744 CASE REPORT BRUNSTING ET AL
TOTALLY ENDOSCOPIC ROBOT-ASSISTED TMR
mosis, infused cardioplegia antegradely, and obtained
cardiac arrest. Under cardiac arrest, we success-
fully removed the pseudoaneurysm without any
thromboembolism.
In summary, for the patients with SVG pseudoaneu-
rysms related to a CABG, the surgical exclusion of the
pseudoaneurysm and re-CABG were a useful option for
the treatment of this fatal complication. We performed
the re-revascularization of the RCA first under the beat-
ing heart with an in situ RGEA graft followed by a
pseudo-aneurysmectomy under the arrested heart. There
were no complications such as thromboembolism or
perioperative myocardial infarction associated with this
procedure.
References
1. Williams ML, Rampersaud E, Wolfe WG. A man with saphe-
nous vein graft aneurysms after bypass surgery. Ann Thorac
Surg 2004;77:18157
FEATURE ARTICLES
2. Dieter RS, Patel AK, Yandow D, et al. Conservative vs
invasive treatment of aortocoronary saphenous vein graft
aneurysms: treatment algorithm based upon a large series.
Cardiovasc Surg 2003;11:50713.
3. Voutilainen S, Verkkala K, Jarvinen A, et al. Angiographic
5-year follow-up study of right gastroepiploic artery grafts.
Ann Thorac Surg 1996;62:5015.
4. Ochi M, Hatori N, Fuji M, et al. Limited flow capacity of the
right gastroepiploic artery graft: postoperative echocardio-
graphic and angiographic evaluation. Ann Thorac Surg 2001;
71:1210 4.
5. Shah PJ, Gordon I, Fuller J, et al. Factors affecting saphenous
vein graft patency: clinical and angiographic study in 1402
symptomatic patients operated on between 1977 and 1999.
J Thorac Cardiovasc Surg 2003;126:19727.
Totally Endoscopic Robot-Assisted
Transmyocardial Laser
Revascularization
Louis A. Brunsting III, MD, Robert S. Binford, MD
Kimberly C. Braly, RN, NP-C, and Chad R. Swan, MD
The Heart Team, Centennial Medical Center, Nashville,
Tennessee
We describe the first use of totally endoscopic, off-pump,
robot-assisted transmyocardial laser revascularization in
a 58-year-old man with refractory rest angina who had
undergone two prior coronary bypass operations. Preop-
erative testing revealed reversible ischemia of the left
ventricular apex with diffuse coronary atherosclerotic
disease not suitable for further treatment by conven-
tional techniques. During surgery a fiberoptic laser de-
livery system was manipulated using the da Vinci ro-
botic system to create 25 transmural channels in the left
Accepted for publication Oct 18, 2005.
Address correspondence to Dr Brunsting, 2400 Patterson St, Suite 223,
Nashville, TN 37203; e-mail: lab.theheartteam@comcast.net.
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
Ann Thorac Surg
2006;82:744 6
ventricular myocardium. Postoperative recovery was
rapid and uneventful, with complete relief of anginal
symptoms at 30 days.
(Ann Thorac Surg 2006;82:744 6)
2006 by The Society of Thoracic Surgeons
T ransmyocardial laser revascularization (TMR) ap-
plied through a left limited thoracotomy is a thera-
peutic option in patients with medically refractory, se-
vere angina due to diffuse, late-stage ischemic heart
disease that is not amenable to treatment using percuta-
neous coronary interventions or coronary artery bypass
graft surgery [1]. Peer-reviewed research identifies de-
nervation as an explanation for the early relief of symp-
toms seen in some patients, with angiogenesis becoming
the dominant mechanism in the months that follow due
to the development of mature collateral vessels in the
treated regions [2]. Clinically, in the Food and Drug
Administrations approved trial involving sicker class IV
patients, this translated into sustained and significantly
superior angina relief through 5 years in patients receiv-
ing TMR compared with medical therapy, with a corre-
sponding survival benefit [3]. Recently, initial clinical
feasibility and safety of a closed chest thoracoscopic
approach to sole therapy TMR has been demonstrated
using the original Food and Drug Administrations ap-
proved holmium:yttriumaluminum garnet laser and
delivery system [4].
