Francis Sutter - Academia.edu (original) (raw)

Papers by Francis Sutter

The Annals of Thoracic Surgery, May 1, 1992

We present a surgical technique that we believe provides superior cerebral protection for simulta... more We present a surgical technique that we believe provides superior cerebral protection for simultaneous correction of carotid and cardiac pathology with low operative mortality and stroke rate. Our study population consists of 23 consecutive patients undergoing cardiac operation between August 1989 and April 1991 who also had associated critical (>85%) carotid artery stenosis. Using 20°C systemic hypothermia for cerebral protection, we performed simultaneous correction of both lesions during the aortic cross-clamp period, using continuous retrograde blood cardioplegia for myocardial protection. Mean patient age was 69.4 years; 83% were 65 years or older. Eighty-seven percent had angina, 35% had recent owering the incidence of neurologic events in patients L with combined cardiac and carotid artery disease has remained a desired goal. Historically, the risk of stroke is substantial when cardiac operation is contemplated in this group of patients. The risk remains whether medical therapy or a variety of surgical strategies is employed for the carotid disease. We present an operative plan that offers the additional cerebral protection of the deeper hypothermia available during aortic cross-clamping. It is predicated upon the superb myocardial protection provided by continuous cold blood retrograde perfusion, and does not necessitate prolonged pump time for rewarming. Material and Methods The carotid artery is exposed through an incision anterior to the sternocleidomastoid muscle. Median sternotomy is made and conduit is harvested. The patient is heparinized and cannulated. If the aorta is free of disease, proximal aortosaphenous anastomoses are constructed before bypass with a partial occlusion clamp. If the aorta is diseased, or for most reoperations, proximal anastomoses are constructed during cross-clamp. Extracorporeal circulation is initiated and established for an average period of 143 minutes (median, 130 minutes; flow range, 1.6 to 2.0 L. m-'. min-I). A retrograde cannula is placed in the coronary sinus, and a vent is placed in the ascending aorta. The aorta was cross-clamped an average of 111

The American Journal of Cardiology

Journal of Vascular Surgery, 1995

The purpose of this study is to determine whether the routine use ofintraoperative surface aortic... more The purpose of this study is to determine whether the routine use ofintraoperative surface aortic ultrasonography decreases the stroke rate in coronary artery bypass graft surgery (CABG). Methods: One hundred ninety-five consecutive patients undergoing CABG between July 1, 1992, and June 30, 1993 (study group), were evaluated by intraoperative surface aortic ultrasonography. Based on information obtained, changes in the operative technique were made in an effort to decrease the incidence of embolic stroke from unsuspected atherosclerotic disease of the ascending aorta. The outcome of these patients was compared with that of 164 consecutive patients who underwent CABG between July 1, 1991, and June 30, 1992 (control group), in whom the ascending aorta was assessed by inspection and palpation only. Results: Significant disease was detected in three (2.0%) of 164 patients in the control group. Modifications in their operative technique Consisted of hypothermic fibrillatory arrest with no cross-clamping of the aorta and left ventricular venting in two patients and single cross-clamping in one patient. There were five strokes overall in this group (3.0%), and six patients died (3.6%), one in whom the stroke contributed directly to the cause of death. In the study group the ultrasonic findings were normal to mild in 168 patients, moderate in 20 patients, and severe in seven patients. These results led to a modification of the technique in 19 patients, (10%): hypothermic fibrillatory arrest with no cross-clamping of the aorta and left ventricular venting in 14 patients, modification in the aortic cannulation site or single cross-clamping in three patients, and modification in placement of proximal anastomoses or all arterial grafts in two patients. No strokes occurred in this group (p < 0.02, Fisher's exact test). Five patients died, for an operative mortality rate of 2.6%. Conclusion: These data indicate that intraoperative ultrasonography of the ascending aorta with simple modifications in operative technique reduces the stroke rate in CABG. (J VASC SURG 1995;21:98-109.) Despite advances in perioperative management and operative, and bypass techniques, stroke remains a significant, particularly morbid, and costly complication of coronary artery bypass grafting (CABG). It is estimated that the cost of a stroke in terms of hospitalization, rehabilitation, and lost

