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Objectives: Hybrid coronary revascularization, performing a left internal thoracic artery (LITA) to left anterior descending (LAD) bypass followed by percutaneous coronary intervention (PCI) in a non-LAD coronary artery lesion, represents an evolving revascularization strategy. It utilizes the survival benefit of the LITA-to-LAD bypass, while providing complete revascularization with PCI to a non-critical vessel to decrease procedural morbidity. However, quantitative patency results and clinical outcomes remain understudied. The objective of this study was to assess clinical follow-up and graft and stent patency at 6 months and 5 years in a single-stage hybrid revascularization population., Methods: From 2004 to 2012, a total of 96 patients (64 ± 12 years; 70 males and 26 females) consented to robotic-assisted LITA harvesting and a small left anterior thoracotomy for off-pump coronary artery bypass anastomosis onto the LAD. This was followed immediately by PCI in a non-LAD vessel in the same fluoroscopy-equipped hybrid operating room. Patients underwent a yearly clinical follow-up and a protocol-directed assessment of graft patency via a coronary angiogram at 6 months and cardiac computed tomography (CT) angiography with single-photon emission computed tomography myocardial perfusion scintigraphy (MPS) at 5 years., Results: Successful single-stage hybrid revascularization occurred in 94 of the 96 patients (2 patients required intraoperative conversion to conventional coronary bypass). Six-month protocol coronary angiogram follow-up has been performed in 85 patients. Fitzgibbon Grade A or B LITA-to-LAD patency at 6-month follow-up was 94% in those studied. A total of 105 stents were deployed (89 drug-eluting stents (DES) and 16 bare metal), and at 6-month follow-up in 85 patients, 79 stents were widely patent; 8 had in-stent restenosis, and 2 were completely occluded. To date, 19 patients have undergone 5-year coronary CT angiography and MPS. The LITA-to-LAD anastomosis was patent in 17 of the 19 patients. Of the 19 lesions in which PCI was performed, 17 were widely patent, while 2 circumflex DES were occluded. Five-year clinical outcome demonstrated 91% survival, 94% freedom from angina and 87% freedom from any form of coronary revascularization., Conclusions: A single-stage hybrid revascularization strategy appears to have acceptable 6-month and angiographic patency results for both LITA-LAD grafts and PCI interventions. Survival, freedom from angina and freedom from revascularization also appear favourable at the 5-year clinical follow-up.

Objective: The aim of this study was to compare the early systemic inflammatory response of the Resting Heart System (RHS; Medtronic, Minneapolis, MN USA), a miniaturized cardiopulmonary bypass (CPB) system, with two groups using a standard extracorporeal circulation system during on-pump coronary artery bypass grafting (CABG) surgery., Methods: A total of 60 consecutive patients requiring CABG were prospectively randomized to undergo on-pump CABG using conventional CPB without cardiotomy suction (group A), conventional CPB with cardiotomy suction (group B), or the RHS (group C). Blood samples were collected at five time points: immediately before CPB, 30 minutes into CPB, immediately at the end of CPB, 30 minutes post-CPB, and 1 hour post-CPB. Inflammation was analyzed by changes in (a) levels of plasma proteins, including inflammatory cytokines (interleukin-6 [IL-6], IL-10, and tumor necrosis factor-α), chemokines (IL-8, monokine induced by interferon-γ, monocyte chemotactic protein-1, regulated on activation normal T cell expressed and secreted, and interferon-inducible protein-10), and acute phase proteins (C-reactive protein and complement protein 3); (b) biochemical variables (cardiac troponin I, hematocrit, and immunoglobulin G); and (c) cell numbers (leukocytes, neutrophils, and thrombocytes)., Results: The RHS showed more delayed secretion of the cytokines tumor necrosis factor-α and IL-10, chemokines monokine induced by interferon-γ (P < 0.001); IL-8, and interferon-inducible protein-10; and complement protein 3 than conventional CPB systems did. Median thrombocyte numbers were higher in the RHS group. Levels of cardiac troponin I, monocyte chemotactic protein-1, and IL-6 were lower in both the RHS and conventional CPB without suction than with suction. Levels of C-reactive protein and regulated on activation normal T cell expressed and secreted, plus leukocyte and neutrophil numbers, were similar in all groups., Conclusions: The Medtronic RHS may induce less systemic inflammation than conventional CPB systems, particularly when cardiotomy suction was used, but it did not result in improved clinical benefit.

