Robotic-assisted MIDCAB procedure through a minithoracotomy: Step-by-step instructions.

Minimally invasive cardiac surgery has evolved in recent years. Complex minimally invasive surgical techniques can further reduce the morbidity associated with surgical coronary bypass grafting. Robotic-assisted minimally invasive direct coronary artery bypass grafting is an effective and safe procedure in all risk groups. More experience with this procedure over the coming years should lead to the implementation of guidelines and the incorporation in heart-team decisions of schemes for individual patient care. We present a young male patient with familial hypercholesterolemia and chronic total occlusion of the left anterior descending artery (LAD) treated in January 2021 with a robotic-assisted minimally invasive direct coronary artery bypass graft through a minithoracotomy. The procedure was. The patient showed a fast recovery from the uncomplicated procedure and was discharged from the hospital after 3 days. We prepared this case report to facilitate training for this complex technical procedure. Robotic-assisted MIDCAB through a minithoracotomy is a technically demanding but safe minimally invasive alternative to coronary artery bypass grafting in patients with severe coronary lesions not suitable for percutaneous coronary intervention. In a hybrid coronary revascularization strategy, this technique minimizes surgical risk and optimizes long-term outcomes with high patency of surgical grafts.

Corrigendum: Robotic Cardiac Surgery in Europe: Status 2020.

[This corrects the article DOI: 10.3389/fcvm.2021.827515.].

Safe implementation of robotic-assisted minimally invasive direct coronary artery bypass: application of learning curves and cumulative sum analysis.

BACKGROUND: Learning curves are inevitably encountered when first implementing an innovative and complex surgical technique. Nevertheless, a cluster of failures or complications should be detected early, but not deter learning, to ensure safe implementation. Here, we aimed to examine the presence and impact of learning curves on outcome after robotic-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB). METHODS: A retrospective analysis of the first 300 RA-MIDCAB surgeries between July 2015 and December 2020 was performed. Learning curves were obtained via logarithmic regression for surgical time. Cumulative sum (CUSUM) analysis was performed for (I) major complications including MI, stroke, repeat revascularization, and mortality, and (II) other complications, including prolonged ventilation, pneumonia, pleura puncture, lung herniation, pericarditis, pleuritis, arrhythmia, wound complications, and delirium. Expected and unacceptable rates were set at 12% and 20%, respectively, for major complications, and at 40% and 60% for other complications, based on historical data in conventional coronary artery bypass grafting (CABG). RESULTS: Demographic characteristics did not differ between terciles, except for more smokers in the first tercile, and less hypercholesterolemia and more complex procedures in the third tercile. The mean surgical time for all operations was 258±81 minutes, ranging from 127 to 821 minutes. A learning curve was only observed in the first tercile. Subgroup analysis revealed that this learning curve was only observed for procedures consisting of single internal mammary artery (SIMA) with 1 or 2 distal anastomoses but not with bilateral internal mammary arteries (BIMA) or more than 2 distal anastomoses. CUSUM analysis showed that the cumulative rate of major and other complications never crossed the lines for unacceptable rates. Rather, the lower 95% confidence boundary was crossed after 50 cases, indicating improvement in safety. CONCLUSIONS: These results suggest that integration of RA-MIDCAB in the surgical landscape can be safely achieved and complication rates can quickly be reduced below those expected in traditional CABG. Collective experience plays a key role in overcoming the learning curve when more complex procedures and cases are introduced.

Starting an aortic valve repair program: is it worthwhile? Aortic valve repair compared to replacement.

OBJECTIVES: Increasing evidence suggests that aortic valve (AV) repair may have better long-term outcomes than AV replacement for aortic insufficiency. However, most literature is limited to centres of excellence and has not sufficiently been replicated in nascent programs. This single-centre experience of a newly established AV repair program aims to compare short-term outcomes of AV sparing versus replacement surgery. METHODS: A retrospective cohort study of patients who underwent elective surgery for aortic regurgitation or aortic root dilatation at the Leuven University Hospital between 2013 and 2018 was performed. Patients with a critically ill presentation, endocarditis, aortic stenosis or requiring redo surgery were excluded. Patients were assigned to repair versus replacement based on preoperative intention to preserve the AV. Nearest neighbour propensity score matching was performed to compare both groups. Safety (mortality, morbidity), efficiency (cross-clamp and bypass times) and efficacy end points (repair rate, postoperative echocardiography) were compared. RESULTS: One hundred and seven patients underwent AV surgery (48 repair, 59 replacement), from which 2 groups of 23 matched patients were created. There were 1 death and 2 reoperations after repair and no death and 1 reoperation after replacement. Extracorporeal circulation and aortic cross-clamp time were significantly longer while ventilation and total hospital stay were significantly shorter after AV repair. Echocardiographic follow-up showed comparable aortic regurgitation but lower transvalvular gradients after repair. Freedom from major complications was comparable in both cohorts. CONCLUSIONS: Early results suggest the feasibility of replicating experienced centres' perioperative and short-term outcomes in nascent programs.

