Advanced Brotherspostgraduatebooks.jaypeeapps.com/pdf/Cardiology/... · Syed Asrar Ahmed Qadri MCH Department of Cardiovascular Surgery Escorts Heart Institute and Research Center

Advanced CardiovasCular MediCine

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Advanced CardiovasCular MediCine

New Delhi | London | Philadelphia | PanamaThe Health Sciences Publisher

Editors

Ashok SethFRCP (London, Edin, Irel) FACC FESC FSCAI (USA) FCSI DSc (honoris Causa) DLitt (honoris Causa)

Chairman Fortis Escorts heart Institute

Chairman Cardiology Council

Fortis Group of hospitalsNew Delhi, India

Sameer ShrivastavaMD DM FISCU FESC FIAE FISC

Director Noninvasive Cardiology

Fortis Escorts heart Institute and Research Center New Delhi, India

Upendra KaulMD DM FCSI FICC FACC FSCAI FAMS

Executive Director Interventional Cardiology

Fortis Escorts heart Institute and Research Center New Delhi, India

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Jaypee Brothers Medical Publishers (P) Ltd.

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© 2016, Jaypee Brothers Medical Publishers

The views and opinions expressed in this book are solely those of the original contributor(s)/author(s) and do not necessarily represent those of editor(s) of the book.

All rights reserved. No part of this publication may be reproduced, stored or transmitted in any form or by any means, electronic, mechanical, photo copying, recording or otherwise, without the prior permission in writing of the publishers.

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Medical knowledge and practice change constantly. This book is designed to provide accurate, authoritative information about the subject matter in question. However, readers are advised to check the most current information available on procedures included and check information from the manufacturer of each product to be administered, to verify the recommended dose, formula, method and duration of administration, adverse effects and contra indications. It is the responsibility of the practitioner to take all appropriate safety precautions. Neither the publisher nor the author(s)/editor(s) assume any liability for any injury and/or damage to persons or property arising from or related to use of material in this book.

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Advanced Cardiovascular Medicine

First Edition: 2016

ISBN: 978-93-5152-437-3

Printed at

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Dedicated toAll our friends

and well-wishers

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Contributors

Ajay Kaul MCH

Chairman and Head

Department of Cardiothoracic and Vascular Surgery

BLK Center for Cardiac Sciences

BLK Super Specialty Hospital

New Delhi, India

AK Khera MD DNB MNAMS

Principal Consultant in Non-invasive Cardiology

Fortis Escorts Heart Institute

New Delhi, India

AK Singh MD (Respiratory Medicine)

Consultant

Department of Pulmonology

Sleep Medicine and Critical Care


New Delhi, India

Amit Varma MBBS MD

Director

Department of Critical Care Medicine


New Delhi, India

Amitesh Chakravarty MD

Fortis Escorts Heart Institute and Research Center

New Delhi, India

Anil Karlekar MD

Executive Director and Head

Department of Cardiac Anesthesiology and Critical Care


New Delhi, India

Ankush Sachdeva MD

Associate Consultant

Department of Cardiology


New Delhi, India

Anumeha Omar MBBS

Resident

Non-invasive Cardiology


New Delhi, India

Aparna Jaswal MD DNB CCDS FHRS FACC

Heart Rhythm Society-IBHRE World Ambassador

Senior Consultant Electrophysiologist


New Delhi, India

Arvind Sethi MD DNB Chairman

Interventional Cardiology


New Delhi, India

Aseem Dhall MD DM (Cardiology)

Senior Intervention Cardiologist Department of Cardiology Fortis Escorts Heart Institute and Research Center New Delhi, India

Ashok K Omar MD FESC FIAE FASE FCSI

Director Non-invasive Cardiology Head Heart Command and Emergency Fortis Escorts Heart Institute New Delhi, India

Ashok Seth FRCP (London, Edin, Irel) FACC FESC

FSCAI (USA) FCSI DSc (Honoris Causa) DLitt (Honoris Causa)

Chairman Fortis Escorts Heart Institute Chairman, Cardiology Council Fortis Group of Hospitals New Delhi, India

Ashutosh Marwah MD FNB

Principal Consultant Department of Pediatric and Congenital Heart Diseases Fortis Escorts Heart Institute New Delhi, India

Atul Verma MBBS DRM Principal Consultant and Head Nuclear Medicine Fortis Escorts Heart Institute New Delhi, India

Avinash Verma MD DNB

Junior Consultant Department of Electrophysiology Fortis Escorts Heart Institute New Delhi, India

Bhumika S Anand

Physician Assistant Fortis Escorts Heart Institute New Delhi, India

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viii Advanced Cardiovascular Medicine

Biswajit Paul MD DNB

Consultant Cardiologist Department of Non-invasive Cardiology Fortis Escorts Heart Institute New Delhi, India

Devesh Dutta MD FNB

Junior consultant Department of Anesthesia and Critical Care Medicine Fortis Escorts Heart Institute New Delhi, India

Dheeraj Gandotra MD DNB (Cardiology)

Junior Consultant Interventional Cardiology Fortis Escorts Heart Institute New Delhi, India

Kenneth Lee Harris MS

Fortis Totipotent RX Center for Cellular Medicine Fortis Memorial Research Institute Gurgaon, Haryana, India

Khushboo Choudhury MSc


KK Sharma MD

Anesthesiologist

Department of Anesthesiology and Intensive Care Fortis Escorts Heart Institute New Delhi, India

Krishna S Iyer MBBS MS MCH

Executive Director Pediatric and Congenital Heart Surgery Fortis Escorts Heart Institute New Delhi, India

Lal C Daga DNB (Fellow) DNB (Cardiology) Junior Consultant Fortis Escorts Heart Institute New Delhi, India

Malay Shukla MD DM

Junior Consultant Fortis Escorts Heart Institute New Delhi, India

Mitu A Minocha MD

Associate Consultant Department of Cardiology Fortis Escorts Heart Institute and Research Center New Delhi, India

Mona Bhatia MD

Head Department of Radiodiagnosis and Imaging Fortis Escorts Heart Institute New Delhi, India

N Dalal MBBS MD Associate Consultant Department of Pulmonology, Sleep Medicine and Medical Critical Care Fortis Hospital, Vasant Kunj, New Delhi, India Fortis Escorts Heart Institute New Delhi, India

Neel Bhatia MD Junior Consultant Fortis Escorts Heart Institute New Delhi, India

Neeraj Awasthy MD DM Associate Consultant Department of Pediatric Cardiology and Congenital Heart diseases Fortis Escorts Heart Institute New Delhi, India

Nishant Kumar MBBS PGDCC Clinical Assistant Non-invasive Cardiology Fortis Escort Heart Institute New Delhi, India

Nishith Chandra MD DM Director Interventional Cardiology Fortis Escort Heart Institute New Delhi, India

Niti Chadha MD DM (Cardiology) IBHRE Certified EP Specialist Department of Pacing and Electrophysiology Fortis Escorts Heart Institute New Delhi, India

Parvathi U Iyer MBBS MD FICU Director Pediatric Intensive Care Fortis Escorts Heart Institute New Delhi, India

Peeyush Jain MD (Med) DM (Cardiology) Head Department of Preventive and Rehabilitative Cardiology Fortis Escorts Heart Institute New Delhi, India

Poonam Khurana MD Principal Consultant Department of Radiodiagnosis and Imaging Fortis Escorts Heart Institute New Delhi, India

Pradyut Bag MD IDCCM FNB EDIC Consultant Critical Care Medicine Fortis Escorts Heart Institute New Delhi, India

Pramod Joshi MD DNB Junior Consultant Fortis Escorts Heart Institute New Delhi, India

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Contributors ix

Rajat Agrawal MBBS MD Senior Consultant Critical Care Medicine Fortis Escorts Heart Institute New Delhi, India

