Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery最新文献

Objective: Right anterior minithoracotomy (RAMT) and ministernotomy (MS) are established approaches for minimally invasive aortic valve replacement (MIAVR). There is no consensus about which technique offers better results.

Methods: A literature search was conducted in MEDLINE, Scopus, and Cochrane Library, focusing on studies that compared RAMT and MS for MIAVR. RevMan 8.13.0 (The Cochrane Collaboration, London, UK) was used to calculate effect estimates reported as odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs).

Results: We included 21 studies with 6,986 patients, of whom 45.8% underwent RAMT. RAMT was associated with a shorter hospital stay (MD = -0.8 days, 95% CI: -1.4 to -0.2, P = 0.002) and reduced blood loss (MD = -22.3 mL, 95% CI: -32.8 to -11.8, P < 0.001), transfusion rates (OR = 0.7, 95% CI: 0.5 to 0.9, P = 0.01), and incidence of acute kidney injury (AKI; OR = 0.7, 95% CI: 0.5 to 0.9, P = 0.02). However, RAMT was also associated with a slightly longer cardiopulmonary bypass (CPB) time (MD = 9.0 min, 95% CI: 0.7 to 17.3, P = 0.03, I² = 97%) and incisional pain score (standardized MD = 0.5, 95% CI: 0.4 to 0.6, P < 0.001). Mortality, stroke, and other complications were similar between the 2 techniques.

Conclusions: RAMT offers advantages including shorter hospital stay and reduced blood loss, transfusion, and AKI rates but at the cost of slightly longer CPB time and greater incisional pain. These findings underscore the need for individualized patient selection based on surgical risk, anatomical considerations, and recovery priorities.

Objective: We aimed to study the feasibility and automation of intracorporeal lung specimen dissolution using NaOH to decrease specimen extraction trauma.

Methods: Twenty-three cadaveric porcine lungs were weighed, cannulated, placed in laparoscopic tissue extraction sacs, and submerged in water baths (37 °C). Lungs were digested for 6 to 36 h with dissolution fluid replacement through various cannulation strategies. Dissolution was quantified by changes in solid mass and structural and histologic integrities. After optimization, we performed 24-hour lung dissolution in a cadaveric porcine model. Next, a system was built using polyvinyl chloride, solenoid valves, water flow sensors, tubing, a vacuum pump, and an Arduino UNO (Monza, Italy). Flow tests were performed. System feasibility and safety were tested. A vacuum chamber was added for gentle agitation to the digestion solution through fluid oscillation. Functional tests were repeated.

Results: There were no containment failures. Compared with saline, NaOH exhibited significant dissolution by 6 h (P < 0.001) progressing to a port-extractable, jelly-like material by 24 h (<20% initial mass). The degeneration of parenchymal histology correlated with NaOH exposure (r = 0.98, P = 0.02). Neither enzyme use (P = 0.3) nor specimen vascular cannulation (P = 0.15) improved dissolution compared with bathing. At 24 h, the clinical emulation model demonstrated no leaks and lung tissue effects proportionate to volume of delivered lye. During the flow tests, inflow was more precise, with minimal deviation. Outflow was more accurate, with measurements closer to the true value. The system passed 6-hour safety tests without leaks, with and without the vacuum chamber.

Conclusions: These preliminary results suggest that automation of intracorporeal lung specimen digestion is feasible.

Objective: The clinical outcomes of bilateral internal mammary arteries (BIMA) in situ were compared with Y-grafts in endoscopic coronary artery bypass grafting (endo-CABG), a less-invasive alternative to conventional CABG, providing reduced trauma and faster recovery.

Methods: A retrospective single-center study was performed from January 2016 until February 2023 on endo-CABG patients, dividing them into in situ BIMA graft or Y-graft recipients. As endo-CABG was performed in all patients requiring surgical revascularization, this represents an unselected cohort. The primary outcome comprised freedom from major adverse cardiac and cerebrovascular events (MACCE). The secondary outcomes were target lesion revascularization (TLR) and 1-year overall survival.

Results: A total of 1,328 endo-CABG patients (BIMA in situ, n = 693; Y-graft, n = 634) were included. Overall, characteristics of both groups were comparable, except that Y-graft patients had more comorbidities (diabetes mellitus and myocardial infarction), which was reflected in the EuroSCORE II. Furthermore, most Y-graft patients had triple-vessel disease and a higher number of bypasses required. The 1-year MACCE-free survival did not differ significantly between the groups (91.9% vs 89%; univariable hazard ratio [HR] = 1.42, 95% CI: 0.96 to 2.11, P = 0.079; multivariable HR = 1.07, 95% CI: 0.70 to 1.63, P = 0.771), as did the 1-year survival rate (95.7% vs 93.2%; univariable HR = 1.67, 95% CI: 1.01 to 2.75, P = 0.046; multivariable HR =1.34, 95% CI: 0.77 to 2.33, P = 0.297). TLR did not differ significantly between groups (univariable HR = 0.68, 95% CI: 0.22 to 2.08, P = 0.499) or after adjustment (multivariable HR = 0.31, 95% CI: 0.08 to 1.24, P = 0.100).

Conclusions: Creating a Y-graft for distal lesions and in cases in which more than 2 anastomoses are required serves as a favorable alternative without a difference between in situ and Y-grafts in 1-year MACCE-free survival.

Objective: A P2 prolapse comes in all sizes, and the original description of mitral loop repair (premeasured neochords) does not account for prolapse size. This technique "blind spot" can result in residual billowing or prolapse, especially in larger leaflets. Ventricular remodeling after repair can cause neochordal pseudo-elongation that worsens this residual prolapse, leading to regurgitation. We sought to study the effect of P2 prolapse size on neochordal anchoring location on the prolapse. To account for the P2 prolapse size in loop technique, we measured this intraoperatively (edge-to-annulus distance) and anchored the neochords incrementally farther from the leaflet edge in larger prolapses. Neochordal length was measured from the flattened prolapsed leaflet edge to the papillary muscle anchoring point.

Methods: Of 180 endoscopic repairs for degenerative mitral disease, 95 involved P2 neochords and 50 were premeasured (loop technique). We studied the relationship between P2 prolapse size and leaflet neochordal anchoring in 50 P2 prolapses through surgical footage review. Echocardiography at discharge and 3 months provided immediate and short-term follow-up.

Results: All 50 repairs were successful without residual billowing or regurgitation above mild when anchoring neochords based on prolapse size. The P2 prolapses were grouped by size into 4 grades: grade 1 (<1.5 cm, n = 15), grade 2 (1.5 to 2 cm, n = 18), grade 3 (2 to 3 cm, n = 10), and grade 4 (>3 cm, n = 7). Each prolapse grade had consistent neochordal leaflet anchoring away from the edge: grade 1 = 3 mm, grade 2 = 5 to 8 mm, grade 3 = 1 to 1.5 cm, and grade 4 = 1.5 to 2 cm.

Conclusions: Our adaptation of the loop technique to include P2 prolapse size prevents residual billowing or prolapse and prevents suboptimal leaflet anchoring.