The lack of established cause and effect between putative mediators of inflammation and adverse clinical outcomes has been responsible for many failed anti-inflammatory interventions in cardiopulmonary bypass (CPB). Candidate interventions that impress in preclinical trials by suppressing a given inflammation marker might fail at the clinical trial stage because the marker of interest is not linked causally to an adverse outcome. Alternatively, there exist examples in which pharmaceutical agents or other interventions improve clinical outcomes but for which we are uncertain of any antiinflammatory mechanism. The Outcomes consensus panel made 3 recommendations in 2009 for the conduct of clinical trials focused on the systemic inflammatory response. This panel was tasked with updating, as well as simplifying, a previous consensus statement. The present recommendations for investigators are the following: (1) Measure at least 1 inflammation marker, defined in broad terms; (2) measure at least 1clinical end point, drawn from a list of practical yet clinically meaningful end points suggested by the consensus panel; and(3) report a core set of CPB and perfusion criteria that maybe linked to outcomes. Our collective belief is that adhering to these simple consensus recommendations will help define the influence of CPB practice on the systemic inflammatory response, advance our understanding of causal inflammatory mechanisms, and standardize the reporting of research findings in the peer-reviewed literature.

Background: Simultaneous integrated coronary artery revascularization combines coronary artery bypass surgery and percutaneous coronary intervention into a single procedure. This approach provides immediate, complete and optimal myocardial revascularization in a less invasive manner. Because simultaneous integrated coronary revascularization necessitates two distinct anticoagulation protocols for the surgical and percutaneous aspects of the procedure, combining these anticoagulation protocols carries a bleeding risk. Using a single anticoagulant to facilitate the necessities of both aspects of the integrated approach may alleviate this risk., Case Presentation: A 45-year-old man with an occluded left anterior descending artery and a moderately stenotic circumflex artery underwent simultaneous integrated coronary revascularization. Bivalirudin was used to achieve anticoagulation for the duration of the procedure. The patient was asymptomatic with excellent patency of both the bypass graft and the stented circumflex artery via angiography at 10 months., Conclusion: Bivalirudin can be used to effectively achieve a unified anticoagulation protocol for simultaneous integrated revascularization.

Objective: Traditionally integrated coronary artery revascularization has been described as a 2-stage procedure. We evaluated the safety and feasibility of 1-stage, simultaneous, hybrid, robotically assisted coronary artery bypass grafting surgery and percutaneous coronary intervention., Methods: Fifty-eight patients underwent simultaneous, integrated coronary artery revascularization in an operating theater equipped with angiographic equipment. Forty-five patients were men. The mean age was 59 years. All internal thoracic arteries were harvested with robotic assistance. All anastomoses were manually constructed through a small anterior non-rib-spreading incision without cardiopulmonary bypass on the beating heart. Immediately after and within the same operative suite, both angiographic confirmation of graft patency and percutaneous coronary intervention were performed. In 52 patients therapeutic anticoagulation was achieved with the direct thrombin inhibitor bivalirudin., Results: There were no deaths or wound infections. There was 1 perioperative myocardial infarction. One patient had a stroke, and 3 patients required re-exploration for bleeding. The median lengths of intensive care and hospital stay were 1 and 4 days, respectively. All patients were alive and symptom free at follow-up (mean, 20.2 months; range, 1.1-40.8 months). Long-term angiographic follow-up in 54 patients showed 49 (91%) patent grafts (mean, 9.0 months; range, 4.3-40.8 months). There were 7 in-stent restenoses and 2 occluded stents., Conclusion: For multivessel coronary artery disease, simultaneous integrated coronary artery revascularization with bivalirudin is safe and feasible. This approach enables complete multivessel revascularization with decreased surgical trauma and postoperative morbidity. Further studies are necessary to better determine patient selection and long-term outcomes.

