Didier Loulmet - Academia.edu (original) (raw)

Papers by Didier Loulmet

Research paper thumbnail of Systolic anterior motion of the mitral valve: a 30-year perspective

The Journal of thoracic and cardiovascular surgery, 2014

Systolic anterior motion (SAM) can occur after mitral valve repair (MVr), most frequently in pati... more Systolic anterior motion (SAM) can occur after mitral valve repair (MVr), most frequently in patients with degenerative valve disease. Our initial observations (1981-1990) revealed that most patients with SAM can be successfully treated medically. Here the authors review the last 16 years of their experience with SAM after MVr. Between January 1996 and October 2011, 1918 patients with degenerative mitral valve disease underwent MVr at our institution. We performed a retrospective analysis of SAM in this patient population. The incidence of SAM was 4.6% (89 of 1918) overall, 4.0% (77 of 1906) in patients who did not have SAM preoperatively (de novo). Compared with our previously published report, the incidence of SAM decreased from 6.4% to 4.0% (P = .03). Hospital mortality was 2.0% (38 of 1918) overall, 1.3% (14 of 1078) for isolated MVr. One patient with de novo SAM (1 of 77; 1.3%) died after emergency MVr. All patients with de novo SAM were successfully managed conservatively with...

Research paper thumbnail of Outcomes of peripheral perfusion with balloon aortic clamping for totally endoscopic robotic mitral valve repair

The Journal of thoracic and cardiovascular surgery, 2014

Although the technique of totally endoscopic robotic mitral valve repair (TERMR) has been well de... more Although the technique of totally endoscopic robotic mitral valve repair (TERMR) has been well described, few reports have examined the results of peripheral perfusion with balloon clamping. We analyzed the outcomes of TERMR performed using this strategy. A total of 108 consecutive patients underwent TERMR by a 2-surgeon team. The preoperative evaluation included chest computed tomography and abdominal and pelvis computed tomography. Additional procedures included appendage exclusion in 96, patent foramen ovale closure in 29, cryoablation in 16, tricuspid valve repair in 2, and septal myectomy in 2. The mean patient age was 59 years (range, 21-86). Central venous drainage was obtained with a long cannula. Arterial return was achieved with femoral cannulation, when possible. An endoballoon catheter was placed through the femoral artery. Transesophageal echocardiography was used to position all catheters. Femoral artery perfusion was possible in 103 of 108 patients (95.3%). The subcla...

Research paper thumbnail of A Prospective Randomized Study of Paravertebral Blockade in Patients Undergoing Robotic Mitral Valve Repair

Journal of Cardiothoracic and Vascular Anesthesia, 2015

The aim of this study was to evaluate the addition of paravertebral blockade to general anesthesi... more The aim of this study was to evaluate the addition of paravertebral blockade to general anesthesia in patients undergoing robotic mitral valve repair. A randomized, prospective trial. A single tertiary referral academic medical center. 60 patients undergoing robotic mitral valve surgery. Patients were randomized to receive 4-level paravertebral blockade with 0.5% bupivicaine before induction of general anesthesia. All patients were given a fentanyl patient-controlled analgesia upon arrival to the intensive care unit, and visual analog scale pain scores were queried for 24 hours. On postoperative day 2, patients were given an anesthesia satisfaction survey. After obtaining institutional review board approval, surgical and anesthetic data were recorded perioperatively and compared between groups. Compared to general anesthesia alone, patients receiving paravertebral blockade and general anesthesia reported significantly less postoperative pain and required fewer narcotics intraoperatively and postoperatively. Patients receiving paravertebral blockade also reported significantly higher satisfaction with anesthesia. Successful extubation in the operating room at the conclusion of surgery was 90% and similar in both groups. Hospital length of stay also was similar. No adverse reactions were reported. The addition of paravertebral blockade to general anesthesia appears safe and can reduce postoperative pain and narcotic usage in patients undergoing minimally invasive cardiac surgery. These findings were similar to previous studies of patients undergoing thoracic procedures. Paravertebral blockade alone likely does not reduce hospital length of stay. This may be more closely related to early extubation, which is possible with or without paravertebral blockade.

Research paper thumbnail of Fluorescence-guided placement of an endoaortic balloon occlusion device for totally endoscopic robotic mitral valve repair

The Journal of Thoracic and Cardiovascular Surgery, 2015

Research paper thumbnail of Combined heart-lung-liver, double lung-liver, and isolated liver transplantation for cystic fibrosis in children

Transplant International, 1997

Between June 1990 and September 1995, 8 of 24 children with cystic fibrosis (CF) who were accepte... more Between June 1990 and September 1995, 8 of 24 children with cystic fibrosis (CF) who were accepted either for combined transplantation or isolated liver transplantation died while waiting for a graft; 11 underwent transplantation and 5 are currently on the waiting list. Of the 11 children who had surgery, 7 (group 1) underwent one of the following procedures: heart-lung-liver (n = 4), sequential double lung-liver (n = 2), or bilateral lobar lung from a split left lung and reduced liver (n = 1). During the same period, the four other children (group 2) underwent isolated liver transplantation (three full-size livers, one partial liver). There was one perioperative death in each group. Pulmonary infection was the most common cause of morbidity in group 1. Other complications in group 1 included tracheobronchial stenosis (n = 2), biliary stricture (n = 2), and severe ascites (n = 2). All were successfully treated. Obliterative bronchiolitis developed in three patients. This was treated with FK 506. In group 2, pulmonary function tests improved or remained stable after liver transplantation. Surgical complications in group 2 included severe ascites (n = 1), biliary stricture (n = 1), and abscess of the liver (n = 1). Actuarial survival was 85.7% +/- 2% in group 1 at 1 year; it remained unchanged at 3 years and was 64.2% at 5 years.

