVES

Minimally invasive cardiac valve surgery is safe, effective and increasingly popular. It is performed worldwide with the use of either external aortic clamping or endoaortic balloon occlusion.

METHODS

We conducted a literature search using MEDLINE, EMBASE, Scopus and Web of Science. Primary outcomes included aortic dissection, conversion to sternotomy, mortality, stroke and cross-clamp time. Secondary outcomes included atrial fibrillation, acute kidney injury, reoperation for bleeding, cardiopulmonary bypass times, myocardial infarction, use of intra-aortic balloon pump and length of hospital stay. The random effects model was used to calculate the outcomes of both binary and continuous data.

RESULTS

Thirty retrospective studies were included in the meta-analysis. The incidence of aortic dissection (pooled odds ratio = 3.88, 95% confidence interval = 1.06-14.18; P =0.04) and conversion to sternotomy (pooled odds ratio = 3.07, 95% confidence interval = 1.33-7.10; P = 0.009) was higher in the endoaortic balloon occlusion group than in the external aortic clamping group, in whom a direct comparison was possible. The remaining observational studies did not show any significant differences in either group. There was no significant difference in 30-day mortality (P = 0.37), stroke (P = 0.26), cross-clamp time (P = 0.20), atrial fibrillation (P = 0.18), acute kidney injury (P = 0.49), reoperation for bleeding (P = 0.24), cardiopulmonary bypass time (P = 0.06), myocardial infarction (P = 0.74), use of intra-aortic balloon pump (P = 0.11) or length of hospital stay (P = 0.47).

CONCLUSIONS

External aortic clamping may be safer than endoaortic balloon occlusion with respect to aortic dissection and conversion to sternotomy. However, mortality, length of stay, stroke, cross-clamp time and other cardiovascular complication rates were similar between the 2 techniques.

The Mid-term Results of Thoracoscopic Closure of Atrial Septal Defects

Background and Objectives

Recently, minimally invasive surgical (MIS) techniques including robot-assisted operations have been widely applied in cardiac surgery. The thoracoscopic technique is a favorable MIS option for patients with atrial septal defects (ASDs). Accordingly, we report the mid-term results of thoracoscopic ASD closure without robotic assistance.

Subjects and Methods

We included 66 patients who underwent thoracoscopic ASD closure between June 2006 and July 2014. Mean age was 27±9 years. The mean size of the ASD was 25.9±6.3 mm. Eleven patients (16.7%) had greater than mild tricuspid regurgitation (TR). The TR pressure gradient was 32.4±8.6 mmHg.

Results

Fifty-two (78.8%) patients underwent closure with a pericardial patch and 14 (21.2%) underwent direct suture closure. Concomitant procedures included tricuspid valve repair in 8 patients (12.1%), mitral valve repair in 4 patients (6.1%), and right isthmus block in 1 patient (1.5%). The mean length of the right thoracotomy incision was 4.5±0.9 cm. The mean cardiopulmonary bypass time was 159±43 minutes, and the mean aortic cross clamp time was 79±29 minutes. The mean hospital stay lasted 6.1±2.6 days. There were no early deaths. There were 2 reoperations. One was due to ASD patch detachment and the other was due to residual mitral regurgitation after concomitant mitral valve repair. However, there have been no reoperations since July 2010. There were 2 pneumothoraxes requiring chest tube re-insertion. There was one wound dehiscence in an endoscopic port. The mean follow-up duration was 33±31 months. There were no deaths, residual shunts, or reoperations during follow-up.

Conclusion

Thoracoscopic ASD closure without robotic assistance is feasible, suggesting that this method is a reliable MIS option for patients with ASDs.

Minimally Invasive Cardiac Surgery versus Conventional Median Sternotomy for Atrial Septal Defect Closure

BACKGROUND

Median sternotomy is the standard approach for atrial septal defect (ASD) closure. However, minimally invasive cardiac surgery (MICS) has been introduced at many centers in adult/grown-up congenital heart patients. We retrospectively reviewed the results of right anterolateral thoracotomy compared with conventional median sternotomy (CMS) for ASD closure at Seoul National University Hospital.

METHODS

We retrospectively analyzed 60 adult patients who underwent isolated ASD closure from January 2004 to December 2013 (42 in the CMS group, 18 in the MICS group). Preoperative, operative, and postoperative data were collected and compared between the 2 groups.

RESULTS

The MICS group was younger (44.6 years vs. 32.4 years, p=0.002) and included more females (66.7% vs. 94.4%, p=0.025) than the CMS group. Operation time (188.4 minutes vs. 286.7 minutes, p<0.001), cardiopulmonary bypass time (72.7 minutes vs. 125.8 minutes, p<0.001), and aortic cross-clamp time (25.5 minutes vs. 45.6 minutes, p<0.001) were significantly longer in the MICS group. However, there were no significant differences in morbidity and mortality between groups. Only chest tube drainage in the first 24 hours (627.1 mL vs. 306.1 mL, p<0.001) exhibited a significant difference.