Rajat Gupta DNB FNB Associate Consultant Fortis Escorts Heart Institute New Delhi, India

Rajeev Dhalwani MD Junior Consultant Non-invasive Cardiology Fortis Escorts Heart Institute New Delhi, India

Rajesh Chauhan MD (Anesthesia) Principal Consultant Anesthesia Department of Cardiac Anesthesiology Fortis Hospital, Vasant Kunj New Delhi, India

RC Khurana MD Head Transfusion Medicine Fortis Escorts Heart Institute New Delhi, India

Rishabh Khurana MD Postgraduate student Department of Radiodiagnosis Maulana Azad Medical College New Delhi, India

RS Chatterji MD DNB Senior Consultant Department of Pulmonology Critical Care and Sleep Medicine Fortis Escorts Heart Institute New Delhi, India

S Radhakrishnan MD DM Director and Head Department of Pediatric and Congenital Heart Disease Fortis Escorts Heart Institute New Delhi, India

S Yadav MBBS PGDCC Senior Resident Fortis Escorts Heart Institute New Delhi, India

Sachin V Chaudhary DNB Fellow (Cardiology) Department of Cardiology Fortis Escorts Heart Institute and Research Center New Delhi, India

Sameer Shrivastava MD DM FISCU FESC FIAE FISC Director Non-invasive Cardiology Fortis Escorts Heart Institute and Research Center New Delhi, India

Sanjay Gupta MD DNB Associate Director Department of Cardiac Anesthesiology Principal Consultant Department of Cardiac Surgery Fortis Flt Lt Rajan Dhal Hospital, Vasant Kunj New Delhi, India

Sanjeev Pandey MBBS DRM Consultant Nuclear Medicine Fortis Escorts Heart Institute New Delhi, India

Sanjiv Bharadwaj MD DM Senior Consultant Invasive Cardiology Fortis Escorts Heart Institute New Delhi, India

Saramma Thomas MRS Head Regional Nursing Fortis Escorts Heart Institute New Delhi, India

Satyendra Kumar Tiwari DNB Fellow (Cardiology) Department of Cardiology Fortis Escorts Heart Institute and Research Center New Delhi, India

Savitri Srivastava MD (Med) DM (Card) FAMS FACC Director Pediatric and Congenital Heart Disease Fortis Escorts Heart Institute New Delhi, India

Seema Thakur DM (Medical Genetics) Senior Consultant Genetics and Fetal Medicine Fortis Hospitals New Delhi, India

Smita Mishra MD (Pediatrics) FDNB (Ped Cardiology) Senior Consultant Pediatric Cardiologist Fortis Escorts Heart Institute New Delhi, India

Subhash Chandra MD DM (AIIMS) DNB Associate Director Interventional Cardiology Fortis Escorts Heart Institute New Delhi, India

Sujeet Narain MD DNB (Cardiology) Junior Consultant Fortis Escorts Heart Institute New Delhi, India

Suman Bhandari MD DM FSCAI Chairman Interventional Cardiology Saket City Hospital New Delhi, India

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x Advanced Cardiovascular Medicine

Syed Asrar Ahmed Qadri MCH

Department of Cardiovascular Surgery Escorts Heart Institute and Research Center New Delhi, India

TS Kler MD DM (Cardiology)

Executive Director and Head Department of CardiologyFortis Escorts Heart Institute New Delhi, India

Upendra Kaul MD DM FCSI FICC FACC FSCAI FAMS

Executive Director Interventional Cardiology Fortis Escorts Heart Institute and Research Center New Delhi, India

V Nangia MD FCCP

Fellowship in Sleep Medicine (Standford) (USA) Diploma in Interventional Bronchoscopy (Spain) MSc in Infectious Diseases (UK) Director and Head Pulmonology Sleep Medicine and Medical Critical Care Fortis Hospital, Vasant Kunj Fortis Escorts Heart Institute New Delhi, India

Venkatesh Ponemone PhD

Director Laboratory and Clinical Research Affairs


Vibhu Ranjan Gupta MBBS MPhil Medical Director Fortis Escorts Heart Institute and Research Center New Delhi, India

Vijay Kumar MD DNB (Cardiology) Senior Consultant Cardiologist Fortis Escorts Heart Institute and Research Center New Delhi, India

Vinay Kumar Sharma MD DM Senior Consultant Department of Non-invasive Cardiology Fortis Escorts Heart Institute New Delhi, India

Vinay Sanghi MD DM Associate Director Department of Interventional Cardiology Fortis Hospital, Shalimar Bagh New Delhi, India

Vishal Rastogi MD DM FSCAI Senior Interventional Cardiologist Fortis Escorts Heart Institute New Delhi, India

Vivek Kumar MD Principal Consultant Cardiologist Fortis Escorts Heart Institute New Delhi, India

Yugal K Mishra MBBS MS PhD Director Department of Cardiovascular Surgery Fortis Escorts Heart Institute and Research Center New Delhi, India

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PrefaCe

The last 25 years have witnessed unprecedented scientific advancements in the field of cardiology. Every year, new drugs, new devices and new technologies continue to improve outcomes and prolong lives of our patients with heart disease. Every year, robust clinical trials influence our management of life-threatening cardiac conditions to save lives. To the extent that the way, we practice cardiology today, is distinctly superior and different from what we practiced even 3–5 years ago.

‘Staying updated’ with the present knowledge has become never as more important than before to benefit our patients and do justice to our profession and receive satisfaction in doing so.

Advanced Cardiovascular Medicine brings you the ‘up-to-date’ knowledge of the art and science of management of the most important cardiac conditions, we face in our clinical practice. We have ensured that the book covers a vast variety of relevant topics, which would be very useful to all physicians and cardiologists in their daily care of patients. Each chapter has been written by acknowledged international and national authorities in the field, who have ensured that their presentation of advanced science and technology is combined with their own vast experience of its applications to the Indian Clinical Scenario.

As we continue to look beyond the horizon and strive for the ultimate advancements of gene therapies and genomics, artificial blood, organ regeneration in laboratory, etc. We believe that this book will become an inseparable companion to us for delivering our best to our patients in 2016 and beyond.

Wish you a very successful and fruitful professional journey with Advanced Cardiovascular Medicine.

Ashok SethSameer Shrivastava

Upendra Kaul

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aCknowledgMents

We acknowledge all those people who are part of this project and have helped us in making Advanced Cardiovascular Medicine see the light of the day.

Working with such multitalented personalities and an excellent team has indeed been an honor and it is hard to pen down words for the enormous care, empathy and affection they bestowed upon us!!

We are grateful to all our residents and juniors for their valuable suggestions, unmatched enthusiasm, constructive criticism and constant efforts. We would like to thank all the staff from our department for their persistent support.

We also express our highest regards to our parents and our families for their prayers and blessings. We are thankful to M/s Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, and their dedicated staff for the

skillful and admirable production qualities of the book.Last but not least, our sincere thanks to all our patients without whose participation this book would not have been possible.