Research paper thumbnail of Computer-assisted cardiac surgery

The Lancet, 1999

Computer-assisted cardiac surgery. By - Alain Carpentier, Didier Loulmet, Bertrand Aupecle, Alain... more Computer-assisted cardiac surgery. By - Alain Carpentier, Didier Loulmet, Bertrand Aupecle, Alain Berrebi, John Relland.

Research paper thumbnail of Pulmonary bipartitioning and lobar transplantation: A new approach to donor organ shortage

The Journal of Thoracic and Cardiovascular Surgery, 1997

The scarcity of small donors has significantly limited lung transplantation for pediatric and sma... more The scarcity of small donors has significantly limited lung transplantation for pediatric and small adult patients. Use of single lobes procured from size-unmatched donors has overcome this difficulty, but only in a few selected cases and, in addition, it represents a waste of lung tissue. In an animal model we have shown that it is possible to divide one lung with careful partitioning of the vascular and bronchial structures and thus obtain two viable lobar grafts suitable for bilateral implantation in a smaller animal. We have now applied this procedure clinically in seven patients operated on between May 1993 and November 1994. The indications were cystic fibrosis in three children, primary pulmonary hypertension in two adults, bronchiectasis in one, and idiopathic pulmonary fibrosis in one. There were three children aged 13 to 17 years (median 14) and four adults aged 40 to 53 years (median 45). There was a 46% to 50% discrepancy for weight between recipient and donor and a 12% to 17% discrepancy for height. The surgical technique consisted of careful partitioning of the left donor lung, bilateral anterior thoracotomy in the recipient, and, with the use of cardiopulmonary bypass, implantation of the lower lobe in the left hemithorax and the upper lobe in the right hemithorax. Vascular and bronchial connections were facilitated by leaving a long pedicle on the recipient side. The pulmonary artery anastomosis for the donor left upper lobe was done with the "fissure" side of the artery to ensure an anastomosis without tension. An end-to-end bronchial anastomosis overcame the problem of size discrepancy. Six patients are alive and well 10 to 27 months (median 19) after operation. One patient with cystic fibrosis died of systemic aspergillosis infection. All were discharged from the hospital within the first or second postoperative month. No technical problems were identified: repeated bronchoscopy has demonstrated satisfactory healing without early stricture formation. All patients remain well subjectively with good exercise tolerance and all patients achieve greater than 70% of predicted values of forced expiratory volume in 1 second. Perfect adaptation of the transplanted lobes to the recipient pleural space has been demonstrated by postoperative computed tomographic scan. In conclusion, bilateral lobar transplantation from a single donor lung is possible in small adults or children when there is a large size discrepancy with the donor. This may help resolve the problem of donor availability in the pediatric population.

Research paper thumbnail of Combined lung and liver transplantation in patients with cystic fibrosis: A 4 1/2-year experience

The Journal of Thoracic and Cardiovascular Surgery, 1995

Research paper thumbnail of Less invasive techniques for mitral valve surgery

The Journal of Thoracic and Cardiovascular Surgery, 1998

Objective: Minimally invasive surgical techniques aim at reducing the consequences of currently u... more Objective: Minimally invasive surgical techniques aim at reducing the consequences of currently used large incisions, such as bleeding, pain, and risk of infection. Although this new approach developed rapidly in coronary surgery, it remains questionable in mitral valve surgery. This article reports the longest experience with minimally invasive mitral valve surgery, with particular attention to approach and techniques. Methods: From February 1996, the date of the first case of minimally invasive mitral valve reconstruction, to April 1997, 22 patients with a mean age of 54 ؎ 2.7 years were subjected to mitral valve surgery performed with less invasive techniques. Exposure of the mitral valve was achieved through a minithoracotomy (n ‫؍‬ 12) or a ministernotomy (n ‫؍‬ 10). Video assistance was used in all cases. Peripheral arterial cannulation (n ‫؍‬ 21) and venous drainage (n ‫؍‬ 22) were used in most cases. Results: In this series, valve surgery consisted in 19 repairs, two replacements, and one closure of a periprosthetic leak. In two cases it was necessary to convert to a larger incision. The average duration of cardiopulmonary bypass was 157 ؎ 8.2 minutes, ventilatory assistance 16 ؎ 4.6 hours, and intensive care unit stay 2.1 ؎ 0.4 days. Two patients required reoperation for bleeding and another for early recurrence of mitral valve regurgitation. There were no deaths and all patients were discharged with normal valve function. At most recent follow-up, all patients were in functional class I, with resumption of normal activity. Conclusion: Mitral valve surgery can be performed safely by means of less invasive techniques, but with increased technical difficulty. A low asymmetric median sternotomy seems preferable to an anterior thoracotomy. (J Thorac Cardiovasc Surg 1998;115:772-9)

Research paper thumbnail of Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments

The Journal of Thoracic and Cardiovascular Surgery, 1999

Objective: The development of endoscopic coronary artery bypass grafting has been limited because... more Objective: The development of endoscopic coronary artery bypass grafting has been limited because of poor visualization and increased technical difficulties in carrying out operations through ports. We investigated whether the use of robotic assisted instruments could minimize these difficulties. Methods: After a period of technical development and training on cadavers (n = 8) with the Intuitive Surgical system (Intuitive Surgical, Inc, Mountain View, Calif), the first clinical application in coronary artery surgery was performed in 4 male patients (mean age 59 ± 6 years) with the indication of grafting the left internal thoracic artery to the left anterior descending coronary artery. Robotic assisted 3dimensional endoscopes and instruments were introduced into the left side of the chest through 3 intercostal ports. The Heartport system (Heartport, Inc, Redwood City, Calif) was used for arresting the heart during the anastomosis. Results: In 2 patients, the harvesting of the left internal thoracic artery was completed endoscopically with robotic assisted instruments and the anastomosis to the left anterior descending artery was performed through a minithoracotomy with conventional instruments. In 2 other patients, the entire operation was completed endoscopically with robotic assisted instruments. Early postoperative coronary angiography demonstrated the patency of the grafts in all cases. At 6-month follow-up, all patients were free of symptoms. Conclusions: Robotic assisted instruments make endoscopic coronary bypass possible and open a new era in minimally invasive surgery. (J Thorac Cardiovasc Surg 1999;118:4-10)

