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

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.

Objective: Thoracic endovascular aortic repair (TEVAR) and transcatheter aortic valve replacement (TAVR) necessitate large-bore arterial access for stent/valve delivery. With improvement of device delivery technology, percutaneous access has become the standard. This may be associated with fewer complications, although the literature is conflicting. The purpose of this study was to compare the outcomes of open versus percutaneous large-bore arterial access at a single institution.

Methods: A total of 1,018 patients who underwent TEVAR or TAVR between 2006 and 2022 were included. Only groins accessed for delivery sheath were included in the analysis, with sizes ranging from 12 to 28 Fr. Access complications included bleeding (hematoma, perforation, rupture, pseudoaneurysm), infection, seroma, dissection, and distal embolization.

Results: Delivery sites were successfully closed using a median of 2 percutaneous closure devices. Larger sheath diameter was associated with conversion to open (20 Fr vs 16 Fr, P = 0.004). There was a significantly higher rate of total complications (35.0% vs 8.6%, P < 0.001), infection, bleeding, seroma, dissection, and distal embolization in open compared with percutaneous cases. Multivariable analysis confirmed a significantly lower rate of complication with the percutaneous approach relative to the open approach (odds ratio = 0.17, P < 0.001).

Conclusions: Percutaneous access is associated with significantly lower rates of total complications, infection, bleeding, dissection, and distal embolization when compared with surgical cutdown. Delivery sheath size was associated with conversion to open arteriotomy closure, but the overall incidence was low. Large-bore arterial access closure can be safely achieved using a percutaneous strategy, resulting in fewer complications than with the open approach.

Objective: In mitral valve surgery, it is important to be aware of adjacent intraoperatively invisible anatomy, to avoid complications and enhance safety. In this feasibility study, we aimed to develop semi-automated intraoperative 3-dimensional (3D) augmented reality (3D-AR) overlays for robotic mitral valve repair.

Methods: In 5 patients undergoing robot-assisted mitral valve repair, a 3D point cloud was generated, using intraoperatively recorded images from both eyes of the stereoscopic da Vinci camera (Intuitive Surgical, Sunnyvale, CA, USA). An intraoperative 3D-AR overlay was created using a scale-adaptive iterative closest point algorithm and landmarks placed on the mitral valve annulus. Finally, important anatomical structures such as the circumflex artery, Koch's triangle, and aortic valve leaflets could be visualized as a 3D-AR overlay on top of the surgical vision. To evaluate the accuracy, these 3D point clouds were validated by calculating the 3D point cloud accuracy and landmark registration error (LRE).

Results: The 3D point clouds and 3D-AR overlays were successfully created for all 5 patients. The 3D point clouds were accurate, with a median error of -0.92 mm, and the LRE was 5.12 mm. The time for creating the 3D-AR overlay was approximately 5 min. Besides creating the 3D-AR overlays, we could visualize the models directly within the robotic console during the surgical procedure.

Conclusions: We present an algorithm for generating accurate semiautomatic 3D-AR overlays, visualizing essential anatomical structures during robot-assisted mitral valve repair. This may lead to automated intraoperative 3D-AR vision during robotic cardiac surgery, with the potential of increasing safety, accuracy, and efficiency.

Objective: Port sites are a common source of perioperative bleeding in robotic cardiac surgery, which can be exacerbated by patient anatomy and anticoagulation. We present results from the liberal usage of a balloon-tipped coudé catheter for tamponade of robotic port sites during robotic mitral surgery.

Methods: All patients who underwent robotic mitral valve surgery at our institution from August 2016 to July 2022 were studied (N = 320). Patients converted to sternotomy were excluded (n = 5). Patients were then divided into 2 groups for before or after implementation of a protocol for the liberal use of balloon tamponade for patients with port site bleeding refractory to cautery. Catheter balloon tamponade was applied to a bleeding port site while weaning from cardiopulmonary bypass and usually removed after protamine administration. In rare cases of severe coagulopathy, the catheter was left inserted and removed in the intensive care unit after the coagulopathy resolved.

