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Background: In preclinical testing, ventricular wall injection of hydrogels has been shown to be effective in modulating ventricular remodeling and preserving cardiac function. For some approaches, early-stage clinical trials are under way. The hydrogel delivery method varies, with minimally invasive approaches being preferred. Endocardial injections carry a risk of hydrogel regurgitation into the circulation, and precise injection patterning is a challenge. An epicardial approach with a thermally gelling hydrogel through the subxiphoid pathway overcomes these disadvantages., Methods: A relatively stiff, thermally responsive, injectable hydrogel based on N-isopropylacrylamide and N-vinylpyrrolidone (VP gel) was synthesized and characterized. VP gel thermal behavior was tuned to couple with a transepicardial injection robot, incorporating a cooling feature to achieve injectability. Ventricular wall injections of the optimized VP gel have been performed ex vivo and on beating porcine hearts., Results: Thermal transition temperature, viscosity, and gelling time for the VP gel were manipulated by altering N-vinylpyrrolidone content. The target parameters for cooling in the robotic system were chosen by thermal modeling to support smooth, repeated injections on an ex vivo heart. Injections at predefined locations and depth were confirmed in an infarcted porcine model., Conclusions: A coupled thermoresponsive hydrogel and robotic injection system incorporating a temperature-controlled injectate line was capable of targeted injections and amenable to use with a subxiphoid transepicardial approach for hydrogel injection after myocardial infarction. The confirmation of precise location and depth injections would facilitate a patient-specific planning strategy to optimize injection patterning to maximize the mechanical benefits of hydrogel placement., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Functional mitral regurgitation or functional tricuspid regurgitation most commonly result from maladaptive remodeling due to ischemic heart disease or idiopathic dilatative cardiomyopathy. We report a case of significant functional mitral regurgitation and functional tricuspid regurgitation arising from isolated annular dilatation secondary to atrial fibrillation and associated atrial remodeling. The patient underwent successful mitral and tricuspid valve repair and a bi-atrial Maze procedure., (Copyright © 2010 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Purpose: We developed a novel, highly articulated robotic surgical system (CardioARM) to enable minimally invasive intrapericardial therapeutic delivery through a subxiphoid approach. We performed preliminary proof of concept studies in a porcine preparation by performing epicardial ablation., Description: CardioARM is a robotic surgical system having an articulated design to provide unlimited but controllable flexibility. The CardioARM consists of serially connected, rigid cyclindrical links housing flexible working ports through which catheter-based tools for therapy and imaging can be advanced. The CardioARM is controlled by a computer-driven, user interface, which is operated outside the operative field., Evaluation: In six experimental subjects, the CardioARM was introduced percutaneously through a subxiphoid access. A commercial 5-French radiofrequency ablation catheter was introduced through the working port, which was then used to guide deployment. In all subjects, regional ("linear") left atrial ablation was successfully achieved without complications., Conclusions: Based on these preliminary studies, we believe that the CardioARM promises to enable deployment of a number of epicardium-based therapies. Improvements in imaging techniques will likely facilitate increasingly complex procedures.

Surgical removal or epicardial radiofrequency ablation of the left atrial appendage (LAA) is occasionally required when endocardial ablations fail. We report a modified minimally invasive surgical approach for elimination of recurrent atrial arrhythmias arising from the LAA, including both radiofrequency ablation and appendectomy. Ablation of the LAA base was performed using the Medtronic Cardioblate bipolar radiofrequency device (Medtronic, Minneapolis, MN), and left atrial appendectomy was then completed using the EndoGIA stapling system (US Surgical, Norwalk, CT). This procedure successfully isolated and removed the tachycardia focus, and normal sinus rhythm was restored. Elimination of LAA arrhythmias using a combination of epicardial radiofrequency ablation and appendectomy ensures electrical isolation while minimizing surgical invasiveness.

A patient presenting with a history of transient ischemic attacks was initially diagnosed with a large secundum-type atrial septal defect by transesophageal echocardiography. Subsequent attempts to percutaneously repair the defect using an Amplatzer septal occlude device (AGA Medical, Plymouth, MN) failed to position correctly on multiple attempts. At the time of surgery, a largely deficient and highly fenestrated septum primum was found, which was likely the cause of the Amplatzer device (AGA Medical) failure. The defect was then definitively repaired using a bovine pericardial patch without incident.

We report a novel subxiphoid video pericardioscopy approach for epicardial mapping that allows direct visualization of the epicardium with minimal use of fluoroscopy. The FLEXview system (Boston Scientific Cardiac Surgery, Santa Clara, CA), which is capable of a free navigation around the heart owing to its flexible neck, was inserted into the pericardial space through a small subxiphoid incision. A commercially available mapping catheter advanced through the working port of the device could be navigated around virtually the entire biventricular epicardial surface. The subxiphoid video pericardioscopy approach using the FLEXview system provided adequate visualization and access to the epicardium of both ventricles for electroanatomic mapping while minimizing surgical invasiveness.

