Computer-assisted cardiac surgery.
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Adult↗
Biomedical subjects
D Loulmet
Publications and source records attributed to D Loulmet.
Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments.
OBJECTIVE: The development of endoscopic coronary artery bypass grafting has been limited because of poor visualization and increased technical difficulties in carrying out operations through ports. We investigated whether the use of robotic assisted instruments could minimize these difficulties. METHODS: After a period of technical development and training on cadavers (n = 8) with the Intuitive Surgical system (Intuitive Surgical, Inc, Mountain View, Calif), the first clinical application in coronary artery surgery was performed in 4 male patients (mean age 59 +/- 6 years) with the indication of grafting the left internal thoracic artery to the left anterior descending coronary artery. Robotic assisted 3-dimensional endoscopes and instruments were introduced into the left side of the chest through 3 intercostal ports. The Heartport system (Heartport, Inc, Redwood City, Calif) was used for arresting the heart during the anastomosis. RESULTS: In 2 patients, the harvesting of the left internal thoracic artery was completed endoscopically with robotic assisted instruments and the anastomosis to the left anterior descending artery was performed through a minithoracotomy with conventional instruments. In 2 other patients, the entire operation was completed endoscopically with robotic assisted instruments. Early postoperative coronary angiography demonstrated the patency of the grafts in all cases. At 6-month follow-up, all patients were free of symptoms. CONCLUSIONS: Robotic assisted instruments make endoscopic coronary bypass possible and open a new era in minimally invasive surgery.
Anastomosis, Surgical↗
[Computer assisted open heart surgery. First case operated on with success].
The recent development of less invasive intracardiac surgery using small incisions and videoscopic techniques allowed an evaluation of the advantages and limitations of this new approach. Among the limitations was the increased difficulty of the surgical technique when using long instruments through small incisions and ports. We investigated whether computer assisted surgical instruments might bring a solution to this problem. Among the existing systems, we selected the Intuitive System because of two original features. It provides a stable, magnified, three dimensional view of the operating field at a console where the surgeon is seated to operate, and it uses computer assisted instruments having the same dexterity and range of motion as the hand. After 10 months of active work to adapt this system to intracardiac surgery, the first open heart operation using computer assisted instruments was carried out on a 52-year-old woman presenting an aneurysm and a large defect of the atrial septum. The patient was extubated 8 h after the operation, returned to her room 16 h later and was discharged from the hospital 8 d post-operatively with normal heart function and no residual shunt. This preliminary experience showed that computer assisted cardiac surgery is feasible and may open new and promising directions in open heart surgery.
Cardiac Surgical Procedures↗
Combined heart-lung-liver, double lung-liver, and isolated liver transplantation for cystic fibrosis in children.
Between June 1990 and September 1995, 8 of 24 children with cystic fibrosis (CF) who were accepted either for combined transplantation or isolated liver transplantation died while waiting for a graft; 11 underwent transplantation and 5 are currently on the waiting list. Of the 11 children who had surgery, 7 (group 1) underwent one of the following procedures: heart-lung-liver (n = 4), sequential double lung-liver (n = 2), or bilateral lobar lung from a split left lung and reduced liver (n = 1). During the same period, the four other children (group 2) underwent isolated liver transplantation (three full-size livers, one partial liver). There was one perioperative death in each group. Pulmonary infection was the most common cause of morbidity in group 1. Other complications in group 1 included tracheobronchial stenosis (n = 2), biliary stricture (n = 2), and severe ascites (n = 2). All were successfully treated. Obliterative bronchiolitis developed in three patients. This was treated with FK 506. In group 2, pulmonary function tests improved or remained stable after liver transplantation. Surgical complications in group 2 included severe ascites (n = 1), biliary stricture (n = 1), and abscess of the liver (n = 1). Actuarial survival was 85.7% +/- 2% in group 1 at 1 year; it remained unchanged at 3 years and was 64.2% at 5 years.
Adolescent↗
[Open heart operation under videosurgery and minithoracotomy. First case (mitral valvuloplasty) operated with success].
The development of "less invasive surgery" using small incisions and videoscopic techniques may change, in the near future, our attitude towards "traditional" surgery. This is because of specific advantages such as skin limited incisions, reduced perioperative disability and lower cost. Up to now, only abdominal, thoracic and coronary artery surgery which do not imply the opening of the heart, or closure of simple atrial septal defects, have benefitted from this new approach. This article reports the first case of open heart surgery for complex lesions of the left heart through a minithoracotomy (5 x 4 cm) with the use of videotransmission and peripheral extracorporeal circulation. The patient, a 30-year-old female, was operated upon for a combined mitral valve stenosis and insufficiency of rheumatic origin unsuccessfully treated by a previous percutaneous valve dilatation. The 2.5 h open heart procedure comprised commissurotomy, repair of torn leaflets, chordal transposition and Carpentier-Edwards prosthetic ring implantation. The patient left the hospital 12 days after the operation. Transesophageal echocardiography at discharge showed normal valve function with no residual stenosis or residual leak.
