Novel Brain Protection Method for Zone 0 Endovascular Aortic Repair with Selective Cerebral Perfusion.

Objective: Zone 0 thoracic endovascular aortic repair (TEVAR) is associated with a high incidence of cerebral infarction mostly due to the embolic shower of a plaque from the aortic arch when the stent graft brushes against the aortic wall. Thus, it is important to develop a method for protecting the brain from such embolism. We report the outcomes of Zone 0 TEVAR with a novel brain protection method using selective cerebral perfusion under extracorporeal membrane oxygenation (ECMO). Materials and Methods: Two T-shaped grafts with ringed expanded polytetrafluoroethylene (ePTFE) were created using an 8-mm-ringed ePTFE anastomosed end-to-side with a 7-mm-ringed ePTFE. Carotid-carotid bypass and axillo-axillary bypass were established using these grafts. ECMO was connected to the grafts and the femoral vein. Bilateral carotid and axillary arteries were blocked, and cerebral perfusion was selectively maintained using ECMO. Total endovascular Zone 0 TEVAR was performed. The patency of brachiocephalic artery was maintained using the chimney or in situ fenestration technique. Results: Since August 2016, seven patients with aortic arch aneurysms underwent the procedure. The mortality rate was 0%. No neurological complications developed. Conclusion: This brain protection method using selective cerebral perfusion under ECMO is a safe method for Zone 0 TEVAR.

Safety of perioperative period in robot-assisted atrial septal defect repair under hyperkalemic arrest.

BACKGROUND: Various attempts have been made to meet patient desires, especially among younger and otherwise healthy individuals, for cosmetically satisfying incision with atrial septal defect (ASD) repair. One of procedures was a robotic-assisted totally endoscopic ASD repair via only two ports under hyperkalemic arrest without aortic cross-clamping. This study investigated perioperative management and safety for robotic-assisted total endoscopic ASD repair surgery under hyperkalemic arrest. METHODS: We retrospectively reviewed perioperative management of thirty patients who underwent total endoscopic robot-assisted ASD repair under hyperkalemic arrest. All procedures were performed under general anesthesia using robotic-assisted total endoscopic for ASD repair via two or three ports under hyperkalemic arrest without aortic cross-clamping. RESULTS: A total of 30 patients (mean age 45 ± 17 years, 8 male, 22 female) underwent successful ASD repair with the total endoscopic robotic-assisted procedures under hyperkalemic arrest. Hyperkalemic arrest was achieved and maintained by intravenous administration of mean potassium dose of 91±32 mEq (1.4±0.6 mEq/kg) with the lowest bladder temperature was 31.9±1.4 °C during hyperkalemic arrest. In all cases, serum potassium concentration was <5.0 mEq/L after weaning from cardiopulmonary bypass, although two cases who developed hyperkalemia >6 mEq/L after operation. At other time points, no patient exceeded 6 mEq/L of serum potassium concentration. At admission to the intensive care unit, mean serum creatine phosphokinase-MB level was 32±7mg/dL. There were no cases of arrhythmia or other cardiac complications during recovery. CONCLUSIONS: Perioperative management of robotic-assisted total endoscopic ASD repair under hyperkalemic arrest is safe and is not associated with fatal arrhythmia due to hyperkalemia.

Combined robot-assisted mitral valve plasty and Nuss procedure via small ports.

Pectus excavatum (PE) can be associated with cardiac disorders that also require surgical repair. Totally endoscopic robot-assisted mitral valve plasty for mitral valve regurgitation was performed while elevating the sternum with the aid of our original electrical sternum lifting system. Then, the Nuss procedure was performed successfully via small incision. Simultaneous robot-assisted cardiac surgery and the Nuss procedure is effective. Sternal elevation during cardiac surgery is very important for a safe procedure. The Nuss technique prevents perioperative cardiac compression and allows for correction of the pectus deformity with good cosmetic and functional results.

[Minimally Invasive Cardiac Surgery for a Heart Tumor after Breast Cancer Therapy and Partial Lung Resection for Lung Cancer;Report of a Case].

