Perfusion management of peripheral extracorporeal circulation during robotic heart surgery

Objective To discuss the establishment and perfusion management strategies of peripheral extracorporeal circulation (PECC) during robotic heart surgery. Methods Of the 375 patients who underwent robotic heart surgery using “da Vinci S” surgical system from January 2007 to January 2014, 169 cases underwent repair of atrial septal defect, 22 cases underwent repair of ventricular septal defect, 96 cases underwent mitral valvuloplasty, 38 cases underwent mitral valve replacement, 44 cases underwent resection of left atrial myxoma and 6 cases underwent resection of right atrial myxoma. Surgery approach was achieved through three 0.8 cm trocar incision in the right side of the chest and a 2 cm working port. Extracorporeal circulation (ECC) was established through the femoral artery, femoral vein and right internal jugular vein cannulation with the guidance of transeophageal echocardiography (TEE). Vacuum-assisted venous drainage (VAVD), CDITM 500 continuous blood gas monitoring and ultra filtration were used during ECC procedures. The aortic occlusion was performed with a Chitwood crossclamp and antegrade cardioplegia was delivered directly via chest with cold blood cardioplegic solution or HTK solution for myocardial protection. Results All procedures were successfully performed with no operative death and conversion to a median sternotomy. ECC time and aortic cross-clamp time were 24-219 (94.9±38.8) min and 18-166 (66.7±29.0) min respectively. During ECC, the urine volume were 30-2100 (593.1±459.4) ml, ultra filtration volume was 800-6 700 (3 005.6±1 245.2) ml, and the total fluid balance was subzero-balanced in 299 (80%) patients with subzero-balanced volume of 50-3 100 (856.7±563.8) ml. 255 patients underwent surgery with arrested heart and the cardiac autoresuscitation rate was 81% (207/255). Postoperative intubation time was 4-12 (6.3±1.6) h and drainage volume within 24 h postoperatively was 10-350 (111.5±59.5) ml. 3 cases of femoral vein thrombus and 2 cases of femoral arterial thrombus were observed after the surgery. All the complications were cured using warfarin or embolectomy. Conclusion PECC technology is a precondition for robotic cardiac surgery. Using VAVD and CDI, selecting the reasonable methods of myocardial protection are the key points of ECC management.