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Contents

1. rheumatic fever: time for newer recommendations 1Ashutosh Marwahv Burden of Rheumatic Fever and Rheumatic Heart Disease in India 1 v Revised Jones Criteria for Acute Rheumatic Fever 1 v Evidence of Preceding Streptococcal Infection 2 v Problems in Diagnosis of Rheumatic Fever in Indian Scenario Using Jones Criteria 2 v WHo Guidelines 2 v other Investigations to Aid Diagnosis of Rheumatic Fever 3 v Do we Really Need New Guidelines? 3 v Major Changes 3

2. Pulmonary Hypertension: evaluation and optimizing therapy in the Present era 6Neeraj Awasthyv Classification 6 v Clinical Presentation 6 v Basic Investigations 7 v Baseline Assessment 12 v Interventional Therapy 19 v Transplantation 19

3. Pulmonary embolism: anticoagulation/lytics or intervention for whom? 23AK Khera, Rajeev Dhalwaniv Diagnostic Approach 23 v Therapeutic Considerations 23 v Management of Acute Pulmonary Embolism 23 v Therapeutic options: Indications, Contraindications, and Rationale for Use 25 v Prognosis 31 v Future Research 31

4. sleep apnea and Cardiovascular disease 33RS Chatterji, V Nangia, N Dalal, AK Singhv Extent of the Problem 33 v How obstructive Sleep Apnea Affects Cardiovascular System? 33 v Sympathetic and Parasympathetic Effects of obstructive Sleep Apnea 34 v obstructive Sleep Apnea as an Inflammatory Condition 34 v Hypercoagulability 34 v Central Sleep Apnea and Cardiovascular System 34 v Hypertension 35 v Coronary Artery Disease 35 v Heart Failure 35 v Arrhythmias 36 v Stroke 36 v Pulmonary Hypertension 37 v Cardiovascular Mortality 37

5. syncope: an update 40TS Kler, Niti Chadhav Impact on the Quality of Life of Patients with Syncope 40 v Approach to Evaluation of a Patient of Syncope 40 v Evaluation of a Patient of Syncope 41 v Detailed Physical Examination and Electrocardiogram 41 v Make a Provisional Diagnosis 41 v Echocardiogram 41 v Cardiac Rhythm Monitoring 41 v Tilt-table Testing 42 v Electrophysiology Study 42 v Management of Patients with Vasovagal Syncope 43 v Management Recommendations of Neurally Mediated Syncope (European Society of Cardiology/2009 Recommendations) 43

6. infective endocarditis update: what is the difference now? 45Vivek Kumar, Lal C Dagav Etiology 45 v Pathogenesis 45 v Classification and Diagnosis 46 v Clinical Presentation 48 v Examination 48 v Investigations 48 v Treatment—Antimicrobial Therapy 48 v Treatment options for Streptococci (Penicillin Mic ≤0.125 Mg/L) 49 v Treatment of Streptococci (Penicillin Mic >0.125 to ≤0.5Mg/L) 49 v Treatment of Abiotrophia and Granulicatella Spp. 49 v Treatment of Streptococci in Patients with Significant Penicillin Allergy (Penicillin Mic >0.5 Mg/L) 49 v Recommendations for Enterococcal Endocarditis 50 v Treatment Recommendations for Q Fever 51 v Treatment Recommendations for Bartonella Infective Endocarditis 51 v other Gram-negative Bacteria 51 v Fungal Endocarditis 51 v Surgical Management 51Ja

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7. Hypertension: Controversies in newer guidelines 56Ankush Sachdevav Understanding the Controversy 56 v Basic Workup and Management of Hypertension 57 v Trials Influencing the Guidelines 57 v Understanding Joint National Committee (JNC) 8 Guidelines 59

8. statin-induced Myopathy 64Peeyush Jainv Statin-induced Muscle Symptoms 64 v Incidence 64 v Mechanism of Statin Myopathy 65 v Predisposing Factors 65 v Determinants of Statin Myopathy 66 v Low-density Lipoprotein Cholesterol Lowering in Statin Intolerant Patients 66 v Management of Statin Myopathy 68 v Persistence of Myopathy after Statin Withdrawal 68

9. atrial fibrillation update, 2014 71Sanjiv Bharadwaj, Sujeet Narainv Genetics Predisposition 71 v Classification 71 v Natural History 72 v Clinical Presentation 72 v Diagnosis 72 v Management 72 v Newer Antiarrhythmic Drug 76 v Risk of Bleeding 78 v Newer Antithrombotic Drugs 79 v New Treatment option 80 v Newer Pharmacological Agents 81

10. newer antiplatelets and anticoagulants: filling it into Clinical Practices 83Arvind Sethi, Upendra Kaulv Antiplatelet Drugs 83 v Antiplatelet Drug Resistance 83 v Need for Newer Antiplatelet Drugs 84 v Anticoagulants 86 v New oral Anticoagulants 87 v Drug Interactions with New oral Anticoagulants 92 v Laboratory Testing and Monitoring for the NoAS 92 v Perioperative Management 93 v Complex Clinical Scenarios 93 v Management of Bleeding Complications/overdose 94 v Choosing an oral Anticoagulant 94

11. drug Management of arrhythmias: newer insights 98Aseem Dhall, Satyendra Kumar Tiwariv Newer Insights in Antiarrhythmic Treatment of Atrial Fibrillation 98

12. Chest radiography and Cardiovascular disease: is it still relevant in the era of 105 other imaging Modalities? Poonam Khurana, Rishabh Khuranav Status of Chest Radiography: Past and Present 105 v Status of Chest Radiography in Intensive Care Unit: A Unique and Indispensable Role 107 v Role of Chest Radiography in Detection and Diagnosis of Congenital Heart Disease 108 v Dependency of other Modalities on Chest Radiography: Diagnosis of Cardiovascular Disease 108 v Need and Importance of Repeat Imaging: Chest Radiography and other Modalities 108 v Radiologist, Clinicians, and Chest Radiography 109 v Chest Radiography and Cardiovascular Disease: Summary and Conclusion 112

13. ambulatory arrhythmia Monitoring devices 115Niti Chadhav Implantable Loop Recorders 115 v Holter Monitor 115 v Event Monitors 115 v Who are the Candidates for Which Device? 120 v Studies Comparing the Diagnostic Yields of Various Monitoring Devices 120

14. exercise stress testing (stress echocardiography): where does it stand with other Modalities? 123Neel Bhatia, Sameer Shrivastavav overview 123 v Indications of Stress Echocardiography 123 v Advantages 124 v Drawbacks of Exercise Stress Echocardiography 124 v Pharmacologic Stress Testing 124 v Appropriate Use Criteria 2011 124 v Exercise Echocardiography in Valvular Heart Disease 125 v Diagnostic Accuracy 125 v Conclusion 125 v Future 127 v Cardiac Computed Tomography 128 v Cardiac CT Angiography 129 v Future Directions in Noninvasive Testing 129

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15. three-dimensional echocardiography: utility in Clinical Practice 132Vinay Kumar Sharmav Data Acquisition Modes and Display of Images 132 v Acquisition of the Three-dimensional Dataset 133 v Clinical Applications of Three-dimensional Echocardiography 133

16. Coronary Ct angiography Current Perspective: redefining the gold standard for 142 Coronary angiographyMona Bhatiav Lumenography 142 v Insufficient Sampling 142 v Quantitation of Minimum Luminal Area and Minimum Luminal Diameter 143 v overlap and Foreshortening 143 v Plaque Composition, Distribution, and Severity 144 v Technical Decision Making and Procedure Planning Using Coronary Computed Tomography Angiography 145 v Clinical Decision Making 146 v Additional Advantages of Coronary Computed Tomography Angiography 146 v Evaluation of Myocardial Perfusion 147 v Fractional Flow Reserve 147 v Limitation of Coronary Computed Tomography Angiography 147 v Advances in Coronary Computed Tomography Angiography Acquisitions 147

17. role of nuclear imaging for damaged ventricles 149Atul Verma, Sanjeev Pandeyv Myocardial Infarction 149 v Role of Nuclear Imaging in Acute Coronary Syndrome 149 v Acute ST-Segment Elevation Myocardial Infarction 150 v Unstable Angina and Non–ST-Segment Elevation Myocardial Infarction 151 v Non–ST-Segment Elevation Myocardial Infarction 152 v Nuclear Imaging in Heart Failure 152 v Cardiac Autonomic Imaging with Spect Tracers 153 v Future Prospects of Nuclear Imaging in Heart Failure 154

