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Ann Thorac Surg 2006;82:744-746
© 2006 The Society of Thoracic Surgeons
The Heart Team, Centennial Medical Center, Nashville, Tennessee
Accepted for publication October 18, 2005.
* Address correspondence to Dr Brunsting, 2400 Patterson St, Suite 223, Nashville, TN 37203 (Email: lab.theheartteam{at}comcast.net).
| Drs Brunsting and Binford and Ms Braly disclose that they have a financial relationship with Intuitive Surgical and Cardiogenesis.
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Transmyocardial laser revascularization (TMR) applied through a left limited thoracotomy is a therapeutic option in patients with medically refractory, severe angina due to diffuse, late-stage ischemic heart disease that is not amenable to treatment using percutaneous coronary interventions or coronary artery bypass graft surgery [1]. Peer-reviewed research identifies denervation as an explanation for the early relief of symptoms seen in some patients, with angiogenesis becoming the dominant mechanism in the months that follow due to the development of mature collateral vessels in the treated regions [2]. Clinically, in the Food and Drug Administration's approved trial involving sicker class IV patients, this translated into sustained and significantly superior angina relief through 5 years in patients receiving TMR compared with medical therapy, with a corresponding survival benefit [3]. Recently, initial clinical feasibility and safety of a closed chest thoracoscopic approach to sole therapy TMR has been demonstrated using the original Food and Drug Administration's approved holmium:yttrium–aluminum–garnet laser and delivery system [4].
Totally endoscopic cardiothoracic surgery on the beating heart with the aid of the da Vinci surgical system (Intuitive Surgical, Inc, Sunnyvale, CA) is a rapidly evolving field. Experimental studies have shown the feasibility, precision, and safety of totally endoscopic, robotically-assisted, off-pump TMR using an optimized, flexible fiberoptic holmium:yttrium–aluminum–garnet laser delivery system deployed with the da Vinci system to create transmural channels in all targeted areas of the left ventricle [5]. Because of the demonstrated clinical benefits of TMR to carefully select patients, and the demonstrated feasibility of totally endoscopic robot-assisted techniques, it is reasonable to expect enhanced patient experience postoperatively using the combination of these advanced technologies.
A 58-year-old man with a body mass index of 23.5 and severe ischemic heart disease was evaluated for totally endoscopic TMR. He had suffered 10 prior myocardial infarctions and undergone angioplasty with stenting followed by quadruple bypass grafting and subsequent redo bypass in the past 9 years. He has a long history of renal disease, chronic obstructive pulmonary disease, hypothyroidism, and hyperlipidemia, and has become progressively debilitated to the point of being unable to work or engage in routine daily activities. He was treated with maximally tolerated medications without abatement of persistent New York Heart Association functional class IV anginal symptoms.
Preoperatively, reversible myocardial ischemia was demonstrated in the left ventricular apex by gated tomographic myocardial perfusion study with dobutamine stress testing. Ejection fraction was 57%. Due to the patient's history and the nature and severity of the disease, both cardiology and cardiothoracic surgery consults determined him to be a no option patient. Transmyocardial laser revascularization was recommended according to the Food and Drug Administration's approved protocol that assesses safety of the modified fiberoptic delivery system specifically designed for totally endoscopic robot-assisted use. The institutional review board approved the protocol and procedure, and the patient provided written informed consent.
Ventilation was accomplished with a double lumen endotracheal tube. Transesophageal echocardiography was performed to confirm channel transmurality (by observing left ventricular microbubbles) and to assess left ventricular function. The patient was placed in right lateral decubitus position with his arms bent at 90 degrees, and the operative table was angled at 45 degrees with the patient's head toward the robotic surgical cart. Four thoracoscopic ports were inserted as follows: (1) a 12-mm port in the seventh intercostal space, posterior axillary line, through which a 10-mm zero angle videoscope was inserted; (2) the da Vinci 8-mm right arm instrument port in the seventh intercostal space, posterior axillary line (just anterior to the scapular tip); (3) the da Vinci 8-mm left arm instrument port in the seventh intercostal space, mid-axillary line; and (4) a 5-mm port at the fifth intercostal space, mid-axillary line. This site was used for introduction of the fiberoptic TMR delivery system (Cardiogenesis Corp, Foothill Ranch, CA). The pericardium was opened 2 to 3 cm anterior to the phrenic nerve from the atrial appendage to the apex. Curved robotic scissors were used to expose the distal two thirds of the left ventricular free wall. Twenty-five transmural channels were placed approximately 1 cm apart in the left ventricle free wall, treating the apical (n = 10), anterior (n = 6), anterolateral (n = 6), and posterolateral (n = 3) segments. Flexible handpiece manipulation using the Cadiere instrument in the right arm and a Debakey instrument in the left arm allowed firm and perpendicular contact between the distal tip and epicardium (Fig 1). Hemostasis was achieved with gentle pressure over bleeding channels using robotic instruments or by holding the pericardium closed. The inferior region in this patient was not treated, and the posterolateral region was treated with only three channels to avoid potential injury to a patent sequential saphenous vein graft supplying the posterior descending and posterolateral coronary arteries. Subsequent patients have had all regions treated, with up to 47 channels per patient. All regions of the left ventricle were accessible without need for positioning devices or rotation among ports. No complications occurred during the procedure. At the completion of the 173-minute surgery, the pericardium was closed with two 3-0 Gore-Tex sutures (W.L. Gore & Assoc, Flagstaf, AZ). The left pleural space was drained for 48 hours with a 28-French chest tube placed through the left arm instrument port site. Intercostal blocks were performed at each port site with ropivacaine. The patient was extubated in the operating room. His intensive care unit and hospital length of stay were 20.5 hours and 2 days, respectively. At 30 days follow-up, he was asymptomatic with no anginal symptoms and no delayed complications.
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