Papillary fibroelastoma is a benign tumor of the heart, constituting less than 10% of heart tumors. When papillary fibroelastoma is diagnosed, surgical treatment must be considered because it may cause embolization such as myocardial infarction and strokes. We experienced a patient with papillary fibroelastoma of the tricuspid valve after total resection of the right breast for breast cancer and partial lung resection for lung cancer. Minimally invasive cardiac surgery (MICS) with right thoracotomy was perfomed to resect the tumor. Though median sternotomy is still the most widely used approach for cardiac tumor, MICS is a useful method for preventing sternal wound infection and promoting wound healing, particularly in a patient with high risk of wound infection like this case.

First Major Clinical Outcomes of Totally Endoscopic Robotic Mitral Valve Repair in Japan　- A Single-Center Experience.

BACKGROUND: In 2018, Japan became the first country to have robotic cardiac surgery covered under the national health insurance. The number of patients undergoing robotic mitral valve (MV) repair has been estimated to increase remarkably, but no reports in Japan have yet described the outcomes of robotic MV repair. This study aimed to analyze the early clinical outcomes of patients undergoing totally endoscopic robotic MV repair (TERMVR) as a landmark national study for this procedure.Methods and Results:A total of 213 patients (152 men; mean age, 55±11 years) underwent TERMVR during May 2014 to December 2018. Preoperative demographics, operative profiles, and postoperative outcomes, including follow-up echocardiography, were analyzed. Successful TERMVR was achieved in all patients. Operation, cardiopulmonary bypass, and aortic cross-clamp times were 192±49.8, 127±23.8, and 70.1±16.2 min, respectively. Intraoperative transfusion was performed in 20 patients (10%). There were no in-hospital deaths. All patients were alive during the median follow-up period of 255 days (interquartile range, 32.5-208 days). Freedom from recurrence of MR >grade 2+ was 97.3%, 95.0%, and 90.7% at 6, 12, and 24 months, respectively. CONCLUSIONS: TERMVR is an effective and safe procedure with acceptable early postoperative outcomes.

A Novel Shape-Memory Monofilament Suture for Minimally Invasive Thoracoscopic Cardiac Surgery.

OBJECTIVES: Endoscopic knot tying can complicate or prolong minimally invasive surgical procedures. A novel shape-memory monofilament suture with a spiral tail has been developed to speed up suture fixation during minimally invasive cardiac surgery. The purpose of this study was to evaluate its usefulness and safety in minimally invasive cardiac surgery. METHODS: We installed a needle with a 4-0 monofilament suture, composed of polyvinylidene difluoride and hexafluoropropylene copolymers, in an originally invented jig and heated it in an oven. By only passing through the needle and then into the spiral made at the tail of the suture, a hangman's knot was easily made. For the fundamental experiment, to evaluate the effectiveness of the novel shape-memory monofilament suture, 4 surgeons with varying thoracoscopic experience tied knots within a simulated minimally invasive setting, using both the novel shape-memory and conventional monofilament sutures. The time elapsed for knot tying and tensile strength of each knot was measured. RESULTS: The mean knot-tying time was significantly shorter with the novel suture than with the conventional suture (108 ± 29 vs. 172 ± 42 seconds, P = 0.01). The ultimate tensile strength of each knot was 17.4 N in the novel suture and 16.5 N in the conventional suture. CONCLUSIONS: The novel shape-memory monofilament suture has great potential for reducing operative time of minimally invasive thoracoscopic surgery while retaining the strength of the knot.

Nonresectional Simplified Folding Technique in Robotic Mitral Valve Plasty: Comparison with Leaflet Resection Technique.

OBJECTIVE: The mitral valve plasty (MVP) technique for degenerative disease is typically leaflet resection and suturing. However, this technique is time consuming and unreproducible. To overcome this disadvantage, we developed a nonresectional folding technique, which is fast and reproducible. In this report, we examine our new folding technique in robotic MVP. METHODS: The new folding technique was performed in 10 patients (age 56 ± 15 years), and the conventional resection and suturing (RS) technique was performed in 22 patients (age 53 ± 8 years). In our new folding technique, we used two sutures to fold the prolapsed leaflet to the left ventricle side. The first folding suture line is a land mark, and the second line adjusts the height of the posterior leaflet to the anterior leaflet so that sufficient coaptation depth can be obtained. RESULTS: MVP was successful in all patients. In the folding technique group, the operation time, cardiopulmonary bypass time, and cross clamp time was faster than the conventional RS technique group (188 ± 31, 97 ± 32, and 55 ± 3 min, versus 242 ± 51, 137 ± 25, and 70 ± 15 min; P < .05). Hospital stays were significantly shorter in the folding technique group (13 ± 2 days versus 17 ± 7 days; P < .05). All patients were discharged without complications. The post-echocardiography revealed no mitral valve regurgitation in any patient. CONCLUSION: The new folding technique facilitated efficient MVP for posterior leaflet prolapse in mitral valve regurgitation, without the need for the resection of the leaflet.