Robotic Cardiac Surgery in Europe: Status 2020.

BACKGROUND: European surgeons were the first worldwide to use robotic techniques in cardiac surgery and major steps in procedure development were taken in Europe. After a hype in the early 2000s case numbers decreased but due to technological improvements renewed interest can be noted. We assessed the current activities and outcomes in robotically assisted cardiac surgery on the European continent. METHODS: Data were collected in an international anonymized registry of 26 European centers with a robotic cardiac surgery program. RESULTS: During a 4-year period (2016-2019), 2,563 procedures were carried out [30.0% female, 58.5 (15.4) years old, EuroSCORE II 1.56 (1.74)], including robotically assisted coronary bypass grafting (n = 1266, 49.4%), robotic mitral or tricuspid valve surgery (n = 945, 36.9%), isolated atrial septal defect closure (n = 225, 8.8%), left atrial myxoma resection (n = 54, 2.1%), and other procedures (n = 73, 2.8%). The number of procedures doubled during the study period (from n = 435 in 2016 to n = 923 in 2019). The mean cardiopulmonary bypass time in pump assisted cases was 148.6 (63.5) min and the myocardial ischemic time was 88.7 (46.1) min. Conversion to larger thoracic incisions was required in 56 cases (2.2%). Perioperative rates of revision for bleeding, stroke, and mortality were 56 (2.2%), 6 (0.2 %), and 27 (1.1%), respectively. Median postoperative hospital length of stay was 6.6 (6.6) days. CONCLUSION: Robotic cardiac surgery case numbers in Europe are growing fast, including a large spectrum of procedures. Conversion rates are low and clinical outcomes are favorable, indicating safe conduct of these high-tech minimally invasive procedures.

A novel tissue treatment to reduce mineralization of bovine pericardial heart valves.

OBJECTIVE: With the increasing use of bioprostheses worldwide, continuous efforts have been made to improve tissue durability. We introduce a new treatment for bovine pericardium combining octanediol-ethanol based phospholipid removal with taurine-based glutaraldehyde neutralization and storage in an aldehyde-free solution (FREE). METHODS: Treated tissues were evaluated by mechanical and biochemical characterization, phospholipid content, aldehyde levels, cell cultures on pericardial samples (L929 fibroblasts and human umbilical vein endothelial cells), rat subcutaneous implantations, and long-term juvenile sheep mitral valve implantations (n = 3). Comparisons were made to glutaraldehyde-fixed bovine pericardium or to samples from commercially available biological valves (ie, Trifecta [St Jude Medical, Saint Paul, Minn] and Perimount Magna Ease [Edwards Lifesciences, Irvine, Calif]). RESULTS: FREE-treated pericardium had similar mechanical strength and biochemical properties as commercially available valves. Compared with glutaraldehyde-only samples, FREE-treated samples showed lower phospholipid levels (P < .01), significantly better growth of L929 fibroblasts, and lower calcification levels in rat subcutaneous implants (P < .01). Compared with samples from Linx- (Trifecta) and ThermaFix-treated (Perimount Magna Ease) valves, similar low levels of phospholipids were observed as were similar low calcification levels in subcutaneous implants, but tissue extractions from FREE-treated samples showed the lowest levels of extracted aldehydes (P < .01). Mitral implants of FREE-treated valves in juvenile sheep had excellent hemodynamic behavior without any sign of degeneration or calcification at 5 months. CONCLUSIONS: The new FREE treatment combines an adequate phospholipid reduction and aldehyde neutralization with storage in an aldehyde-free solution. This combination enhances the anticalcification properties and may thereby improve long-term durability of the tissue.

Hospital cost savings and other advantages of sutureless vs stented aortic valves for intermediate-risk elderly patients.

