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Ann Thorac Surg 2001;71:1501-1502
© 2001 The Society of Thoracic Surgeons
a Department of Surgery, East Carolina University School of Medicine, Greenville, NC 27858, USA
e-mail: chitwoodw{at}mail.ecu.edu
Doctor Byhahn and associates from Frankfurt have evaluated carefully the hemodynamic effects of thoracic cavity CO2 pressurization used for lung compression needed to render optimal visualization of the internal thoracic artery (ITA) during endoscopic robotic harvesting. Although numerous surgeons have reported endoscopic ITA harvesting, few reports have highlighted usage of new robotic methods or have evaluated physiologic effects during thoracic insufflation. The current authors concluded that during single lung pressure insufflation at 10 to 12 torr, oxygenation remains unaffected; however, both arterial CO2 levels and heart rate rise. Nevertheless, both the arterial blood pressure and PaCO2 still remain at safe levels. In comparison, when both thoracic cavities are insufflated simultaneously, arterial CO2 levels rise to concerning levels.
From this study cardiac surgeons should conclude that intrathoracic insufflation of CO2 during endoscopic thoracic surgery can cause significant hemodynamic abnormalities; however, at lower pressure levels these abnormalities remain relatively safe. The study also highlights the fact that simultaneous insufflation of both chest cavities should be avoided unless meticulous hemodynamic and gas exchange monitoring is done throughout the procedure. Elevated blood CO2 levels cause pulmonary arterial vasoconstriction. Moreover, coronary vasospasm also could result from significant CO2 retention, despite relatively stable hemodynamics. Surgeons should be aware of this danger especially in patients with severe three-vessel disease. To date, the majority of patients undergoing robotic internal thoracic artery harvests have had one and two vessel coronary disease. In the presence of more advanced coronary disease, a watchful eye for insidious ischemia is important during these preparatory moments. Perhaps, continuous ST-T wave analysis during CO2 pressurization would be prudent.
Recently most robotic coronary surgeons have selected between 3 and 10 torr during CO2 insufflation and have not experienced difficulties. To date groups from Dresden and Leipzig have had the greatest experience in harvesting internal thoracic arteries using robotic devices. Recently, Cichon and coworkers reported 17 patients undergoing bilateral ITA harvesting using similar methods of ventilation and thoracic insufflation without hemodynamic problems [1]. Similarly, Mohr and Falk and their colleagues have not reported significant problems using less than 10 torr for CO2 pressurization [2]. Reichenspurner and associates in Munich have harvested ITA arteries robotically with safety, using similar insufflation methods [3]. In the United States Damiano [5] has limited experience with robotic ITA harvesting but with good results using similar methods. Boyd and colleagues recently reported 18 Canadian patients undergoing robotic single ITA harvests using CO2 pressures between 5 and 10 torr without hemodynamic compromise [4]. Thus, as discovered earlier by Nataf [6] with nonrobotic endoscopic ITA harvests, the current paper confirms blood chemistry and hemodynamic safety when lower levels of CO2 insufflation are used during robotic intra-thoracic conduit harvests. However, "fail-safe" methods must be developed with proper alarm systems to assure constant low-level pressurization. CO2 pressures of over 15 torr have been shown to be hemodynamically deleterious. Devastating complications could arise without surgical vigilance, especially in patients with severe three-vessel disease, who are undergoing bilateral thoracic cavity entry.
References
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