Totally endoscopic cardiothoracic surgery on the beat-
ing heart with the aid of the da Vinci surgical system
(Intuitive Surgical, Inc, Sunnyvale, CA) is a rapidly evolv-
ing field. Experimental studies have shown the feasibil-
ity, precision, and safety of totally endoscopic, roboti-
cally-assisted, off-pump TMR using an optimized,
flexible fiberoptic holmium:yttriumaluminum garnet
laser delivery system deployed with the da Vinci system
to create transmural channels in all targeted areas of the
left ventricle [5]. Because of the demonstrated clinical
benefits of TMR to carefully select patients, and the
demonstrated feasibility of totally endoscopic robot-
assisted techniques, it is reasonable to expect enhanced
patient experience postoperatively using the combina-
tion of these advanced technologies.
A 58-year-old man with a body mass index of 23.5 and
severe ischemic heart disease was evaluated for totally
endoscopic TMR. He had suffered 10 prior myocardial
infarctions and undergone angioplasty with stenting fol-
lowed by quadruple bypass grafting and subsequent
redo bypass in the past 9 years. He has a long history of
renal disease, chronic obstructive pulmonary disease,
hypothyroidism, and hyperlipidemia, and has become
progressively debilitated to the point of being unable to
work or engage in routine daily activities. He was treated
Drs Brunsting and Binford and Ms Braly disclose that
they have a financial relationship with Intuitive Surgi-
cal and Cardiogenesis.
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2005.10.017
Ann Thorac Surg CASE REPORT BRUNSTING ET AL 745
2006;82:744 6 TOTALLY ENDOSCOPIC ROBOT-ASSISTED TMR

with maximally tolerated medications without abatement

of persistent New York Heart Association functional class
IV anginal symptoms.
Preoperatively, reversible myocardial ischemia was
demonstrated in the left ventricular apex by gated tomo-
graphic myocardial perfusion study with dobutamine
stress testing. Ejection fraction was 57%. Due to the
patients history and the nature and severity of the
disease, both cardiology and cardiothoracic surgery con-
sults determined him to be a no option patient.
Transmyocardial laser revascularization was recom-
mended according to the Food and Drug Administra-
tions approved protocol that assesses safety of the mod-
ified fiberoptic delivery system specifically designed for
totally endoscopic robot-assisted use. The institutional
review board approved the protocol and procedure, and
the patient provided written informed consent.
Ventilation was accomplished with a double lumen
endotracheal tube. Transesophageal echocardiography
was performed to confirm channel transmurality (by Fig 1. Creation of a laser channel in the lateral wall of the left ven-
tricle. The pericardium has been opened anterior to the phrenic

observing left ventricular microbubbles) and to assess
left ventricular function. The patient was placed in right
lateral decubitus position with his arms bent at 90 de-
grees, and the operative table was angled at 45 degrees
with the patients head toward the robotic surgical cart.
Four thoracoscopic ports were inserted as follows: (1) a
12-mm port in the seventh intercostal space, posterior
axillary line, through which a 10-mm zero angle video-
scope was inserted; (2) the da Vinci 8-mm right arm
instrument port in the seventh intercostal space, poste-
rior axillary line (just anterior to the scapular tip); (3) the
da Vinci 8-mm left arm instrument port in the seventh
intercostal space, mid-axillary line; and (4) a 5-mm port at
the fifth intercostal space, mid-axillary line. This site was
used for introduction of the fiberoptic TMR delivery
system (Cardiogenesis Corp, Foothill Ranch, CA). The
pericardium was opened 2 to 3 cm anterior to the phrenic
nerve from the atrial appendage to the apex. Curved
robotic scissors were used to expose the distal two thirds
of the left ventricular free wall. Twenty-five transmural
channels were placed approximately 1 cm apart in the
left ventricle free wall, treating the apical (n 10),
anterior (n 6), anterolateral (n 6), and posterolateral
(n 3) segments. Flexible handpiece manipulation using
the Cadiere instrument in the right arm and a Debakey
instrument in the left arm allowed firm and perpendic-
ular contact between the distal tip and epicardium (Fig 1).
