bluuebunny/crossref_metadata_2025 huggingface dataset:
Regulation of Blood‐Brain Barrier Permeability by Transient Receptor Potential Type C and Type V Calcium‐Permeable Channels
Authors: Brown Rachel C. , Wu Ling , Hicks Kali , O'neil Roger G.
Published: May 2008

Objective: To identify plasma membrane ion channels mediating calcium influx at the blood‐brain barrier in response to disrupting stimuli.

Methods: We examined the expression and function of candidate transient receptor potential channels using reverse transcriptase polymerase chain recation, Fura‐2 calcium imaging, and permeability assays.

Results: Immortalized mouse brain microvessel endothelial cells expressed multiple transient receptor potential isoforms: transient receptor potential C1, C2, C4, and C7, M2, M3, M4, and M7, and V2 and V4. Similar profiles were observed in freshly isolated cerebral microvessels and primary cultured rat brain endothelial cells. Thrombin‐stimulated calcium influx in brain endothelial cells was blocked by transient receptor potential C inhibitors. Transient receptor potential V activating stimuli also increased intracellular calcium. This increase was inhibited by a transient receptor potential V blocker or by removal of extracellular calcium. Barrier integrity was compromised by thrombin, hypo‐osmolar stress, and PMA treatment. The increase in barrier permeability induced by transient receptor potential V activators was blocked by transient receptor potential V inhibition, while thrombin effects were inhibited by transient receptor potential C inhibitors.

Conclusions: These results demonstrate that transient receptor potential C and transient receptor potential V channels mediate calcium influx at the blood‐brain barrier, and as a consequence, may modulate barrier integrity.
Kank regulates RhoA-dependent formation of actin stress fibers and cell migration via 14-3-3 in PI3K–Akt signaling
Authors: Kakinuma Naoto , Roy Badal Chandra , Zhu Yun , Wang Yong , Kiyama Ryoiti
Published: May 2008

Phosphoinositide-3 kinase (PI3K)/Akt signaling is activated by growth factors such as insulin and epidermal growth factor (EGF) and regulates several functions such as cell cycling, apoptosis, cell growth, and cell migration. Here, we find that Kank is an Akt substrate located downstream of PI3K and a 14-3-3–binding protein. The interaction between Kank and 14-3-3 is regulated by insulin and EGF and is mediated through phosphorylation of Kank by Akt. In NIH3T3 cells expressing Kank, the amount of actin stress fibers is reduced, and the coexpression of 14-3-3 disrupted this effect. Kank also inhibits insulin-induced cell migration via 14-3-3 binding. Furthermore, Kank inhibits insulin and active Akt-dependent activation of RhoA through binding to 14-3-3. Based on these findings, we hypothesize that Kank negatively regulates the formation of actin stress fibers and cell migration through the inhibition of RhoA activity, which is controlled by binding of Kank to 14-3-3 in PI3K–Akt signaling.
Endoscopic Vascular Harvest in Coronary Artery Bypass Grafting Surgery: A Consensus Statement of the International Society of Minimally Invasive Cardiothoracic Surgery (ISMICS) 2005
Authors: Allen Keith , Cheng Davy , Cohn William , Connolly Mark , Edgerton James , Falk Volkmar , Martin Janet , Ohtsuka Toshiya , Vitali Richard
Published: May 2008

Objective

This purpose of this consensus statement was to compare endoscopic vascular graft harvesting (EVH) with conventional open vascular harvesting (OVH) in adults undergoing coronary artery bypass grafting (CABG) surgery and to determine which resulted in improved clinical and resource outcomes.

Methods

Before the consensus conference, the consensus panel reviewed the best available evidence, whereby systematic reviews, randomized trials, and nonrandomized trials were considered in descending order of importance. Evidence-based statements were created, and consensus processes were used to determine the ensuing statements. The AHA/ACC system was used to label the level of evidence and class of recommendation.

Results

The consensus panel agreed upon the following statements: 1. EVH is recommended to reduce wound related complications when compared with OVH (Class I, Level A). 2. Based on quality of conduit harvested, either endoscopic or open vein harvest technique may be used (Class IIa; Level B). 3. Based on major adverse cardiac events and angiographic patency at 6 months, either endoscopic or open vein harvest technique may be used (Class IIa; Level A). 4. EVH is recommended for vein harvesting to improve patient satisfaction and postoperative pain when compared with OVH in CABG surgery (Class I, Level A). 5. EVH is recommended for vein harvesting to reduce postoperative length of stay and outpatient wound management resources (Class I, Level A).

Conclusions

Given these evidence-based statements, the consensus panel stated that EVH should be the standard of care for patients who require saphenous vein grafts for coronary revascularization (Class I, Level B). Future research should address long-term safety, cost-effectiveness, and endoarterial harvest.
Thoracic Epidural Anesthesia for Coronary Bypass Surgery Affects Autonomic Neural Function and Arrhythmias
Authors: Yashiki Noriyoshi , Watanabe Go , Tomita Shigeyuki , Nishida Satoru , Yasuda Tamotsu , Arai Sadahiko
Published: May 2008

Background

In recent years, the invasiveness of coronary reconstruction has been markedly reduced. Awake off-pump coronary artery bypass (AOCAB), coronary bypass surgery with thoracic epidural anesthesia (TEA) without general anesthesia and cardiopulmonary bypass), has been reported in the literature. Because the details of this technique are still unclear, we evaluated its usefulness by examining the autonomic neural state and the incidence of arrhythmia.