Research paper thumbnail of Emergency conversion to cardiopulmonary bypass during attempted off-pump revascularization results in increased morbidity and mortality

Journal of Thoracic and Cardiovascular Surgery, 2004

We sought to evaluate outcomes and predictors of emergency conversion to cardiopulmonary bypass d... more We sought to evaluate outcomes and predictors of emergency conversion to cardiopulmonary bypass during attempted off-pump coronary bypass surgery. From January 1999 through July 2002, 1678 consecutive isolated coronary artery bypass operations were performed at Lenox Hill Hospital, with the intention to treat all patients with off-pump coronary bypass surgery. Fifty (2.97%) patients required urgent conversion to cardiopulmonary bypass. All the preoperative, intraoperative, and postoperative variables were collected and analyzed in accordance with the New York State Cardiac Surgery Reporting System. Multivariate regression analysis was performed to determine predictors for conversion. In-hospital mortality and major morbidity were significantly lower in the nonconverted group compared with the converted patients (mortality: 1.47% [n = 24] vs 12% [n = 6], P = .001; stroke: 1.1% [n = 18] vs 6% [n = 3], P = .02; renal failure: 1.23% [n = 20] vs 6% [n = 3], P = .02; deep sternal wound infection: 1.54% [n = 25] vs 8% [n = 4], P = .009; respiratory failure: 3.75% [n = 61] vs 28% [n = 14], P < .0001; nonconverted vs converted patients, respectively). The annual incidence of conversion decreased during the study period. There was a significant reduction in the incidence of conversion after routine use of a cardiac positioning device to performing lateral and inferior wall grafts (4.2% [n = 27] vs 2.3% [n = 23], P = .04). None of the preoperative variables were independent predictors of conversion on multivariate regression analysis. Because emergency conversion to cardiopulmonary bypass during attempted off-pump coronary bypass surgery results in significantly higher morbidity and mortality, studies comparing off-pump coronary bypass surgery with conventional coronary artery surgery should include converted patients in the off-pump group. In our experience, emergency conversion is an unpredictable event. The incidence of conversion decreases with increasing experience of surgeons in performing off-pump coronary surgery and use of a cardiac positioning device.

Research paper thumbnail of Giant Nonfamilial Left Atrial Myxoma Presenting With Eye Embolism and Nonvalvular Streptococcus sanguinis Endocarditis

Journal of the American College of Cardiology, 2014

Research paper thumbnail of Robotic-assisted cardiac surgery: Anesthetic and postoperative considerations

Journal of Cardiothoracic and Vascular Anesthesia, 2002

Objective: To assess the feasibility of endoscopic telemanipulated cardiac surgery and describe t... more Objective: To assess the feasibility of endoscopic telemanipulated cardiac surgery and describe the anesthetic, postoperative, and surgical implications of minimally invasive robotic-assisted cardiac surgery.

Research paper thumbnail of Chirurgie à cœur ouvert assistée par ordinateur. Premier cas opéré avec succès

Comptes Rendus de l'Académie des Sciences - Series III - Sciences de la Vie, 1998

... cas op6r6 avec succk Alain Carpentier*, Didier Loulmet, Bertrand AupPcle, Jean-Philippe Kieff... more ... cas op6r6 avec succk Alain Carpentier*, Didier Loulmet, Bertrand AupPcle, Jean-Philippe Kieffer, Dominique Tournay, Pierre Guibourt, Annick Fiemeyer, Denis ... peut explorer j loisir les parois rutilantes, Its reliefs liigure 2). Ces 4lknents en place, le c hirurgieri gagne la contrast& ...

Research paper thumbnail of Partial replacement of the tricuspid valve by mitral homografts in acute endocarditis

The Annals of Thoracic Surgery, 2002

http://ats.ctsnetjournals.org/cgi/content/full/73/6/1808 on the World Wide Web at:

Research paper thumbnail of The “Physio-Ring”: an advanced concept in mitral valve annuloplasty

The Annals of Thoracic Surgery, 1995

A new annuloplasty ring has been developed with the aim of adding flexibility to the remodeling a... more A new annuloplasty ring has been developed with the aim of adding flexibility to the remodeling annuloplasty concept. Here we report its clinical use with special emphasis on segmental valve analysis and valve sizing. From October 1992 through June 1994, 137 patients aged 4 to 76 years (mean age, 49.1 years) were operated on. The main causes of mitral valve insufficiency were degenerative, 90; bacterial endocarditis, 15; and rheumatic, 13. The indication for operation was based on the severity of the mitral valve insufficiency (90 patients were in grade III or IV) rather than on functional class (60 patients were in class III or IV). At echocardiography 6 patients had normal leaflet motion (type I), 119 leaflet prolapse (type II), and 12 restricted leaflet motion (type III). Surgical repair was carried out using Carpentier techniques of valve reconstruction. In 3 patients, inadequate ring sizing was responsible for systolic anterior motion of the anterior leaflet diagnosed by intraoperative echo. The valve was replaced in 2 patients. There were three hospital deaths, no late deaths, one reoperation for recurrent mitral valve insufficiency due to chordal rupture 1 month after repair, one reoperation for atrial thrombus formation 5 months after repair, one anticoagulant-related hemorrhage, and one thromboembolic episode. Mid-term follow-up between 6 and 18 months was available in 94 patients. Echocardiography showed trivial or no regurgitation in 93.2% of the patients and minimal regurgitation in 6.8%. The average transmitral diastolic gradient was 3.55 +/- 1.93 mm Hg. Left ventricular end-systolic diameter and volume decreased postoperatively, demonstrating an improved left ventricular function. This preliminary experience has provided promising results and allowed us to define the indications of the Physio-Ring versus the classic ring. It has also shown that valve sizing and proper ring selection are of primary importance.

