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Ann Thorac Surg 2003;76:417
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Invited commentary

^a Department of Cardiovascular Surgery, National Cardiovascular Center 5-7-1 Fujishirodai Suita, Osaka 565-8565 Japan

e-mail: jkobayas{at}hsp.ncvc.go.jp

In the past decade, minimally invasive cardiac surgery has been introduced with the attempt to perform valve surgery and congenital heart surgery through small skin incisions. Various video-assisted systems and alternative methods of aortic clamping, vascular cannulation, and cardiopulmonary bypass have been developed. With the introduction of robotic surgical systems, totally endoscopic cardiac surgery has become realistic.

In 2002, 1744 cardiac procedures were carried out using the da Vinci robotic system. Jansen and colleagues have successfully implanted the left ventricular (LV) epicardial lead for biventricular pacing therapy for chronic heart failure by a robotic surgical system in 13 patients. Although conventional cardiac resynchronization therapy has been approved for the treatment of chronic heart failure, appropriate transvenous insertion of the left ventricular lead thorough the coronary sinus has been difficult and time-consuming. The authors report better chronic pacing thresholds of LV epicardial leads implanted by the robotic, procedure than by an intravenous LV lead. In addition, the robotic procedural time has been shortened to 15 minutes by a relatively sharp learning curve in 5 cases. This robotic procedure is composed of fixing the lead by two stitches. It must be very difficult to perform this procedure by conventional VATS using conventional surgical instruments. EndoWrist articulating instruments of the da Vinci robotic system facilitate putting stitches through a small hole and on the groove of the epicardial lead accurately and safely.

One of the problems of the robotic surgical system is the absence of tactile impressions and reception of the grasping power of surgical instruments. Accidental damage on a lead made of polyurethane or silicone by grasping with the robotic instrument is possible. The second problem is that the amount of space between the heart and the chest wall is limited without CO₂ insufflation. There may be a risk of additionally impairing LV diastolic function in patients with end-stage chronic heart failure. The other issue is the high cost of the robotic surgical system. A large-sized U-clip may facilitate the fixing of a lead on the LV using standard VATS techniques. In the future the development of suture-less epicardial leads may be possible without using the robotic technique.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Kobayashi, J. Search for Related Content PubMed Articles by Kobayashi, J.