Methods

Fifty-five patients who underwent elective coronary artery bypass grafting (CABG) between April and December 2003 were included in the study. Patients who underwent CABG under high TEA alone comprised group A, those who underwent CABG under general anesthesia combined with TEA comprised group B, and those who underwent CABG under general anesthesia alone comprised group C. Holter electrocardiography was performed before and after surgery, and perioperative electrocardiograms were recorded (before surgery and during surgery, postoperative days 0–3, and postoperative day 7). On obtained electrocardiograms, the autonomic neural state was evaluated by analysis of heart rate variability, and the incidence of atrial fibrillation.

Results

Concerning the autonomic neural state, sympathetic inhibition was observed during TEA in both groups A and B. After discontinuation of TEA, sympathetic activity recovered. Vagal activity was not inhibited in group A, but decreased during surgery and gradually recovered after surgery in group B. Evaluation of the balance between sympathetic and vagal activities showed that sympathetic activity became predominant rapidly on postoperative day 2 in group B but gradually after surgery in group A. The incidence of postoperative atrial fibrillation was the highest in group B.

Conclusions

In AOCAB, because there is no vagal inhibition, vagal dominance can be maintained after surgery. This may be associated with the lower incidence of postoperative atrial fibrillation in group A compared with group B. Further studies are necessary to evaluate the details of AOCAB.
Prospective Evaluation of the St. Jude Medical Aortic Connector for Aortic-to-Autologous Vessel Graft Anastomoses
Authors: Diegeler Anno , Setina Marek , Antona Carlo , Lakew Fitsum , Mokracek Alex , Scrofani Roberto , Eckstein Friedrich S. , Gibson Michael , Bonilla Luis , Carrel Thierry
Published: May 2008

Background

Evolving technologies of proximal anastomosis devices meet the endeavor of surgeons to minimize manipulation of the ascending aorta during surgical myocardial revascularization. The objective of this study was to compare the patency rate of the saphenous vein coronary bypass grafts in which the proximal anastomoses were performed with automatic connector devices to the suture technique.

Methods

From September 2002 through July 2003, 86 patients underwent coronary artery bypass grafting with at least 1 vein graft anastomosed to the ascending aorta with the Symmetry G2 connector. Six-month clinical and angiographic follow-up, including Core-Lab quantitative coronary angiography (QCA) and corrected TIMI frame count (CTFC), was performed.

Results

Eighty patients had at least 1 connector successfully implanted. Freedom from MACE (cardiac mortality myocardial infarction and target vessel reintervention) was 72/80 (90%). Six patients underwent a target vessel reintervention on the connector grafts. Six-month (mean 193 ± 36 days) angiography patency rates for the connector grafts were 72/81 (88.89%), 37/40 (92.5%) in sutured grafts, and 60/62 (96.8%) in arterial grafts. By QCA, 64/65 (98.5%) patent connector-grafts were free from more than 50% stenosis (1 connector-graft with a 51% stenosis). CTFC showed 65/65 (100%) patent connector-grafts with nonrestrictive flow.

Conclusions

Saphenous vein grafts anastomosed to the aorta with the Symmetry G2 connector have early and midterm patency rates comparable to the conventional sutured anastomoses. These results support the efficiency of the second generation of symmetry aortic connectors.
Concomitant Beating-Heart Mitral Valve Surgery and Coronary Artery Bypass in Patients with Compromised Ventricular Function
Authors: Di Luozzo Gabriele , Lombardi Pierluca , Maldonado Alberto , Ricci Marco , Salerno Tomas A.
Published: May 2008

Background

Surgical repair of mitral valve disease and concomitant coronary artery occlusive disease has high operative risk. Myocardial protection for protracted, complicated procedures is seminal to the overall operative outcome; specifically, preservation of left ventricular function.

Methods

The authors conducted a retrospective review of 25 patients undergoing combined mitral valve repair/replacement (MVR) and coronary artery bypass surgery (CABG) using the beating-heart technique at the Miller/University of Miami School of Medicine. The CABG was performed without cardiopulmonary bypass support. During the mitral valve surgery the perfusion pressure was maintained at 80–90 mm Hg and the systemic temperature at 35–36°C. The aorta was not cross-clamped.

Results

Twenty-five patients underwent MVR/CABG, including 7 patients with acute myocardial infarction. Preoperative echocardiograms revealed a mean ejection fraction (EF) of 41 ± 4.5%. One patient required a preoperative intraarterial balloon pump. An average of 2.12 ± 0.9 grafts and a total of 10 mitral valve repairs were performed. The average length of stay in the intensive care unit was 14 ± 1.8 days, and average hospitalization time was 23 ± 3. The mean postoperative EF was 41 ± 4.5%. The mortality in this patient group was 12 % (3/25) with a morbidity rate of 52% (13/25).

Conclusions

The data suggest that the technique is safe and reproducible, and that it potentially has a short-term benefit on left ventricular function. Therefore, this particular technique may be efficacious in patients with compromised left ventricular function requiring a combined MVR/CABG.
Thoracoscopic Lobectomy with the da Vinci Surgical System
Authors: Ishikawa Norihiko , Sun You Su , Nifong L. Wiley , Watanabe Go , Chitwood W. Randolph
Published: May 2008

Thoracoscopic upper lobectomy has been performed with the da Vinci surgical system in human cadavers. A minithoracotomy and two additional thoraco ports provided access to the thoracic cavity. An auxiliary port was used for both retraction of the lung and suction. The pulmonary vessels were ligated by robotic instruments, and the bronchi were divided after suturing robotically or with automatic staplers. A standard lymph node dissection was performed. The current da Vinci surgical system provided superior optics and enhanced dexterity. The application of the system for minimally invasive lobectomy may add benefits for both surgeon and patients.
Total Endoscopic Beating-Heart Coronary Artery Bypass Grafting using a New 3D Imaging System
Authors: Tomita Shigeyuki , Watanabe Go , Tabata Shigeki , Nishida Satoru
Published: May 2008

Objective

Since 1999, the authors of this study have performed total endoscopic beating-heart coronary artery bypass. They have developed a new three-dimensional (3D) endoscopic imaging system and have used it successfully in three patients.

