Transesophageal echocardiography guided cannulation for peripheral cardiopulmonary bypass during robotic cardiac surgery

Background Minimally invasive cardiac surgery and closed chest cardiopulmonary bypass （CPB） techniques continue to evolve. Previous reports have demonstrated the benefits of fluoroscopy guided cannulation for endovascular CPB during port access cardiac surgery. However, few data are available on the role of transesophageal echocardiography （TEE） guided cannulation for peripheral CPB during robotic cardiac surgery. The purpose of this study was to evaluate TEE guided cannulation for peripheral CPB during robotic cardiac surgery. Methods We performed a retrospective analysis of intraoperative data of 129 consecutive patients underwent robotic cardiac surgical procedures requiring peripheral CPB from September 2007 to August 2011, which was established using femoral arterial inflow and kinetic venous drainage by way of the femoral vein and right internal jugular vein and a transthoracic aortic cross clamp. TEE was used to guide cannulation of the inferior vena cava （IVC）, superior vena cava （SVC）, and ascending aorta （AAO）. The success rate and the complication rate of TEE guided cannulation for peripheral CPB were evaluated and compared with the results of fluoroscopy guided cannulation in a historical control group. Results One hundred and twenty-nine consecutive patients underwent robotic cardiac surgical procedures requiring peripheral CPB. There were 67 female （51.9%） and 62 male （48.1%） patients, ranging in age from 13 to 70 years （mean （43.94 ± 13.82） years） and body surface area 1.32 to 2.39 m2 （mean （1.71± 0.20） m2）. Some 61 （47.3%） patients underwent mitral valve repair, 27 （20.9%） mitral valve replacement, 27 （20.9%） left atrial myxoma removal, and 14 （10.9%） ventricular septal defect repair. Of the 129 patients, TEE guided cannulation of the IVC or SVC was successful in all patients （100%）, and no puncture related complications occurred in all patients. Of the 129 patients, successful cannulation of the AAO was achieved in all patients （100%）, and aortic perforation occurred in 1 patient （0.78%） under TEE guidance. Of the 42 patients in the historical control group, successful cannulation occured in 39 patients （92.86%）, and major complications occurred in 3 patients （7.14%） under fluoroscopy guidance. TEE guided cannulation of the AAO significantly improved success rate （100% vs. 92.86%, P=0.014） and decreased complication rate （0.78% vs. 7.14%, P=0.046）.

Ultrasound-guided cannulation of the internal jugular vein in robotic cardiac surgery

Background Robotic assisted minimally invasive cardiac sugery is a new technique that uses small port sites and peripheral vessel cannulation for cardiopulmonary bypass （CPB） has been used. The right internal jugular vein （IJV） is commonly used for intraoperative venous access to the central circulation and identified with an external landmark. Previous studies have demonstrated the superiority of ultrasound guidance over external landmark technique in anaesthetic and intensive care settings. The aim of the present study was to delineate the utility of ultrasound-guided cannulation of the IJV during establishment of peripheral CPB in robotic cardiac surgery. Methods We prospectively studied 296 adult patients undergoing ultrasound-guided right IJV cannulation during establishment of peripheral CPB in robotic cardiac surgery at our institute from January 2007 to October 2012 （ultrasound group）. The success rate, the first attempt success rate, access time and the complication rate of ultrasound-guided method were compared with the landmark-guided method used for 302 historical control patients （landmark group）. Results In the ultrasound group, 296 consecutive adult patients underwent ultrasound-guided right IJV cannulation during establishment of peripheral CPB in robotic cardiac surgery. In the landmark group, 302 patients underwent right IJV cannulation using the landmark-guided technique. The success rate and the first attempt success rate in the ultrasound group were significantly higher than that in the landmark group （100% vs. 88.1%, P 〈0.000 and 98.6% vs. 38.4%, P 〈0.000）. Average access time in the ultrasound group was shorter than that in the landmark group （（6.3＋13.6） seconds; interquartile range （4-62） seconds vs. （44.5＋129.5） seconds; interquartile range （5-986） seconds）. The complication rate in the ultrasound group was significantly lower than that in the landmark group （0.3% vs. 8.3%, P 〈0.000）. Conclusion Compared with the landmark-guided approach, ultrasound-guided cannulation of the right IJV significantly improves success rate, decreases access time and reduces complication rate during establishment of peripheral CPB in robotic cardiac surgery.