The Journal of Thoracic and Cardiovascular Surgery, Jul 1, 2009

Objective: During coronary surgery, proximal vein graft anastomoses have been performed by using ... more Objective: During coronary surgery, proximal vein graft anastomoses have been performed by using an aortic partial occlusion clamp to allow for a hand-sewn anastomosis. The purpose of this multicenter, prospective, randomized trial was to evaluate the efficacy of the PAS-Port device (Cardica, Inc, Redwood City, Calif), which allows an automated proximal anastomosis to be performed without aortic clamping. Methods: Between June 22, 2006, and March 22, 2007, 220 patients requiring coronary artery bypass grafting with at least 2 vein grafts were enrolled. Within each patient, 1 graft was randomly assigned to receive a PAS-Port device, and the other was assigned to receive a hand-sewn anastomosis to the ascending aorta. The primary end point was angiographic patency (<50% stenosis) 9 months after surgical intervention. Secondary end points included average time to complete each anastomosis and 9-month freedom from major adverse cardiac events. Results: One hundred eighty-three patients received matched grafts that were angiographically assessed at 9 months. The 9-month graft patency was 82.0% (150/183) for hand-sewn and 80.3% (147/183) for PAS-Port grafts. The patency rate of PAS-Port anastomoses was statistically noninferior to that of hand-sewn anastomoses (95% lower confidence limit for difference, À7.95%). The freedom from major adverse cardiac events at 9 months was 97.7% for PAS-Port (95% confidence interval, 94.5%-99.0%) and 98.2% for hand-sewn (95% confidence interval, 95.1%-99.3%) grafts. The PAS-port device was associated with a 4.6 AE 3.9-minute reduction in anastomotic time compared with that seen with a hand-sewn anastomosis (P < .001). Conclusions: The PAS-Port proximal anastomotic device produces an effective anastomosis with a 9-month patency rate that is comparable with that of a hand-sewn anastomosis. It allows for construction of a proximal anastomosis without aortic clamping and requires less time than a hand-sewn anastomosis.

Annals of cardiothoracic surgery, Sep 1, 2018

Masters of Cardiothoracic Surgery Harvesting one or both internal thoracic artery(s) (ITA) is acc... more Masters of Cardiothoracic Surgery Harvesting one or both internal thoracic artery(s) (ITA) is accomplished through the same ports and robotic setup. Robotic port placement and ITA harvest are paramount to successful minimally-invasive coronary practice (1). Clinical vignette A 58-year-old male presented with exertional chest tightness and associated exertional dyspnea. A positive stress test prompted cardiac catheterization, revealing a long 95% lesion in the left anterior descending artery (LAD), 80% ostial ramus, 40% left coronary artery (LCx) lesion and a focal 90% right coronary artery (RCA) lesion. The cardiologist and surgeon agreed to hybrid revascularization with robotic-assisted left ITA (LITA) to LAD and right ITA (RITA) to ramus arteries, followed at later date with percutaneous coronary intervention (PCI) to RCA. Surgical techniques-preparation Positioning and anesthesia consideration

The Annals of Thoracic Surgery, Nov 1, 1990

Prosthetic mitral valve reoperation complicated by atrioventricular groove pseudoaneurysm and cir... more Prosthetic mitral valve reoperation complicated by atrioventricular groove pseudoaneurysm and circumflex ventricular fistula is presented. Ligation of the circumflex artery during mitral valve replacement is implicated after review of a previous cardiac angiogram.

The Journal of Thoracic and Cardiovascular Surgery, Feb 1, 2023

Typical robotic platform used for cardiac valve surgery. CENTRAL MESSAGE Contemporary robotic car... more Typical robotic platform used for cardiac valve surgery. CENTRAL MESSAGE Contemporary robotic cardiac training recommendations focus on safety and sustainability.