Methods

From January 2004, a new 3D endoscopic imaging system was used. This device, composed of an optical high-resolution, 3D endoscope and two liquid crystal monitors, gives bright, natural, 3D imaging and enables quick, precise manipulation. After the 15-mm port for the 3D endoscope was inserted through fourth intercostal space (ICS) in the posterior axillary line, the left internal thoracic artery (LITA) was taken down endoscopically in semiskeletonized fashion, using two instrumental 5-mm ports (third and sixth anterior axillary ICS). The pericardium was then opened, and the left anterior descending artery was identified. Another 10-mm port for an endoscopic needle holder was inserted through fourth ICS in the midclavicular line. Three ports were placed in the fourth ICS in line for the anastomosis. An original suction stabilizer was inserted through the first instrumental port, and the left anterior descending artery was immobilized. A conventional end-to-side anastomosis was done with 8–0 Prolene running sutures.

Results

The average LITA harvesting time was significantly shortened from 68 minutes with two-dimensional imaging to 36 minutes with new 3D imaging. The average anastomotic time was shortened from 34 minutes with two-dimensional imaging and 27 minutes with former 3D imaging to 17 minutes with new 3D imaging. There were no complications and no operative deaths.

Conclusions

This new 3D endoscopic imaging system facilitates quick, precise anastomosis and is a useful device for endoscopic coronary bypass surgery.
Complete Repair of a Total Defect Type Aortopulmonary Window in an Extremely Low Birth Weight Neonate
Authors: Takasaki Tai-ichi , Miyaji Kagami , Ohara Kuniyoshi
Published: May 2008

The authors performed a complete repair for a total defect type aortopulmonary window (APW) in an extremely low birth weight neonate weighing 1.1 kg. The APW was repaired using an autologous pericardial patch. A novel cardiopulmonary bypass system with low priming volume allowed a safe surgery for the premature patient.
Simple Amiodarone Protocol Reduces Postoperative Atrial Fibrillation
Authors: Allen Keith B. , Heimansohn David A. , Robison Robert J. , Schier John J. , Griffith Gary L.
Published: May 2008

Background

Incorporating amiodarone into an existing postoperative atrial fibrillation (AF) prevention pathway may reduce postoperative AF and length of stay (LOS).

Methods

From July 2002 through December 2002, 476 consecutive cardiac surgical patients were managed with an AF prevention protocol using aggressive potassium replacement, intraoperative/ postoperative magnesium supplementation, and postoperative resumption of β-blockers. From January 2003 through June 2003, 592 additional patients were subjected to the same protocol except amiodarone was initiated intraoperatively (150 mg intravenously) and continued postoperatively until discharge (200 mg orally three times daily). Incidence of AF, postoperative LOS, and AF risk factors were collected prospectively and compared using regression models with propensity scores to adjust for dissimilarities between groups.

Results

Incorporating amiodarone into an existing AF protocol resulted in a 45% reduction in postoperative AF (29% [136/476] versus 16% [94/592], P < 0.0001). After adjustment for covariates and propensity score, the relative risk reduction with amiodarone in this protocol remained significant (P = 0.001, RR 0.65, 95% CI 0.5–0.8). Multivariate risks for postoperative AF included no amiodarone (P = 0.0001), age (P < 0.0001), ejection fraction <40% (P = 0.0005), ventilator support >24 hours (P = 0.002), no postoperative β-blocker (P = 0.002), and mitral valve procedure (P = 0.03). When postoperative AF did occur, risk adjusted LOS was less in patients on the amiodarone protocol (mean 9.4 days versus 13.1 days, P = 0.06). Readmission after discharge for any reason (10% [49/476] versus 8% [45/592], P = 0.1) or for AF (1.1% [5/476] versus 0.7% [4/592], P = 0.5) was similar between groups.

Conclusion

Amiodarone initiated intraoperatively followed by oral dosing significantly reduces postoperative AF and tends to reduce LOS if AF occurs.
Planned Simultaneous Beating-heart Totally Endoscopic Coronary Artery Bypass (TECAB) and Percutaneous Intervention in a Single Operative Setting
Authors: Srivastava Sudhir , Gadasalli Suresh , Tijerina Orlando , Barrera Reyna , Quismundo Shaune , Srivastava Vishwa
Published: May 2008

Background

Staged hybrid revascularization integrated with minimally invasive coronary artery bypass grafting (CABG) and arrested heart totally endoscopic CABG has been reported. We report the first case of planned simultaneous hybrid coronary revascularization, integrating beating-heart TECAB, and percutaneous intervention (PCI) in the same operative setting.

Methods

A 73-year-old woman with symptoms of angina and a history of diabetes was found to have 2-vessel coronary artery disease involving the left anterior descending (LAD) and the right coronary artery (RCA). Left internal thoracic artery (LITA) to the LAD grafting was done on a beating heart in a totally endoscopic manner using the da Vinci robotic system through 4 ports. Immediately after LITA to LAD TECAB, percutaneous angioplasty and stent placement was done through the right femoral artery using the OEC 9800 mobile C-arm in the operating room.