Research paper thumbnail of Biatrial inferior transseptal approach to the mitral valve

The Annals of Thoracic Surgery, 1995

The standard surgical approach to the mitral valve is via a longitudinal incision in the left atr... more The standard surgical approach to the mitral valve is via a longitudinal incision in the left atrium. This is applicable in the vast majority of patients. In cases of small left atrium with poor exposure the standard incision may be modified. We report a biatrial inferior transseptal approach that we have employed in 25 patients over a 2-year period. The technique is simple to execute and is without risk to surrounding structures.

Research paper thumbnail of Results of the Prospective Multicenter Trial of Robotically Assisted Totally Endoscopic Coronary Artery Bypass Grafting

The Annals of Thoracic Surgery, 2006

Background. Robotic technology has been proven safe and efficacious in the performance of mitral ... more Background. Robotic technology has been proven safe and efficacious in the performance of mitral valve repair and atrial septal defect repair. This report describes a Food and Drug Administration-sanctioned multicenter study of the safety and efficacy of the da Vinci system (Intuitive Surgical, Inc, Mountain View, CA) for totally endoscopic coronary artery bypass (TECAB) surgery.

Research paper thumbnail of Endoscopic radial artery harvesting: results of first 300 patients

The Annals of Thoracic Surgery, 2002

With the expanded use of the radial artery as a bypass conduit in patients undergoing coronary ar... more With the expanded use of the radial artery as a bypass conduit in patients undergoing coronary artery bypass grafting, an endoscopic radial artery harvesting method was used to improve esthetics and patient acceptance, and possibly, to decrease hand neurologic complications. After informed consent and confirmation of adequate ulnar collateral blood flow, 300 consecutive patients undergoing coronary artery bypass grafting had their nondominant radial artery endoscopically removed through a small 3-cm incision just proximal to the radial styloid prominence. Standard endoscopic vein equipment (30-degree 5-mm endoscope, subcutaneous retractor, and vessel dissector) with ultrasonic harmonic coagulating shears were used. After radial artery isolation, the radial artery was proximally clipped and transected 1 to 2 cm distal to the visualized ulnar artery origin to the inferior end of the wrist incision. The mean age was 62.2 years; 23% of the patients were women, 39% had diabetes mellitus, and 28% had peripheral vascular disease. All 300 endoscopic radial arteries were grossly acceptable and used for grafting. Early in the series, 29 patients (9.7%) required a second 3-cm incision proximally for vascular control. Only one wrist incision was required at the last 200 cases. The conduit length varied between 18 and 24 cm. Occurring early in the series, hospital complications were two tunnel hematomas requiring drainage and one brachial artery clipping repaired primarily without sequela. At 30 days postoperative follow-up, 5 patients (1.6%) had been treated with oral antibiotics for incisional cellulitis and 26 patients (8.7%) had objective dorsal thenar sensory numbness. No ischemic hand complication, perioperative myocardial infarction, reintervention in radial artery graft distribution, or numbness in the lateral forearm occurred. All patients expressed marked satisfaction with the small incision and cosmetic result. In our initial experience, endoscopic radial artery harvesting can be performed safely, with minor, infrequent complications. A full-length radial artery conduit can be obtained with improved esthetics and patient satisfaction and acceptance. Late dorsal thenar paresthesias, although infrequent, continue to be a problem as with the open method.

Research paper thumbnail of Less Invasive Intracardiac Surgery Performed Without Aortic Clamping

The Annals of Thoracic Surgery, 2008

Aortic clamping and cardioplegia delivery add complexity to performing intracardiac procedures th... more Aortic clamping and cardioplegia delivery add complexity to performing intracardiac procedures through a right minithoracotomy. Recent publications have shown excellent patient outcomes after mitral valve (MV) procedures undertaken through thoracotomy on the fibrillating heart. We reviewed our experience with this approach. From March 2000 to September 2006, 100 patients underwent MV repair (n = 42), MV annuloplasty (n = 28), MV replacement (n = 18), atrial septal defect closure (n = 10), tricuspid valve repair (n = 1), and left atrial myxoma excision (n = 1). A modified maze procedure (n = 4) or left minimally invasive direct coronary bypass grafting (MIDCABG) (n = 2) was combined in six cases. The mean age was 57 +/- 11 years (range, 22 to 89); 27 patients were in New York Heart Association (NYHA) class III or IV; 24 cases were first or second time reoperations; 20 patients had a left ventricular ejection fraction of less than 0.3. All the operations were carried out on the fibrillating heart without cross-clamping the aorta through a right minithoracotomy using peripheral cannulation. Mean fibrillation time was 73 +/- 31 minutes (range, 10 to 198 minutes). There was no conversion to sternotomy. Postoperative inotropic support was needed in 20 cases. One patient who underwent a third time reoperation died within 30 days of mesenteric ischemia (hospital mortality = 1%). Complications were the following: four reoperations for bleeding (4%); two strokes (2%). Postoperative median hospital length of stay was five days (range, 2 to 58 days). None of the patients has required MV reoperation after hospital discharge. Follow-up was complete. All survivors were in NYHA class I or II. Ventricular fibrillation simplifies less invasive intracardiac procedures and carries lower complication rates and perioperative mortality compared with conventional surgery.

