Faculty Bibliography

Non-typhoid Salmonellae (NTS) commonly cause gastroenteritis but are rarely found pathogens in prosthetic heart valve endocarditis. The details of two patients from the authors' institution and 15 published cases are reviewed in terms of their risk factors, clinical findings and outcomes. Only two of eight patients with paravalvular leakage or abscess--the most serious local complications--survived, both with surgery. It appears that NTS bacteremia in patients with prosthetic valves and concomitant risk factors should be treated early with high-dose antimicrobials for up to six weeks in order to minimize the risk of endocarditis

The Gerbode defect is a congenital shunt from the left ventricle to the right atrium. The type I defect (2) results in a direct shunt through a portion of the membranous septum, while a type II (indirect) defect occurs if the membranous septal defect lies below the attachment of the septal leaflet of the tricuspid valve. The shunt is directed towards the right atrium through a cleft or perforations of the septal leaflet. Acquired Gerbode defects have been identified in endocarditis, after mitral or aortic valve surgery, or may be post-traumatic. The case is presented of a 69-year-old woman with a postoperative Gerbode defect in association with aortic prosthetic endocarditis caused by non-typhoid Salmonella

BACKGROUND: Aortic clamping and cardioplegia delivery add complexity to performing intracardiac procedures through a right minithoracotomy. Recent publications have shown excellent patient outcomes after mitral valve (MV) procedures undertaken through thoracotomy on the fibrillating heart. We reviewed our experience with this approach. METHODS: From March 2000 to September 2006, 100 patients underwent MV repair (n = 42), MV annuloplasty (n = 28), MV replacement (n = 18), atrial septal defect closure (n = 10), tricuspid valve repair (n = 1), and left atrial myxoma excision (n = 1). A modified maze procedure (n = 4) or left minimally invasive direct coronary bypass grafting (MIDCABG) (n = 2) was combined in six cases. The mean age was 57 +/- 11 years (range, 22 to 89); 27 patients were in New York Heart Association (NYHA) class III or IV; 24 cases were first or second time reoperations; 20 patients had a left ventricular ejection fraction of less than 0.3. All the operations were carried out on the fibrillating heart without cross-clamping the aorta through a right minithoracotomy using peripheral cannulation. RESULTS: Mean fibrillation time was 73 +/- 31 minutes (range, 10 to 198 minutes). There was no conversion to sternotomy. Postoperative inotropic support was needed in 20 cases. One patient who underwent a third time reoperation died within 30 days of mesenteric ischemia (hospital mortality = 1%). Complications were the following: four reoperations for bleeding (4%); two strokes (2%). Postoperative median hospital length of stay was five days (range, 2 to 58 days). None of the patients has required MV reoperation after hospital discharge. Follow-up was complete. All survivors were in NYHA class I or II. CONCLUSIONS: Ventricular fibrillation simplifies less invasive intracardiac procedures and carries lower complication rates and perioperative mortality compared with conventional surgery

Limited access, off-pump coronary artery bypass grafting for revascularization of all the various coronary arteries is an acceptable alternative to standard on-pump coronary bypass grafting through sternotomy. A variety of small, targeted incisions are used to approach various coronary locations. Technical advances in conduit harvesting, stabilization, cardiac positioning devices, and anastomotic connectors have made these procedures more standardized and replicable. This has resulted in reduced morbidity as a consequence of less invasive approaches. These efforts have paved the way for the ultimate goal of same day surgical coronary revascularization

BACKGROUND: Robotic technology has been proven safe and efficacious in the performance of mitral valve repair and atrial septal defect repair. This report describes a Food and Drug Administration-sanctioned multicenter study of the safety and efficacy of the da Vinci system (Intuitive Surgical, Inc, Mountain View, CA) for totally endoscopic coronary artery bypass (TECAB) surgery. METHODS: Patients requiring left anterior descending (LAD) coronary artery revascularization were eligible. The procedure was performed with femoro-femoral cardiopulmonary bypass (CPB), endoaortic balloon occlusion, and thoracoscopy. All aspects of the procedure were performed with the robotic system, from internal mammary artery harvest to coronary anastomosis. RESULTS: Ninety-eight patients requiring single-vessel LAD revascularization were enrolled at 12 centers. Thirteen patients (13%) were excluded intraoperatively (eg, failed femoral cannulation, inadequate working space). In 85 patients (69 men, age 58 +/- 10 years) who underwent TECAB, CPB time was 117 +/- 44 minutes, cross-clamp time was 71 +/- 26 minutes, and hospital length of stay was 5.1 +/- 3.4 days. There were five (6%) conversions to open techniques. There were no deaths or strokes, one early reintervention, and one myocardial infarction (1.5%). Three-month angiography was performed in 76 patients, revealing significant anastomotic stenoses (> 50%) or occlusions in 6 patients. Overall freedom from reintervention or angiographic failure was 91%. CONCLUSIONS: Robotic TECAB was accomplished with no mortality, low morbidity, and angiographic patency and reintervention rates comparable with published data. Although the use of CPB was a limitation of the technique, this experience represents a step toward more advanced procedures, such as multivessel or off-pump TECAB