Results

There was no stenosis noted in the RCA after the intervention. LITA angiography showed a completely patent anastomosis. The total operative time for both procedures was 165 minutes. Occlusion and anastomotic times were 14 and 8 minutes, respectively. Total PCI and fluoroscopy times were 10 and 3 minutes, respectively. The patient received clopidogrel (Plavix) and aspirin in the immediate postoperative period and was discharged home on the second postoperative day.

Conclusion

This planned hybrid approach involving a beating-heart single-vessel TECAB and simultaneous angioplasty-stent in a single operative setting achieved complete coronary artery revascularization in a less invasive way.
Off-Pump Coronary Artery Bypass Leads to a Regional Hypercoagulable State Not Detectable Using Systemic Markers
Authors: Kon Zachary N. , Kwon Michael H. , Collins Michael J. , Kallam Seeta , Sangrampurkar Rupali , Ozeki Toshinaga , Brown Emile N. , Romar Linda G. , Pierson Richard N. , Gammie James S. , Brown James M. , Griffith Bartley P. , Poston Robert S.
Published: May 2008

Objective

It is believed that off-pump coronary artery bypass grafting (OPCAB) leads to hypercoagulability, but efforts to document such a state have been unrevealing. We hypothesized that OPCAB increases the risk of developing a regional hypercoagulable state.

Methods

Blood was obtained from the aorta and coronary sinus (CS) after CABG performed off- (N = 69) or on-pump (N = 35) to determine the transcardiac gradients of F1.2 (thrombin production), XIIa (coagulation activation), myoglobin (ischemia) and IL-6, IL-8 using ELISA and platelet-derived microparticles using FACS. Platelet function was measured using aggregometry. Regional myocardial pH and SVG flow were recorded intraoperatively. SVG biopsies were analyzed for endothelial integrity (EI) using immunohistochemistry and graft patency was determined by predischarge CT angiography.

Results

Compared with on-pump, OPCAB provoked significantly higher transcardiac F1.2 (117±200 v. 31±38%), FXII-a (14±29 v. 2±4%), microparticles (14± −9.5% v. 6.4±—4.1%), IL-6 (119±183 v. 28±39%), and a trend toward increased IL-8 (67±94 v. 24±46%, P = 0.077). Myoglobin release after OPCAB, also greater than on-pump CABG (54±89 v. 8±14%, P < 0.01), correlated with regional pH change (R = −0.96, P < 0.0001), and F1.2 release (R = 0.55, P = 0.0002). In contrast, systemic changes in these markers were all less after OPCAB. SVG flow was significantly reduced in OPCAB (39.4 versus 66.5 mL/min, P = 0.0002), but EI and graft patency rates were the same.

Conclusions

Through the use of transcardiac assays, we illustrated that regional coagulation was enhanced after off- compared with on-pump CABG. If the findings of this pilot study are confirmed, OPCAB may require additional antithrombotic therapies to respond to this local hypercoagulable state.
Starfish™ Heart Positioner Maintains Right Ventricular Function During Lateral Wall Displacement
Authors: Ishikawa Nobuki , Watanabe Go , Ohtake Hiroshi , Terada Takuro
Published: May 2008

Background

The authors examined parameters of cardiovascular function using Starfish and deep pericardial sutures (DPS) in a beating heart porcine model and to clarify toleration of right ventricular function with Starfish in lateral wall displacement.

Methods

Eight healthy pigs were used. In addition to normal pressure monitor catheters, a Swan-Ganz continuous cardiac output (CO) and end diastolic volume thermodilution catheter was used for precise and quantitative monitoring of the right ventricular function.

Results

Lateral displacement of the heart with DPS resulted in a significant hemodynamic compromise. Cardiac output and right ventricular ejection fraction (RVEF) decreased from 3.0 ± 0.9 to 2.6 ± 1.0 L/min (P = 0.014) and from 27.9 ± 3.0% to 23.3 ± 4.8% (P = 0.019). With Starfish™, CO and RVEF were maintained from 3.0 ± 0.9 to 3.0 ± 0.9 L/min (P = 0.743) and from 27.9 ± 3.0% to 28.3 ± 3.8% (P = 0.476).

Conclusion

Starfish™ contributed to the stability of hemodynamics by maintaining the right ventricular function. Lateral displacement with PDS resulted in significant hemodynamic compromised compared with Starfish™ and baseline neutral position.
Off-Pump versus Conventional Coronary Artery Bypass Grafting: A Meta-Analysis and Consensus Statement from the 2004 ISMICS Consensus Conference
Authors: Puskas John , Cheng Davy , Knight John , Angelini Gianni , DeCannier Didier , Diegeler Anno , Dullum Mercedes , Martin Janet , Ochi Masami , Patel Nirav , Sim Eugene , Trehan Naresh , Zamvar Vipin
Published: May 2008

Background

The purpose of this evidence-based consensus statement is to systematically review and meta-analyze the randomized and nonrandomized evidence comparing off-pump (OPCAB) to conventional coronary artery bypass (CCAB) surgery and to provide consensus on the role of OPCAB in low- and high-risk surgical patients.

Methods and Results

This consensus conference was conducted according to the American College of Cardiology (ACC)/American Heart Association (AHA) standards for development of clinical practice guidelines. The Steering Committee collated all published studies of OPCAB versus CCAB through May 2004 and developed six questions central to controversies surrounding OPCAB surgery in mortality, morbidity, and resource utilization. For mixed-risk patient populations, meta-analysis of 37 randomized clinical trials (3,369 patients, Level A) reported across a total of 53 papers, and two meta-analyses of nonrandomized trials (Level B) comparing OPCAB versus CCAB were identified. For high-risk patient populations, we performed a meta-analysis of 3 randomized and 42 nonrandomized trials (26,349 patients, Level B).