The causal factors of the systemic inflammatory response to cardiopulmonary bypass (CPB) were correctly identified in the early 1990 s: "... activation of complement, coagulation, fibrinolytic, and kallikrein cascades, activation of neutrophils with degranulation and protease enzyme release, oxygen radical production, and the synthesis of various cytokines from mononuclear cells" [Butler 1993]. Why therefore have clinical advances to curb the systemic inflammatory response proven such a disappointment? Part of the problem is that cardiac surgery has never taken intellectual ownership of this issue, borrowing its diagnosis from critical care medicine and failing to define the minimal criteria that should be measured when reporting on the systemic inflammatory response. An evidence based review of the current literature by many of the coauthors on this paper found that the majority of studies on the systemic inflammatory response did not measure a single one of the causal factors listed above - thus hindering our ability to identify mechanisms of causation and identify drug targets [Landis 2008]. A panel of experts convened at the Outcomes XII meeting, Barbados 2008, drafted the present consensus document in order to provide a framework to guide future studies and interdictions of the systemic inflammatory response. Herein, we have recommended: 1) mandatory reporting of minimal CPB and perfusion criteria that may affect outcomes, 2) reporting of a minimal set of causal inflammatory markers linked to adverse sequelae, and 3) reporting of at least one clinical end-point of organ injury, from a list of endpoints and markers of organ injury that balance practicality with clinical meaningfulness. It is our collective belief that this document will serve as a foundation for furthering our understanding of the influence of CPB practice with the systemic inflammatory response by standardizing the reporting of research findings in the peer-reviewed literature.

Background: The purpose of this study was to compare the quality of left internal thoracic arteries harvested by the conventional open approach versus minimally invasive videoscopic and robotic-assisted telesurgical techniques., Methods: One hundred and fifty consecutive patients with single vessel coronary artery disease were prospectively studied. The left internal thoracic artery was harvested using three different approaches, with 50 patients consecutively assigned to each group. The off-pump coronary artery bypass (OPCAB) group underwent median sternotomy with direct visualization. The automated endoscopic system for optimal positioning (AESOP) group employed the AESOP 3000 system (Computer Motion Inc, Goleta, CA) for robotic-assisted visualization with endoscopic manual left internal thoracic artery harvesting. The Zeus group used the Zeus robotic telesurgical system (Computer Motion Inc) and internal thoracic artery harvesting was performed remotely from a surgical console. Postanastomotic left internal thoracic artery flows and day one postoperative angiography were used to assess internal thoracic artery quality and patency., Results: Average left internal thoracic artery harvest times were 23 +/- 2.5, 63.3 +/- 20.3, and 66.1 +/- 17.9 minutes in the OPCAB, AESOP, and Zeus groups, respectively (p < 0.001, OPCAB vs AESOP and Zeus). Intraoperative graft flows averaged 28.1 +/- 11.9, 33.7 +/- 19.3, and 36.9 +/- 24.6 mL/minute, respectively in the OPCAB, AESOP, and Zeus groups (p = 0.317, OPCAB vs AESOP and Zeus). There was no significant angiographic difference in the patency rate of the harvested left internal thoracic arteries in the three groups (p = 0.685, overall)., Conclusions: The left internal thoracic artery can be harvested safely and effectively using minimally invasive videoscopic and robotic-assisted telesurgical techniques. Although the less invasive approaches require specialized equipment and training as well as increased operative time, they offer the potential for less traumatic myocardial revascularization through smaller incisions and reduced postoperative morbidity.

Hybrid myocardial revascularization combines coronary surgery with percutaneous intervention as an alternative therapy for ischemic heart disease. The order and sequence of the hybrid approach is not yet clearly defined. We report on the benefits of an enhanced surgical suite equipped with a carbon fiber operating table and digital C-arm for robotic-assisted hybrid revascularization in a single operative sequence. To our knowledge, this is the first reported case of concurrent robotic-assisted hybrid revascularization utilizing an enhanced operative suite.

