Off-pump coronary artery bypass surgery: physiology and anaesthetic management

Revolutionizing Cardiovascular Surgery: The Role Of Robotics

At the forefront of modern medicine, cardiovascular surgery is a complex and challenging field that has evolved over the years with the sole aim of decreasing mortality and improving patient care and outcomes. Cardiovascular surgery is a field requiring immense precision and skill to address the complex anatomy that is the heart and blood vessels.

Integration of robotics will see the dawn of a new era in the medical field that promises to be transformative. With unparalleled precision, improved magnification, and visual fields, robotics, can offer cardiovascular surgeons, a vision of the operative field that is not possible with human eyes. With improved position will come improved outcomes and reduced recovery times revolutionising the field of cardiovascular surgery.

Precision and accuracy are big advantages of robotics technology. Procedures and surgeries rely heavily on the human hand.

Robotics can offer steady and precise movements that will allow surgeons to perform intricate procedures without physical limitations, such as fatigue or tremors. This will improve the accuracy of the procedure performed.

Robotics, utilise advanced technology, such as 3-D mapping, augmented reality, high definition, cameras, and magnification, providing a more enhanced understanding and vision of the patient's anatomy. This level of detail and enhanced understanding allows the proceduralist to navigate complex procedures with unprecedented clarity, reducing the risk of inadvertent damage and improving outcomes.

Another key benefit of robotics in cardiovascular surgery is the ability to perform procedures through minimally invasive techniques. Minimally invasive surgeries involve smaller incisions compared to traditional open surgeries, resulting in less trauma to the surrounding tissues, reduced pain, and faster recovery times for patients. Robotic systems excel in performing minimally invasive procedures by offering greater maneuverability and precision within confined spaces. Surgeons can manipulate miniature instruments attached to robotic arms with remarkable precision, accessing hard-to-reach areas of the heart and blood vessels while minimising trauma to surrounding tissues. This approach reduces the risk of complications such as excessive bleeding, infection, and scarring, leading to shorter hospital stays and quicker return to normal activities for patients. The integration of robotics into cardiovascular surgery expands the range of procedures that can be performed with improved outcomes. Complex surgeries that were once deemed too risky or technically challenging can now be undertaken with greater confidence, thanks to the capabilities offered by robotic systems.

For instance, robotic-assisted coronary artery bypass grafting (CABG) allows surgeons to bypass blocked or narrowed coronary arteries with precision and efficiency, reducing the risk of complications associated with traditional open-heart surgery. Similarly, robotic mitral valve repair enables surgeons to repair or replace the mitral valve with greater accuracy, preserving the function of the heart and improving long-term outcomes for patients.

Advancements in robotics have also paved the way for remote surgery and telemedicine in cardiovascular procedures. Remote surgery involves performing procedures on patients located in different geographical locations from the surgeon, with the assistance of robotic systems and high-speed internet connectivity.

This innovation holds immense promise for extending specialised cardiovascular care to underserved areas, where access to skilled surgeons may be limited. Surgeons can remotely control robotic systems equipped with cameras and instruments, performing surgeries with the same level of precision as if they were physically present in the operating room. Additionally, telemedicine platforms enable real-time consultation and collaboration between surgeons, allowing for expert guidance and decision-making during complex procedures.

Despite the significant advancements made in robotic cardiovascular surgery, challenges remain, including the high cost of equipment, the need for specialised training, and concerns regarding patient safety and outcomes. However, ongoing research and development efforts aim to address these challenges and further enhance the capabilities of robotic systems in cardiovascular surgery. Future directions in robotic cardiovascular surgery include the development of smarter and more intuitive robotic platforms, integration of artificial intelligence and machine learning algorithms for real-time decision support, and refinement of remote surgery techniques for broader adoption and accessibility.

Overall, robotics have emerged as a game-changer in cardiovascular surgery, offering unprecedented precision, enhanced surgical capabilities, and expanded access to specialised care. As technology continues to evolve, the potential for robotics to revolutionise the field of cardiovascular surgery and improve patient outcomes remains endless.

The article is written by Dr.Parija Sharedalal, MD, American University of Antigua, Interventional Cardiologist,New Jersey, USA

(DISCLAIMER: The views expressed are solely of the author and ETHealthworld.Com does not necessarily subscribe to it. ETHealthworld.Com shall not be responsible for any damage caused to any person/organisation directly or indirectly)

Published On May 2, 2024 at 02:03 PM IST

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Successful 'first In Human' Clinical Trial Of Pioneering Guidance For Heart Bypass Surgery

A new approach to the guidance, planning and conduct of heart bypass surgery has been successfully tested on patients for the first time in a clinical trial coordinated by a research team at University of Galway.