Conclusion

Meta-analysis of Level A and B evidence provided the basis for the following consensus statements in patients undergoing surgical myocardial revascularization: (1) OPCAB should be considered a safe alternative to CCAB with respect to risk of mortality [Class I, Level A]; (2) With appropriate use of modern stabilizers, heart positioning devices, and adequate surgeon experience, similar completeness of revascularization and graft patency can be achieved [Class IIa, Level A]; (3) OPCAB is recommended to reduce perioperative morbidity [Class I, Level A]; (4) OPCAB may be recommended to minimize midterm cognitive dysfunction [Class IIa, Level A]; (5) OPCAB should be considered as an equivalent alternative to CCAB in regard to quality of life [Class I, Level A]; (6) OPCAB is recommended to reduce the duration of ventilation, ICU and hospital stay, and resource utilization [Class I, Level A]; (7) OPCAB should be considered in high-risk patients to reduce perioperative mortality, morbidity, and resource utilization [Class IIa, Level B].
Transabdominal Off-Pump Coronary Artery Bypass Grafting Using the Right Gastroepiploic Artery
Authors: Tavilla Giuseppe
Published: May 2008

Background

Anastomosis of the right gastroepiploic artery to vessels of the inferior wall of the heart can be performed using a transabdominal approach without sternotomy and without cardiopulmonary bypass.

Methods

From July 1999 to December 2004, 18 patients presenting with only right coronary artery disease were operated on by the transabdominal approach using a pedicled right gastroepiploic artery graft. In 14 patients, it was a redo operation. In all redo patients, a patent graft to the anterior wall was present. Median EuroSCORE was 5 (range 1–13). The right descending posterior artery was grafted in 10 patients, the right coronary artery in 8 patients.

Results

There was no hospital mortality and no conversion to sternotomy. Hospital morbidity consisted only of a right pleural hemothorax and a superficial wound infection. No blood transfusion was necessary in 16 (89%) patients. Hospital stay averaged 6 days. Follow-up is complete and averaged 2 years (range 0.5–5.5 years). There was no late mortality. Seventeen patients (94%) were asymptomatic. One patient who experienced return of angina 1 year after the procedure underwent a percutaneous transluminal coronary angioplasty of the right coronary artery. Thirteen patients underwent a stress test at median follow-up of 14 months without signs of myocardial ischemia.

Conclusions

Off-pump coronary bypass grafting using a right gastroepiploic artery by the transabdominal approach is a safe and effective procedure with a low hospital morbidity and excellent follow-up. In redo operations, this technique excludes the risk of damaging patent grafts to the left coronary system.
Cardioscopic Trans-septal Cryoablation of Left Atrium in Nonmitral Cases
Authors: Ohtsuka Toshiya , Ninomiya Mikio , Maemura Taisei
Published: May 2008

Background

A modified maze procedure in which trans-septal cardioscopy was used for cryoablation in the left atrium is described.

Methods

The technique was used in 11 consecutive patients (9 men and 2 women, 56.5 ± 19.8 years) with permanent atrial fibrillation (Af) and concomitant nonmitral cardiac or aortic disease: aortic valvular disease in 4 patients, atrial septal defect (ASD) in 2 patients, tricuspid regurgitation in 2 patients, acute aortic dissection in 1 patient, arch aneurysm in 1 patient, and coronary artery disease in 1 patient. The mean Af duration detected in 7 cases was 18.5 ± 10.1 months. Partial sternotomy was used in aortic valve replacement, ASD closure, and tricuspid valve plasty, and fullsternotomy was used in aortic graft replacement and coronary artery bypass. Cardiopulmonary bypass was established, aortic cross-clamp was performed, a right atriotomy was created, a cryoablation probe and cardioscope (3 mm) were introduced into the left atrium through a 1-cm cut at the fossa ovalis or ASD, and cardioscopic left-atrial endocardial cryoablation was performed. The right-side maze procedure was conducted directly. The atrial appendages were excised in each case.

Results

Left-atrial cardioscopic cryoablation required 25.0 ± 5.5 minutes, and no deaths or procedure-related morbidities occurred. The mean follow-up period was 12 ± 8.5 months. One patient with tricuspid regurgitation died of liver failure. With the exception of coronary and acute dissection cases, all patients have maintained a sinus rhythm.

Conclusion

Although experience is limited, videocardioscopic trans-septal left-atrial cryoablation is a viable method for nonmitral Af cases, and the partial sternotomy approach can be performed.
Endoscopic Lesser Saphenous Vein Harvesting for Coronary Artery Bypass Grafting: First Reported Case
Authors: Nickum Christopher W. , Dullum Mercedes KC. , Boyd W. Douglas , Gray Dana R.
Published: May 2008

Endoscopic vessel harvesting has become a widely used modality for harvesting venous and arterial conduits for coronary artery bypass grafting. Specifically, it has been used to harvest the greater saphenous vein, internal thoracic artery, and the radial artery. A case of endoscopic lesser saphenous vein harvesting for coronary artery bypass grafting is reported.
Intermediate-Term Results of 505 Consecutive Minithoracotomy Mitral Valve Procedures
Authors: Martin Jeffrey S. , Davis R. Duane , Glower Donald D.
Published: May 2008

Background

Patient demand for less invasive surgery and interest in avoiding sternotomy has led to the increased use of the minithoracotomy for mitral valve surgery. Although the feasibility of this approach has been established, few data are available regarding intermediate-term results.

