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Evaluation Of New Graft For Minimally Invasive Aortic Root Replacement
Fraser William Haven Sutherland1, Cristiano Spadaccio
2, Rocco Bilancia
3.
1Circle Health Group Ross Hall Hospital, Glasgow, United Kingdom,
2University of Cincinnati College of Medicine, Cincinnati, OH, USA,
3Golden Jubilee University National Hospital, Glasgow, United Kingdom.
BACKGROUND: Current state of the art in minimally invasive aortic root replacement (ARR) is limited to a mini-sternotomy incision using conventional grafts. Considerable technical expertise is required to perform such surgeries routinely. We sought to evaluate a new graft for minimally invasive ARR, capable of being used more widely with potential for totally endoscopic approach akin to other cardiothoracic procedures, now routinely executed through multiport or even uniportal access.
METHODS: A custom graft designed specifically for minimally invasive ARR and surgical robot were used to execute the procedure through a novel totally endoscopic, transcervical access. The standard ARR procedure was broken down to its constituent parts and each step reimagined, with an eye on ease of execution and risk. Key risks peculiar to ARR surgery include bleeding and coronary ischaemia which can be difficult to fix or prove fatal. The new graft was created to diminish these risks. The graft was firstly tested in a bovine heart model; the surgery was then practised on benchtop models; before progressing to evaluation of the entire procedure in a dedicated cadaver laboratory equipped with surgical robot. A robot and robot enabling transcervical retractor system were selected to execute the surgery for improved visualisation, provision of bipolar cautery for bloodless dissection and the ambidexterity that attends robotic platforms. Surgical access through transcervical approach was selected because of its 360 degree access to the aortic root from start-to-end and moreover for ease of mobilisation of the proximal arch for distal anastomosis.
RESULTS: All steps of robotic endoscopic aortic root replacement were performed through the transcervical access using the robot and next generation graft. The graft proved easy to orient and manipulate for attachment of coronary arteries. The surgical robot was invaluable for dissection of aortic root, and manipulation of sutures and needles. The graft design and transcervical access meant that all suture lines could be inspected at end of procedure for additional suture placement, if required.
CONCLUSIONS: Totally endoscopic aortic root replacement looks feasible using next generation graft, transcervical approach, surgical robotic and robot enabling transcervical retraction system (CardioPrecision Ltd., Glasgow UK).
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