The Annals of Thoracic Surgery, Apr 1, 1991

A case is presented of vein graft rupture leading to myocardial infarction and subsequent pseudoa... more A case is presented of vein graft rupture leading to myocardial infarction and subsequent pseudoaneurysm formation.

Journal of Cardiothoracic and Vascular Anesthesia, Oct 1, 2010

Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery, May 1, 2012

Coronary artery bypass grafting remains the treatment choice for coronary artery disease; but ste... more Coronary artery bypass grafting remains the treatment choice for coronary artery disease; but sternotomy, the most commonly used approach, compromises its benefits with postoperative morbidity, higher complication rates, and prolonged length of hospital stay. Despite this, minimally invasive and robotic-assisted technology has not been adopted or widely embraced because supporting literature on robotic-assisted coronary artery bypass grafting is extremely limited. Since 2005, the cardiothoracic surgical team at our institution has been developing and maturing an effective method using robotic harvesting of the left internal mammary artery (LIMA) and beating heart surgery through a minithoracotomy for coronary revascularization. This surgical technique involves precisely placing the robotic endoscopic port immediately over the left anterior descending (LAD) artery target site. The robotically harvested LIMA is secured to the epicardium at the LAD target, the robotic instruments are removed, and the endoscopic port site is enlarged slightly greater than 1 cm to become the minithoracotomy and allow for LIMA-to-LAD anastomosis. The other two robotic ports are used to complete the procedure without a need for additional incisions. This standardized method has been used in more than 750 patients, and since 2009, the last 377 consecutive non-rib-spreading minithoracotomy incisions measured a median of 3.9 cm (mean [SD], 4.16 [1.2748] cm; range, 2.3Y12.0 cm). This ''How I Do It'' article describes our methods in detail and associated robotic nuances.

Clinical Anatomy, 1994

Fifteen consecutive patients having open heart surgery using retrograde cardioplegia were studied... more Fifteen consecutive patients having open heart surgery using retrograde cardioplegia were studied to demonstrate that important venous collateralization exists between the coronary sinus (CS) and its left ventricular branches and the right ventricle (RV). The venous collateralization makes possible RV myocardial protection during retrograde cardioplegia. Right ventricular venous drainage principally occurs via anterior cardiac veins, which drain into the right atrium, and thebesian veins, which drain into both the RV and the atrium, generally without connection to the CS. Retrograde cardioplegia used during open heart surgery should, therefore, give inadequate myocardial protection to the RV. Two RV temperature probes used as markers for RV perfusion were monitored continuously during cardiac arrest. Systemic temperature while on cardiopulmonary bypass was 2YC, and the retrograde perfusate solution temperature was 4°C. Coronary sinus pressure during the bypass procedure was maintained between 20 torr and 50 torr. Mean temperatures at the two probe sites were 16.1"C and 14.5"C. We conclude that a complex network of venous collaterals between the coronary sinus and left ventricle and the right ventricle allow excellent myocardial protection during retrograde cardioplegia.

Journal of the American College of Cardiology, Mar 1, 2013

Hybrid coronary revascularization (HCR), an emerging treatment paradigm, combines minimally invas... more Hybrid coronary revascularization (HCR), an emerging treatment paradigm, combines minimally invasive internal mammary artery (IMA) to left anterior descending artery (LAD) revascularization with percutaneous coronary intervention (PCI) to treat multi–vessel coronary artery disease (CAD) that