Methods

A total of 505 consecutive minithoracotomy mitral valve procedures performed between 1996 and 2004 were analyzed. Procedures were mitral replacement (191/505, 38%) and repair (314/505, 62%). Concomitant cardiac procedures were performed in 78 cases (13%) (maze 36, tricuspid 29, atrial septal defect/patent foramen ovale 13) and reoperation in 92 cases (18%). Arterial cannulation was ascending aorta in 403 cases (80%), femoral in 101 cases (20%), and axillary in 1 case (< 1%). An endoluminal aortic clamp was used in 406 cases (80%), an external clamp was used in 19 cases (4%), and 80 procedures (16%) were performed with ventricular fibrillation. Robotic assistance was used in 12 cases (2%).

Results

Mean patient age was 58.7 years (range 18–90 years). Median follow-up was 3.1 years. Operative mortality was 4 of 505 cases (<1%). Major complications included stroke in 7 cases (1%) and reoperation for bleeding in 18 cases (4%); there were no cases of mediastinitis. Late complications included chronic aortic dissection in 1 case (<1%) and mitral reoperation in 13 cases (3%) (subacute bacterial endocarditis 6, failed repair 2, other 5). Five-year survival was (83% ± 2%) and freedom from mitral reoperation was (96% ± 1%). Follow-up echocardiograms were available in 246 of 314 cases (78%) mitral repairs and mean mitral regurgitation grade was 1 ± 1. Mitral regurgitation was grade 3–4+ in 14 of 246 cases (6%) (subacute bacterial endocarditis 4, low ejection fraction 5, other 5). Five-year freedom from 3–4+ mitral regurgitation was 89% ± 3%.

Conclusions

Mitral valve surgery via minithoracotomy can be performed safely with a low perioperative complication rate. A durable technical result and excellent long-term survival can be expected.
Midterm Follow-up of Robotic Biventricular Pacing Demonstrates Excellent Lead Stability and Improved Response Rates
Authors: DeRose Joseph J. , Balaram Sandhya , Ro Charles , Swistel Daniel G. , Steinberg Jonathan S. , Joshi Sandeep , Ashton Robert C.
Published: May 2008

Background

Robotically assisted left ventricular (LV) lead placement is an effective minimally invasive rescue procedure for cardiac resynchronization in the setting of failed coronary sinus lead insertion. The long-term response rate and durability of this technique has not been reported. The authors evaluated the midterm outcome of biventricular pacing performed with robotically placed LV leads.

Methods

Forty-two patients underwent implantation of LV epicardial leads using robotic assistance and the posterior approach. Half of the patients had prior cardiac surgery. All leads were placed in an optimal site along the posterolateral surface of the LV. The patients were prospectively followed up for clinical response, LV reverse remodeling, and LV lead stability over a mean period of 16.7 ± 9.5 months (range, 3–34 months). A multivariate Cox proportional hazards model was used to determine predictors of response.

Results

All patients had successful LV lead placement with no postoperative mortality. Statistically significant improvements in left ventricular ejection fraction, NYHA heart failure class, systolic left ventricular internal dimension index, and diastolic left ventricular internal dimension index. The 3-month clinical response rate was 81% and dropped to 71% at average maximal follow-up. Multivariate analysis of 9 variables revealed only LVEF greater than 15% and absence of pulmonary hypertension to be predictors of response. No difference in operative time, response rate, or LV lead stability was detected when primary versus reoperative cases were compared.

Conclusions

Robotic LV lead placement is a reliable technique for optimal lead placement with durable long-term results.
Three-Year Experience with Totally Endoscopic Robotic Thymectomy
Authors: Ro Charles Y. , DeRose Joseph J. , Connery Cliff P. , Balaram Sandhya K. , Ashton Robert C.
Published: May 2008

Background

Robotic technology has facilitated the evaluation and treatment of anterior mediastinal pathology. We describe a 3-year experience using the da Vinci Robotic Surgical System to perform thymectomies for a range of diseases.

Methods

From March 2002 to November 2004, 9 patients (3 myasthenia gravis, 3 mediastinal mass, 2 myasthenia gravis plus thymoma, 1 hyperparathyroidism) underwent totally endoscopic robotic thymectomy. Medical records and operative databases were reviewed. The cohort was divided into an early experience (group A) and a later experience (group B). Data were analyzed with the Fisher exact test and Mann-Whitney test.

Results

Complete robotic resection of the thymus was accomplished in all 9 patients. The mean age for the entire cohort was 40 ± 12 years (range 28–66 years) and 78% of the patients were women. No significant differences in age, gender, or operative conversions were detected between the groups. Patients in group A were more likely to have a bilateral approach. Group B demonstrated statistically significant reductions in operating room and operation time and a trend toward decreased chest tube days and length of stay. No morbidity or mortality associated with the procedure was noted in either group.

Conclusions

Robotic thymectomy is a safe and effective procedure. Its steep learning curve promises to allow more surgeons to adopt minimally invasive approaches to the mediastinum safely and efficiently.
Robotic Replacement of the Descending Thoracic Aorta: An Alternative to Endovascular Therapy?
Authors: Porat Eyal E. , Herrera Peter D. , Sheinbaum Roy , Estrera Anthony L. , Huynh Tam T.T. , Azizzadeh Ali , Meada Riad , Miller Charles C. , Safi Hazim J.
Published: May 2008

Background

Replacement of the descending thoracic aorta is traditionally performed via a left thoracotomy. Endovascular treatment of descending thoracic aortic aneurysms has recently evolved as an alternative treatment for selected patients, yet no long-term results are available. The authors replaced the descending thoracic aorta in a group of pigs with an interposition Dacron graft using a closed-chest, totally robotic technique.