Adult↗
Combined lung and liver transplantation in patients with cystic fibrosis. A 4 1/2-year experience.
Patients with cystic fibrosis who have end-stage respiratory failure and associated liver cirrhosis have been considered poor candidates for lung transplantation because of high morbidity and mortality resulting from hepatic insufficiency after the operation. Since April 1989, our policy has been to combine heart-lung or lung and liver transplantation in this group of patients. Between June 1990 and March 1995, among 25 patients accepted in the program for combined transplantation, nine died awaiting transplantation and 10 underwent one of the following procedures: heart-lung-liver transplantation (n = 5), en bloc double lung-liver transplantation (n = 1), sequential double lung-liver transplantation (n = 3), and bilateral lobar lung transplantation from a split left lung and reduced liver transplantation (n = 1). There were 5 male and 5 female patients. The ages of the recipients ranged from 10 to 24 years. Mean forced expiratory volume in 1 second was 29% and mean forced vital capacity was 35% of predicted values. All patients were infected with resistant Pseudomonas, three with Pseudomonas cepaceia, and two patients had Aspergillus species in addition. All patients had severe cirrhosis with portal hypertension. Four patients had a history of esophageal variceal bleeding and two had had previous portosystemic shunts. The operation was performed as a two-stage procedure, the intrathoracic operation being completed before the abdominal stage was begun. Cardiopulmonary bypass was used in all patients because of poor clinical condition. Immunosuppression consisted of azathioprine, cyclosporine, and prednisone, as for isolated lung transplantation. There were two perioperative deaths, one caused by primary liver failure and the second by early lung dysfunction. For the first 3 months after transplantation pulmonary infection was the most common cause of morbidity. Other complications included tracheal stenosis (n = 1), bronchial stenosis (n = 1), biliary stricture (n = 2), and severe ascites (n = 3). All were successfully treated. Obliterative bronchiolitis developed in three patients. This was stabilized with FK 506 in two patients; the other patient underwent retransplantation at 38 months but eventually died of bleeding. Actuarial survival was 70% at 1 year and remained unchanged at 3 years. Significant functional improvement was observed in all survivors. For patients who have chronic respiratory failure with advanced cirrhosis, lung transplantation combined with liver transplantation can be performed with a satisfactory outcome.
Adolescent↗
Electrophysiologic effects of bupivacaine in the isolated rabbit heart.
To assess the direct electrophysiologic effects of bupivacaine, we examined the spontaneous sinus rhythm and induced rapid and premature atrial and ventricular pacing in 11 isolated rabbit hearts perfused in the Langendorff apparatus with varying concentrations (designated by []) of bupivacaine (control, n = 2; 0.3 microgram/mL, n = 3; 1.5 micrograms/mL, n = 3; 3.0 micrograms/mL, n = 3). There was no change in sinus node automaticity or sinus node recovery time at any concentration and no evidence of abnormal automaticity. Depression of conduction was reflected by prolongation of the PR interval at the following concentrations: 1.5 micrograms/mL (65.0 ms before, 96.6 ms after) and 3.0 micrograms/mL (61.6 ms before, 103.3 ms after) and increase in atrial and ventricular pacing thresholds at 3.0 micrograms/mL (atrial: 0.86-8.6 mA, ventricular: 2.0-10.0 mA). No spontaneous tachyarrhythmias occurred; 2:1 spontaneous atrioventricular block (n = 1) and a decrease in maximal paced rate with 1:1 anterograde or retrograde atrioventricular conduction were noted at all concentrations of bupivacaine. Thus bupivacaine did not change automaticity but had a depressant effect on conduction at the atrial, ventricular, and atrioventricular levels, providing a basis for clinically occurring atrioventricular block and reentrant arrhythmias.
Action Potentials↗
Isoproterenol corrects the effects of bupivacaine on the electrophysiologic properties of the isolated rabbit heart.
The purpose of this study was to test the hypothesis that isoproterenol could reverse bupivacaine toxicity. In eight isolated rabbit hearts an electrophysiologic evaluation was performed then repeated during infusion of bupivacaine (1 microgram/mL) alone and bupivacaine plus isoproterenol (1-2 micrograms/mL). Bupivacaine alone increased electrocardiographic intervals (P wave, QRS complex, PR, AV, and QTc interval) and refractory periods of the myocardium and atrioventricular junction as well as the Wenckebach cycle and pacing thresholds. The addition of isoproterenol corrected partially or completely all bupivacaine-induced abnormalities, and decreased sinus cycle length, suggesting a potential therapeutic value in the treatment of bupivacaine intoxication.
Action Potentials↗