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

Objective: To develop a novel endoscopic system that reduces trauma to the patient and declutters the surgical field for the surgeon in minimally invasive heart valve surgery.

Methods: We designed and developed a retractor-camera combination for minimally invasive heart surgery; the cable and camera were connected to the underbelly of the left atrial retractor blade to provide an illuminated, wide-angle view of the mitral valve. We conducted ex vivo, in vivo, and, ultimately, a first-in-man randomized, nonanonymized clinical trial on 20 patients who required minimally invasive mitral valve surgery. Data from the preoperative period and the immediate postoperative period were gathered, and patients were followed for 3 months.

Results: Our camera-retractor combo demonstrated safe and efficient exposure and vision in all detailed studies. The total operation time for the intervention group (316.5 ± 65.1 min) was slightly shorter than for the control group (317.5 ± 50.8 min). There was no significant difference in the ability to provide exposure of the mitral valve and surrounding left atrial tissue for both control and test articles. The novel camera-retractor reduced clutter in the operation field substantially and eliminated chest penetration for the camera. We also observed that the camera did not fog, did not stain with blood, and did not require frequent corrections to its position.

Conclusions: We launch a novel atrial retraction-imaging platform that is less invasive for the patient and eliminates clutter and redundant movements for the surgeon.

We present a case of a 38-year-old male patient with symptomatic hypercalcemia secondary to primary hyperparathyroidism. After evaluation, the source of the excess parathyroid hormone was found to be an adenoma localized to the middle mediastinum. Specifically, it was located in the left paratracheal space along the lesser curve of the aortic arch. We discuss this case with a corresponding video to demonstrate the necessary equipment and setup as well as the 5 operative steps recommended to access this paratracheal subaortic location from a minimally invasive transthoracic approach. The pitfalls for this operation are also discussed. The purpose is to make this operation more reproducible for other surgeons.

By sparing the sternum, the right anterior minithoracotomy (RAMT) approach may facilitate a quicker functional recovery when compared with conventional aortic valve replacement (AVR). In the following review, outcomes after RAMT AVR are compared with full sternotomy AVR. The RAMT approach is described, including suggestions for patient selection. The application of the RAMT approach for other cardiac procedures is also discussed.

Objective: There is no consensus on the optimal ablation strategy for nonparoxysmal atrial fibrillation (NPAF) with enlarged left atrium. We aimed to explore whether hybrid ablation (HA) of combined thoracoscopic surgical ablation with catheter ablation (CA) was superior to CA alone in these patients.

Methods: Patients with NPAF and left atrial diameter (LAD) ≥45 mm who underwent hybrid biatrial ablation or CA procedure from June 2014 to July 2021 were included in this study. Propensity score matching was applied to select patients in each group. The primary endpoint was freedom from atrial tachyarrhythmias after procedures.

Results: After propensity score matching, 52 patients with enlarged left atrium (median LAD = 51 mm) were enrolled in each group. The median follow-up was 36 months. The probability of freedom from atrial tachyarrhythmias at 12, 24, and 36 months on antiarrhythmic drugs (AADs) was 70.1%, 65.4%, and 62.6% in the HA group and 34.3%, 29.4%, and 22.0% in the CA group, respectively (P < 0.001); off AADs was 57.1%, 52.7%, and 50.0% in the HA group and 25.0%, 16.2%, and 11.5% in the CA group (P < 0.001); on AADs after redo CA was 76.2%, 73.7%, and 73.7% in the HA group and 43.6%, 43.6%, and 38.2% in the CA group, respectively (P < 0.001); off AADs after redo CA was 62.5%, 60.1%, and 60.1% in the HA group and 30.4%, 25.1%, and 20.9% in the CA group, respectively (P < 0.001).

Conclusions: For patients with NPAF and enlarged left atrium, hybrid biatrial ablation was superior to CA in sinus rhythm maintenance even if redo CA was performed.

Objective: Safety and sustainability are key elements of a robotic mitral valve (MV) program at any stage of development. Challenges include the positioning of the surgeon at the robotic console, increasing patient complexity, and upstream administrative staffing difficulties. We instituted a systems approach to maximize patient safety and maintain robotic service viability.

Methods: A single dedicated robotic operating room (OR) was equipped as a microsystem with team training in the operative steps, ergonomics, digital tools, and an explicit culture of safety. Outcomes of all robotic mitral procedures including concomitant procedures in the microsystem OR by a single surgeon were retrospectively reviewed.

Results: From January 2014 through December 2023, 1,529 consecutive MV patients were operated with an endoscopic robotic approach. Ten patients (0.65%) were converted to conventional approaches. Overall, 1,300 MV repairs (85%) were performed with residual MV regurgitation of none to trace in 1,205 patients (92.7%), mild in 92 patients (7.1%), and moderate in 3 patients (0.23%). MV replacements were performed in 229 patients (15%) with no paravalvular leaks. Mortality was 0.08% in the repair group and 0.87% in the replacement group. No deaths have occurred in the last 38 months. Stroke occurred in 0.31% of repair patients and 1.3% of replacement patients. One patient developed transient renal failure.

Conclusions: Organization of the robotic OR as a microsystem is associated with surgical efficacy and very low morbidity and mortality. A comparable microsystem approach using all or select components may promote safety and sustainability for robotic MV programs at all levels.