Methods

Ten pigs, weighing 25 to 45 kg, underwent surgery using the DaVinci robotic surgical system. Under single-lung ventilation and CO2 insufflation, the descending thoracic aorta was completely mobilized. Proximal and distal cross-clamps were applied through separate accessory stab wounds. The mid-descending thoracic aorta was excised. An interposition Dacron graft was robotically sewn in an end-to-end fashion to the descending thoracic aorta using interrupted nitinol clips.

Results

All animals survived the procedure. Mean aortic clamp time was 55 ± 14 minutes. All anastomoses were completed without difficulty with a mean total anastomotic time of 42 ± 11 minutes. The anastomoses were challenged for bleeding by administrating α1-adrenergic receptor agonists to a systolic blood pressure of 200 mm Hg with no evidence of leak.

Discussion

Robotic replacement of the thoracic aorta is feasible and reproducible. This procedure provides the standard Dacron graft repair with its known long-term results. The added value of robotic technology to the therapeutic armamentarium in the treatment of thoracic aortic aneurysms may be worth the effort required for procedural development. Furthermore, it may serve as a valid alternative to endovascular treatment of thoracic aortic aneurysms.
Clinical Application of an Original Flexible MK Stent-Graft for Nonruptured Thoracic Aortic Aneurysms: Early Experience
Authors: Ohtake Hiroshi , Kimura Keiichi , Watanabe Go , Sanada Junichiro , Matsui Osamu
Published: May 2008

Objective

To obtain early MK stent-grafting results for nonruptured thoracic aortic aneurysms and thoracoabdominal aortic aneurysms.

Methods

The authors analyzed 47 patients who underwent treatment using MK stent-grafting. All patients (40 men and 7 women; mean age, 70.8 years) underwent elective procedures. Straight, curved, or tapered MK stents were constructed from a nitinol wire and covered with seamless, cylindrical woven polyester fabric grafts. The mean stent-graft diameter was 24 to 48 mm. In cases where the aneurysm had a short proximal neck (under 15 mm), supraaortic arch artery bypass surgery was planned to lengthen the neck.

Results

Simple stent-grafting without bypass was performed in 26 patients, whereas stent-grafting with supraaortic arch artery bypass was performed in 21 patients. An 18 or 20 F sheath was used as the delivery system in 46 patients (96%). In all 47 patients, the stent-grafts were successfully deployed. Two patients died while in hospital, and another 2 patients suffered a stroke. No other perioperative complications were observed. Postoperative computed tomography after 3 months showed complete thrombus formation in 42 patients (93.3%; 42/45 patients).

Conclusions

Forty-seven patients with thoracic aortic aneurysm were treated with our original flexible MK stent-graft system. Using a small sheath system, straight or curved M-K stent-grafts could be deployed to adequately fit to the aorta as planned. Furthermore, simultaneous bypass surgery widened the application of stent-grafting. However, careful long-term observation is necessary, and further studies are needed to assess such stent-grafting with bypass surgery.
A New Multisuction Cardiac Positioner for Multivessel Off-Pump Coronary Artery Bypass Grafting
Authors: Arai Hirokuni , Mizuno Tomohiro , Yoshizaki Tomoya , Itoh Fusahiko , Oi Keiji , Someya Takeshi , Tanaka Hiroyuki , Sunamori Makoto
Published: May 2008

Objective

To accomplish successful multivessel off-pump coronary artery bypass grafting, safe, reproducible, and effective exposure of all coronary territories is essential. For this purpose, we developed a new, simple, multisuction cardiac positioner.

Methods

This new cardiac positioner consists of 3 small independent suction cups and suction tubes made of silicone. Unlike an apical suction cardiac positioner, this positioner has no arm. The suction cups can be applied with negative pressure of 300 mm Hg to various surfaces of the ventricle, including not only the apex but also the lateral, inferior, and right ventricular walls, according to surgeon preference. We applied this positioner in 15 clinical multivessel off-pump coronary artery bypass procedures.

Results

In all cases, all target vessels including those on the lateral or inferior wall were successfully exposed and grafted without hemodynamic compromise. Surgical exposure, especially on the lateral and inferior walls, was quite similar to that of conventional coronary artery bypass graft procedures performed during cardiopulmonary bypass.

Conclusions

The multisuction cardiac positioner provided reproducible and easy access in multivessel off-pump coronary artery bypass surgery. This simple, variable, and inexpensive cardiac positioner may be used as a new tool to aid in the performance of successful multivessel off-pump coronary artery bypass surgery.
Single Venous Return for Mitral Valve Operations
Authors: Gammie James S. , Vander Salm Thomas J.
Published: May 2008

Objective

Most cardiac surgeons routinely perform bicaval venous cannulation for mitral valve operations. We describe the technique and advantage of a single-venous cannulation strategy.

Methods/Results

Single venous cannulation with a 29-French small-bore cannula (facilitated by vacuum-assisted venous drainage) yields reliable decompression of the right heart and affords outstanding exposure of the mitral valve.

Conclusions

We recommend and use this technique for all mitral valve operations not requiring opening the right atrium.
Autonomic Ganglionated Plexi: Characterization and Effect of Epicardial Microwave Ablation in a Canine Model of Vagally Induced Acute Atrial Fibrillation
Authors: Balkhy Husam H. , Hare John , Sih Haris J.
Published: May 2008

Objective

Autonomic ganglionated plexi (GP) in fat pads near the pulmonary veins may contribute to initiation and maintenance atrial fibrillation (AF). We attempted to localize these plexi in a canine model, and evaluate the efficacy of microwave ablation in eliminating their vagal reflexes.