Background: Lung volume reduction surgery (LVRS) has been demonstrated to provide symptomatic relief and to improve lung function in patients with end-stage emphysema. The goal of this study was to assess the additional morbidity associated with lung transplantation after LVRS for end-stage emphysema with regard to immediate postoperative outcomes, longitudinal spirometry, and survival rates compared to an age-, gender-, procedure-matched, and transplant time-matched cohort that had lung transplantation alone., Methods: We compared the postoperative and long-term outcomes of a sequential procedure cohort to a matched cohort to assess the possible added post-transplant morbidity., Results: Fifteen patients who underwent sequential LVRS (including 11 unilateral LVRS, 4 bilateral LVRS) and lung transplantation (ipsilateral in 7 and contralateral in 8) on average 28.1 +/- 17.2 months (median, 27.4 months; range, 3.7 to 61.7 months) later were assessed. No significant differences were noted in pretransplant demographics, post-transplant variables, longitudinal spirometric indices, or survival. A trend toward a lower pretransplant arterial carbon dioxide tension was apparent in the sequential procedure cohort. Group analysis revealed a significant increase in the number of patients requiring transfusion and in the total number of units transfused in patients undergoing ispsilateral transplantation after LVRS; a significant increase in the length of intensive care unit stay; and a trend toward an increase in the duration of hospital stay in patients undergoing lung transplantation within 18 months of LVRS., Conclusions: In appropriate candidates, LVRS bridged the time to transplantation by an average of 28.1 +/- 17.2 months (median, 27.4 months; range, 3.7 to 61.7 months) without significantly increasing post-transplant morbidity or mortality. Furthermore, bilateral LVRS bridged the time to transplantation to a greater extent than unilateral LVRS (34.9 +/- 29.8 months; median, 32.1 months versus 25.4 +/- 16.3 months; median, 22.3 months; p = 0.23).

This report describes the case of a 51-year-old man with myocardial ischemia resulting from in-stent restenosis of the left anterior descending coronary artery who underwent a minimally invasive direct coronary artery bypass using thoracic epidural analgesia while awake, without general endotracheal anesthesia.

Background: Transmyocardial laser revascularization (TMR) provides relief for patients with chronic angina, nonamenable to direct coronary revascularization. Unmanageable, unstable angina (UUA) defines a subset of patients with refractory angina who are at high risk for myocardial infarction and death. Patients were classified in the UUA group when they had been admitted to the critical care unit with unstable angina for 7 days with three failed attempts at weaning them off intravenous antianginal medications., Methods: Seventy-six treated patients were analyzed to determine if TMR is a viable option for patients with unmanageable unstable angina. These patients were compared with 91 routine protocol patients (protocol group [PG]) undergoing TMR for chronic angina not amenable to standard revascularization. The procedure was performed through a left thoracotomy without cardiopulmonary bypass. These patients were followed for 12 months after the TMR procedure. Both unmanageable and chronic angina patients had a high incidence of at least one prior surgical revascularization (87% and 91%, respectively)., Results: Perioperative mortality (< or = 30 days post-TMR) was higher in the UUAG versus PG (16% vs 3%, p = 0.005). Late mortality, up to 1 year of follow-up, was similar (13% vs 11%, UUAG vs PG; p = 0.83). A majority of the adverse events in the UUAG occurred within the first 3 months post-TMR, and patients surviving this interval did well, with reduced angina of at least two classes occurring in 69%, 82%, and 82% of patients at 3, 6, and 12 months, respectively. The percent improvement in angina class from baseline was statistically significant at 3, 6, and 12 months. A comparable improvement in angina was found in the protocol group of patients., Conclusions: TMR carried a significantly higher risk in unmanageable, unstable angina than in patients with chronic angina. In the later follow-up intervals, however, both groups demonstrated similar and persistent improvement in their angina up to 12 months after the procedure. TMR may be considered in the therapy of patients with unmanageable, unstable angina who otherwise have no recourse to effective therapy in the control of their disabling angina.

Background: Lung transplantation for pulmonary failure resulting from systemic disease is controversial. We reviewed our transplant experience in patients with sarcoidosis, scleroderma, lymphangioleiomyomatosis, and graft-versus-host disease., Methods: This retrospective review examined the outcome of 23 patients who underwent pulmonary transplantation for these systemic diseases. Group 1 included 15 patients with pulmonary hypertension who underwent transplantation (9 for sarcoidosis, 6 for scleroderma), and group 2 included 8 patients with normal pulmonary artery pressures who underwent transplantation (5 for lymphangioleiomyomatosis, 3 for graft-versus-host disease). The incidences of infection and rejection, pulmonary function, and survival were measured and compared with those of patients who underwent transplantation for isolated pulmonary disease., Results: Although there were no differences in the rate of infection between patients who underwent transplantation for systemic versus isolated disease, patients with pulmonary hypertension who underwent transplantation for systemic disease had significantly lower rates of rejection. Four patients with sarcoidosis and 2 with lymphangioleiomyomatosis demonstrated recurrence in the allograft. Survival was similar between patients who underwent transplantation for systemic versus isolated disease., Conclusions: Patients with respiratory failure resulting from these systemic diseases can undergo transplantation with outcomes comparable to those obtained in patients who undergo transplantation for isolated pulmonary disease.