Seminars in Thoracic and Cardiovascular Surgery, Jul 1, 2001

The stentless porcine aortic valve prostheses have the potential to provide superior hemodynamic ... more The stentless porcine aortic valve prostheses have the potential to provide superior hemodynamic function and durability. Our institution was a trial site for the investigational device exemption (IDE) for 2 of the 3 stentless valve bioprostheses and has clinical experience in all 3 valves that are soon to be available. From July 1996 to January 2001, we have implanted 213 porcine stentless valves: the Toronto SPV (159), the Freestyle (20), and the Prima Plus (34) (current IDE). Fifty-five percent of these patients had concomitant coronary artery bypass graft procedures, 44% had isolated aortic valve replacements, and 3 patients required aortic valve and mitral valve procedures. Fifty-nine percent of the patients were men, 9% of procedures were reoperations, and 22% of patients were in New York Heart Association classification III or IV preoperatively. Extubation occurred within 5 hours for 52% of patients, median cardiothoracic intensive care unit length of stay was 1 day, and postoperative length of stay was 6 days. Reoperations for bleeding occurred in 5.3% of patients (0 in the past 12 months), atrial fibrillation in 28.2%, and permanent neurologic deficit in 1.9%. No patients required valve-related reoperations or had either sepsis or sternal infections. Operative mortality was 1.4%. We have also analyzed a subset of patients who had minimally invasive aortic valve replacement versus the standard approach and found no important differences in mortality (none), postoperative complications, cardiopulmonary bypass, or cross-clamp times. There was a trend towards earlier ambulation, less atrial fibrillation (15.8% v 24.1%), and earlier hospital discharge (5.6 days v 7.2 days). We conclude that excellent results were obtained with all 3 stentless aortic valve bioprostheses. Hospital events should be predictably low in elderly patients and those requiring concomitant procedures. Stentless aortic valve bioprostheses can be incorporated into regular cardiac surgical practice with the techniques described.

The Annals of Thoracic Surgery, Oct 1, 1993

The most frequent catheter-related complication of retrograde cardioplegia, in our experience, ha... more The most frequent catheter-related complication of retrograde cardioplegia, in our experience, has been catheter displacement. An easily placed coronary sinus snare that maintains proper retrograde catheter position is described.

Angiology, May 1, 1997

Embolization of atheromatous debris from old saphenous vein grafts is a major factor that increas... more Embolization of atheromatous debris from old saphenous vein grafts is a major factor that increases the risk of reoperative coronary artery bypass grafting (CABG) when compared with primary CABG. To decrease this risk, a technique consisting of minimal dissection of the heart prior to cross clamping, continuous retrograde coronary sinus perfusion with 32°C blood, and temporary posterior cardiac interventricular vein occlusion, during which time all dissection and anastomoses are performed, was evaluated prospectively in 130 consecutive patients from January 2, 1991, through February 28, 1995. This group was compared with a cohort of 1107 patients undergoing primary CABG performed concur rently. The two groups were similar in age (median sixty-eight years), incidence of hyper cholesterolemia, peripheral vascular disease, smoking history, and left main stem stenosis. More patients undergoing reoperative CABG had previous myocardial infarctions (61.5% vs 54.5%), a higher incidence of triple-vessel coronary artery disease (89.2% vs 77.1%, P=0.002), and a lower ejection fraction (54.0% vs 56.9%). The median interval from primary CABG to reoperative CABG was one hundred twenty-seven months with a range of 2.5 to two hundred seventy-nine months. The cross clamp time (median one hundred three vs sixty-nine minutes, P=0.000001) and perfusion time (median one hundred thirty-four vs ninety-four minutes, P=0.000001) were significantly higher in the reoperative CABG group. The requirements for inotropic support postoperatively, perioperative myocardial infarction (1.5% vs 2.4%, P=0.397), and mortality (3.1% vs 3.4%, P=0.54) were statistically equivalent in the two groups. These data reveal that continuous retrograde coronary sinus perfusion, posterior cardiac interventricular vein occlusion, and single cross-clamping technique improve outcomes of reoperative CABG to that approaching primary CABG.