Methods

8 Mongrel dogs (25–31 kg), underwent cervical vagal trunk stimulation to produce AV nodal block and sustained AF. Sternotomy was performed and the epicardial fat on the posterior left atrium and pulmonary veins was locally stimulated at high-frequency (20 Hz, 3–5 mA). Locations that produced a vagal response were identified and in 7 dogs ablated using the Flex 4 epicardial microwave ablation probe (Guidant Corp) at 65 watts/90 sec. One animal was a control and not ablated. Vagal responses were retested with local stimulation as well as stimulation of the cervical vagal trunks. The presence of AV block and duration of sustained AF was recorded.

Results

Baseline cervical vagal stimulation produced AV block and AF in all the animals. Local high-frequency stimulation (HFS) elicited vagal responses at the junction of the inferior vena cava and the middle pulmonary vein (IVC-MPV) in 8 animals, the base of the left pulmonary veins/ligament of Marshall (LoM) in 5 animals, and between the upper and lower right pulmonary veins (RPV) in 2 animals. Microwave ablation at the IVC-MPV eliminated the vagal response upon local fat pad HFS. Cervical vagal trunk stimulation yielded less AV block (n = 2) or no AV block (n = 5) after microwave ablation of the IVC-MPV alone (n = 4) or in conjunction with LoM area ablation (n = 3). The average duration of AF during cervical vagal stimulation decreased significantly from baseline (52.7 ± 27.0 sec) versus after fat pad ablation (13.8 ± 20.3 sec, p = 0.004).

Conclusions

In a canine model we found the primary epicardial autonomic ganglionated plexi to be at the junction of the IVC-MPV. Epicardial microwave ablation of this GP eliminated the vagal response during local fat pad stimulation; and attenuated or eliminated AV block and induction of sustained AF during cervical vagal trunk stimulation. Epicardial microwave ablation of the ganglionated plexi in epicardial fat pads is feasible and can eliminate vagal reflexes that maybe important in atrial fibrillation.
Incidence of Residual Clot Strands in Saphenous Vein Grafts after Endoscopic Harvest
Authors: Burris Nicholas , Schwartz Kimberly , Brown Jamie , Kwon Michael , Pierson Richard , Griffith Bartley , Poston Robert
Published: May 2008

Objective

Strands of clot are frequently flushed out of saphenous vein grafts (SVG) during preparation for grafting, particularly those that are endoscopically harvested. However, saline distention at uncontrolled pressures increases graft thrombogenicity and the risk of early failure after coronary artery bypass grafting. The purpose of this prospective investigation was to define the incidence of intraluminal clot within endoscopically harvested SVG and the effect of attempted removal by saline distention.

Methods

Endoscopically harvested SVG were intraoperatively prepared for grafting by using saline distention at uncontrolled pressure (n = 24) or without distension (n = 20). Optical coherence tomography, a catheter-based infrared imaging system, was used to identify and characterize intraluminal clot strands in surplus SVG segments (average length for analysis, 4.9 ± 2.6 cm). These segments were also assessed for luminal tissue factor activity and percent endothelial integrity by CD31-directed immunohistochemistry.

Results

Clot strands were observed in 45.4% (20 of 44) of imaged SVG segments (severity of observed clots: 54%, mild; 32%, moderate; 14%, severe). Compared with grafts distended with saline, vein segments that were not distended displayed significantly higher endothelial integrity (60.1% ± 27.2% versus 24.7% ± 24.1%, P < 0.05) and lower tissue factor activity (1.28 ± 0.95 versus12.3 ±5.5 U/cm2, P < 0.001) despite having a higher incidence of clot stands (65.0% versus 29.1%, P < 0.02, Fisher exact test). Static flow was observed in veins during endoscopic harvest.

Conclusions

Clot strands of varying severity are a common finding after endoscopic vein harvest. Saline distention is not completely effective in removing clot strands and increases overall graft thrombogenicity. Therefore, prevention of clot or less traumatic methods of removing clot are indicated.
Predictors of Early Postoperative Atrial Fibrillation after Off-Pump Myocardial Revascularization
Authors: Prapas Sotirios , Karatza Dimitra C. , Panagiotopoulos Ioannis , Kotsis Vassilios , Protogeros Dimitrios , Kouri Eleni , Katinioti Anastasia , Michalopoulos Argyris
Published: May 2008

Objective

We determined the incidence and the predisposing factors of atrial fibrillation (AF) after aorta nontouch coronary artery bypass grafting without extracorporeal circulation.

Methods

From February 2001 to November 2005, 1359 patients (1159 men, 85.3%) of mean (±SD) age 64.8 (±9.8) years, who underwent off-pump coronary artery bypass grafting (OP-CAB), were prospectively enrolled. Demographics, perioperative data, and comorbidities were recorded in all patients. A 24-hour rhythm monitoring was performed in all patients until hospital discharge.

Results

Among 1359 patients, 273 (20.1%) had development of atrial fibrillation in the early postoperative period. Patients with AF had higher mean (±SD) age, 68.3 (±8.8) years, compared with control subjects [63.9 (± 9.9)] (P ≤ 0.0005). Univariate analysis showed that apart from age, history of arterial hypertension (P ≤ 0.02), chronic obstructive pulmonary disease (P ≤ 0.02), and the use of bilateral internal mammary arteries (P≤< 0.01) were predisposing factors for the development of AF. Logistic regression analysis showed that age, history of arterial hypertension, and the use of bilateral internal mammary arteries were predisposing factors for early postoperative AF after OP-CAB.

Conclusions

Atrial fibrillation occurred in approximately 20% of patients undergoing OP-CAB, mainly in older patients with arterial hypertension who received bilateral internal mammary artery grafts.