Hemostasis was achieved with gentle pressure over
bleeding channels using robotic instruments or by hold-
ing the pericardium closed. The inferior region in this
patient was not treated, and the posterolateral region was
treated with only three channels to avoid potential injury
to a patent sequential saphenous vein graft supplying the
posterior descending and posterolateral coronary arter-
ies. Subsequent patients have had all regions treated,
with up to 47 channels per patient. All regions of the left
ventricle were accessible without need for positioning
devices or rotation among ports. No complications oc-
curred during the procedure. At the completion of the
FEATURE ARTICLES
nerve, with the apex of the heart to the left and the base to the right.
The blue bands on the laser fiber are crush-resistant zones for ro-
botic instrument manipulation.
173-minute surgery, the pericardium was closed with two
3-0 Gore-Tex sutures (W.L. Gore & Assoc, Flagstaf, AZ).
The left pleural space was drained for 48 hours with a
28-French chest tube placed through the left arm instru-
ment port site. Intercostal blocks were performed at each
port site with ropivacaine. The patient was extubated in
the operating room. His intensive care unit and hospital
length of stay were 20.5 hours and 2 days, respectively. At
30 days follow-up, he was asymptomatic with no anginal
symptoms and no delayed complications.
Comment
In a procedure in which the primary clinical outcome is
improved cardiac pain control (ie, angina reduction), it is
incumbent for the treating physician to explore available
options to improve the patient experience. The develop-
ment of robotically-assisted, videoscopic surgical alterna-
tives represents an effort aimed at improving visualiza-
tion and reducing acute and chronic pain that has been
associated with increased length of hospital stay after a
standard thoracotomy [5]. This report shows the feasibil-
ity of combined TMR using a port-enabled fiberoptic
delivery system and advanced robotic techniques in
patients with disabling angina refractory to medical ther-
apy, which may lead to continued development of tech-
niques to minimize access-induced trauma, while estab-
lishing the safety profile, potential risks, and patient
selection algorithm for totally endoscopic robotically-
assisted cardiothoracic techniques.
The authors appreciate the assistance of Janet Fauls in the
preparation of the manuscript of this article.
 746 CASE REPORT HEID ET AL
ECC AND CARDIAC ARREST FOR PULMONARY ARTERY STENTING
References
1. Allen KB, Dowling RD, Fudge TL, et al. Comparison of
transmyocardial revascularization with medical therapy in
patients with refractory angina. N Engl J Med 1999;341:1029
36.
2. Hughes GC, Biswas SS, Yin B, et al. A comparison of mechan-
ical and laser transmyocardial revascularization for induction
of angiogenesis and arteriogenesis in chronically ischemic
myocardium. J Am Coll Cardiol 2002;39:1220 8.
3. Allen KB, Dowling RD, Angell W, et al. Transmyocardial
revascularization: five-year follow-up of a prospective, ran-
domized, multicenter trial. Ann Thorac Surg 2004;77:1228 34.
4. Allen GS. Mid-term results following thoracoscopic
transmyocardial laser revascularization. Ann Thorac Surg
2005;80:553 8.
5. Yuh D, Simon B, Fernandez A, et al. Totally endoscopic
robot-assisted transmyocardial revascularization. J Thorac
Cardiovasc Surg 2005;130:120 4.
Extracorporeal Circulation and
Cardiac Arrest in an Awake
Patient: A Safe Approach for Single
FEATURE ARTICLES
Lung Pulmonary Artery Stenting?