Risk factors to predict leg ischemia in patients undergoing single femoral artery cannulation in minimally invasive cardiac surgery.

BACKGROUND: In peripheral cannulation for cardiopulmonary bypass, there is always a risk of ischemia in the extremities, caused by femoral artery cannulation. This report aimed to evaluate the outcome and the risk factors in patients undergoing minimally invasive cardiac surgery in mitral valve surgery. METHODS: We retrospectively reviewed all minimally invasive mitral valve surgery at our institute from May 2014 to December 2016. Operative outcomes and intra-operative monitoring for distal leg saturation were measured by the near-infrared spectroscopy values. For post-operative outcomes, the creatinine phosphorus kinase level was measured for the assessment of leg ischemia. Risk factors were evaluated for the elevation of post-operative creatinine phosphorus kinase. RESULTS: There were 162 patients who underwent single femoral artery cannulation for minimally invasive mitral valve surgery. The mean operation, cardiopulmonary bypass and aortic cross-clamp time were 212±44, 124±30, 76.6±22 minutes (min), respectively. The factors related to increased creatinine phosphorus kinase were male, body mass index, larger cannula size, operation time, cardiopulmonary bypass time and aortic cross-clamp time. The measurement of minimum near-infrared spectroscopy values did not show any association with creatinine phosphorus kinase elevation. There were significant associations between body mass index, cannula size and operation time and post-operative creatinine phosphorus kinase increase by multiple regression analysis. Two male patients had extremely high post-operative creatinine phosphorus kinase (18188 U/L and 16831 U/L) and they had high body mass index, large cannula size and longer operation time. CONCLUSIONS: In peripheral cannulation for minimally invasive cardiac surgery, body mass index, cannula size and operation time can be considered as risk factors for leg ischemia.

No-touch aorta robot-assisted atrial septal defect repair via two ports.

OBJECTIVES: Atrial septal defect (ASD) repairs have been successfully performed on arrested hearts with robotic assistance. The present study assessed the feasibility, safety, and efficacy of totally endoscopic cardiac surgery using a no-touch aorta technique for ASD via only 2 ports, and we named this procedure two-port robotic cardiac surgery (TROCS). METHODS: Between May 2014 and June 2016, 8 consecutive patients underwent TROCS for ASD using the da Vinci surgical system (Intuitive Surgical Inc.) at our institute. All of the procedures were performed via only 2 port incisions in the right chest. One was the camera port, and the other was the port for the robotic instruments. Both robotic instruments were inserted through this port and crossed while being prevented from colliding with each other. The surgeon console was set to the reverse of default settings so that both masters would control the inverse instrument. TROCS for ASD was carried out under ventricular fibrillation induced by combinations of an electrical fibrillator, injection of potassium, and hypothermia without aortic cross-clamping. RESULTS: All cases were successfully repaired. The mean operation, cardiopulmonary bypass and ventricular fibrillation times were 129.6 ± 29.0 min, 66.9 ± 24.5 min and 9.6 ± 5.9 min, respectively, and the estimated blood loss volume was 28.1 ± 58.6 ml. No patients required blood transfusion during their hospital stay, and their cosmetic results were excellent. CONCLUSIONS: TROCS for ASD using no-touch aorta technique was achieved safely with good clinical results and excellent cosmetic results.

Hybrid treatment combining robotic coronary artery bypass grafting and percutaneous catheter radiofrequency ablation.

Isolated coronary artery bypass grafting associated with atrial fibrillation is routinely performed through a sternotomy, and cardiac arrest. Advancements in this surgical approach have led to better cosmesis, a quick postoperative recovery, with the same postoperative results. We report a case of a novel, less invasive hybrid treatment combining robot-assisted coronary artery bypass grafting and percutaneous radiofrequency catheter ablation.

