Subjects
147 patients who underwent cardiac surgery under Da Vinci robotic CPB from July 2016 to June 2022 in Daping Hospital of Army Medical University were selected. Inclusion criteria:1.Aged≥18 years old, gender, race is not limited, no long-term use of drugs for significant renal impairment, no underlying kidney disease;2. Preoperative vascular assessment to determine suitable surgery, including: thoracic and abdominal computed tomography (CT), transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), lower limb vascular ultrasonography;3.Our department performed Da Vinci robotic cardiac surgery, including simple or combined: mitral valve replacement, mitral valvuloplasty, aortic valve replacement, tricuspid valvuloplasty, tricuspid valve replacement, congenital heart disease correction, cardiac tumor resection;4.Patients with complete electronic medical records, especially perioperative data. Exclusion criteria:1.Age<18 years, emergency surgery, chronic kidney disease, arrhythmia;2.Da Vinci robotic non-CPB cardiac surgery, such as coronary artery bypass grafting, pericardial cyst resection, etc.;2.Patients with severe coronary artery disease, aortic calcification, thoracic tissue adhesion, macroangiopathy, iliofemoral artery disease, severe cardiac insufficiency, respiratory insufficiency, liver and kidney dysfunction, coagulopathy;3.Previous history of nephrectomy, kidney transplantation or renal artery stenosis;4.Patients without complete clinical data to be collected. Patients were divided into arrhythmia group (n=23) and non-arrhythmia group (n=123) according to whether arrhythmia occurred after operation.The study was reviewed and approved by the Ethics Committee of General Daping Hospital of Army Medical University (No.266 (2022)). Informed consent was obtained from all subjects.All methods were carried out in accordance with the ethical standards in the Declaration of Helsinki.
Monitoring indicators
Patient information was collected using our electronic case system, medical order system, and surgical anesthesia system. Basic information:hospitalization number, gender, age, height, weight, body mass index (BMI), body surface area (BSA), obesity classification, hypertension, diabetes, smoking, alcohol consumption, New York Heart Association (NYHA) functional classification, left ventricular ejection fraction (LVEF), left ventricular shortening fraction (FS), atrioventricular diameter, tricuspid valve pressure gradient, and pulmonary arterial pressure (SPAP); perioperative data:operation time, CPB time, aortic cross-clamp time, intraoperative blood product input, drainage volume on the first postoperative day, postoperative tracheal tube time, postoperative intensive care unit stay, postoperative hospital stay, postoperative complications, type of cardiac surgery, and peripheral cardiopulmonary bypass intubation; laboratory tests: preoperative and postoperative biochemical indicators and blood routine.
According to clinical needs, the diagnostic criteria for postoperative acute kidney injury (AKI) were: serum creatinine (SCr) increased by≥26.4 μmol/L within 24 hours, or increased by≥50% compared with the baseline value (the most recent SCr value before surgery), or urine volume<0.5 ml/(kg · h) for 6 hours[1,2]. In this study, the urine volume data of patients after surgery were not statistically complete, so urine volume was not used to assess renal function. Indications for continuous renal replacement therapy (CRRT) include volume overload, severe metabolic acidosis, metabolite accumulation, hyperkalemia, and low cardiac output syndrome[3]. Diagnostic criteria for pulmonary infection: postoperative purulent sputum, chest radiography showed inflammatory lesions, and positive sputum culture were diagnostic criteria. Diagnostic criteria for liver function injury:alanine aminotransferase (ALT) was greater than normal within 24 hours after surgery[4], because aspartate aminotransferase (AST) was greatly affected by cardiac surgery, ALT was used as a diagnostic indicator. Abnormal bilirubin metabolism:Bilirubin greater than normal within 24 hours after surgery. Diagnostic criteria for hypoproteinemia: albumin (ALB) level≤35 g/L within 24 hours after surgery. Postoperative hypoalbuminemia: prealbumin (PA) level≤150 mg/L within 24 h after operation. Postoperative delirium Early, rapid screening for postoperative delirium using assessment of confusion is recommended according to ESA guidelines[5].
