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W Douglas Boyd

Publications and source records attributed to W Douglas Boyd.

11 recordsLinked to original sources
PubMed2006

Prospective angiographic comparison of direct, endoscopic, and telesurgical approaches to harvesting the internal thoracic artery.

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.

Adult↗
PubMed2006

Mitral valve papillary fibroelastoma: surgical considerations.

Cardiac papillary fibroelastomas are uncommon primary cardiac tumors. Due to their infrequent occurrence, an appropriate management strategy has been difficult to define. We report a 51-year-old female with a papillary fibroelastoma of the mitral valve diagnosed during a source of embolism evaluation, where the association between symptoms and the tumor were equivocal. The mitral valve papillary fibroelastoma was electively surgically excised, based on the proposed guidelines that allow for identification of patients at greatest risk of embolic events. We review the evaluation and selection of those patients who might benefit from surgical therapy even in the absence of symptoms.

Echocardiography, Transesophageal↗
PubMed2005

Division of the brachioradialis muscle: a modification of the current technique in endoscopic radial artery harvesting.

BACKGROUND: Utilization of the radial artery as a conduit for coronary artery bypass grafting has increased significantly over the past 8 years. Concurrently, minimally invasive surgical techniques have been increasingly applied resulting in improved aesthetics, less pain, and decreased morbidity and length of hospital stay. Endoscopic radial artery harvesting (ERAH) has been shown to be of benefit to patients undergoing coronary artery bypass grafting. The brachioradialis is a recognized limitation in ERAH. To date, the standard operative techniques for ERAH have included maintaining the integrity of the brachioradialis muscle. Objective. The aim of this study was to assess the effect of dividing the medial border of the brachioradialis muscle during ERAH. METHODS: We performed ERAH on 9 cadaveric arms using standard endoscopic vein harvesting equipment (30-degree/5-mm endoscope, subcutaneous retractor, and pig-tail vessel dissector) and ultrasonic harmonic coagulating shears. In 5 cadaveric arms, the medial aspect of the brachioradialis muscle was preserved during the dissection. In 4 arms, the medial border of the brachioradialis muscle was divided. All 9 harvests were timed and compared. At the completion of the endoscopic dissection, all 9 arms were opened and examined for neurovascular injury. RESULTS: In cadaveric arms, modifying the current ERAH technique by dividing the medial border of the brachioradialis muscle resulted in a visible increase in tunnel size. In the group where the brachioradialis muscle was divided, a statistically significant reduction in harvest time of 32% was observed (P = .02). Post-harvest examination revealed no gross neurovascular injury; specifically, no injuries to the superficial branches of the radial nerve or the lateral antebrachial cutaneous nerves were identified. CONCLUSION: Division of the medial border of the brachioradialis muscle during endoscopic radial artery harvesting appears to be a safe technique modification that subjectively improves working space and vision of vital structures, facilitating ease of the procedure. Objectively, division of the medial border of the brachioradialis muscle resulted in a statistically significant reduction in harvest time in cadaveric arms when compared with the current technique of ERAH. A clinical pilot study to verify the efficacy and safety of this technique modification is warranted.

Cadaver↗
PubMed2003

Analysis of the learning curve in telerobotic, beating heart coronary artery bypass grafting: a 90 patient experience.

BACKGROUND: Recent articles have commented on the "learning curve" in robotic-assisted coronary artery bypass grafting. We systematically studied this phenomenon using standard statistical and cumulative sum (CUSUM) failure methods. METHODS: Ninety patients underwent internal thoracic artery (ITA) takedown and an attempt at ITA to coronary bypass on the beating heart using the Zeus telerobotic system from September 1999 to December 2001. The rates of mortality and 11 predefined major complications were compared in five quintiles of 18 consecutive patients each and a CUSUM curve was generated for the entire cohort. RESULTS: All patients but one underwent successful endoscopic ITA takedown. Thirteen patients had a totally endoscopic anastomosis, whereas in 61 a small mini-thoracotomy or mini-sternotomy was used. Sixteen patients (17.8%) were converted electively to a sternotomy: 11 patients underwent off-pump and 5 patients on-pump surgery. There were no deaths; 13 patients (14.4%) incurred one or more of the 11 major complication(s), including 5, 1, 2, 3, and 2 in each of the five quintiles (p = 0.39). Standard statistical analyses identified a significant decrease in operating room time (p < 0.0001), as well as a decrease in the incidence of an occluded graft or wrong vessel grafted from quintiles 1 to 5 (p = 0.03). On CUSUM analysis, the failure curve was steep for the first 18 to 20 patients, before moderating its slope for the remainder of the experience. CONCLUSIONS: Robotic ITA to coronary bypass on the beating heart has a moderately steep learning curve, which is mitigated by further experience. CUSUM analysis complimented standard statistical methods in detecting a cluster of suboptimal results during the early experience with this procedure.