PURPOSE: To evaluate and compare the clinical outcomes and hospital costs of using sutureless aortic valves vs conventional stented aortic valves. METHODS: Between 2007 and 2011, 52 elderly patients undergoing aortic valve replacement for aortic stenosis in our center had a sutureless valve inserted. From among 180 patients who had a stented valve inserted during the same period, 52 patients were matched to the sutureless group, based on age, gender, and operation type. We compared clinical outcomes and hospital costs between the two groups. RESULTS: The sutureless group had a higher Euroscore (logistic Euroscore I) risk (12.8 vs 9.7; p = 0.02), with significantly shorter aortic cross-clamp (ACC) time (p < 0.01), cardiopulmonary bypass (CPB) time (p < 0.01), intensive care unit stay (p < 0.01), intubation time (p < 0.01), and overall hospital stay (p = 0.05). The sutureless group also revealed a significant hospital cost saving of approximately 8200€ (p = 0.01). CONCLUSIONS: The clinical and hemodynamic outcomes of using the sutureless bioprosthesis were excellent. The reduced ACC and CPB times had a favorable effect on the duration of intubation and intensive care stay, resulting not only in faster recovery and discharge home, but also in a significant hospital cost reduction.

Control of a hybrid robotic system for computer-assisted interventions in dynamic environments.

PURPOSE: Minimally invasive surgery is becoming the standard treatment of care for a variety of procedures. Surgeons need to display a high level of proficiency to overcome the challenges imposed by the minimal access. Especially when operating on a dynamic organ, it becomes very difficult to align instruments reliably and precisely. In this paper, a hybrid rigid/continuum robotic system and a dedicated robotic control approach are proposed to assist the surgeon performing complex surgical gestures in a dynamic environment. METHODS: The proposed robotic system consists of a rigid robot arm on top of which a continuum robot is mounted in series. The continuum robot is locally actuated with McKibben muscles. A control scheme based on quadratic programming framework is adopted. It is shown that the framework allows enforcing a set of constraints on the pose of the tip, as well as of the instrument shaft, which is commanded to slide in and out through the entry point. RESULTS: Through simulation and experiments, it is shown how the robot tool tip is able to follow sinusoidal trajectories of 0.37 and 2 Hz, while maintaining the instrument shaft pivoting along the entry point. The positioning and tracking accuracy of such system are shown to lie below 4.7 mm in position and [Formula: see text] in angle. CONCLUSION: The results suggest a good potential for applying the proposed technology to assist the surgeon during complex robot-assisted interventions. It is also illustrated that even when using flexible hence relatively safe end-effectors, it is possible to reach acceptable tracking behaviour at relatively high frequencies.

Aortic valve replacement through full sternotomy with a stented bioprosthesis versus minimally invasive sternotomy with a sutureless bioprosthesis.

OBJECTIVES: The aim of this study was to analyse early postoperative outcomes and 2-year survival after aortic valve replacement (AVR) through a ministernotomy with a sutureless bioprosthesis implantation compared with a full sternotomy with implantation of a stented bioprosthesis. METHODS: Patients who underwent primary isolated non-emergent AVR at six European centres were included in the study. Of these, 182 (32%) underwent a ministernotomy with a sutureless bioprosthesis (ministernotomy sutureless group) and 383 (68%) a full sternotomy with a stented bioprosthesis (full sternotomy stented group). Propensity score matching was used to reduce selection bias. RESULTS: In the overall cohort, 30-day mortality was 1.6 and 2.1%, and 2-year survival was 92 and 92% in the ministernotomy sutureless group and in the full sternotomy stented group, respectively. Propensity score matching resulted in 171 pairs with similar characteristics and operative risk. Aortic cross-clamp (40 vs 65 min, P < 0.001) and cardiopulmonary bypass time (69 vs 87 min, P < 0.001) were shorter in the ministernotomy sutureless group. Patients undergoing ministernotomy received less packed red blood cells but the risk for postoperative permanent pacemaker implantation was higher. There were no differences regarding 30-day mortality or 2-year survival between the two groups. CONCLUSIONS: AVR through a ministernotomy with implantation of a sutureless bioprosthesis was associated with shorter aortic cross-clamp and cardiopulmonary bypass time and less transfusion of packed red blood cells, but a higher risk for postoperative permanent pacemaker implantation compared with a full sternotomy with a stented bioprosthesis.

Functional performance and quality of life in high-risk comorbid patients undergoing transcatheter aortic valve implantation for symptomatic aortic valve stenosis.