Robotic mitral valve plasty for mitral regurgitation after blunt chest trauma in Barlow's disease.

We successfully treated a case of mitral regurgitation due to chest trauma in Barlow's disease. A 71-year-old man was admitted with severe mitral regurgitation after blunt compression of the chest by a heavy object 5 months earlier. Preoperative examination revealed wide chordae tendineae rupture and myxomatous changes to the bileaflets. Neo-chordae reconstruction of the anterior mitral leaflet using loop technique, triangular resection of the posterior mitral leaflet, and ring annuloplasty was performed via surgical robot. Robotic mitral valve plasty for severe mitral regurgitation due to chest trauma in Barlow's disease was achieved safely with good clinical and excellent cosmetic results.

Surgical Repair for the Treatment of Pulmonary Vein Stenosis After Radiofrequency Ablation.

Radiofrequency ablation procedures for atrial fibrillation are occasionally associated with pulmonary vein stenosis (PVS). A common treatment for PVS is catheter intervention; however, because of the high restenosis rate, it is not suitable for young patients. The case presented herein is of a young male patient with severe bilateral PVS who underwent successful surgical pulmonary vein repair by sutureless technique. The stenotic lesions of the pulmonary veins were dissected and were covered using autologous pericardium. An enhanced computed tomographic scan revealed that all the pulmonary veins were widely patent after 6 months from the operation.

Hyperkalemic arrest and the aortic no-touch technique in minimally invasive atrial septal defect closure in adults.

To avoid aortic cross-clamping and cardioplegic ischaemia, we propose the induction of hyperkalemic arrest and using aortic no-touch technique in minimally invasive atrial septal defect (ASD) closure. Twenty-eight patients were included in this study. After establishment of cardiopulmonary bypass, potassium was administered to induce hyperkalemic arrest. The mean dose of injected potassium was 1.2 ± 0.45 mEq/kg. Following the direct closure of the ASD, potassium was filtered out using a hemodialyzer. At the end of the operation, serum potassium was normalized to 4.1 ± 0.5 mEq/l. The mean arrest time was 11 ± 4.4 min without complications. Hyperkalemic arrest in combination with aortic no-touch technique is safe and efficacious in minimally invasive ASD closure.

A Novel Robotic Bilateral Internal Mammary Artery Harvest Using Double Docking Technique for Coronary Artery Bypass Grafting.

da Vinci Surgical System (da Vinci) enabled port access for internal mammary arteries (IMA) harvesting. However, bilateral IMA (BIMA) harvesting is difficult when performed on single side. We developed a novel technique of double docking the da Vinci by transpositioning from the left side to the right and examined the feasibility. Twelve patients underwent BIMA harvesting using the double-docking technique. First, the da Vinci was set on the patient's left side for the right IMA harvesting. Afterward, the da Vinci was undocked and transpositioned from the patient's left side to the right side. The time elapsed during rotation was measured. Subsequently, the left IMA was harvested from patient's right side. Distal anastomoses were performed by a small anterolateral thoracotomy. All of the IMAs were harvested and then bypassed without damage. The mean ± SD time that elapsed during rotation was 6.5 ± 0.6 minutes. There was no conversion to sternotomy. Bilateral IMA harvesting by the bilateral docking technique was performed successfully with acceptable feasibility.

Totally endoscopic robotic resection of left atrial myxoma with persistent left superior vena cava.

A 68-year old man with a cardiac tumour was admitted for robotic tumour resection using the da Vinci S Surgical System. While undergoing preoperative examination, he was found to have a persistent left superior vena cava. After general anaesthesia and single-lung ventilation, cardiopulmonary bypass was established, with venous drainage through bilateral internal jugular and right femoral veins and arterial return through the right femoral artery. Robotic tumour resection was performed by four ports in the right chest. There were no difficulties during the operation, and successful tumour resection was achieved with satisfactory margins. He was discharged without complications. Persistent left superior vena cava is very rare, but if diagnosed preoperatively and an appropriate operative plan is made, robotic cardiac surgery can be performed safely. With robotic surgery, cardiac tumour resection can be feasibly performed, with cosmetic benefits.