Heart Surgery Forum, Mar 25, 2005

BACKGROUND Neurological and cognitive deficits are known complications after coronary artery bypa... more BACKGROUND Neurological and cognitive deficits are known complications after coronary artery bypass surgery (CABG) and are believed to be secondary to brain ischemia. Diffusion-weighted magnetic resonance imaging (DW-MRI) of the brain is especially sensitive and can depict ischemic areas that may not be evident clinically or with conventional MRI. Abnormalities found at brain MRI following CABG performed with cardiopulmonary bypass (ie, on pump) have been reported, but data are limited for CABG performed without use of cardiopulmonary bypass (ie, off pump). The objective of this study was to determine the rate of DW-MRI detection of brain lesions following off-pump CABG. METHODS AND RESULTS Sixteen patients consecutively undergoing off-pump CABG underwent DW-MRI prior to and after surgery. A neuroradiologist blinded to patient data coded the location and size of lesions. Neurological function was assessed with the National Institutes of Health Stroke Scale. Five (31%) of the patients had new focal ischemic lesions found at postoperative DW-MRI. Risk factors for postoperative brain ischemic lesions were similar between patients with and those without lesions found at DW-MRI. No patient had a definite clinical stroke after surgery. CONCLUSIONS Ischemic lesions found at DW-MRI are seen after off-pump CABG at a rate similar to that reported for CABG with cardiopulmonary bypass. This finding suggests that these lesions are not totally due to cardiopulmonary bypass. Further prospective clinical studies would be helpful for determining which factors are causally related to brain ischemia following CABG.

The Annals of Thoracic Surgery, Apr 1, 2000

Background. Should coronary artery bypass grafting (CABG) be performed in patients on long-term d... more Background. Should coronary artery bypass grafting (CABG) be performed in patients on long-term dialysis? This subject has been debated for several years. We retrospectively reviewed the charts of all patients who had CABG from August 1989 to October 1997. Methods. We identified 70 patients who were on longterm dialysis and had CABG during that time period. Patients were evaluated by chart review and telephone survey. Forty-nine patients (70%) had unstable angina and 37 patients (52%) had triple vessel disease. Patient risk factors included 60 patients with hypertension (85%), 40 patients with diabetes mellitus (57%), 35 patients who had congestive heart failure (50%), 35 patients who had a previous myocardial infarction (50%), and 31 smokers (44%). Operative procedures included 49 patients who had CABG only and 21 patients who had concomitant CABG with valve replacement or repair. During the postoperative period, complications developed in 50% of patients. Results. Review of these complications showed that 25% of patients required prolonged mechanical ventilation, and 10% of patients had septicemia. Operative mortality was high, with 10 patient deaths (14.3%) within 30 days of the procedure. Six (60%) of these deaths occurred in patients who had CABG and valve repair or replacement. Long-term follow up at 50.3 months showed no improvement in survival in patients who had CABG compared with the known mortality rate of 22% per year in dialysis patients regardless of comorbid conditions. Quality of life subjectively improved in only 41% of patients in follow-up telephone survey. Conclusions. Patients requiring long-term dialysis with coexistent severe cardiac disease should be thoroughly evaluated preoperatively. One must weigh the high morbidity and mortality risk against the limited long-term resolution of angina and ultimate survival.

Journal of Cardiac Surgery, Nov 15, 2022

Journal of Visualized Surgery

Background and Objective: Robotic coronary artery bypass surgery is an established procedure for ... more Background and Objective: Robotic coronary artery bypass surgery is an established procedure for treatment of coronary artery disease. The goal of this manuscript is to provide an overview on how to build a successful robotic coronary artery bypass grafting (CABG) surgery program and analyze its learning curve. Methods: We performed a narrative review of the current medical literature comparing the robotic CABG survival rate. English literature published by January 30 th , 2021 were searched in PubMed/MEDLINE, Embase, SciELO, LILACS, CCTR/CENTRAL and Google Scholar.

State of the Art Surgical Coronary Revascularization

With a general trend in surgery towards endoscopic approaches, cardiac surgeons, over the last 15... more With a general trend in surgery towards endoscopic approaches, cardiac surgeons, over the last 15 years, have recognized the importance of achieving video dexterity and are adopting video-assisted techniques in increasing numbers. The early work by Drs Nataf in Paris, Mayfield in Atlanta, and Wolf in Cincinnati, laid the groundwork for an endoscopic minimally invasive revolution. The development of video-assisted techniques and the use of new equipment in cardiac procedures represented a paradigm shift and quantum leap in our efforts to provide a less traumatic coronary revascularization procedure. In parallel to these developments, new robotic technology was emerging and demonstrating efficacy in endoscopic surgery in other disciplines.