Results: A total of 315 patients were divided into a pre-protocol group ("control," n = 127) and a post-protocol group ("balloon," n = 188). The balloon group showed lower rates of reoperation for bleeding (0% vs 4.7%, P = 0.004), lower rates of pacemaker insertion (0.5% vs 3.9%, P = 0.04), and higher rates of chest tube removal on the first postoperative day (83% vs 70%, P = 0.01). Postoperative and intraoperative transfusion rates as well as hospital length of stay were similar between groups.

Conclusions: The liberal use of intraoperative balloon tamponade of robotic port sites may decrease the risk of bleeding complications in robotic mitral valve surgery.

Objective: Venovenous (VV) extracorporeal membrane oxygenation (ECMO) cannulation may pose venous access challenges. Subclavian vein (SCV) cannulation is an alternative site. This study hypothesizes that SCV access is a safe alternative in VV ECMO.

Methods: This is a single-center, retrospective study of peripheral VV ECMO that was stratified by SCV cannulation. Each site was considered as a separate cannulation event. Descriptive statistics, groupwise comparisons, and mixed-effects logistic regression were used. Primary endpoints included cannulation-specific complications and ECMO-related adverse events.

Results: From 2020 to 2023, 157 patients were supported with VV ECMO. The cohort was 57% male patients with a median age of 44 (34 to 56) years and a median body mass index of 34 (28 to 44) kg/m². Thirty-five percent of patients (n = 55) had an SCV cannula during their ECMO course. Both groups had similar pre-ECMO variables, except for higher rates of COVID-19 (69% [n = 38] vs 49% [n = 49], P = 0.016) in the SCV cohort. There was no unadjusted survival difference (P = 0.8). There were 392 unique cannulation events. SCV cannulations were more commonly employed for additional cannulas and transitioning to single-site dual-lumen cannulation (P < 0.001). There was an increased cannulation-associated pneumothorax rate in the SCV arm (P < 0.001) when compared with all non-SCV sites. Mixed-effects logistic regression showed no site-related differences in adverse events or complication rates.

Conclusions: Between the SCV and non-SCV groups, there was no difference in site-related adverse events or complications. This study supports the use of SCV cannulation as a viable alternative in patients supported with VV ECMO.

Objective: This study evaluates the impact of transitioning from video-assisted thoracoscopic surgery (VATS) to robot-assisted thoracoscopic surgery (RATS) on patient outcomes and costs, based on the experience of a single surgeon at a quaternary center.

Methods: We reviewed patients who underwent anatomic lung resections by a single surgeon between 2015 and 2022, excluding nonanatomic resections and those involving robotic bronchoscopy followed by resection. We compared baseline characteristics, short-term outcomes, and costs between the VATS (2015 to 2018) and robotic (2018 to 2022) groups. Charges were adjusted to 2023 dollars for comparison across different time periods.

Results: A total of 210 patients (140 robotic, 70 VATS) were analyzed, with no significant differences in baseline characteristics. Robotic surgery had a longer median procedure time (161 vs 145 min, P < 0.002). Length of stay was similar (5.3 ± 6.3 days for robotic vs 6.54 ± 7.5 days for VATS, P = 0.23), as were 30-day readmission rates (5% for robotic vs 5.7% for VATS, P = 0.83). Major complications occurred in 5 robotic and 5 VATS cases (P = 0.528). Adjusted direct charges were $40,250.40 (95% confidence interval [CI]: $34,739.0 to $45,761.8) for robotic and $44,124.00 (95% CI: $35,036.0 to $53,211.9) for VATS (P = 0.47). Total hospital charges were $74,199.00 (95% CI: $64,398.9 to $83,999.2) for robotic and $80,549.00 (95% CI: $63,028.9 to $98,069.3) for VATS (P = 0.498).

Conclusions: Transitioning from VATS to RATS can be done safely without increasing costs or morbidity. In addition, the robotic approach demonstrated numerically lower charges, even during the surgeon's early learning curve. Hospital cost savings would be expected to increase as operative efficiency improves.