18. blood banking for Patient-care has evolved 159RC Khuranav Transfusion-related Acute Lung Injury 159 v Transfusion-associated Cardiac overload 159 v Transfusion-related Immunomodulation 160 v Post-transfusion Iron overload 160 v Transfusion-associated Graft Versus Host Disease 160 v Avoiding Deleterious Effects of Transfusion 161 v Universally Safe Blood 161 v Novel Cellular Therapies 161

19. risk Markers for atherothrombosis 163Dheeraj Gandotra, Subhash Chandrav Conventional Risk Factors 163 v Novel Atherosclerotic Risk Markers 165 v Noninvasive, Imaging Markers/Modalities to Evaluate Atherothrombosis 167 v Direct Plaque Imaging 167 v Intravascular Ultrasound 167 v Molecular Imaging 168

20. Cardiovascular diseases in women: does the gender bias exist? 172Malay Shukla, Aparna Jaswalv What Next? 173

21. what is optimal Medical therapy and what does it achieve: Medical Management of Coronary 175 artery disease—is it a full Circle traveled? Amitesh Chakravarty, Vijay Kumarv Stich: Surgical Treatment for Ischemic Heart Failure 175 v Polypill for Increase in Treatment Compliance 176 v Background 176 v Global Scenario 176 v Useful Therapies 176 v Efficacy of optimal Medical Therapy 177 v Additional Therapies 177 v Discussion 177

22. optimal Medical therapy: what does it Mean and deliver? 179Mitu A Minocha, Sachin V Chaudharyv Management of Stable Coronary Artery Disease 179 v Pharmacological Management of Stable Cad Patients 180 v Anti-ischemic Drugs 180 v Newer Agents 182 v Drugs for Event Prevention 182 v optimal Medical Therapy or Myocardial Revascularization Therapy for Stable Angina: Recent Evidence 183

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23. Complications of Myocardial infarction 188Nishant Kumar, Ashok K Omar, Anumeha Omar, Mitu A Minocha, Sameer Shrivatavav Cardiogenic Shock 188 v Arrhythmic Complication of Myocardial Infarction 189

24. Heart lung Machine for Cabg: should it be relegated to archives? 199Rajesh Chauhan, Sanjay Guptav The History of Coronary Artery Bypass Grafting 200 v Discussion 207

25. Coronary artery bypass graft in awake: a reality Check 211KK Sharma, Devesh Duttav Advantages of Awake Coronary Artery Bypass 211 v Disadvantages of Awake Coronary Artery Bypass 212 v Current Status 212

26. surgery on aorta: Current status and desires of a surgeon 214Ajay Kaulv History 214 v Definition 214 v Etiology 215 v Indications for Surgery or Intervention 215 v operative Procedure 217 v operative Steps 218 v Descending Thoracic and Thoracoabdominal Aneurysm 218 v Paraparesis or Paraplegia 218

27. Preoperative anesthetic Considerations for adult Cardiac Patient undergoing noncardiac surgery 220Anil Karlekarv The Challenge 220 v Cardiac Clearance and Fitness for Surgery 221 v Getting started: Unearthing the ‘cardiac load’ 222 v Additional Tests 230 v optimization of Patient Status with medications and/or interventions 232

28. Minimally invasive Cardiac surgery: Has it delivered its Promise? 238Yugal K Mishra, Syed Asrar Ahmed Qadriv Invasiveness of Conventional Cardiac Surgery 239 v Minimally Invasive Coronary Artery Bypass Grafting 239 v Minimally Invasive Direct Coronary Artery Bypass 239 v Minimally Invasive Cardiac Surgery/Coronary Artery Bypass Grafting 240 v Endoscopic Harvest of Conduits 240 v Minimally Invasive Valve Surgery 241 v Minimally Invasive Atrial Septal Defect Closure 243 v other Minimally Invasive Cardiac Procedures 243 v Robotic Cardiac Surgery 243 v Robot-assisted Coronary Artery Bypass Grafting 244 v Robotic Internal Mammary Harvest 244 v Robot-assisted Minimally Invasive Direct Coronary Artery Bypass 244 v open Chest Robotic Anastomosis 245 v Totally Endoscopic Coronary Artery Bypass on Arrested Heart 245 v Totally Endoscopic Coronary Artery Bypass on Beating Heart 245 v Robotic Coronary Artery Bypass Grafting as Part of Hybrid Coronary Intervention 245 v Robotic Atrial Septal Defect Surgery 245 v Robotic Mitral Valve Surgery 246

29. Management of advanced Heart failure 248Vishal Rastogi, Bhumika S Anandv Surgically Implanted v Ventricular Assist Device 248 v Preprocedural Planning 248 v Percutaneous Left Ventricular Assist Devices 249 v Tandemheart 249 v Impella 250 v Extracorporeal Life Support 251

30. diastolic Heart failure 253Sameer Srivastava, Avinash Vermav Heart Failure 253 v 40% or 50%—What should be the Cut-off? 254 v Assessment of Diastolic Heart Failure 259 v Management 263 v Future 266

31. stem Cells: a new Horizon toward Cardiac regenerative Medicine 270Vinay Sanghi, Khushboo Choudhury, Kenneth Lee Harris, Venkatesh Ponemonev Sources of Progenitor Stem Cells 273 v Routes of Progenitor Stem Cell Administration 274 v Cell Migration and Homing 274 v Human Clinical Trials 275 v Mechanism of Action 277

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32. left Main stenting: appropriate in Current era 281Pramod Joshi, S Yadav, Dheeraj Gandotra, Suman Bhandariv Importance of Left Main Coronary Artery Stenosis 281 v Surgical outcome in Left Main Disease 281 v Results of Percutaneous Coronary Intervention with Bare-metal Stents in Left Main Stenosis 281 v Evidence of Percutaneous Coronary Intervention with Drug-eluting Stent in Left Main Coronary Artery Stenosis 282 v Who is the Good Candidate for LMCA Stenting? 286 v Impact of Diabetes on the Clinical outcome 286 v Adjunctive Management 291 v The Future 294

33. Cardiomyopathies: revisit beyond 2013 298Nishith Chandra, Nishant Kumarv Hypertrophic Cardiomyopathy 298 v Dilated Cardiomyopathy 300 v Infiltrative Cardiomyopathy 301 v Sarcoidosis 301 v Fabry’s Disease 302 v Role of Genetic Test 303

34. Cardiac tumors: a story of unbridled excitement! 307Biswajit Paulv Case Vignette 307 v When to Suspect Cardiac Tumors 308 v Approach to Cardiac Tumors: The IFs and BUTs! 309 v A Few Words on Imaging Modalities 309 v Secondary Cardiac Tumors 309 v Benign Primary Cardiac Tumors 310 v Malignant Primary Cardiac Tumors 312

35. Pregnancy and Heart diseases: advancement in Management 315Smita Mishra, Seema ThakurSection I: Introduction, Epidemiology, Genetics, and Fetal Screening 315v Epidemiology 315 v Genetic Testing and Counseling 315

Section II: General Consideration of Pregnancy with Cardiovascular Diseases 317v Combating Stress on Cardiovascular System in Pregnancy and Parturition 317 v Evaluation of Cardiac Reserve and Risk Scoring in Pregnancy with CVD 317 v Cardiac Function in Pregnancy 318 v Effect of Labor on Pregnancy with CVD 319 v General Recommendations in Pregnancy with CVD 319 v Modified WHo Classification of Maternal Cardiovascular Pregnancy Risk 320 v Anesthesia in Pregnancy with CVD 321

Section III: Cardiac Diseases in Pregnancy 327v Pregnancy in Patients with Pre-existing Cardiomyopathies 327 v Hypertension in Pregnancy 327 v Valvular Heart Diseases 331 v Congenital Heart Disease 334