Research paper thumbnail of Systolic anterior motion of the mitral valve: a 30-year perspective

The Journal of thoracic and cardiovascular surgery, 2014

Systolic anterior motion (SAM) can occur after mitral valve repair (MVr), most frequently in pati... more Systolic anterior motion (SAM) can occur after mitral valve repair (MVr), most frequently in patients with degenerative valve disease. Our initial observations (1981-1990) revealed that most patients with SAM can be successfully treated medically. Here the authors review the last 16 years of their experience with SAM after MVr. Between January 1996 and October 2011, 1918 patients with degenerative mitral valve disease underwent MVr at our institution. We performed a retrospective analysis of SAM in this patient population. The incidence of SAM was 4.6% (89 of 1918) overall, 4.0% (77 of 1906) in patients who did not have SAM preoperatively (de novo). Compared with our previously published report, the incidence of SAM decreased from 6.4% to 4.0% (P = .03). Hospital mortality was 2.0% (38 of 1918) overall, 1.3% (14 of 1078) for isolated MVr. One patient with de novo SAM (1 of 77; 1.3%) died after emergency MVr. All patients with de novo SAM were successfully managed conservatively with...

Research paper thumbnail of Outcomes of peripheral perfusion with balloon aortic clamping for totally endoscopic robotic mitral valve repair

The Journal of thoracic and cardiovascular surgery, 2014

Although the technique of totally endoscopic robotic mitral valve repair (TERMR) has been well de... more Although the technique of totally endoscopic robotic mitral valve repair (TERMR) has been well described, few reports have examined the results of peripheral perfusion with balloon clamping. We analyzed the outcomes of TERMR performed using this strategy. A total of 108 consecutive patients underwent TERMR by a 2-surgeon team. The preoperative evaluation included chest computed tomography and abdominal and pelvis computed tomography. Additional procedures included appendage exclusion in 96, patent foramen ovale closure in 29, cryoablation in 16, tricuspid valve repair in 2, and septal myectomy in 2. The mean patient age was 59 years (range, 21-86). Central venous drainage was obtained with a long cannula. Arterial return was achieved with femoral cannulation, when possible. An endoballoon catheter was placed through the femoral artery. Transesophageal echocardiography was used to position all catheters. Femoral artery perfusion was possible in 103 of 108 patients (95.3%). The subcla...

Research paper thumbnail of A Prospective Randomized Study of Paravertebral Blockade in Patients Undergoing Robotic Mitral Valve Repair

Journal of Cardiothoracic and Vascular Anesthesia, 2015

The aim of this study was to evaluate the addition of paravertebral blockade to general anesthesi... more The aim of this study was to evaluate the addition of paravertebral blockade to general anesthesia in patients undergoing robotic mitral valve repair. A randomized, prospective trial. A single tertiary referral academic medical center. 60 patients undergoing robotic mitral valve surgery. Patients were randomized to receive 4-level paravertebral blockade with 0.5% bupivicaine before induction of general anesthesia. All patients were given a fentanyl patient-controlled analgesia upon arrival to the intensive care unit, and visual analog scale pain scores were queried for 24 hours. On postoperative day 2, patients were given an anesthesia satisfaction survey. After obtaining institutional review board approval, surgical and anesthetic data were recorded perioperatively and compared between groups. Compared to general anesthesia alone, patients receiving paravertebral blockade and general anesthesia reported significantly less postoperative pain and required fewer narcotics intraoperatively and postoperatively. Patients receiving paravertebral blockade also reported significantly higher satisfaction with anesthesia. Successful extubation in the operating room at the conclusion of surgery was 90% and similar in both groups. Hospital length of stay also was similar. No adverse reactions were reported. The addition of paravertebral blockade to general anesthesia appears safe and can reduce postoperative pain and narcotic usage in patients undergoing minimally invasive cardiac surgery. These findings were similar to previous studies of patients undergoing thoracic procedures. Paravertebral blockade alone likely does not reduce hospital length of stay. This may be more closely related to early extubation, which is possible with or without paravertebral blockade.

Research paper thumbnail of Fluorescence-guided placement of an endoaortic balloon occlusion device for totally endoscopic robotic mitral valve repair

The Journal of Thoracic and Cardiovascular Surgery, 2015

Research paper thumbnail of Combined heart-lung-liver, double lung-liver, and isolated liver transplantation for cystic fibrosis in children

Transplant International, 1997

Between June 1990 and September 1995, 8 of 24 children with cystic fibrosis (CF) who were accepte... more Between June 1990 and September 1995, 8 of 24 children with cystic fibrosis (CF) who were accepted either for combined transplantation or isolated liver transplantation died while waiting for a graft; 11 underwent transplantation and 5 are currently on the waiting list. Of the 11 children who had surgery, 7 (group 1) underwent one of the following procedures: heart-lung-liver (n = 4), sequential double lung-liver (n = 2), or bilateral lobar lung from a split left lung and reduced liver (n = 1). During the same period, the four other children (group 2) underwent isolated liver transplantation (three full-size livers, one partial liver). There was one perioperative death in each group. Pulmonary infection was the most common cause of morbidity in group 1. Other complications in group 1 included tracheobronchial stenosis (n = 2), biliary stricture (n = 2), and severe ascites (n = 2). All were successfully treated. Obliterative bronchiolitis developed in three patients. This was treated with FK 506. In group 2, pulmonary function tests improved or remained stable after liver transplantation. Surgical complications in group 2 included severe ascites (n = 1), biliary stricture (n = 1), and abscess of the liver (n = 1). Actuarial survival was 85.7% +/- 2% in group 1 at 1 year; it remained unchanged at 3 years and was 64.2% at 5 years.