CONCLUSION

MICS via right anterolateral thoracotomy is an alternative choice for ASD closure. The results demonstrated similar morbidity and mortality between groups, and favored MICS in chest tube drainage in the first 24 hours.

Current Trend of Robotic Thoracic and Cardiovascular Surgeries in Korea: Analysis of Seven-Year National Data

Background

Robotic surgery is an alternative to minimally invasive surgery. The aim of this study was to report on current trends in robotic thoracic and cardiovascular surgical techniques in Korea.

Methods

Data from the National Evidence-based Healthcare Collaborating Agency (NECA) between January 2006 and June 2012 were used in this study, including a total of 932 cases of robotic surgeries reported to NECA. The annual trends in the case volume, indications for robotic surgery, and distribution by hospitals and surgeons were analyzed in this study.

Results

Of the 932 cases, 591 (63%) were thoracic operations and 340 (37%) were cardiac operations. The case number increased explosively in 2007 and 2008. However, the rate of increase regained a steady state after 2011. The main indications for robotic thoracic surgery were pulmonary disease (n=271, 46%), esophageal disease (n=199, 34%), and mediastinal disease (n=117, 20%). The main indications for robotic cardiac surgery were valvular heart disease (n=228, 67%), atrial septal defect (n=79, 23%), and cardiac myxoma (n=27, 8%). Robotic thoracic and cardiovascular surgeries were performed in 19 hospitals. Three large volume hospitals performed 94% of the case volume of robotic cardiac surgery and 74% of robotic thoracic surgery. Centralization of robotic operation was significantly (p<0.0001) more common in cardiac surgery than in thoracic surgery. A total of 39 surgeons performed robotic surgeries. However, only 27% of cardiac surgeons and 23% of thoracic surgeons performed more than 10 cases of robotic surgery.

Conclusion

Trend analysis of robotic and cardiovascular operations demonstrated a gradual increase in the surgical volume in Korea. Meanwhile, centralization of surgical cases toward specific surgeons in specific hospitals was observed.

Totally endoscopic congenital heart surgery compared with the traditional heart operation in children

Objective

Totally endoscopic surgery compared with the conventional heart operation in children is described in this article to find a preferable treatment for congenital heart diseases.

Methods

Between May 2000 and December 2007, 708 children with congenital heart disease were divided into two groups: endoscopic group and conventional group. For the endoscopic group, all children underwent total endoscopic procedures with peripheral cardiopulmonary bypass, transthoracic aortic cross-clamp, and antegrade cardioplegia, whereas for the conventional group, all children were operated in traditional way. Three 1–2-cm intercostal ports in the right chest were used for access in the endoscopic group. The intrathoracic part of the operation was performed completely under two-dimensional video, using conventional instruments. Directly closureed of the atrial septal defect was performed in 74 cases, patch closureed of the atrial septal defect in 48 cases, directly closureed of the ventricular septal defect in 158 cases, patch closureing of the ventricular septal defect in 116 cases. For the conventional group, all operations were done with traditional median sternotomy. Directed closureing of the atrial septal defect was performed in 38 cases, patch closed of the atrial septal defect in 56 cases, directly closureed of the ventricular septal defect in 76 cases, patch closureed of the ventricular septal defect in 142 cases.

Results

There was no hospital mortality in both groups. For the endoscopic group, operations were performed successfully in 390 (98.5 %) patients, enlarging a port to a 5-cm incision in 4 children. Reoperation was necessary in two children, and no conversion to median sternotomy incision was necessary. The mean duration of operation was 132 ± 48 min, and cardiopulmonary bypass and aortic cross-clamp times were 54 ± 16 min and 25 ± 8 min, respectively. Major postoperative complications occurred in nine (2.3 %, p < 0.05) cases. For the conventional group, all children were operated by median sternotomy, and the mean duration of operation was 118 ± 41 min (p < 0.05); cardiopulmonary bypass and aortic cross-clamp times were 51 ± 13 min and 21 ± 6 min (p < 0.05), respectively. Major postoperative complications occurred in 16 (5.1 %) cases. Also, the intensive care unit stay time (8.3 ± 2.8 h versus 8.9 ± 2.9 h, p < 0.01), postoperative drainage (120 ± 21 ml versus 433 ± 140 ml, p < 0.05), and hospital time (8.6 ± 1.8 days versus 11.5 ± 1.9 days, p < 0.05) were statistically different.

Conclusions

Totally endoscopic closed chest congenital heart surgery in children was feasible and safe. The results were similar or even superior to the traditional operations due to the decreased use of blood products and shortened hospital time. Degree of satisfaction with cosmetic result and postoperative comfort were very high. Therefore, endoscopic surgery will become a new popular choice for some congenital heart disease patients in the future.