Section Iv: Rhythm Disorder in Pregnancy 339v Resting Electrocardiography 340 v Direct Current Cardioversion 340 v Implantable Cardioverter Defibrillators 340 v Management of Specific Arrhythmias 340 v Conclusion 342 v Appendix 343 v Drugs During Pregnancy and Breastfeeding 343 v US Food and Drug Administration Classification 343

36. fluid and electrolyte Management in Critically ill Cardiac Patients 351Amit Varma, Rajat Agrawal, Pradyut Bagv Fluid Resuscitation and Management 351 v History of Fluid Resuscitation 351 v Colloid Versus Crystalloid: Clinical Studies 351 v Common Electrolyte Disorders 354 v Principles of Potassium Replacement 357 v Chronic Kidney Disease 359

37. transcatheter aortic valve implantation: status for low risk group 363Vijay Kumar, Ashok Sethv Risk Stratification in Transcatheter Aortic Valve Replacement 363 v Studies on Transcatheter Aortic Valve Replacement for Low- and Intermediate-risk Patients 364

38. approach to acyanotic Congenital Heart diseases 367Neeraj Awasthy, S Radhakrishnanv Classification of Acyanotic Congenital Heart Disease 367 v Pathophysiology of Acyanotic Congenital Heart Disease 367 v How to Suspect Acyanotic Congenital Heart Disease 369 v Clinical Examination 370 v Chest X-ray 373 v Electrocardiogram 374 v Echocardiography 377 v Direction of Shunt and Pulmonary Arterial Pressure 383 v obstructive Lesions 383

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xx Advanced Cardiovascular Medicine

39. approach to Congenital Cyanotic Heart disease: is it entirely surgical approach? 389Rajat Gupta, Savitri Srivastavav Duct-dependent Pulmonary Circulation 389 v Duct-dependent Systemic Blood Flow 391 v Patent Ductus Arteriosus-dependent Admixture Lesions 392 v Pulmonary Hypertension of the Newborn 393 v Cyanotic Patients 393 v Pre- and Peroperative Catheter Interventions 394 v Hybrid Procedures 394 v Postoperative Cases 395

40. Pediatric Cardiac intensive Care: expectations of the future 397Parvathi U Iyerv Indian Scenario and Difference 397 v Challenges 398 v Home Grown Strategies 398 v Complex Arrhythmias 399 v Newer Modalities in Treatment of Pulmonary Hypertension 399 v Manpower and Workforce Issues 399

41. surgery for Congenital Heart disease: in search of Perfection! 400Krishna S Iyer

42. role of nurses in Cardiac sciences 405Saramma Thomasv Role of Informatics Nursing in Cardiac Sciences 405 v Nursing in Cardiac Specialty Units (Heart Command Center/Coronary Care Units/Emergency Room) 405 v Role of Cardiac Nurse in Preoperative Units 406 v Role of Nurse in Cardiothoracic operation Theater 406 v Role of Nurse in Cardiopthoracic Recovery Units 407 v High Dependency Units/Step Down Units Cardiac Nursing 407 v Role of Cardiac Nurse in Cardiac Catheterization Laboratory 407 v Patient and Family Education 407 v Nurses Role in Cardiac Rehabilitation Unit 407 v Cardiac Nurses as Mentors 407 v Role of Cardiac Nurse in Knowledge and Skill Development 408 v Role of Cardiac Nurse in Managing End of Life Issues 408

43. ethical and legal issues in Cardiology 409Vibhu Ranjan Guptav Consent 409 v Consent Prerequisites 411 v Timing of Consent 411 v Special Consents 411 v Validity Period of Consent 412 v Ethical Concerns 412 v Legal Concerns 412 v Disclosure of Information 412 v Ethical and Legal Issues in Emergency Cardiovascular Care 413 v Society for Cardiovascular Angiography Code of Ethics 413 v Legal Implications of Medical Records 414

Index 417

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Minimally Invasive Cardiac Surgery: Has it Delivered its Promise?

Yugal K Mishra, Syed Asrar Ahmed Qadri

28

INTRODUCTIONEndoscopic procedures have been introduced in nearly all surgical disciplines during the last few decades and have become the standard of care. Patients are increasingly requesting less invasive procedures. In an attempt to achieve this and also maintain or improve on results of full median sternotomy many minimally invasive and endoscopic approaches have been tried in the cardiac surgery. In the 1990s when minimally invasive cardiac surgery (MICS) was introduced, concern centered on longer operations, greater risk, and more complications for the perceived benefit of better cosmetic results, better respiratory function, and less pain and bleeding. The adoption of minimally invasive techniques in cardiac surgery and especially for coronary artery bypass grafting (CABG) is challenging due to following reasons. First, cardiac surgery is not straightforward and adding endoscopic approaches further increases the complexity; second, until recently the cardiac surgery community had no endoscopic surgical tradition; and third, the use of conventional thoracoscopic instrumentation in early attempts to perform cardiac surgery failed completely.1

Open operations for acquired heart disease have been standardized, but cardiac surgery results are heavily scrutinized despite low mortality and excellent results, so the bar has been raised for any new technique that will cause a paradigm shift in the scenario of cardiac surgery, which has slowed its adoption. Surgical outcomes are better with minimal access (Fig. 28.1) as compared to full sternotomy in terms of cosmesis, postoperative pain, bleeding and transfusion, respiratory function and length of ICU and hospital stay.2-4 However, there is also a concern about longer operation times, greater risk, and more complications. Less bleeding and fewer transfusions are likely due to the less extensive mediastinal dissection required for the minimally invasive approach. Less pain is likely due to less surgical dissection, and less spreading of the sternum and no

stretch on the posterior rib head and costovertebral ligaments as chest is not widely opened as a trap door. The better pulmonary function can be explained by no interference with the diaphragm or dissection along it. Also with less chest wall pain, patients might have less splinting of the chest and thus can breathe easy. Robotic cardiac surgery was developed in order to overcome the limitations and difficulties associated with minimally invasive surgery and to improve the abilities of cardiac surgeon. A surgical robot allows the surgeon to perform surgery by instruments on robotic arms that are controlled by him from a console situated away from the operating table. A wide array of procedures is possible through small 1–2 cm incisions using robotic control, visualization, dexterity, and precision.

Fig. 28.1 Minimal access cardiac surgery

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Minimally Invasive Cardiac Surgery: Has it Delivered its Promise? 239

The aim of advanced cardiac surgery is to ameliorate two potentially invasive components of conventional cardiac surgery: (1) cardiopulmonary bypass (CPB) machine and (2) sternotomy. In order to reduce the morbidity of con-ventional cardiac surgery and to maintain same safety and efficiency, surgeons were mandated to develop and adopt lesser invasive approaches.

INVASIVENESS OF CONVENTIONAL CARDIAC SURGERYThere are four major invasive aspects of conventional cardiac surgery, which have demerits of their own:1. CPB machine: Use of pump has been the backbone of all

cardiac surgeries till recently when off-pump techniques were developed for CABG. Use of pump causes a multitude of derangements in many homeostatic mechanisms like coagulation and compliments. In short, it causes systemic inflammatory response syndrome. Normal body organs have lot of reserve capability to overcome this trauma, but CPB can have a major influence in case of a patient with borderline organ dysfunction like chronic renal failure, liver dysfunction, and chronic obstructive pulmonary disease (COPD). CPB is also associated with neurocognitive changes either short-term or long-term.

2. Sternotomy: The trauma of access is much more than trauma of surgery. It is a cause of major morbidity especially in old patients with osteoporotic sternum, diabetes, immunocompromised status, obesity and also in redo cases.