AIMS: We assessed the impact of transcatheter aortic valve implantation (TAVI) on functional performance and quality of life (QoL) in a high-risk patient population with multiple comorbidities. METHODS AND RESULTS: Between January 2009 and December 2014, 145 high-risk patients (EuroSCORE II 7.3% [4.9; 14.9]) with severe symptomatic aortic valve stenosis (AS) underwent TAVI in a single centre. We prospectively evaluated New York Heart Association (NYHA) functional class, 6-minute walking distance (6MWD), and QoL using the validated Dutch version of the EuroQol-5D (EQ-5D) descriptive assessment and a visual analogue scale (EQ-VAS) at baseline, 30 days, as well as 6, 12, and 24 months after TAVI. All patients were eligible for analysis. New York Heart Association functional class improved significantly at 30-day, 6-, 12-, and 24-month follow-up (P < 0.001 for all). The absolute 6MWD improved significantly at 30 days (+19.3 ± 8.2 m; P= 0.0499) and at 6 months (+23.3 ± 8.1 m; P = 0.0194). A favourable trend was maintained at 12 months (+17.1 ± 8.8 m; P = 0.1879), whereas at 24 months 6MWD was similar to baseline values. No significant change in the descriptive assessment of QoL (EQ5D) was observed, whereas the EQ-VAS showed a significant improvement in QoL up to 24 months (P < 0.0180 for all time-points). CONCLUSION: In high-risk comorbid patients with symptomatic AS, TAVI results in a significant but temporary improvement of functional performance when assessed with objective measures of 6MWD but not of EQ-5D. Moreover, TAVI has a significant and sustained impact on subjective well-being and exercise capacity assessed with the EQ-VAS and NYHA score.

Starting minimally invasive valve surgery using endoclamp technology: safety and results of a starting surgeon.

OBJECTIVES: To critically review the learning curve, safety issues and outcome of a single surgeon while starting up minimally invasive mitral valve surgery (MIMVS). METHODS: We performed a descriptive, retrospective study of 138 patients with minimally invasive mitral valve surgery between March 2004 and December 2010. The learning curve was assessed using a logarithmic curve-fit regression analysis of the cardiopulmonary bypass parameters and defined as the end of the steepest part. Complexity was assessed by the number of different techniques performed on the mitral valve and the number of concomitant procedures. Follow-up was obtained for embolic events, endocarditis, bleeding, reintervention, echocardiographic data and NYHA class. RESULTS: The learning curve was found in the last 30 cases. There was a significant reduction in aortic cross-clamp time before and after the end of the learning curve [Patients 1-30: 120.77 (±28.28); Patients 31-138: 97.57 (±5.66); P <0.0001]. Operations during the learning curve did not correlate with intensive care unit (ICU) [1.77 (±0.97) vs 2.06 (±1.38)] and hospital stay [10.00 (±2.74) vs 9.10 (±3.36)]. In 104 patients, the valve was reconstructed, whereas in 34 it was replaced. The complexity of mitral valve reconstruction gradually increased and proportion of mitral valve replacement decreased, partly by expanding minimally invasive mitral valve surgery indications. Eighteen patients underwent 25 concomitant procedures and four conversions were necessary (after Patient 30). Minimal follow-up was 1 year with a mean follow-up of 1211 ± 651 days. No procedure-related mortality was encountered and mitral regurgitation after mitral valve repair was classified as Grade 1 or less in 101 of 104 patients at the end of follow-up. CONCLUSIONS: Implementation of new equipment and techniques is challenging. However, minimally invasive mitral valve surgery with the endoclamp system is safe even during the learning curve. During our evolution from simple reconstructions/replacements to complex valve surgery with concomitant procedures, we could safely optimize our technique without mortality. A longer aortic cross-clamp time during the learning curve did not result in longer ICU and hospital stay.

Ministernotomy versus full sternotomy aortic valve replacement with a sutureless bioprosthesis: a multicenter study.

BACKGROUND: The aim of this study was to analyze early postoperative outcomes and 2-year survival after aortic valve replacement (AVR) with the sutureless Perceval bioprosthesis (Sorin Biomedica Cardio Srl, Salluggia, Italy) performed through ministernotomy compared with full sternotomy. METHODS: This was a study of 267 consecutive patients who underwent isolated AVR with the sutureless Perceval bioprosthesis between 2007 and 2014 at 6 European centers. Of these, 189 (70.8%) were performed through ministernotomy and 78 through a full sternotomy. Propensity score matching was used to reduce selection bias. RESULTS: In the overall cohort of ministernotomy and full sternotomy patients, in-hospital mortality was 1.1% and 2.6% and 2-year survival was 92% and 91%, respectively. Propensity score matching resulted in 56 pairs with similar characteristics and operative risk. Aortic cross-clamp (44 minutes in both groups, p = 0.931) and cardiopulmonary bypass time (69 vs 74 minutes, p = 0.363) did not differ between the groups. Apart from higher values in the ministernotomy group for postoperative peak gradients (28.1 vs 23.3 mm Hg, p = 0.026) and mean aortic valve gradients (15.2 vs 11.7 mm Hg, p = 0.011), early postoperative outcomes did not differ in the propensity-matched cohort. There were no differences in the in-hospital mortality rate or 2-year survival between the groups. CONCLUSIONS: AVR with the sutureless Perceval bioprosthesis through a ministernotomy was a safe and reproducible procedure that was not associated with prolonged aortic cross-clamp or cardiopulmonary bypass time compared with a full sternotomy. Early postoperative outcomes and 2-year survival were comparable between patients undergoing ministernotomy and full sternotomy.