Research paper thumbnail of Computer-assisted cardiac surgery

The Lancet, 1999

Computer-assisted cardiac surgery. By - Alain Carpentier, Didier Loulmet, Bertrand Aupecle, Alain... more Computer-assisted cardiac surgery. By - Alain Carpentier, Didier Loulmet, Bertrand Aupecle, Alain Berrebi, John Relland.

Research paper thumbnail of Pulmonary bipartitioning and lobar transplantation: A new approach to donor organ shortage

The Journal of Thoracic and Cardiovascular Surgery, 1997

The scarcity of small donors has significantly limited lung transplantation for pediatric and sma... more The scarcity of small donors has significantly limited lung transplantation for pediatric and small adult patients. Use of single lobes procured from size-unmatched donors has overcome this difficulty, but only in a few selected cases and, in addition, it represents a waste of lung tissue. In an animal model we have shown that it is possible to divide one lung with careful partitioning of the vascular and bronchial structures and thus obtain two viable lobar grafts suitable for bilateral implantation in a smaller animal. We have now applied this procedure clinically in seven patients operated on between May 1993 and November 1994. The indications were cystic fibrosis in three children, primary pulmonary hypertension in two adults, bronchiectasis in one, and idiopathic pulmonary fibrosis in one. There were three children aged 13 to 17 years (median 14) and four adults aged 40 to 53 years (median 45). There was a 46% to 50% discrepancy for weight between recipient and donor and a 12% to 17% discrepancy for height. The surgical technique consisted of careful partitioning of the left donor lung, bilateral anterior thoracotomy in the recipient, and, with the use of cardiopulmonary bypass, implantation of the lower lobe in the left hemithorax and the upper lobe in the right hemithorax. Vascular and bronchial connections were facilitated by leaving a long pedicle on the recipient side. The pulmonary artery anastomosis for the donor left upper lobe was done with the "fissure" side of the artery to ensure an anastomosis without tension. An end-to-end bronchial anastomosis overcame the problem of size discrepancy. Six patients are alive and well 10 to 27 months (median 19) after operation. One patient with cystic fibrosis died of systemic aspergillosis infection. All were discharged from the hospital within the first or second postoperative month. No technical problems were identified: repeated bronchoscopy has demonstrated satisfactory healing without early stricture formation. All patients remain well subjectively with good exercise tolerance and all patients achieve greater than 70% of predicted values of forced expiratory volume in 1 second. Perfect adaptation of the transplanted lobes to the recipient pleural space has been demonstrated by postoperative computed tomographic scan. In conclusion, bilateral lobar transplantation from a single donor lung is possible in small adults or children when there is a large size discrepancy with the donor. This may help resolve the problem of donor availability in the pediatric population.

Research paper thumbnail of Combined lung and liver transplantation in patients with cystic fibrosis: A 4 1/2-year experience

The Journal of Thoracic and Cardiovascular Surgery, 1995

Research paper thumbnail of Less invasive techniques for mitral valve surgery

The Journal of Thoracic and Cardiovascular Surgery, 1998

Objective: Minimally invasive surgical techniques aim at reducing the consequences of currently u... more Objective: Minimally invasive surgical techniques aim at reducing the consequences of currently used large incisions, such as bleeding, pain, and risk of infection. Although this new approach developed rapidly in coronary surgery, it remains questionable in mitral valve surgery. This article reports the longest experience with minimally invasive mitral valve surgery, with particular attention to approach and techniques. Methods: From February 1996, the date of the first case of minimally invasive mitral valve reconstruction, to April 1997, 22 patients with a mean age of 54 ؎ 2.7 years were subjected to mitral valve surgery performed with less invasive techniques. Exposure of the mitral valve was achieved through a minithoracotomy (n ‫؍‬ 12) or a ministernotomy (n ‫؍‬ 10). Video assistance was used in all cases. Peripheral arterial cannulation (n ‫؍‬ 21) and venous drainage (n ‫؍‬ 22) were used in most cases. Results: In this series, valve surgery consisted in 19 repairs, two replacements, and one closure of a periprosthetic leak. In two cases it was necessary to convert to a larger incision. The average duration of cardiopulmonary bypass was 157 ؎ 8.2 minutes, ventilatory assistance 16 ؎ 4.6 hours, and intensive care unit stay 2.1 ؎ 0.4 days. Two patients required reoperation for bleeding and another for early recurrence of mitral valve regurgitation. There were no deaths and all patients were discharged with normal valve function. At most recent follow-up, all patients were in functional class I, with resumption of normal activity. Conclusion: Mitral valve surgery can be performed safely by means of less invasive techniques, but with increased technical difficulty. A low asymmetric median sternotomy seems preferable to an anterior thoracotomy. (J Thorac Cardiovasc Surg 1998;115:772-9)

Research paper thumbnail of Endoscopic coronary artery bypass grafting with the aid of robotic assisted instruments

The Journal of Thoracic and Cardiovascular Surgery, 1999

Objective: The development of endoscopic coronary artery bypass grafting has been limited because... more Objective: The development of endoscopic coronary artery bypass grafting has been limited because of poor visualization and increased technical difficulties in carrying out operations through ports. We investigated whether the use of robotic assisted instruments could minimize these difficulties. Methods: After a period of technical development and training on cadavers (n = 8) with the Intuitive Surgical system (Intuitive Surgical, Inc, Mountain View, Calif), the first clinical application in coronary artery surgery was performed in 4 male patients (mean age 59 ± 6 years) with the indication of grafting the left internal thoracic artery to the left anterior descending coronary artery. Robotic assisted 3dimensional endoscopes and instruments were introduced into the left side of the chest through 3 intercostal ports. The Heartport system (Heartport, Inc, Redwood City, Calif) was used for arresting the heart during the anastomosis. Results: In 2 patients, the harvesting of the left internal thoracic artery was completed endoscopically with robotic assisted instruments and the anastomosis to the left anterior descending artery was performed through a minithoracotomy with conventional instruments. In 2 other patients, the entire operation was completed endoscopically with robotic assisted instruments. Early postoperative coronary angiography demonstrated the patency of the grafts in all cases. At 6-month follow-up, all patients were free of symptoms. Conclusions: Robotic assisted instruments make endoscopic coronary bypass possible and open a new era in minimally invasive surgery. (J Thorac Cardiovasc Surg 1999;118:4-10)