BACKGROUND: Minimimal access multivessel coronary artery bypass grafting with same day hospital discharge remains the ultimate goal. We evaluated the feasibility for achieving multivessel coronary bypass through minimal access. METHODS: From January to July 2003, 30 patients under went off-pump minimally invasive multivessel coronary bypass. Internal mammary arteries were harvested with robotic telemanipulation with three ports. A 2-inch to 3-inch incision with soft tissue retractor was used to perform coronary anastomosis. Robotic ports were used to introduce stabilization and cardiac positioning devices. Endoscopic harvesting of radial artery was done when necessary. RESULTS: Twenty-three patients (77%) had anterior throracotomy approach and 7 (23%) had transabdominal approach. Average number of bypass grafts was 2.6 (range 2-4). There was no mortality in hospital or on 30-day follow-up. Twenty-nine patients (97%) were extubated on the operating table. Two patients required reoperation for bleeding and 1 of those patients needed conversion to sternotomy for additional bypass grafting. Within 24 hours of surgery 50% of patients (n = 15) were discharged, 10% (n = 3) were discharged in 24 to 36 hours, 17% (n = 5) were discharged in 36 to 48 hours, 17% (n = 5) were discharged in 48 to 72 hours, and 2 patients stayed more than 3 days in the hospital. Two patients needed readmission to hospital within 30 days; 1 for pleural effusion and 1 for wound infection. CONCLUSIONS: Robotic harvesting of internal mammary arteries and port access stabilization and cardiac positioning allows multivessel coronary bypass to be performed through a small incision. Currently, the majority of the patients can be safely discharged within 36 hours of operation

OBJECTIVE: We sought to evaluate outcomes and predictors of emergency conversion to cardiopulmonary bypass during attempted off-pump coronary bypass surgery. METHODS: From January 1999 through July 2002, 1678 consecutive isolated coronary artery bypass operations were performed at Lenox Hill Hospital, with the intention to treat all patients with off-pump coronary bypass surgery. Fifty (2.97%) patients required urgent conversion to cardiopulmonary bypass. All the preoperative, intraoperative, and postoperative variables were collected and analyzed in accordance with the New York State Cardiac Surgery Reporting System. Multivariate regression analysis was performed to determine predictors for conversion. RESULTS: In-hospital mortality and major morbidity were significantly lower in the nonconverted group compared with the converted patients (mortality: 1.47% [n = 24] vs 12% [n = 6], P = .001; stroke: 1.1% [n = 18] vs 6% [n = 3], P = .02; renal failure: 1.23% [n = 20] vs 6% [n = 3], P = .02; deep sternal wound infection: 1.54% [n = 25] vs 8% [n = 4], P = .009; respiratory failure: 3.75% [n = 61] vs 28% [n = 14], P < .0001; nonconverted vs converted patients, respectively). The annual incidence of conversion decreased during the study period. There was a significant reduction in the incidence of conversion after routine use of a cardiac positioning device to performing lateral and inferior wall grafts (4.2% [n = 27] vs 2.3% [n = 23], P = .04). None of the preoperative variables were independent predictors of conversion on multivariate regression analysis. CONCLUSIONS: Because emergency conversion to cardiopulmonary bypass during attempted off-pump coronary bypass surgery results in significantly higher morbidity and mortality, studies comparing off-pump coronary bypass surgery with conventional coronary artery surgery should include converted patients in the off-pump group. In our experience, emergency conversion is an unpredictable event. The incidence of conversion decreases with increasing experience of surgeons in performing off-pump coronary surgery and use of a cardiac positioning device