3. Aortic manipulation: Cannulation, partial or complete clamping of aorta is not tolerated well especially in patients with aortic atherosclerosis and can be a cause of major or minor stroke.

4. Conduits harvest: Harvest of conduits like long saphenous vein, radial artery requires pretty long incision that can be much more morbid than main operation, especially in patients with obesity, diabetes, and old age.

The various minimally invasive cardiac procedures are listed below:1. Coronary artery surgery

a. MIDCAB—minimally invasive direct coronary artery bypassi. Anteriorii. Lateraliii. Anterolateraliv. Transabdominal

b. MICS CABG—minimally invasive cardiac surgery coronary artery bypass grafting

2. Endoscopic conduit harvest3. Minimally invasive valve surgery4. Minimally invasive atrial septal defect (ASD) surgery5. Other minimally invasive cardiac procedures

6. Robotic cardiac surgerya. Robot-assisted CABG (RACABG)b. Totally endoscopic coronary artery bypass (TECAB)c. Robotic ASD closured. Robotic valve surgery.

MINIMALLY INVASIVE CORONARY ARTERY bYPASS GRAFTINGEarly attempts at sternal sparing techniques for coronary bypass surgery began in mid-1990s.5 These mostly involved a left anterior thoracotomy, direct harvest of left internal mammary artery (LIMA), and beating heart anastomosis to the left anterior descending (LAD) coronary artery. This procedure was called MIDCAB for minimally invasive direct coronary artery bypass. However, the relatively anterior thoracotomy led to cartilage disruption, which was frequently more painful than a sternotomy. Access to LIMA was limited by medial incision; only the LAD artery could be approached easily, the ascending aorta remained out of reach and instruments for this approach were not well developed. In 2005, Mc Ginn at Staten Island University introduced MICS CABG. This is a sternal sparing technique that is versatile and easier to perform. A more lateral incision avoids cartilage disruption and gives a good view of the LIMA allowing complete harvest from first rib to the bifurcation. With easier access to the lateral wall of left ventricle, all the coronary arteries can be approached. Lower profile single shafted instruments enhance visibility. It allows safe access to the aorta. Aortic proximal anastomosis can now be performed using any technique that the surgeon prefers. MICS CABG offers the ability to perform multivessel bypass with access to aorta and thus preserves the proven configuration of grafts performed with sternotomy techniques. This is done in a less invasive way without violating the bony integrity of the thorax. Preserving the structural integrity of the chest helps in a faster recovery and an earlier return to work. Elderly, deconditioned patients can resume upper body weight bearing sooner without the burden of sternal precautions.

MINIMALLY INVASIVE DIRECT CORONARY ARTERY bYPASSThe major advantages of MIDCAB are avoidance of CPB and avoidance of sternotomy. Avoidance of sternotomy decreases risk of infection and shortens hospital stay compared to conventional CABG. The various types of MIDCAB approaches used are described below:1. Anterior MIDCAB: The LAD or the diagonal braches

on the front of the heart are often the only arteries that

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240 Advanced Cardiovascular Medicine

have significant blockages requiring surgical bypass. The conduit used most often is LIMA. MIDCAB is done without the support of CPB.6 Surgery is accomplished through a 5 cm skin incision.

2. Anterolateral MIDCAB: This approach is used for grafting of ramus intermedius that is not accessible through the anterior or lateral approach. This graft is brought up to its new blood supply in the neck with a small incision under the left clavicle and then directed into the chest. A separate small incision high on the anterolateral aspect of the chest allows the graft to be anastomosed to the ramus intermedius artery.

3. Lateral MIDCAB: The circumflex coronary artery and its obtuse marginal branch run along the left side of the heart. They can be reached and grafted through a small lateral incision on the left side of chest below the armpit. This approach is particularly important when prior cardiac surgery has resulted in grafts on the anterior aspect of heart that are patent and should be left undisturbed during surgery.

4. Transabdominal MIDCAB: This approach is used to revascularize the right coronary artery and its posterior descending branch that travel along the base of the heart. A small subcostal incision in the upper abdomen provides access to the right coronary artery and the posterior descending artery. The right gastroepiploic artery can be harvested without compromising the blood supply to the stomach and it easily reaches through base of heart.

MINIMALLY INVASIVE CARDIAC SURGERY/CORONARY ARTERY bYPASS GRAFTINGThe differences between MICS CABG operation and MIDCAB operation that are restricted to the performance of a single graft7,8 are following: 1. MICS CABG is not restricted to single vessel grafting but

allows complete revascularization in the presence of triple vessel or diffuse coronary artery disease.

2. Approach in the MICS CABG is smaller and more lateral on the chest wall that allows for maximal rib spreading without the risk of costochondral or rib injury, and also the space occupied by the left lung is used to work inside the chest as lung deflated during the surgery.

3. As the pericardium is widely opened, all the three coronary arteries and their branches are visualized, which allows proper selection of the anastomotic site.

4. The internal mammary arteries can be easily harvested either along with the pedicle or skeletonized, right from the origin up to the bifurcation avoiding the possibility of steal phenomenon from the side branches of internal mammary artery.9,10

5. Proximal anastomoses are routinely performed onto the ascending aorta.

It is wise to begin with single vessel bypass (LIMA to LAD) and gain experience with exposure of aorta and other coronary targets. One may then progress to diagonal and lateral wall targets. Surgical team must constantly assess its abilities and stay within its limitations. Absolute contraindications to MICS CABG include severe chest wall deformity, severe COPD, emergency surgery, morbid obesity, aortoiliac disease, left subclavian stenosis; diffuse coronary artery disease, and severe left ventricular (LV) dysfunction. MICS CABG requires experience in off-pump surgery. It is done under direct vision, using single lung ventilation. Defibrillation pads are placed before starting surgery. The patient is placed supine with a longitudinal roll under the left chest. A 6–10 cm incision is given just below and medial to the nipple in males and extended laterally. An inframammary incision is given in Figure 28.2. The thoracic cavity is entered through fourth or fifth intercostal space. Some surgeons use additional ports in subxiphoid area and seventh intercostal space to pass coronary stabilizers. LIMA is harvested by elevating the anterior chest wall with the help of Rultract attached to anterior blade of Thoratrak retractor. The ascending aorta should be brought as close access to the right coronary artery and the posterior as possible to the incision and the proximal anastomosis may be performed using a partial occlusion clamp, a clampless anastomotic device (heartstring, Macquet Inc.) or a fully automated anastomotic connector (passport, Cardica Inc.). The apical suction device (starfish) can be placed through the subxiphoid port and the tissue stabilizer (Octo Nova) is placed through the sixth or seventh intercostal port. It is possible to access virtually any coronary artery with the help of pericardial traction sutures and patient positioning. One should not hesitate to assist the circulation with peripheral cannulation in the event of hemodynamic instability.

ENDOSCOPIC HARVEST OF CONDUITSHaving added surgical endoscope in the armamentarium has allowed us to reduce the morbidity associated with conduit harvest for CABG, especially in elderly patients, patients with diabetes, obesity, and immunocompromised status. It is a technique that has made a great impact on patients undergoing CABG. Endoscope is inserted and advanced over the anterior portion of the conduit in a cephalad direction. With continuous CO

2 insufflation a space is created in the

subcutaneous tissue within which the dissection is carried out. Branches are then clipped and cut with vascular clips and endoscopic scissors. Once the conduit is freed, the proximal portion is first ligated with a large clip and then cut with endoscopic scissors. Two to four transverse incisions of 2 cm are employed for the whole procedure.

