How to handle remote access perfusion for endoscopic cardiac surgery.

INTRODUCTION Remote access is a prerequisite for endoscopic cardiac surgery on the arrested heart. Despite careful patient selection, technical problems and complications occur with the use of this sophisticated technique, and we aim to describe these problems and suggest solutions. PATIENTS AND METHODS From 2001 to 2004 remote access cardiopulmonary bypass (CPB) was installed in 70 patients, aged 55 (16-70) years. The operations performed were AHTECAB in 44, ASD repair via minithoracotomy in 10, totally endoscopic ASD repair in 11, and minimally invasive mitral valve operation in 5 cases. CPB time was 134 (72-342) minutes and aortic endoocclusion time was 70 (35,223) minutes. RESULTS In 3 cases the guide wire had to be detected in the aortic root fluoroscopically because it could not be detected in the aortic root on TEE. Initial balloon migration requiring repositioning occurred in 30 cases. After achieving a stable balloon position and incision of the atrium/coronary artery balloon migration occurred in 2 cases, which could be overcome by a quick repositioning maneuver. In 1 patient no stable position of the balloon could be achieved and conversion to median sternotomy was necessary. Balloon rupture occurred in 2 cases. In one case, rupture of the balloon occurred before the endoscopic LIMA-to-LAD anastomosis was started. The cannula could be successfully replaced and the TECAB procedure finished without complications. In the second case, the balloon ruptured after finishing the LIMA-to-LAD anastomosis and no replacement of the cannula was necessary. Inadequate CPB flow was found in 1 case, and sufficient flows were achieved by an additional 15 F arterial cannula which was placed in the contralateral groin. We had no major surgical complication related to the use of the remote access perfusion device, such as aortic dissection, leg ischemia reperfusion injury, or neurological injury and no hospital death. Wound infection of the groin occurred in 1 patient, which resolved after surgical revision. Ten patients suffered temporarily from lymphatic secretion of the groin. CONCLUSION Remote access is technically challenging, but most difficulties can be overcome if regular application by a dedicated team is guaranteed. Remote access perfusion can be performed with an acceptable risk if exclusion criteria are carefully observed.