Research paper thumbnail of Emergency conversion to cardiopulmonary bypass during attempted off-pump revascularization results in increased morbidity and mortality

Journal of Thoracic and Cardiovascular Surgery, 2004

We sought to evaluate outcomes and predictors of emergency conversion to cardiopulmonary bypass d... more We sought to evaluate outcomes and predictors of emergency conversion to cardiopulmonary bypass during attempted off-pump coronary bypass surgery. From January 1999 through July 2002, 1678 consecutive isolated coronary artery bypass operations were performed at Lenox Hill Hospital, with the intention to treat all patients with off-pump coronary bypass surgery. Fifty (2.97%) patients required urgent conversion to cardiopulmonary bypass. All the preoperative, intraoperative, and postoperative variables were collected and analyzed in accordance with the New York State Cardiac Surgery Reporting System. Multivariate regression analysis was performed to determine predictors for conversion. In-hospital mortality and major morbidity were significantly lower in the nonconverted group compared with the converted patients (mortality: 1.47% [n = 24] vs 12% [n = 6], P = .001; stroke: 1.1% [n = 18] vs 6% [n = 3], P = .02; renal failure: 1.23% [n = 20] vs 6% [n = 3], P = .02; deep sternal wound infection: 1.54% [n = 25] vs 8% [n = 4], P = .009; respiratory failure: 3.75% [n = 61] vs 28% [n = 14], P < .0001; nonconverted vs converted patients, respectively). The annual incidence of conversion decreased during the study period. There was a significant reduction in the incidence of conversion after routine use of a cardiac positioning device to performing lateral and inferior wall grafts (4.2% [n = 27] vs 2.3% [n = 23], P = .04). None of the preoperative variables were independent predictors of conversion on multivariate regression analysis. Because emergency conversion to cardiopulmonary bypass during attempted off-pump coronary bypass surgery results in significantly higher morbidity and mortality, studies comparing off-pump coronary bypass surgery with conventional coronary artery surgery should include converted patients in the off-pump group. In our experience, emergency conversion is an unpredictable event. The incidence of conversion decreases with increasing experience of surgeons in performing off-pump coronary surgery and use of a cardiac positioning device.

Research paper thumbnail of Giant Nonfamilial Left Atrial Myxoma Presenting With Eye Embolism and Nonvalvular Streptococcus sanguinis Endocarditis

Journal of the American College of Cardiology, 2014

Research paper thumbnail of Robotic-assisted cardiac surgery: Anesthetic and postoperative considerations

Journal of Cardiothoracic and Vascular Anesthesia, 2002

Objective: To assess the feasibility of endoscopic telemanipulated cardiac surgery and describe t... more Objective: To assess the feasibility of endoscopic telemanipulated cardiac surgery and describe the anesthetic, postoperative, and surgical implications of minimally invasive robotic-assisted cardiac surgery.

Research paper thumbnail of Chirurgie à cœur ouvert assistée par ordinateur. Premier cas opéré avec succès

Comptes Rendus de l'Académie des Sciences - Series III - Sciences de la Vie, 1998

... cas op6r6 avec succk Alain Carpentier*, Didier Loulmet, Bertrand AupPcle, Jean-Philippe Kieff... more ... cas op6r6 avec succk Alain Carpentier*, Didier Loulmet, Bertrand AupPcle, Jean-Philippe Kieffer, Dominique Tournay, Pierre Guibourt, Annick Fiemeyer, Denis ... peut explorer j loisir les parois rutilantes, Its reliefs liigure 2). Ces 4lknents en place, le c hirurgieri gagne la contrast& ...

Research paper thumbnail of Partial replacement of the tricuspid valve by mitral homografts in acute endocarditis

The Annals of Thoracic Surgery, 2002

http://ats.ctsnetjournals.org/cgi/content/full/73/6/1808 on the World Wide Web at:

Research paper thumbnail of The “Physio-Ring”: an advanced concept in mitral valve annuloplasty

The Annals of Thoracic Surgery, 1995

A new annuloplasty ring has been developed with the aim of adding flexibility to the remodeling a... more A new annuloplasty ring has been developed with the aim of adding flexibility to the remodeling annuloplasty concept. Here we report its clinical use with special emphasis on segmental valve analysis and valve sizing. From October 1992 through June 1994, 137 patients aged 4 to 76 years (mean age, 49.1 years) were operated on. The main causes of mitral valve insufficiency were degenerative, 90; bacterial endocarditis, 15; and rheumatic, 13. The indication for operation was based on the severity of the mitral valve insufficiency (90 patients were in grade III or IV) rather than on functional class (60 patients were in class III or IV). At echocardiography 6 patients had normal leaflet motion (type I), 119 leaflet prolapse (type II), and 12 restricted leaflet motion (type III). Surgical repair was carried out using Carpentier techniques of valve reconstruction. In 3 patients, inadequate ring sizing was responsible for systolic anterior motion of the anterior leaflet diagnosed by intraoperative echo. The valve was replaced in 2 patients. There were three hospital deaths, no late deaths, one reoperation for recurrent mitral valve insufficiency due to chordal rupture 1 month after repair, one reoperation for atrial thrombus formation 5 months after repair, one anticoagulant-related hemorrhage, and one thromboembolic episode. Mid-term follow-up between 6 and 18 months was available in 94 patients. Echocardiography showed trivial or no regurgitation in 93.2% of the patients and minimal regurgitation in 6.8%. The average transmitral diastolic gradient was 3.55 +/- 1.93 mm Hg. Left ventricular end-systolic diameter and volume decreased postoperatively, demonstrating an improved left ventricular function. This preliminary experience has provided promising results and allowed us to define the indications of the Physio-Ring versus the classic ring. It has also shown that valve sizing and proper ring selection are of primary importance.

