Journal of cardiac surgery
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Reduction of surgical trauma is the aim of minimally invasive cardiac surgery. This can be achieved by reducing the size of the incision or by eliminating or changing the cardiopulmonary bypass system. However, certain cardiac surgical procedures, such as valvular surgery and complex multivessel coronary artery surgery, are not feasible without the use of cardiopulmonary bypass. Therefore endovascular cardiopulmonary bypass may allow reduction of surgical trauma for these patients. ⋯ The EndoCPB endovascular cardiopulmonary bypass system allows the application of true Port-Access minimally invasive cardiac surgery in procedures that require the use of cardiopulmonary bypass and cardioplegic arrest. Sternotomy and its potential complications can be avoided, and the surgical procedures can be performed safely on an empty, arrested heart with adequate myocardial protection.
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The duration of safe circulatory arrest for replacement of the ascending aorta for a type A dissection, without additional cerebral perfusion measures, is not clearly defined. If prolonged periods (> 60 minutes) are anticipated, retrograde cerebral perfusion or selective antegrade carotid perfusion may be required. The latter requires separate cannulas with subsequent snaring of the cerebral vessels, which may be time consuming and cumbersome. ⋯ The origin of the innominate artery is then occluded establishing selective antegrade right carotid artery perfusion. The distal ascending or aortic arch anastomosis is then performed while the remainder of the body is under selective systemic circulatory arrest. The proximal aortic anastomosis is performed after the graft is clamped proximally and flows return to appropriate perfusion levels.
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Most patient concerns and demands for less invasive surgery are focused on comfort, cosmesis, and rehabilitation that are all related to the degree of invasiveness. The degree of invasiveness of cardiac surgery depends on two factors: the surgical approach--the length of the skin incision, the degree of retraction and aggression to the tissue, and the loss of blood--and the use of cardiopulmonary bypass. ⋯ Minimally invasive cardiac surgery is undergoing an explosive evolution, and although the indications and best strategies for the different categories are yet to be determined, the trend cannot be stopped. We try to distinguish between "fashionable" strategies and those that are truly revolutionary and investments in the future.
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In Ebstein's anomaly, the septal and posterior tricuspid leaflets are plastered to the endocardium. We postulated that tricuspid valve function could be corrected by restoring mobility of these leaflets. (Feasibility of such repair was explored by anatomical and clinical studies.) ⋯ Repair of the septal and posterior tricuspid leaflets was found to be feasible and effective as tricuspid valvuloplasty for Ebstein's anomaly.
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Comparative Study
Minimally invasive direct coronary artery bypass: technical considerations and instrumentation.
Minimally invasive coronary artery bypass is defined as any maneuver or modification of conventional coronary bypass that decreases adverse effects. These adverse effects fall into three broad categories, which are access trauma, consequences of cardiopulmonary bypass, and aortic manipulation. In the minimally invasive direct coronary artery bypass (MIDCAB) approach, coronary revascularization is performed via a limited access incision, usually a left anterior thoracotomy, through which a left internal mammary artery is anastomosed under direct vision to the left anterior descending artery on a stabilized beating heart. ⋯ Graft patency data from early series of stabilized MIDCAB procedures and published series of left internal mammary artery graft patency with conventional bypass grafting appear to be comparable. Current indications for MIDCAB include restenosis of the left anterior descending artery after catheter-based therapy and the necessity for target vessel revascularization in elderly high-risk patients with multivessel disease. Limitations of the MIDCAB procedure include mostly single vessel revascularization of the anterior aspect of the heart.