Robotic‐assisted cardiac surgery without aortic cross‐clamping: A safe alternative approach

Abstract

Background and Aim: Attempting to place an aortic cross-clamp may complicate surgery and postoperative outcomes in patients who have mediastinal adhesions or in those with extensive aortic calcification. Although right-sided cardiac surgery via thoracotomy is not a new technique in these patients, robotic-assisted intracardiac repair without cross-clamping was not reported in a large group of patients previously. In this study, the safety of robotic-assisted cardiac surgery without aortic cross-clamping was examined. Methods: From January 2010 to March 2020, 304 patients underwent roboticassisted cardiac surgery in our center and in 25 of these patients (8.2%) with a mean age of 65.5 ± 20 years myocardial protection was succeeded with moderate hypothermic ventricular fibrillatory arrest. Severe pericardial adhesions or existence of highly calcified ascending aorta were the indications for fibrillatory arrest during robotic assistant surgery. Results: Most patients were in New York Heart Association Class ≥II (88.0%) and the mean logistic Euroscore value was 18.5 ± 22.3. The type of operations were mitral/tricuspid valve repair/replacement, cryoablation, atrial septal defect closure, and pericardiectomy. Cardiopulmonary bypass times were 141.5 ± 47 (minimum 77-maximum 252) min. There was no case of conversion to open thoracotomy or sternotomy. Hemiparesis was observed in one patient. Two patients with 78.2 and 81.9 Euroscore values had mesenteric ischemia and multiorgan failure, respectively, and died at postoperative period. Conclusions: Robotic-assisted cardiac surgery without cross-clamping may provide reasonable outcomes in patients with severe aortic calcification or mediastinal adhesions undergoing intracardiac repair. These acceptable outcomes may encourage surgeons to perform this approach in appropriate group of patients.

Robotic redo mitral valve replacement combined with dysfunctional amplatzer plug resection on a beating heart

“…Although previous sternotomy and thoracotomy are considered relative contraindications for robotic surgery, robot-assisted reoperations can be successfully performed. [ 3 , 6 ] For redo operations, main goals of robotic surgery are to avoid sternotomy, to use highly mobile instruments, to enable high-definition visualization, and to decrease CPB time by operating on the "target field only". In this regard, aortic cross-clamping (ACC) is a major problem due to dense adhesions around the aorta that cannot be dissected with a robotically approach.…”

“…Ventricular fibrillation (VF) of the heart is another option instead of ACC. [ 3 ] It is obviously a good alternative and may safely be used in daily practice for these patients. On the other hand, many authors have concluded that myocardial energy consumption reaches its highest level in VF.…”

“…[ 1 , 2 ] These cases were performed on an arrested heart using an endoaortic occlusion balloon (EAOB). More recently, Güllü et al[ 3 ] reported their results about robotic cardiac surgery without cross-clamping. In this paper they used fibrillated heart technique safely, with good results.…”

Robot-assisted mitral valve surgery without aortic cross-clamping: An alternative technique

“…In conclusion, robot-assisted cardiac surgery without aortic cross-clamping may provide an alternative approach in patients with severe aortic calcification or mediastinal adhesions. [ 5 ] However, the most important issues to be taken into consideration during the operation are the avoidance of left ventricular distention and air embolism.…”

A day late and a dollar short

“…With increased acceptance of robotic assistance in cardiac surgery, it was only time before nonarrested heart surgery would find its use in this technique also. In this issue of the Journal of Cardiac Surgery , Gullu et al 5 report on 25 patients who underwent predominantly mitral valve and/or tricuspid valve surgery without cardioplegia. The indications for this approach were porcelain aorta or previous surgery making for a difficult and dangerous mediastinal dissection.…”