Between September 1998 to February 2000, 45 consecutive patients underwent robotic-assisted, video-enhanced coronary artery bypass grafting. All IMA's were harvested using the voice-activated robotic assistant (AESOP 3000, Computer Motion Inc, Santa Barbara, CA) and the Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH). Left IMA's were successfully harvested in all patients. Harvested IMA's were anastomosed to LAD's under direct vision through limited left anterior thoracotomy. The IMA harvest time was 57.8 +/- 23.2 min, intraoperative graft flow was 34.3 +/- 20.5 ml/min, postoperative hospital stay was 3.9 +/- 1.5 days. The early postoperative angiogram showed that all grafts were patent. There was no mortality, no significant morbidity. The robotic assisted, video enhanced CABG provides safe and complete LIMA dissection with minimal manipulation and assures sufficient LITA length for tension free anastomosis.

Objective: To determine the efficacy of using the harmonic scalpel and robotic assistance to facilitate thoracoscopic harvest of the internal thoracic artery (ITA)., Design: A case series., Setting: London Health Sciences Centre, University of Western Ontario, London, Ont., Patients and Methods: Fifteen consecutive patients requiring harvest of the ITA for coronary artery bypass grafting., Intervention: Robot-assisted, video-enhanced coronary artery bypass (RAVECAB) through limited-access incisions, using the harmonic scalpel and a voice-activated robotic assistant., Main Outcome Measures: Ease and duration of the harvesting technique, complications of the procedure, graft flow and patency, and duration of postoperative hospitalization., Results: RAVECAB facilitated thoracoscopic dissection of the ITA with the harmonic scalpel in all cases. There were no conversions to a standard approach and no reoperations for bleeding. The mean (and standard deviation) ITA harvest time was 64.1 (22.9) minutes (range from 40 to 118 minutes). Robotic voice command capture rate was greater than 95%. Mean (and SD) intraoperative graft flows were 33.1 (26.8) mL/min (range from 14 to 126 mL/min). There was 100% graft patency on postoperative angiography. There were no deaths, perioperaive myocardial infarction or arrhythmias. Mean (and SD) postoperative hospitalization was 3.3 (0.8) days., Conclusions: RAVECAB is a demanding procedure that addresses many of the disadvantages of the "conventional" minimally invasive coronary artery bypass. It allows complete pedicle dissection with minimal ITA manipulation and assures sufficient conduit length and a tension-free coronary artery anastomosis. All anastomoses were performed under direct vision through a 5- to 8-cm inferior mammary incision.

Background: Successful endoscopic harvesting of arterial conduits is critical to the performance of totally endoscopic bypass grafting. Recent success with computer-enhanced robotic systems in the performance of endoscopic single vessel coronary artery bypass (ENDOCAB) has paved the way for developing techniques for multivessel ENDOCAB. The Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) has previously demonstrated versatility and efficacy in manual endoscopic internal thoracic artery (ITA) harvesting. This study was undertaken to determine the feasibility of adapting this technology to a robotic telemanipulation system and its safety and efficacy in telerobotic ITA harvesting., Methods: The Harmonic Scalpel was adapted to the ZEUS robotic surgical system (Computer Motion, Goleta, CA) and used to harvest the ITA in 19 patients undergoing multivessel off-pump coronary artery bypass (OPCAB) surgery. With the left lung collapsed, the ITA was harvested in all patients with CO2 insufflation through three 5 mm ports in the left chest. Postoperative angiography and transthoracic Doppler studies were performed in all patients., Results: There were no ITA injuries and patients tolerated insufflation without hemodynamic compromise. Side branches were controlled easily without bleeding. Average ITA harvest time was 65 +/- 21 minutes. All vessels were patent after harvesting and demonstrated no angiographic evidence of injury., Conclusions: This paper demonstrates a technique by which the Harmonic Scalpel can be readily adapted to the ZEUS robotic telemanipulation system. Using this system, ITA's can be safely harvested totally endoscopically within a reasonable time frame for patients undergoing ENDOCAB.