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MINIMALLY INVASIVE VALVE SURGERYMajority of valve surgeries are performed through a conventional median sternotomy. There have been many attempts, however, to make the procedure less invasive by reducing incision size and keeping apportion of sternum intact. Since the detailed vascular anastomosis is not needed, less invasive approach to valve surgery has been proved to be more interesting and promising than less invasive approaches for CABG. Many surgeons have shown excellent results with low surgical morbidity and mortality11-15 by using ministernotomy and parasternal incisions. Minimally invasive mitral valve surgery started in the early 1996. The Stanford group used intra-aortic balloon occlusion with cardioplegia to perform the surgery. Video assistance through tiny incisions offers better visualization than through direct vision. Carpentier repaired mitral valve successfully through minithoracotomy with video assistance using cold ventricular fibrillation in February, 1996. Chitwood performed the minimally invasive mitral valve surgery with the use of a percutaneous clamp and cardioplegia in March, 1996. Minimally invasive options should be explored for all patients who present for an isolated valve disease. The integrity, completeness, and safety of an operation must not be compromised in favor of a desire to be minimally invasive. The various types of minimal access approaches for valvular surgery performed frequently are described further.

Upper Partial SternotomyThe sternum is divided in midline down through the third or fourth intercostals space and then incised in a shape of T into that space. A variation in this is J shape into the third or fourth intercostal space, leaving the left table of sternum intact. Central cannulation is straightforward and venous cannulation can either be peripheral or through the robot-assisted appendage. Using pericardial stay stitches will provide excellent exposure of the aorta and after aortotomy the aortic valve. Traditional aortic valve replacement (AVR), mitral valve (MVR), Ross procedures, aortic aneurysmorrhaphy, and some limited bypass procedures can be performed through this exposure. The mitral valve is accessed through the roof of left atrium under the aorta and superior vena cava. This approach has several advantages, including a lack of internal mammary ligation or injury, direct and conventional access, and cannulation and avoiding dividing the lower portion of sternum that bears the majority of stress from chest wall (Fig. 28.3).

Lower Partial SternotomyThe incision is made from the level of third intercostals space to the xiphoid and the sternum is incised in the shape of T at the third space. A J modification can also be done; however, the exposure of aorta for cannulation may be more difficult. Central aortic cannulation is done by retracting the upper

Fig. 28.2 Minimally invasive cardiac surgery (MICS)/ Coronary artery bypass grafting (CABG)

Fig. 28.3 Upper partial sternotomy

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sternal segment. Bicaval cannulation is accomplished using a stab incision in the right thorax and going through the right thorax into the upper right atrium. The inferior vena cava (IVC) can be drained through stab incision in right costal margin and right atrial cannulation or through femoral vein. The mitral valve is accessed in the standard fashion through the Waterston’s groove or through the right atrium and interatrial septum. Exposure for the aortic valve and tricuspid valve is excellent and the incision provides access to the entire heart so double and triple valve operations are possible. This also is the best minimally invasive incision if a coronary artery bypass is necessary in addition to aortic valve replacement (Fig. 28.4).

Right Anterior Thoracotomy for Aortic Valve ReplacementThis approach is typically performed through the second or third intercostal space and cannulation can be central or peripheral. Well-placed pericardial stay sutures will bring the right side of the aorta into the field well and them the operation in as usual. If further exposure is needed, a transverse sternotomy can be performed (Fig. 28.5).

Right Thoracotomy (Heart Port)Platform was developed at Stanford University and New York University Hospital in 1994. It is based on a small right anterolateral 5–7 cm thoracotomy incision through the third or fourth interspace with peripheral cannulation and balloon occlusion of ascending aorta (Fig. 28.6). Several specialized

cannulae are used to put the patient on CPB. Arterial cannulation is done through the femoral artery. Direct aortic cross clamping is done with a long vascular clamp inserted through a stab incision in the second intercostal space. Cardioplegia is given directly into the aortic root or via the coronary sinus. Mitral valve, tricuspid valve, and ASDs are accessed comfortably through this approach. Initially the procedure was done under direct vision. Visual assistance has been added using a 10 mm port in the anterior axillary line at second or third intercostal space.16 Advantages of

Fig. 28.4 Lower partial sternotomy Fig. 28.5 Right anterior thoracotomy

Fig. 28.6 Right thoracotomy (heart port) for MvR. Asterisk shows scar site

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this approach include a very small incision with minimal distraction of ribs resulting in rapid healing and rehabilitation with excellent cosmesis.17

MINIMALLY INVASIVE ATRIAL SEPTAL DEFECT CLOSUREA small anterior thoracotomy through third or fourth intercostal space is performed.13 Cannulation is done through femoral artery and vein. Right internal jugular vein is cannulated to drain the blood from upper body. Cross clamp is passed through the second intercostal space. Antegrade cardioplegia cannula is inserted under direct vision into the ascending aorta. Visual assistance has now been added using a 10 mm port through the second IC space in the anterior axillary line (Fig. 28.7).

OTHER MINIMALLY INVASIVE CARDIAC PROCEDURESBesides above-mentioned cardiac procedures, there are a wide variety of cardiac procedures that are performed through minimal access approach, such as:• Leftatrialclotremoval• Right/leftatrialmyxomaexcision• Mazeprocedure• Epicardialleadimplantation• Rupturedsinusofvalsalvarepair• Radiofrequencyablation.

RObOTIC CARDIAC SURGERYRobotic cardiac surgery was developed in order to overcome the limitations of minimally invasive surgery and to improve

the abilities of cardiac surgeon performing the conventional cardiac surgery. In robot-assisted cardiac surgery, the surgeon performs the normal movements associated with the surgery on a telemanipulator, which are translated through the robotic arms to carry out the movements using end effectors and manipulators to perform the surgery inside the body of patient. Robotic cardiac surgery started in 1997 when Falk et al. used the AESOP 3000 to perform port access mitral surgery using endoaortic clamping.18 In 1998, Chitwood’s group performed a mitral operation using AESOP 3000 robotic arm and a vista three-dimensional camera.19 Carpentier in 1998 performed the first totally robotic, endoscopic ASD closure.20 Mohr and Falk in 1998 harvested LIMA by using da Vinci system and through a small left anterior thoracotomy performed the coronary anastomosis.21 Loulmet et al. performed the world’s first TECAB using robotic assistance in 1998 (Fig. 28.8).22 During subsequent years, development has been significant but at a low pace. In the early stages, only single vessel grafting was done using robotic assistance, then gradually as the surgeons became well acquainted with the system now multiple and complex coronary revascularization is performed. Further development of robotic systems was carried out with the introduction of the third generation of surgical telemanipulators, which provide improvement in the areas of three-dimensional video, range of motion of robotic arm, instrument reach, surgeon comfort, and have the capability of intraoperative training with a dual-console system (Fig. 28.9).23

Robotic cardiac surgery is performed through multiple, small 1–2 cm incision for passage of instruments and camera (Fig. 28.10). A wide array of procedures is possible by using robotic visualization, dexterity, precision, and control. During the operation, surgeon sits on a console in the surgical suite and directs the robotic arm through the telemanipulator.

Fig. 28.7 Anterior thoracotomy for ASD Fig. 28.8 Surgical robot

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The robotic arms seamlessly and directly translate the moments of surgeon’s wrist, hand, and fingers from control at the consol to the instruments inside the patient. Advantages of robotic assistance to a cardiac surgeon are the following:1. It provides the surgeon with a greater range of motion and

precision.2. It provides a magnified, high-definition, three-dimensio-

nal view.3. It enables the surgeon with instruments that resemble the

extension of his own hands and fingers to move the small instruments in a precise and delicate manner.

Advantages of robotic cardiac surgery for the patient are the following:1. Sternotomy is avoided2. Less postoperative pain

3. Shorter hospital stay 4. Reduced blood loss and need for transmission5. Quick recovery and return to normal activity and6. Better cosmesis (Fig. 28.11).