The FAST TRACK CABG study, overseen by the University's CORRIB Research Center for Advanced Imaging and Core Lab, has seen heart surgeons plan and carry out coronary artery bypass grafting (CABG), based solely on non-invasive cardiac-CT scan images, with HeartFlow's AI-powered blood flow analysis of the patient's coronary arteries.

The research was published in the European Heart Journal.

The key findings of this first-in-human study is the 99.1% feasibility, which means that heart bypass surgery without undergoing invasive diagnostic catheterization is feasible and safe, driven by the good diagnostic accuracy of the cardiac CT scan and AI-powered blood flow analysis.

In comparing the safety and effectiveness of heart bypass surgery, the trial had similar outcomes to recent surgical groups of patients who underwent conventional invasive angiogram investigations, which involves inserting a catheter through an artery in the wrist or groin to access diseased arteries and using dye to visualize blockages.

The findings of the FAST TRACK CABG trial suggest that the less invasive approach to heart bypass surgery offers comparable safety and efficacy to established methods. The research team noted that safety issues inherent to invasive investigation can be replaced by a non-invasive technique using CT scan imaging and AI-powered blood flow analysis.

Trial chairman Professor Patrick W Serruys, Established Professor of Interventional Medicine and Innovation at University of Galway, said, "The results of this trial have the potential to simplify the planning for patients undergoing heart bypass surgery. The trial and the central role played by the CORRIB Core Lab puts University of Galway on the frontline of cardiovascular diagnosis, planning and treatment of coronary artery disease."

The study was carried out in leading cardiac care hospitals in Europe and the US and involved 114 patients who had severe blockages in multiple vessels, limiting blood flow to their heart.

Professor Professor Patrick W Serruys in the CORRIB Core Lab at University of Galway explaining the results and significance FAST TRACK CABG trial. Credit: University of Galway

The cardiac CT used in this study (Revolution CT, GE Health care) has a special resolution that makes the non-invasive images as good or even better than the images traditionally obtained by a direct injection of contrast dye in the artery of the heart through a catheter.

During the trial, the analysis of high resolution cardiovascular imagery and data was carried out by the CORRIB Core Lab team and shared by telemedicine with surgeons in trial hospitals.

The HeartFlow Analysis, which provides AI-powered blood flow analysis called Fractional Flow Reserve derived from CT (FFRCT), quantifies how poorly the narrowed vessel provides blood to the heart muscle, assisted the surgeon in clearly identifying which of the patient's vessels should receive a bypass graft.

Professor Serruys added, "The potential for surgeons to address even the most intricate cases of coronary artery disease using only a non-invasive CT scan, and FFRCT represents a monumental shift in health care. Following the example of the surgeon, interventional cardiologists could similarly consider circumventing traditional invasive cineangiography and instead rely solely on CT scans for procedural planning. This approach not only alleviates the diagnostic burden in cath labs but also paves the way for transforming them into dedicated 'interventional suites'- ultimately enhancing patient workflows."

Dr. Yoshi Onuma, Professor of Interventional Cardiology at University of Galway and the medical director of CORRIB Research Center, said, "Exploring the potential for minimizing diagnostic catheterization procedures is important for several reasons- a catheterization procedure is invasive and it is unpleasant for the patient. It is also costly for the health service. While there is a minimal risk associated with the procedure, it is not entirely risk free.

"CT scan analysis, FFRCT, and guidance from the team in Galway is a world first in bypass surgery. It may become a game-changer, altering the traditional relationship between GP, radiologist, cardiologist and cardio-thoracic surgeon for the benefit of the patient."

Dr. Saima Mushtaq, Director of Cardiovascular CT in Centro Cardiologico Monzino, Milan, Italy, said, "This is a historical trial that may change our approach for patients who are candidates for CABG revascularization and with the FAST TRACK CABG trial we have been part of this revolution in which a CT scan is considered a tool to plan revascularization skipping invasive coronary angiography."