Aprotinin, a naturally occurring serine protease inhibitor, has found widespread application during cardiac surgical procedures as a consequence of its ability to decrease blood loss and transfusion requirements. While its efficacy in a variety of clinical situations associated with increased risk of blood loss has been well established, at the same time, various complications including anaphylaxis, renal insufficiency, graft closure and arterial thromboses have been reported in association with aprotinin administration. In order to more fully evaluate the risks and benefits associated with aprotinin usage, this review first of all examines the hazards associated with transfusion of blood and blood products. Consideration is then given to various alternatives to allogeneic transfusion, including autologous predonation, acute normovolemic hemodilution, perioperative cell salvage and intraoperative plasma sequestration. A critique of other available pharmacological therapies, specifically desmopressin, aminocaproic acid and tranexamic acid, reviewing their modes of action, efficacy and associated complications, is then made. The role of aprotinin in cardiac surgery is then discussed and its pharmacology, including consideration of its antifibrinolytic, platelet preserving and anti-inflammatory effects is reviewed. Finally, an analysis of potential complications associated with aprotinin administration is undertaken. Issues involving its influence on specific measures of anticoagulation, namely partial thromboplastin time and activated clotting time, and issues relating to graft patency, hypothermic circulatory arrest, renal function, and allergic reactions are analysed and interpreted. In summary, this review concludes that most of the risks associated with aprotinin administration primarily involve inadequate anticoagulation and those of developing an allergic reaction, particularly upon aproptinin re-exposure. The benefits of aproptinin to decrease blood loss and transfusion requirements are confirmed, and there is evidence pointing to the intriguing possibility of a potential salutary effect on perioperative central nervous system complications.

Background: Propofol has been implicated as causing intraoperative bradyarrhythmias. Furthermore, the effects of propofol on the electrophysiologic properties of the sinoatrial (SA) node and on normal atrioventricular (AV) and accessory pathways in patients with Wolff-Parkinson-White syndrome are unknown. Therefore, this study examined the effects of propofol on the cardiac electrophysiologic properties in humans to determine whether propofol promotes bradyarrhythmias and its suitability as an anesthetic agent in patients undergoing ablative procedures., Methods: Twelve patients with Wolff-Parkinson-White syndrome undergoing radiofrequency catheter ablation were studied. Anesthesia was induced with alfentanil (50 micrograms/kg), midazolam (0.15 mg/kg), and vecuronium (20 mg) and maintained with alfentanil (2 micrograms.kg-1.min-1) and midazolam (1-2 mg, every 15 min, as needed). A electrophysiologic study was performed consisting of measurement of the effective refractory period of the right atrium, AV node, and accessory pathway and the shortest cycle length of the AV node and accessory pathway during antegrade stimulation plus the effective refractory period of the right ventricle and accessory pathway and the shortest cycle length of the accessory pathway during retrograde stimulation. Determinants of SA node function including sinus node recovery time, corrected sinus node recovery time, and SA conduction time; intraatrial conduction time and atrial-His interval also were measured. Reciprocating tachycardia was induced by rapid right atrial or ventricular pacing, and the cycle length and atrial-His, His-ventricular, and ventriculoatrial intervals were measured. Alfentanil/midazolam was then discontinued. Propofol was administered (bolus 2 mg/kg + 120 micrograms.kg-1.min-1), and the electrophysiologic measurements were repeated., Results: Propofol caused a statistically significant but clinically unimportant prolongation of the right atrial refractory period. The effective refractory periods of the AV node, right ventricle, and accessory pathway, as well as the shortest cycle length, were not affected. Parameters of SA node function and intraatrial conduction also were not affected. Sustained reciprocating tachycardia was inducible in 8 of 12 patients, and propofol had no effect on its electrophysiologic properties. All accessory pathways were successfully identified and ablated., Conclusions: Propofol has no clinically significant effect on the electrophysiologic expression of the accessory pathway and the refractoriness of the normal AV conduction system. In addition, propofol has no direct effect on SA node activity or intraatrial conduction; therefore, it does not directly induce bradyarrhythmias. It is thus a suitable agent for use in patients undergoing ablative procedures who require either a neuroleptic or general anesthetic.