Preoperative assessment
In order to ensure that patients meet the conditions for Da Vinci robotic cardiac surgery, cardiac function and thoracic cavity conditions should be confirmed by TTE, ECG, chest radiography, chest CT, coronary CTA, coronary angiography and other examinations before surgery; after judging that patients have surgical conditions, abdominal CT, cervical and lower limb vascular ultrasound and TEE should be performed to assess whether thoracoabdominal aorta, vena cava, iliac vessels and their branches, femoral vessels have the conditions for establishing peripheral cardiopulmonary bypass and anesthesia conditions, and patients with vascular malformations, thrombosis, and severe plaque formation are found by examination, and patients who are expected to be unable to safely establish peripheral vascular access are not suitable for Da Vinci robotic cardiac surgery after evaluation.
Surgical methods
After successful general anesthesia and tracheal intubation with a double-lumen tube, an esophageal ultrasound probe was placed transesophagically.The patient was placed in a supine position with a right padding height of 30 ° C, abduction of the right upper arm, and low head and feet.Surgical marking was performed on the right chest wall beforehand, and the endoscopic orifice was located 6 cm in the fourth intercostal space and anterior axillary line of the right chest wall, avoiding breast tissue, with a diameter of about 1 cm; the working orifice was located 3 cm below the endoscopic orifice of the right chest wall, with a diameter of about 2 cm; the left and right robotic arms were located 4 cm in the second intercostal space and anterior axillary line of the right chest wall and 2 cm in the sixth intercostal space and anterior axillary line, with a diameter of about 1 cm; the active aortic orifice was located 3 intercostal spaces in the midaxillary line, with a diameter of about 0.5 cm, exposing the right inguinal region.Routine disinfection and draping were performed, and body surface electrodes were attached to the left anterior chest wall and right posterior back, respectively.An incision was made in the right inguinal region to fully expose the femoral artery and femoral vein, which was sutured to the wall of the femoral and femoral veins with a sliding purse-string purse-string, and a gap of about 6×5 mm was left in the center of the purse-string as the catheterization site.After left lung one-lung ventilation, mark the incision along the right chest wall intercostal space, incise the skin, subcutaneous tissue and muscular layer successively, enter the thoracic cavity, place each operation hole card, push the robotic arm car of robotic system to the appropriate position on the left side of the patient, connect the robotic arm with the puncture cannula, insert the microporous device, and adjust the robotic arm to the optimal position.Following systemic heparinization, the Seldinger technique was chosen to place the arterial and venous lines.Appropriate extracorporeal circulation conduits were selected according to the patient 's height, weight, and femoral vascular development.Arterial perfusion tube is inserted through femoral artery, 16-22F arterial conduit is often selected for femoral artery; inferior vena cava drainage tube is inserted through femoral vein, 16-25F thick and thin conduit is generally selected for femoral vein tube; superior vena cava drainage tube is inserted through right internal jugular vein, 15-18F thick and thin conduit is generally selected for internal jugular vein tube to establish extracorporeal circulation. Esophageal ultrasound is used during intubation to determine the position of venous conduit and avoid to right atrium.After the superior and inferior vena cava were cuffed, after the nasopharyngeal temperature was cooled, aortic cross-clamp was inserted through the cross-clamp hole, and ascending aortic cardioplegia perfusion needle was inserted through the working hole to block the superior and inferior vena cava and ascending aorta.Blood-cold crystalloid cardioplegia was perfused into the aortic root.After satisfactory cardiac arrest, the surgeon completes the surgical operation before the control table, and assists the surgeon in the operation on the assistant table.Thorough hemostasis was achieved at the end of surgery, and a chest drainage tube was placed in the right operation hole.
Statistical analysis
Data were analyzed using SPSS 22.0 software. Normally distributed measurement data were expressed as "mean ± standard deviation (± s)", and t-test was used for comparison between groups. Non-normally distributed measurement data were presented as median and interquartile range, and Mann-Whitney U test was used for comparison between groups. Enumeration data were expressed as "frequency (rate), n (%)", and chi-square test was used for comparison between groups. Multivariate analysis was performed for factors with univariate P<0.01, and binary logistic regression models were used for multivariate analysis, and ROC curves were used to evaluate the prediction models. P<0.05 was considered statistically significant.