Research paper thumbnail of Biatrial inferior transseptal approach to the mitral valve

The Annals of Thoracic Surgery, 1995

The standard surgical approach to the mitral valve is via a longitudinal incision in the left atr... more The standard surgical approach to the mitral valve is via a longitudinal incision in the left atrium. This is applicable in the vast majority of patients. In cases of small left atrium with poor exposure the standard incision may be modified. We report a biatrial inferior transseptal approach that we have employed in 25 patients over a 2-year period. The technique is simple to execute and is without risk to surrounding structures.

Research paper thumbnail of Results of the Prospective Multicenter Trial of Robotically Assisted Totally Endoscopic Coronary Artery Bypass Grafting

The Annals of Thoracic Surgery, 2006

Background. Robotic technology has been proven safe and efficacious in the performance of mitral ... more Background. Robotic technology has been proven safe and efficacious in the performance of mitral valve repair and atrial septal defect repair. This report describes a Food and Drug Administration-sanctioned multicenter study of the safety and efficacy of the da Vinci system (Intuitive Surgical, Inc, Mountain View, CA) for totally endoscopic coronary artery bypass (TECAB) surgery.

Research paper thumbnail of Endoscopic radial artery harvesting: results of first 300 patients

The Annals of Thoracic Surgery, 2002

With the expanded use of the radial artery as a bypass conduit in patients undergoing coronary ar... more With the expanded use of the radial artery as a bypass conduit in patients undergoing coronary artery bypass grafting, an endoscopic radial artery harvesting method was used to improve esthetics and patient acceptance, and possibly, to decrease hand neurologic complications. After informed consent and confirmation of adequate ulnar collateral blood flow, 300 consecutive patients undergoing coronary artery bypass grafting had their nondominant radial artery endoscopically removed through a small 3-cm incision just proximal to the radial styloid prominence. Standard endoscopic vein equipment (30-degree 5-mm endoscope, subcutaneous retractor, and vessel dissector) with ultrasonic harmonic coagulating shears were used. After radial artery isolation, the radial artery was proximally clipped and transected 1 to 2 cm distal to the visualized ulnar artery origin to the inferior end of the wrist incision. The mean age was 62.2 years; 23% of the patients were women, 39% had diabetes mellitus, and 28% had peripheral vascular disease. All 300 endoscopic radial arteries were grossly acceptable and used for grafting. Early in the series, 29 patients (9.7%) required a second 3-cm incision proximally for vascular control. Only one wrist incision was required at the last 200 cases. The conduit length varied between 18 and 24 cm. Occurring early in the series, hospital complications were two tunnel hematomas requiring drainage and one brachial artery clipping repaired primarily without sequela. At 30 days postoperative follow-up, 5 patients (1.6%) had been treated with oral antibiotics for incisional cellulitis and 26 patients (8.7%) had objective dorsal thenar sensory numbness. No ischemic hand complication, perioperative myocardial infarction, reintervention in radial artery graft distribution, or numbness in the lateral forearm occurred. All patients expressed marked satisfaction with the small incision and cosmetic result. In our initial experience, endoscopic radial artery harvesting can be performed safely, with minor, infrequent complications. A full-length radial artery conduit can be obtained with improved esthetics and patient satisfaction and acceptance. Late dorsal thenar paresthesias, although infrequent, continue to be a problem as with the open method.

Research paper thumbnail of Less Invasive Intracardiac Surgery Performed Without Aortic Clamping

The Annals of Thoracic Surgery, 2008

Aortic clamping and cardioplegia delivery add complexity to performing intracardiac procedures th... more Aortic clamping and cardioplegia delivery add complexity to performing intracardiac procedures through a right minithoracotomy. Recent publications have shown excellent patient outcomes after mitral valve (MV) procedures undertaken through thoracotomy on the fibrillating heart. We reviewed our experience with this approach. From March 2000 to September 2006, 100 patients underwent MV repair (n = 42), MV annuloplasty (n = 28), MV replacement (n = 18), atrial septal defect closure (n = 10), tricuspid valve repair (n = 1), and left atrial myxoma excision (n = 1). A modified maze procedure (n = 4) or left minimally invasive direct coronary bypass grafting (MIDCABG) (n = 2) was combined in six cases. The mean age was 57 +/- 11 years (range, 22 to 89); 27 patients were in New York Heart Association (NYHA) class III or IV; 24 cases were first or second time reoperations; 20 patients had a left ventricular ejection fraction of less than 0.3. All the operations were carried out on the fibrillating heart without cross-clamping the aorta through a right minithoracotomy using peripheral cannulation. Mean fibrillation time was 73 +/- 31 minutes (range, 10 to 198 minutes). There was no conversion to sternotomy. Postoperative inotropic support was needed in 20 cases. One patient who underwent a third time reoperation died within 30 days of mesenteric ischemia (hospital mortality = 1%). Complications were the following: four reoperations for bleeding (4%); two strokes (2%). Postoperative median hospital length of stay was five days (range, 2 to 58 days). None of the patients has required MV reoperation after hospital discharge. Follow-up was complete. All survivors were in NYHA class I or II. Ventricular fibrillation simplifies less invasive intracardiac procedures and carries lower complication rates and perioperative mortality compared with conventional surgery.