Background: The effects of volatile agents and sufentanil anesthesia on the electrophysiologic properties of the accessory pathway and on the incidence of intraoperative tachyarrhythmias in patients with Wolff-Parkinson-White syndrome are unknown. Therefore, we studied these agents for their use in patients undergoing ablative procedures or requiring a general anesthetic for other surgeries., Methods: Twenty-one patients with Wolff-Parkinson-White syndrome undergoing surgical ablation were anesthetized with sufentanil (20 micrograms/kg), lorazepam (0.06 mg/kg), and vecuronium (20 mg). After sternotomy, the electrophysiologic study during antegrade stimulation consisted of the effective refractory period of the right atrium, atrioventricular node, and accessory pathway; the shortest cycle length of the atrioventricular node and accessory pathway; and the coupling interval. During retrograde stimulation, the effective refractory period of the right ventricle and accessory pathway and the shortest cycle length of the accessory pathway were measured and compared to preoperative electrophysiologic values. Patients then were randomized to receive 1 MAC of halothane, isoflurane, or enflurane, and the electrophysiologic study was repeated., Results: Sufentanil-lorazepam caused mild prolongation (P < 0.05) of the effective refractory period of the accessory pathway and the shortest cycle length of the atrioventricular node. Enflurane and isoflurane significantly prolonged all parameters related to refractoriness during antegrade conduction, with enflurane having the largest effect. During retrograde conduction, isoflurane prolonged the effective refractory period of the right ventricle and accessory pathway and the shortest cycle length of the accessory pathway, whereas enflurane prolonged only the accessory pathway effective refractory period and shortest cycle length. Halothane had the least effect on refractoriness, causing significant prolongation of the atrioventricular node effective refractory period and the shortest cycle length of the accessory pathway only during antegrade conduction. The coupling interval, a measure of the period of vulnerability to supraventricular tachycardia, was prolonged only by halothane and isoflurane. Supraventricular tachycardia was still obtainable in all patients., Conclusions: Sufentanil-lorazepam has no clinically significant effect on the electrophysiologic expression of the accessory pathway. Of the volatile agents, enflurane most, isoflurane next, and halothane least increased refractoriness within the accessory and atrioventricular pathways. Therefore, administration of these volatile agents during ablative procedures may confound interpretation of postablative studies used to determine the success of ablation treatment. Conversely, in patients with preexcitation syndrome requiring general anesthesia for nonablative procedures, volatile agents may reduce the incidence of perioperative tachyarrhythmias because of their effects on refractoriness. Enflurane would be the agent of choice because it increases refractoriness the most without prolonging the coupling interval.

The effects of alfentanil-midazolam anaesthesia upon the electrophysiologic (EP) properties of normal atrioventricular (A-V) and accessory pathway (AP) conduction were studied in eight patients with Wolff-Parkinson-White syndrome during accessory pathway surgical ablation. The presence of an AP was confirmed by preoperative EP studies. Anaesthesia was induced with alfentanil (50 micrograms.kg-1) and midazolam (0.15 mg.kg-1) and maintained with an alfentanil infusion (2 micrograms.kg-1.min-1) and intermittent boluses of midazolam (1-2 mg q 15 min, PRN). Following sternotomy, a baseline EP study was performed which consisted of effective refractory period (ERP) and shortest cycle length (SCC) measurement during antegrade conduction in the AV and AP, as well as during retrograde conduction in the AP. Comparison with preoperative EP studies indicated that the administration of alfentanil-midazolam anaesthesia had no effect upon conduction or ERP in either pathway. Haemodynamic stability occurred throughout the surgical procedure with no tachyarrhythmias. We conclude that a combination of alfentanil-midazolam is suitable for general anaesthesia in patients undergoing ablative procedures for accessory pathways.