Clinical Competence↗
PubMed2002

Hybrid robotic coronary artery surgery and angioplasty in multivessel coronary artery disease.

BACKGROUND: Complete surgical revascularization that includes left internal thoracic artery grafting to the left anterior descending coronary artery remains the gold standard of treatment for coronary artery disease. Not all patients are good candidates for sternotomy. Therefore, we sought to identify a strategy that would combine the long-term advantages of internal thoracic artery grafting to lessen surgical trauma while still allowing complete revascularization. METHODS: A total of 54 consecutive patients from four institutions underwent hybrid revascularization combining surgery and angioplasty. All internal thoracic artery grafts were endoscopically harvested with robotic assistance using either the Aesop or Zeus system, and all anastomoses were manually constructed through a 4- to 6-cm anterior thoracotomy incision. Angioplasty was carried out to achieve total revascularization to ungrafted vessels. RESULTS: There were no early or late deaths, myocardial infarctions, strokes, or wound infections. Of the patients, 37 (69%) were extubated in the operating room. Length of stay in the intensive care unit averaged 24.4 hours and hospital stay 3.45 days. In all, 16 patients (29.6%) required transfusion of packed red blood cells. Late complications included 1 patient with stent occlusion at 3 months and 2 patients with in-stent restenosis. Three patients were treated for postpericardiotomy syndrome. Mean follow-up was 11.7 months. Event-free was survival 87.1% and freedom from recurrent angina 98.3%. CONCLUSIONS: Hybrid endoscopic atraumatic internal thoracic artery to anterior descending coronary artery graft surgery combined with angioplasty is a reasonable revascularization strategy in multiple vessel coronary artery disease in selected patients. Longer follow-up and more patient data in a randomized study are needed to determine the patient cohort most likely to benefit from this approach.

Adult↗
PubMed2002

Current status and future directions in computer-enhanced video- and robotic-assisted coronary bypass surgery.

Since 1997, both the Cleveland Clinic and London Health Sciences Centre groups have embraced robotic assistance and more recently demonstrated the efficacy of this technology in totally closed-chest, beating heart myocardial revascularization. This endeavor involved an orderly progression and the learning of new surgical skill sets. We review the evolution of robot-enhanced coronary surgery and forecast the future of endoscopic and computer-enhanced, robotic-enabling technology for coronary revascularization. This report describes a computer-assisted totally closed-chest coronary bypass operation, and preliminary results are discussed. The internal thoracic artery (ITA) was harvested through three 5-mm access ports and prepared and controlled endoscopically. A prototype sternal elevator was used to increase intrathoracic working space. A 10-mm endoscopic stabilizer was placed through the second intercostal space, and the left anterior descending coronary artery was controlled with silastic snares. Telerobotic anastomoses were completed end-to-side using custom-made, double-armed 8-0 polytetrafluroethylene sutures. To date, 84 patients have undergone successful myocardial revascularization with robotic assistance with a 0% surgical mortality rate. ITA harvest, anastomotic, and operating times for the entire group have been longer than for conventional surgery at 61.3 +/- 17.9 minutes, 28.5 +/- 28.2 minutes, and 368 +/- 129 minutes, respectively. Bleeding, ventilatory times, arrhythmias, hospital lengths of stay, and return to normal activity have been reduced. Recently, we have developed a new robotic revascularization strategy called Atraumatic Coronary Artery Bypass that is a promising mid-term step on the pathway to totally endoscopic, beating-heart coronary artery bypass. We conclude that computer-enhanced robotic techniques are safe, and further clinical studies are required to define the full potential of this evolving technology.

Coronary Artery Bypass↗
PubMed2002

Early experience with robotically assisted internal thoracic artery harvest.