Two-Port Robotic Cardiac Surgery (TROCS) for Atrial Septal Defect (ASD) Using Cross-Arm Technique--TROCS ASD Repair.

BACKGROUND: We successfully performed totally endoscopic atrial septal defect (ASD) repair via 2 ports, and we named this procedure two-port robotic cardiac surgery (TROCS).Methods and Results:A 51-year-old woman with secundum ASD underwent robot-assisted ASD repair under ventricle fibrillation without aortic cross-clamping. Two ports were placed in the right side of the chest, and 1 port was for the robotic endoscope. Two robotic instruments were inserted through another port and crossed while preventing them from colliding. CONCLUSIONS: TROCS ASD repair using a cross-arm technique was achieved safely with good clinical results and excellent cosmetic results.

A novel one-shot circular stapler closure for atrial septal defect in a beating-heart porcine model.

PURPOSE: In surgical atrial septal defect (ASD) closure, there are no techniques or devices that can close the ASD accurately in a short time under a beating heart. We have developed a simple and automatic ASD closure technique using a circular stapler. This study assessed the feasibility and efficacy of a new circular stapler closure for ASD. DESCRIPTION: Under a continuous beating heart, hand-sewn patch plasty ASD closure was performed in 6 pigs (group A) and circular stapler ASD closure was performed in 6 pigs (group B). The time to close the ASD and the effectiveness of the closure were compared. EVALUATION: Closure was significantly faster in group B (10.5 ± 1.0 seconds) than in group A (664 ± 10 seconds; p < 0.05). There was no leakage at the closure site, and sufficient tolerance was confirmed. CONCLUSIONS: A circular stapler can be used to treat ASD faster than hand-sewn patch plasty, with sufficient pressure tolerance in a beating heart porcine model.

Co-occurrence of papillary thyroid cancer and MALT lymphoma of the thyroid with severe airway obstruction: A case report and review of the literature.

INTRODUCTION: Co-occurrence of papillary thyroid carcinoma (PTC) and mucosa-associated lymphoid tissue (MALT) lymphoma resulting in severe airway obstruction is very rare. PRESENTATION OF CASE: A 58-year-old woman visited our department because of enlargement of a neck mass. Computed tomography (CT) and ultrasonography showed 2 discrete hypoechoic nodules. Fine-needle aspiration biopsy revealed thyroid lymphoma in the left lobe and PTC in the right lobe. After 1 week, she returned to the emergency room at our hospital with shortness of breath and difficultly in swallowing. CT revealed enlargement of the left lobe, which was severely compressing the trachea. We performed emergency total thyroidectomy with lymphadenectomy. The postoperative course was uneventful, and the patient was discharged without any symptoms. DISCUSSION: The most common treatment for PTC is surgery; however, the treatment for thyroid lymphoma remains controversial. We propose that surgery be performed in the cases of symptoms such as shortness of breath and difficulty in swallowing. CONCLUSION: We performed emergency total thyroidectomy to relieve obstruction of the trachea and to remove the two malignant tumors. We suggest total thyroidectomy for a case of co-occurrence of two malignant tumors, causing severe airway obstruction.

[Aortic valve replacement and ventricular septal defect closure after previous bilateral internal thoracic artery bypass grafting; report of a case].

The patient was a 74-year-old man with a history of ventricular-septal defect (VSD). He underwent coronary artery bypass grafting (CABG), which was performed using the bilateral internal thoracic artery (ITA) 9 years ago. Since 2009, he experienced heart failure, and in 2011, he started administration of tolvaptan, vasopressin V2 receptor antagonist. In 2011, he developed fever, and follow-up echocardiography revealed moderate aortic regurgitation and vegetation around the VSD and the aortic valve. Therefore, we performed redo-aortic valve replacement (AVR) and VSD closure. Both ITAs were carefully dissected and were clamped during cardiac arrest. The patient was discharged on the 36th postoperative day, without tolvaptan. AVR and VSD closure after bilateral ITA bypass grafting is a challenging procedure if the patent ITA crosses the midline. Patent ITA should be occluded to avoid cardioplegia washout during aortic cross-clamping. Multi-detector-row computed tomography (MDCT) enables excellent imaging for dissecting ITA grafts.