Robotic System Advances Cardiac Procedures at Centennial

SHARON H. FITZGERALD

Robotic System Advances Cardiac Procedures at Centennial | da Vinci S HD Surgical System, mitral-valve repair, Centennial Heart Center, Trey Brunsting,

As surgical instruments and equipment become more sophisticated, so do the surgical procedures themselves. When it comes to cardiac surgery, much of today's astounding advances are credited to robotics, and Nashville's Centennial Heart Center is armed with the latest-generation robotic surgical system. Actually, Centennial is armed four times over, since that's the number of interactive robotic arms on the da Vinci® S HD.

Centennial Heart thoracic surgeon Louis A. "Trey" Brunsting said the medical center is using the da Vinci for several heart procedures, including mitral-valve repair. The system, he said, has made the repair "a much smoother, much more reliable operation."

One reason is the high-definition (HD) viewer that offers surgeons digital zoom of the surgical site in 3-D. "Even in an open case, I never saw it like I see it now. It's a 10-times magnified picture, and it's well-lit," Brunsting said.

The da Vinci Surgical System is the product of California-based Intuitive Surgical Inc., which launched the da Vinci in 1999. In 2000, it became the first robotic surgical system cleared by the FDA for general laparoscopic surgery. Since then, the system has been approved for chest and cardiac, urologic and gynecologic procedures. Intuitive holds much of the intellectual property and is the world's sole provider of the equipment. Surgeons operate at a console, with their arm and hand movements mimicked by the robotic arms. The surgery is performed through incisions, called ports, of 1-2 inches, thus decreasing patient healing time.

Brunsting said the da Vinci's latest iteration is by far its best, and not just because of the high-resolution optics. Slimmer arms make for easier manipulation and slightly longer instruments improve access to surgical sites of larger patients. With just a software upgrade, surgeons have access to a picture within a picture and "a heads-up display like a fighter pilot," he said.

da Vinci Use at Centennial

Using the da Vinci, Centennial heart surgeons are repairing holes in the heart and performing both simple and complex mitral-valve repair through the right side of the chest. A simple mitral-valve repair is the use of a cloth ring to cinch the sides of an enlarged valve. A complex repair may mean work on the valve's chords and/or leaflets (the flaps that open and close). "Pretty much anything we can do in an open fashion we can do in a closed fashion now," Brunsting said. The procedure requires four small ports plus another incision of about 2 inches called a "working port," used by another surgeon or assistant at the patient's side to pass through sutures, a valve ring or other surgical necessities. A final 2-3 inch incision in the right groin grants access to the femoral artery and vein for the heart-lung machine.

Eliminating the use of the heart-lung machine for some heart-bypass operations is now possible, thanks to the robotic system. Brunsting said one of the four robotic arms is used as a "positioner" to stabilize a part of the heart for the bypass procedure without stopping the heart. This use of the da Vinci, coupled with the use of a linear stapling device to connect the bypass arteries, is "working very nicely," he said.

Some patients who have had a successful bypass or perhaps multiple stents may continue to suffer disabling chest pain, despite fairly normal heart function and no severe heart damage. Those patients may receive relief with TMR – transmyocardial laser revascularization. Surgeons use the da Vinci to deliver and manipulate a flexible optical fiber that transmits laser energy to "create channels" through the heart muscle, Brunsting explained. About 35 to 60 channels in a grid on the free wall of the left ventricle "does a couple of things," he said. "It promotes the heart to grow more little natural bypasses and improve profusion or blood flow. It also makes the heart less sensitive to the chest pain."

According to Brunsting, the next step in TMR is enhancing the optical fiber with several small needles, which will inject a small amount of the patient's own stem cells into the heart. "That may actually help repair some areas of heart damage and improve heart function for heart-failure patients," he said.

In the Future

While a few institutions are using the da Vinci for mitral-valve replacement, the FDA hasn't approved that procedure for the equipment. Thus, Centennial has held off. "You can always use equipment in an off-label fashion, but I just haven't felt comfortable with that. There's got to be another enabling technological advance to get us to doing it, but I think it's coming. There are several people who are working on it," Brunsting said. He added that valve repair is still the preferred procedure if it's possible. "Valve repair has a much lower mortality and morbidity and a much better functional recovery than valve replacement," he said. In addition, patients aren't required to take blood thinner after a repair, but the medication is a necessity after a replacement.

Also on the horizon is use of the da Vinci to treat atrial fibrillation, and Brunsting predicted that Centennial will be involved in clinical trials for that procedure.