Dr. John Puskas, Mount Sinai Morningside, New York and Professor of Cardiothoracic Surgery, Emory University Hospital Midtown, Atlanta, Georgia, said, "As the only North American surgeon, enrolling many patients in this trial, I have a unique perspective: I can conclusively state that there is no loss in diagnostic precision or accuracy nor any decrement in the quality of surgical planning or performance when the surgical team is guided solely by data from a latest-generation, non-invasive coronary CT scan.

"Once the surgeon is familiar with this new imaging modality, there are several ways in which it is actually a better guide than the historical invasive coronary angiogram."

Professor Fidelma Dunne, Director of the Institute for Clinical Trials at University of Galway, said, "The outcomes of this inaugural human trial are highly promising, prompting further exploration of the advantages offered by this non-invasive methodology through an extensive randomized trial. At the Institute for Clinical Trials we are committed to conducting high-impact trials that have the potential to revolutionize patient care globally."

The pioneering research of the CORRIB Core Lab at University of Galway into cardiovascular diagnosis and coronary artery disease will be further investigated in a large scale randomized trial. The research team is planning for it to involve more than 2,500 patients from 80 hospitals across Europe.

More information: Patrick W Serruys et al, Coronary bypass surgery guided by computed tomography in a low-risk population, European Heart Journal (2024). DOI: 10.1093/eurheartj/ehae199

Citation: Successful 'first in human' clinical trial of pioneering guidance for heart bypass surgery (2024, April 8) retrieved 5 May 2024 from https://medicalxpress.Com/news/2024-04-successful-human-clinical-trial-guidance.Html

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STS Releases New Risk-Prediction Tools For Emerging Surgical Scenarios

The Society of Thoracic Surgeons (STS) has published three new online calculators that spell out personalized risks for mortality and major complications associated with isolated tricuspid valve repair and replacement, surgical aortic valve repair after TAVI, and multivalve surgeries with or without CABG.

The tools are intended for use by surgeons who are counseling patients considering the various surgeries, but also are accessible to patients who wish to use them directly.

"The STS risk calculators cover a large portion of patients undergoing cardiac surgery, but still we were missing a portion of specific and sometimes more nuanced patients," STS President Jennifer C. Romano, MD (University of Michigan Congenital Heart Center, Ann Arbor), told TCTMD, referring to their existing portfolio of adult cardiac surgery risk calculators to predict operative risk and for specific procedures such as surgical repair of primary mitral regurgitation. "Of the over 10 million patients that we have in our database, our risk calculators have examined the most common types of operations," she said

Cardiac surgeries have grown more complex in recent years, with patients often needing multiple valves or redo procedures, so having calculators that are able to take all of that into account will be powerful for providers in counseling their patients, Romano added. Compared with sharing with patients the existing literature, these calculators allow providers to use patient-specific factors, a feature that "enables you to be much more specific—because some patients may be quite low risk, other patients may be quite high risk. The calculators give you much more granularity."

The tricuspid calculator gives operators access to contemporary STS data, drawn from 13,587 patients in the STS Adult Cardiac Surgery Database who underwent isolated tricuspid valve surgery between 2017 and 2023.

Likewise, the growing number of SAVR procedures following TAVI operations spurred the need for its own calculator, according to Romano, especially given the need for device explantation. This tool was based on data from 5,457 patients treated between 2012 and 2023.

Lastly, the multivalve calculator, which was developed based on 32,938 patients treated between 2017 and 2023, covers any surgery involving aortic valve replacement as well as replacement or repair of the mitral valve with and without concomitant CABG.

All three mobile-friendly calculators cleanly display a patient's risk for the following: operative mortality, morbidity and mortality, stroke, renal failure, reoperation, prolonged ventilation, deep sternal wound infection, long hospital stay (> 14 days), and short hospital stay (< 6 days).

Additionally, Romano pointed out that eventually these calculators, once linked with National Death Index data, will be able to predict not only 30-day risks but also those at 5 and 10 years. "Obviously knowing how you're going to be in 30 days is important for people," she said, "but they really want to know: 'How am I going to be doing in the long term?' As we continue to link the National Death Index with the database, we will continue to update these calculators with the aim of providing estimations of long-term outcomes as well."

The STS plans to roll out additional risk calculators for patients undergoing aortic valve surgeries like aortic ascending arch procedures as well as for thoracic surgery, including lung cancer operations.

"The calculators are a great example of how our database is really intended to help our members and our patients," Romano stressed. "This is something that is used day in and day out in the hands of physicians who are guiding care for patients. I think it really shows the value of having built this large database to be able to make sure that people are getting the best care possible."

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