Florian Heid, MD, Stefan Guth, MD,
Eckhard Mayer, MD, Sascha Herber, MD,
Christoph Dber, MD, PhD, Irene Tzanova, MD, and
Christian Werner, MD, PhD
Departments of Anesthesiology, Cardiothoracic and Vascular
Surgery, and Radiology, Johannes Gutenberg-University,
Mainz, Germany
We describe the anesthetic concept and approach in a
single lung patient scheduled for pulmonary artery stent-
ing due to recurrence of a pulmonary artery sarcoma after
left pneumectomy.
(Ann Thorac Surg 2006;82:746 7)
2006 by The Society of Thoracic Surgeons
P ulmonary artery sarcomas are rather rare events. We
describe a patient with a history of left pneumec-
tomy due to pulmonary artery sarcoma. Tumor recur-
rence led to rapid deterioration and this single lung
patient was scheduled for pulmonary artery stenting. We
focused on the anesthetic management of this excep-
tional case, which included extracorporeal circulation
and cardiac arrest in an awake patient.
A left-sided pneumectomy and thromboendarterectomy
of the right pulmonary artery due to primary pulmonary
artery sarcoma was performed on a 50-year-old man in
November 2003. He was in full remission until May 2005
when his health status rapidly deteriorated with dyspnea
and cyanosis leading to emergency hospital admission.
Computerized tomography revealed tumor recurrence,
reducing the diameter of the right pulmonary artery to
Accepted for publication Nov 23, 2005.
Address correspondence to Dr Heid, Department of Anesthesiology,
Johannes Gutenberg-University, Langenbeckstr. 1, Mainz, 55131 Ger-
many; e-mail: heid@uni-mainz.de.
2006 by The Society of Thoracic Surgeons
Published by Elsevier Inc
Ann Thorac Surg
2006;82:746 7
Fig 1. Magnetic resonance angiography before intervention. Note
severe stenosis of the right pulmonary artery (white arrow).
pencil size (Fig 1). Corresponding to these findings, his
impaired pulmonary blood flow led to facial edema and
increased central venous pressure (20 mm Hg). Anatomic
conditions excluded any surgical option; hence an endo-
vascular approach with stent graft implantation was
planned. Considerations concerning anesthetic manage-
ment evolved from the need for temporary but complete
outflow obstruction in an already dilated and insufficient
right ventricle.
After establishing standard monitoring (ie, electrocar-
diogram, noninvasive arterial blood pressure, peripheral
transcutaneous oxygen saturation), the patients right
radial artery was cannulated and a central venous line
through the right internal jugular vein was inserted.
After local anesthesia of the left groin (30 mL of mepiva-
caine, 1%), his femoral artery and vein were catheterized
and connected to a cardiopulmonary bypass circuit. Dur-
ing these measures and thereafter the patient was mod-
erately sedated by intravenous infusion of remifentanil
(0.06 to 0.1g kg-1min-1), with preserved spontaneous
breathing and undiminished responsiveness, corre-
sponding to a Ramsey score of 2. The right femoral vein
was cannulated and an introducer sheath was inserted,
and through this a guidewire was advanced. Before the
guidewire reached the right atrium extracorporeal circu-
lation (ECC) was started to avoid hemodynamic distur-
bance in case of potential dysrhythmia. With the onset of
the ECC, the ventilatory drive of the patient ceased due
to complete extracorporeal oxygenation, and he only
breathed if he wanted to talk to a team member. Right
atrial and ventricular passage of the guidewire was
uneventful, and no dysrhythmias occurred. With the tip
of the guidewire in the pulmonary artery a maximum
ECC flow (3.5 L/min) could not relieve the heart com-
pletely. This was confirmed by a persistent pulsatile flow
through the radial arterial line. Therefore, prior to bal-
loon dilatation, we induced cardiac arrest by bolus injec-
tion of adenosine (24 mg) through the central venous
0003-4975/06/$32.00
doi:10.1016/j.athoracsur.2005.11.065