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J Thorac Cardiovasc Surg 2005;130:120-124
© 2005 The American Association for Thoracic Surgery

Evolving Technology

Totally endoscopic robot-assisted transmyocardial revascularization

^a Division of Cardiac Surgery, Johns Hopkins Hospital, Baltimore, Md
^b Department of Anesthesia and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Md

Received for publication September 27, 2004; revisions received October 27, 2004; accepted for publication November 23, 2004.

^_* Address for reprints: David D. Yuh, MD, Division of Cardiac Surgery, Johns Hopkins Hospital, 600 North Wolfe Street, Blalock 618, Baltimore, MD 21287-4618 (Email: dyuh{at}csurg.jhmi.jhu.edu).

OBJECTIVE: Laser transmyocardial revascularization is an emerging therapy for intractable angina stemming from diffuse, small-vessel coronary disease not amenable to percutaneous coronary intervention or coronary bypass grafting. Presently, this therapy is delivered through a median sternotomy or left thoracotomy. In this pilot study, we sought to combine the advantages of a dexterous robotic surgical platform with a flexible fiberoptic laser to develop a minimally invasive approach toward transmyocardial revascularization.

METHODS: A flexible fiberoptic holmium:yttrium-aluminum-garnet laser probe (CardioGenesis Corporation, Foothill Ranch, Calif), deployed with the da Vinci surgical robotic system (Intuitive Surgical, Sunnyvale, Calif), was used to create transmyocardial channels through all left ventricular wall regions in 5 canine subjects. The channels were localized, quantified, and histologically analyzed to assess distribution, dimensions, and transmurality.

RESULTS: Transmyocardial channels were successfully created in all 6 defined left ventricular wall segments by using this minimally invasive approach without port repositioning, instrument exchange, or probe modifications. Gross pathologic and histologic analyses confirmed the uniform distribution of 1.0-mm transmural channels in all left ventricular regions. No direct pressure, topical hemostatic agents, or suture repairs were required for hemostasis. No significant hemodynamic instability or sustained arrhythmias were encountered at any time during the procedures.

CONCLUSIONS: We report the first use of a prototype flexible fiberoptic laser probe deployed by the da Vinci surgical robotic system to successfully perform totally endoscopic off-pump transmyocardial revascularization in a canine model, demonstrating the feasibility, precision, and safety of this approach. Refinement of this minimally invasive technique may reduce the morbidity of open-chest transmyocardial revascularization and facilitate its use as sole therapy or as an adjunct to percutaneous coronary interventions.

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