RObOT-ASSISTED CORONARY ARTERY bYPASS GRAFTING The learning curve for any robotic procedure is steep and so is true for robot-assisted CABG. So a stepwise approach should be adopted for learning RACABG.

RObOTIC INTERNAL MAMMARY HARVESTSingle lung ventilation is used. After isolating from ventilation, the lung gets collapsed, a camera is inserted through left fifth intercostal space is the mild axillary line. Instruments are inserted through ports made in the left third and seventh intercostal space, for instrument arms. LIMA as well as right internal mammary artery (RIMA) can be harvested after proper port placement. Retrosternal tissue is dissected and right pleura opened for harvesting RIMA.

RObOT-ASSISTED MINIMALLY INVASIVE DIRECT CORONARY ARTERY bYPASSAfter LIMA harvest, small thoracotomy is done through left fourth intercostal space and anastomosis of target vessel usually LAD is accomplished by direst hand suturing. Apical suction positing devices (starfish) and stabilizers area placed through the thoracotomy or through same small ports so as to expose the circumflex and right coronary target vessels.

Fig. 28.9 Surgeon working at console

Fig. 28.10 Marking for surgical ports

Fig. 28.11 Post-robotic surgery appearance

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OPEN CHEST RObOTIC ANASTOMOSISAfter mastering the robotic internal mammary harvesting techniques, one should start doing robotic anastomosis via midline sternotomy as part of standard CABG. It is a reasonable step to enable a safe subsequent totally endoscopic approach.

TOTALLY ENDOSCOPIC CORONARY ARTERY bYPASS ON ARRESTED HEARTRobotic totally endoscopic coronary artery bypass is per-formed very safely on an arrested heart. CPB is initiated through bifemoral cannulation and endoaortic balloon is used for occlusion of the ascending aorta and for cardioplegia. Coronary anastomosis is performed very precisely on an arrested heart as the heart is not moving robotic instruments act as natural extension of surgeon’s hand and fingers. Arrested heart can be easily rotated for access to the circumflex and right coronary artery and also as the lung can be collapsed, the intrathoracic space is significantly enhanced. Coronary anastomosis is performed with the use of double armed 7.0 Prolene sutures, U-clip, or other anastomotic device. Single, multiple, sequential, and even Y-grafts can be constructed robotically.24,25 Rate of revision of anastomosis for bleeding is higher as compared to conventional CABG; however, with increased experience and management of port hole bleeding, these complications have been greatly reduced.

TOTALLY ENDOSCOPIC CORONARY ARTERY bYPASS ON bEATING HEART This is often regarded as the ultimate goal in TECAB. The familiarity with beating heart TECAB is mandatory especially for managing patients with contradiction to remote access perfusion and balloon endo-occlusion of ascending aorta (e.g. severe peripheral vascular disease and ascending aorta dilation); with the availability of endoscopic stabilizers this procedure has been made easy. Latest generation of robots includes a suction stabilizer that is inserted as a robotic instrument and controlled from the telemanipulator. The target coronary artery is stabilized and opened. Coronary anastomosis is performed after putting an endoluminal stent. Doing a TECAB on beating heart is taxing and technically difficult and one should always have a low threshold for conversion to open technique, which should not be regarded as failure but as a second option. Grafting of lateral and posterior wall of the heart is particularly difficult without CPB, but this situation can be overcome by putting the patient on CPB while allowing the heart to beat (pump supported). This dramatically reduces the technical difficulty of beating heart TECAB by emptying the heart and permitting bilateral lung deflation that provides

greater space to work within the closed chest. Technical difficulties like myocardial ischemia, arrhythmia during coronary occlusion, hemodynamic instability, bleeding from target vessels, and organ injuries due to robotic instruments can be managed with prophylactic cannulation and standby CPB.

RObOTIC CORONARY ARTERY bYPASS GRAFTING AS PART OF HYbRID CORONARY INTERVENTIONThe concept of hybrid coronary interventions has come as viable alternative to open CABG and multivessel per-cutaneous coronary intervention so that advantages of both types of coronary revascularization procedures are brought together. Long-term therapeutic concept with potentially enhanced survival with internal mammary artery conduits is an established fact. Hence, it is a valuable element of hybrid coronary revascularization procedures. TECAB involving placement of LIMA to LAD artery or placement of both internal mammary artery grafts to the left ventricle can be followed by percutaneous intervention of other coronary vessels in the same hybrid suite. An increasing number of complex and advanced hybrid coronary interventions are performed thesedays includingmultivesselTECABand/ormultivessel percutaneous coronary intervention.26,27

RObOTIC ATRIAL SEPTAL DEFECT SURGERYThe patient is intubated with a double lumen endotracheal tube so that right lung can be isolated. After heparinization, an appropriate size arterial cannula is inserted in the superior vena cava through the right internal jugular vein. Transesophageal echocardiographic probe is inserted and left in place throughout the procedure in order to confirm the position of cannulae and endoaortic balloon. A transthoracic clamp can also be used for clamping ascending aorta. External defibrillation pads are placed on the chest wall. The patient is positioned with the right side of chest inclined by 30° and the right arm slightly beneath the posterior axillary line. The right lung is deflated, and the camera is introduced through a port in the right fourth intercostal space midway between the nipple and the anterior axillary line. In the third and fifth intercostal spaces on the anterior axillary line, two additional ports are made for the introduction of the robotic instruments. An accessory port is made in the fourth intercostal space on the posterior axillary line. The pericardium is opened and both venae cavae are dissected and encircled by umbilical tapes. After putting the patient on CPB through cannulation of right femoral artery and vein in connection with cannula in the superior vena cava, ASD is closed in the usual manner (Fig. 28.12).

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Fig. 28.13 Robotic mitral valve replacement

RObOTIC MITRAL VALVE SURGERYIt is usually performed with the use of robotic instruments through a minithoracotomy or endoscopic ports. CPB is established through cannulation of femoral artery and vein. Occasionally, superior vena cava can be cannulated through the right internal jugular vein proper venous drainage. The ascending aorta can be occluded with a transthoracic clamp or occasionally with an endoballoon. One arm of the robot is inserted through the third intercostal space in the anterior-axillary line and the other arm is inserted through the fifth intercostal space in the midaxillary line. Through the fourth intercostal space a small thoracotomy or working port is created in the mid-axillary line, and an left atrial retractor is placed in the midclavicular line. Replacement or repair of the valve can be accomplished (Figs 28.13 and 28.14). Acceptance for robotic mitral valve surgery has been limited, despite initial favorable reports, because of the complexity associated with the procedure, high cost of the procedure, as well as its quality and safety.28

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Fig. 28.12 Robotic ASD closure with Dacron patch

Fig. 28.14 Robotic mitral valve repair

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13. Konertz W, Waldenberger F, Schmutzler M, et al. Minimal access valve surgery through superior partial sternotomy: a preliminary study. J Heart Valve Dis. 1996;5:638-40.

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23. Lehr EJ, Grigore A, Reicher B, et al. Dual console robotic system to teach beating heart total endoscopic coronary artery bypass grafting: a video presentation. Interact Cardiovasc Thorac Surg. 2010;8:S113-S114.

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25. Dogan S, Aybek T, Andressen E, et al. Totally endoscopic coronary artery bypass grafting on cardiopulmonary bypass with robotically enhanced telemanipulation: report of forty-five cases. J Thorac Cardiovasc Surg. 2002;123:1125-31.

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28. Chitwood WR, Rodriguez E, Chu MWA, et al. Robotic mitral valve repairs in 300 patients: a single center experience. J Thorac Cardiovasc Surg. 2008;136:436-41.

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Advanced Brotherspostgraduatebooks.jaypeeapps.com/pdf/Cardiology/... · Syed Asrar Ahmed Qadri MCH Department of Cardiovascular Surgery Escorts Heart Institute and Research Center