title: Robotically assisted perventricular closure of perimembranous ventricular septal defects: preliminary results in Yucatan pigs.
abstract: OBJECTIVE
  Robotic systems allow surgeons to perform minimally invasive cardiac surgery in adults. Experience in the pediatric population, however, is limited. Perventricular closure of muscular ventricular septal defects has been reported in humans but requires a median sternotomy. The objective of this study was to assess the feasibility of robotically assisted closure of perimembranous ventricular septal defects by using the perventricular approach.
  
  
  METHODS
  The procedure was attempted in 7 pigs with naturally occurring perimembranous ventricular septal defects. Echocardiography was performed to confirm the presence and assess the size of the defect. A 3-armed da Vinci system consisting of two 8-mm instrument ports and a 12-mm endoscopy port was used. A pericardiotomy was performed, and the right ventricular free wall was visualized. A spinal needle was advanced into the right ventricular cavity. By using echocardiographic guidance, a glide wire was advanced through the angiocatheter and manipulated through the defect into the left ventricle or the ascending aorta. A delivery sheath was advanced over the wire. An appropriately sized Amplatzer device was deployed through the sheath.
  
  
  RESULTS
  The procedure was successful in 5 pigs. One device was removed because it was smaller than the defect and an appropriately sized device was not available. The placement failed in the second pig in the series. Four pigs were followed up for 1 to 4 months. Angiograms performed before the pigs were killed documented complete occlusion in 3 and mild-to-moderate shunt in 1.
  
  
  CONCLUSIONS
  Robotically assisted perventricular closure with the Amplatzer Membranous VSD Occluder is feasible. This approach avoids the associated morbidities of cardiopulmonary bypass and median sternotomy. Further investigation and refinements are needed, however, before application of this approach in humans.
authors.affiliation: Joint Division of Pediatric Cardiology, University of Nebraska/Creighton University, Children's Hospital of Omaha, Omaha, Neb 68114 , USA. zamin@chsomaha.org
authors.forename: Zahid
authors.initials: Z
authors.lastname: Amin
authors.forename: Russell
authors.initials: R
authors.lastname: Woo
authors.forename: David A
authors.initials: DA
authors.lastname: Danford
authors.forename: Stacey E
authors.initials: SE
authors.lastname: Froemming
authors.forename: Vadiyala M
authors.initials: VM
authors.lastname: Reddy
authors.forename: John
authors.initials: J
authors.lastname: Lof
authors.forename: David
authors.initials: D
authors.lastname: Overman
mesh_terms: D000818:Animals; D006348:Cardiac Surgical Procedures; D017548:Echocardiography, Transesophageal; D006345:Heart Septal Defects, Ventricular / Q000000981:diagnostic imaging / Q000601:surgery*; D019060:Minimally Invasive Surgical Procedures; D019736:Prostheses and Implants; D012371:Robotics; D013552:Swine