Minimally invasive cardiac surgery : studies on immediate and mid-term outcomes

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Sammanfattning

The median sternotomy has been the gold standard approach for cardiac surgical procedures since 1957, when the superiority of the median sternotomy over different thoracotomy approaches for cardiac surgery was first described. In the sternotomy approach, surgical access to the heart is achieved after longitudinal division of the sternum. Less invasive methods for cardiac operations were introduced in the late 1990s to avoid the large incisions and sternal trauma caused by the median sternotomy. These minimally invasive techniques have evolved, and totally endoscopic robotically assisted cardiac operations have been performed recently through small ports in the intercostal spaces. This study’s objective was to evaluate the safety and effectiveness of minimally invasive cardiac surgery in a university teaching hospital with respect to learning curve, quality of life, and mid-term outcomes. It also describes a radiological classification for unilateral pulmonary edema (UPE) and evaluates the risk factors for UPE, as well as evaluating in detail a minimal volume ventilation method that aims to reduce pulmonary dysfunction after minimally invasive cardiac surgery. A total of 244 patients who underwent minimally invasive cardiac surgery between 2009 and 2017 at the Helsinki University Hospital were retrospectively reviewed for this study. The safety and efficacy of the robotic myxoma and mitral valve operations were comparable to the outcomes of the sternotomy operations: high repair rates and low complication rates were observed with the robotic and sternotomy approaches. Although intra-operative times and total ventilation times were longer with the robotic approach, intensive care unit stay was shorter after robotic mitral valve operations when compared with the sternotomy approach. Notably, a significant decrease of intra-operative times and ventilation times was observed during the learning curve of the robotic mitral valve operations. The 5-year survival and freedom from reoperation were similar after robotic and sternotomy mitral valve operations. Minimal volume ventilation during cardiopulmonary bypass (CPB) was associated with shorter ventilation times and lower postoperative arterial lactate levels compared with operations with no ventilation during CPB. The grading system for UPE correlated with the postoperative ventilation parameters: patients who had grade I UPE had lower PaO2/FiO2 values than patients who did not develop UPE, and total ventilation times among patients with grade II UPE were longer than with grade I UPE or no UPE. Also, substantial radiological interobserver agreement of the UPE grading was observed. This study showed that the robotic approach is a safe and effective method for mitral valve and myxoma surgery in a university teaching hospital setting. However, a significant early learning curve was observed with the robotic approach. Minimal volume ventilation during cardiopulmonary bypass was beneficial in terms of total ventilation times and postoperative arterial lactate levels, but larger prospective and randomized studies are needed to verify any possible benefits of minimal volume ventilation during minimally invasive cardiac operations. The UPE grading associated with total ventilation times and postoperative PaO2/FiO2 levels. These findings suggest that the grading system is reproducible and associates with clinical outcomes: grade I UPE has a measurable effect and grade II UPE a significant impact on postoperative pulmonary function.
Originalspråkengelska
Handledare
  • Raivio, Peter Markus, Handledare
  • Vento, Antti, Handledare
UtgivningsortHelsinki
Förlag
Tryckta ISBN978-951-51-5394-4
Elektroniska ISBN978-951-51-5395-1
StatusPublicerad - 2019
MoE-publikationstypG5 Doktorsavhandling (artikel)

Bibliografisk information

M1 - 94 s. + liitteet

Vetenskapsgrenar

  • 3126 Kirurgi, anestesiologi, intensivvård, radiologi

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