Early and intermediate outcome after aortic valve replacement with a sutureless bioprosthesis: Results of a multicenter study.

OBJECTIVE: The aim of this study was to evaluate the outcome of aortic valve replacement with the sutureless Perceval S aortic valve bioprosthesis (Sorin Biomedica Cardio Srl, Saluggia, Italy). METHODS: This is a retrospective analysis of 314 patients (mean age, 77.9 ± 5.0 years, mean European System for Cardiac Operative Risk Evaluation II, 9.0% ± 7.6%) who underwent aortic valve replacement with the Perceval S valve with (94 patients) or without (220 patients) concomitant coronary artery bypass surgery at 5 European centers. RESULTS: The Perceval S valve was successfully implanted in all but 1 patient (99.7%). The mean aortic crossclamping time was 43 ± 20 minutes (isolated procedure, 39 ± 15 minutes; concomitant coronary surgery, 52 ± 26 minutes). Severe paravalvular leak occurred in 2 patients (0.6%). In-hospital mortality was 3.2% (1.4% after isolated procedure and 7.4% after concomitant coronary surgery). In-hospital mortality was 2.8% and 4.0% among patients with a European System for Cardiac Operative Risk Evaluation II less than 10% and 10% or greater, respectively (P = .558). Octogenarians had slightly higher in-hospital mortality (5.2% vs 2.0%, P = .125; after isolated procedure: 2.7% vs 0.7%, P = .223; after concomitant coronary surgery: 9.5% vs 5.8%, P = .491) compared with younger patients. Full sternotomy did not increase the in-hospital mortality risk compared with ministernotomy or minithoracotomy access (1.3% vs 1.4%, when adjusted for baseline covariates: P = .921; odds ratio, 0.886; 95% confidence interval, 0.064-12.346). One-year survival was 90.5%. Freedom from valve-related mortality, stroke, endocarditis, and reoperation was 99.0%, 98.1%, 99.2%, and 98.3%, respectively. CONCLUSIONS: The sutureless Perceval S valve is associated with excellent early survival in high-risk patients, particularly among those undergoing an isolated procedure. Further studies are needed to prove the durability of this bioprosthesis.

Migration of a broken scalpel into the heart after spine surgery.

Iatrogenic vascular problems during posterior lumbar interbody fusion are a rare entity. Migration of a broken scalpel towards the heart has, to our knowledge, never been reported. We present the successful surgical retrieval of a broken scalpel from the heart after posterior lumbar interbody fusion without the use of a cardiopulmonary bypass.

Transapical transcatheter aortic valve implantation in a heart transplant recipient with severely depressed left ventricular function.

Transcatheter aortic valve implantation (TAVI) is becoming a valuable alternative to surgical aortic valve replacement in non-operable and high-risk surgical patients. As the population of heart donors and recipients ages, the prevalence of degenerative valvular disease after transplantation will increase. The optimal treatment strategy of valvulopathies in these patients with extensive comorbidity is still unknown because of insufficient published experience. We present a heart transplant recipient with renal failure, systolic heart failure and severe aortic stenosis who was successfully treated with transapical TAVI.

Can a central stitch over the Arantius' nodules provide a solution for preoperative severe native AI in LVAD patients.

PURPOSE: To evaluate the evolution of aortic valve insufficiency (AI) after Park's central stitch in patients with severe, preoperative, native aortic valve insufficiency.
 METHODS: We retrospectively studied 71 continuous flow LVAD patients between January 2004 and December 2010. Four patients with AI≥3/4 were treated with a central stitch. An intensive review of the literature was performed to debate the use of the central stitch in this population. 
 RESULTS: The AI at baseline (AI = 2.75 ± 0.5) and AI at last measurement (AI = 0.75 ± 0.65) is statistically different after central stitch (p<0.05) with mean follow up of 198.25 (± 146.70) days. Total cross clamp-time during the placement of the stitch was 15.5 minutes (± 13.062). CVA was not diagnosed in our cohort.
 CONCLUSIONS: Park's central stitch can be successfully performed on patients with severe native AI (≥3/4) with good long-term results. Short ischemic time and simple application of the stitch are the biggest advantages. Due to the progression of AI in longstanding LVAD, the central stitch may be beneficial for LVAD in destination therapy. Since this is a small group of patients and also an early experience, more cases will be necessary to confirm these positive results.