We sought to determine the efficacy of using robotic assistance to facilitate endoscopic harvesting of internal thoracic arteries (ITAs). A total of 104 patients had ITAs harvested endoscopically with use of both the AESOP 3000 system (Computer Motion, Goleta, CA, U.S.A.) and Zeus robotic telesurgical system (Computer Motion). All ITAs were harvested with a harmonic scalpel (Ethicon Endosurgery, Cincinnati, OH, U.S.A.). With the left lung collapsed, ITAs were harvested with CO2 insufflation through three 5-mm ports in the left chest. All patients tolerated insufflation without hemodynamic compromise. Average ITA harvest time was 61.3 +/- 20.9 minutes. Intraoperative graft flows averaged 36.3 +/- 22.4 mL/min. There were three distal ITA injuries; all other vessels were patent after harvesting and demonstrated no angiographic evidence of injury. This article demonstrates a technique by which ITA can be safely harvested totally endoscopically with use of computer-enhanced robotic systems and a harmonic scalpel, allowing complete pedicle dissection through 5-mm ports with minimal ITA manipulation.

Aged↗
PubMed2002

Is hybrid coronary revascularization favored by cardiologists or cardiac surgeons?

We investigated the present use of integrated coronary revascularization (ICR) by interviewing a sample of United States invasive cardiologists and cardiac surgeons. Both groups still favor left internal mammary artery (LIMA) grafting to revascularize the left anterior descending (LAD) coronary artery. There remains a lack of exposure to and acceptance of ICR, especially for surgeons. We report the findings of this national survey of 180 cardiologists and 160 surgeons, as they may serve as an indicator of the current opinions about ICR and its future applicability as a standard method of coronary artery revascularization. We discuss the limited popularity of minimally invasive hybrid procedures and the importance of further exposing cardiologists and surgeons to ICR.

Attitude of Health Personnel↗
PubMedDate not supplied

Effect of off-pump coronary artery bypass grafting on risk-adjusted and cumulative sum failure outcomes after coronary artery surgery.

BACKGROUND AND AIM: We have shown that cumulative sum (CUSUM) failure analysis may be more sensitive than standard statistical methods in detecting a cluster of adverse patient outcomes after cardiac surgical procedures. We therefore applied CUSUM, as well as standard statistical techniques, to analyze a surgeon's experience with off-pump coronary artery bypass grafting (OPCAB) and on-pump procedures to determine whether the two techniques have similar or different outcomes. METHODS: In 320 patients undergoing nonemergent, first time coronary artery bypass grafting, preoperative patient characteristics, rates of mortality and major complications, and ICU and hospital lengths of stay were compared between the on-pump and OPCAB cohorts using Fisher's exact tests and Wilcoxon two sample tests. Predicted mortality and length of stay were determined using previously validated models of the Cardiac Care Network of Ontario. Observed versus expected ratios of both variables were calculated for the two types of procedures. Furthermore, CUSUM curves were constructed for the on-pump and OPCAB cohorts. A multivariable analysis of the predictors of hospital length of stay was also performed to determine whether the type of coronary artery bypass procedure had an independent impact on this variable. RESULTS: The predicted mortality risk and predicted hospital length of stay were almost identical in the 208 on-pump patients (2.2 +/- 3.9%; 8.2 +/- 2.5 days) and the 112 OPCAB patients (2.0 +/- 2.2%; 7.8 +/- 2.1 days). The incidence of hospital mortality and postoperative stroke were 2.9% and 2.4% in on-pump patients versus zero in OPCAB patients (p = 0.09 and 0.17, respectively). Mechanical ventilation for greater than 48 hours was significantly less common in OPCAB (1.8%) than in on-pump patients (7.7%, p = 0.04). The rate of 10 major complications was 14.9% in on-pump versus 8.0% in OPCAB patients (p = 0.08). OPCAB patients experienced a hospital length of stay that was a median of 1.0 day shorter than on-pump patients (p = 0.01). The observed versus expected ratio for length of stay was 0.78 in OPCAB patients versus 0.95 in on-pump patients. On CUSUM analysis, the failure curve in OPCAB patients was negative and was flatter than that of on-pump patients throughout the duration of the study. Furthermore, OPCAB was an independent predictor of a reduced hospital length of stay on multivariable analysis. CONCLUSIONS: OPCAB was associated with better outcomes than on-pump coronary artery bypass despite a similar predicted risk. This robust finding was documented on sensitive CUSUM analysis, using standard statistical techniques and on a multivariable analysis of the independent predictors of hospital length of stay.

Aged↗