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Published on: July 18, 2014
Displacement of the beating heart with a low-profile suction-based apical positioning device in a closed chest
James Mykytenko1, Thomas A Vassiliades, Jacob Vinten-Johansen
1From the Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA.
Insights
A novel cardiac positioner safely displaces the heart for endoscopic surgery. While displacement impacts cardiac function, Trendelenburg positioning can mitigate these effects, improving surgical feasibility.
Area of Science:
- Cardiovascular Surgery
- Minimally Invasive Procedures
- Surgical Technology
Background:
- Off-pump, multivessel, endoscopic coronary artery bypass necessitates cardiac displacement within an intact chest.
- Current methods for cardiac displacement pose challenges in closed-chest procedures.
Purpose of the Study:
- To evaluate right ventricular performance and systemic hemodynamics using a novel, low-profile, apical suction-based cardiac positioner.
- To assess the efficacy of this device in exposing the posterior heart surface in a closed-chest, beating-heart model.
Main Methods:
- Six pigs were instrumented for hemodynamic monitoring, including cardiac output and right ventricular (RV) pressure-volume loops.
- A novel cardiac positioner was used to displace the heart endoscopically through a port.
- Data were collected during baseline, device coaptation, and cardiac displacement with and without Trendelenburg positioning.
Main Results:
- Cardiac displacement without Trendelenburg significantly decreased cardiac output, coronary blood flow, RV systolic pressure, mean arterial pressure, and RV volumes.
- Adding Trendelenburg during cardiac displacement improved these parameters, with RV systolic pressure, mean arterial pressure, and RV end-diastolic volume comparable to baseline.
- No local complications were observed from device coaptation.
Conclusions:
- The low-profile endoscopic cardiac positioner demonstrated safety and effectiveness in a closed-chest porcine model.
- Cardiac displacement impairs ventricular performance, but Trendelenburg positioning can ameliorate these effects.
- Further technological advancements are needed to optimize cardiac displacement during endoscopic procedures.
Background:
: Off-pump, multivessel, endoscopic coronary artery bypass requires cardiac displacement within an intact chest. The current study evaluated right ventricular performance and systemic hemodynamics while exposing the posterior surface of the heart using a novel, low-profile, apical suction-based cardiac positioner in a closed-chest, beating-heart model.
Methods:
: Six pigs underwent instrumentation with continuous monitoring of arterial pressure by fluid-filled transducer and cardiac output and coronary blood flow by ultrasound transit time flow probe. Right ventricular (RV) pressure-volume loops were generated by an impedance catheter. Heart rate was maintained between 80 and 100 beats per minute pharmacologically. The cardiac positioner displaced the heart endoscopically through a port. Data were obtained in 5 sequential phases: (1) baseline/free-beating, (2) positioner coaptation, (3) addition of Trendelenburg, (4) cardiac displacement with Trendelenburg, and (5) cardiac displacement without Trendelenburg.
Results:
: Cardiac displacement without Trendelenburg (Phase 5) resulted in a significant (P < 0.05) decrease in cardiac output, coronary blood flow, RV systolic pressure (RVSP), mean arterial pressure, RV end-diastolic volume (RVEDV), and RV end-systolic volume (RVESV) compared with baseline (Phase 1). With Trendelenburg added to cardiac displacement (Phase 4), all parameters improved, but only RVSP, mean arterial pressure, and RVEDV were comparable to baseline (Phase 1). There were no local complications from device coaptation.
Conclusions:
: The low-profile endoscopic cardiac positioner is safe and effective in the closed-chest, beating-heart porcine model. Nevertheless, cardiac displacement in a closed chest does cause impairment in ventricular performance that can be ameliorated by the addition of Trendelenburg and further technological progress.
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