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

Objective: Reoperative surgery for isolated tricuspid valve (TV) pathology has been associated with high morbidity and mortality rates; however, the current guidelines recommend intervention for severe, symptomatic TV regurgitation or mild to moderate symptoms with progressive right ventricular dysfunction. There are minimal data regarding reoperative intervention for TV disease. Similarly, there are no large series describing robot-assisted reoperative TV surgery.

Methods: Institutional Society of Thoracic Surgeons Adult Cardiac Surgery Database data were used to identify patients with previous cardiac surgery undergoing robot-assisted TV surgery from 2017 to 2022 from 2 tertiary referral hospitals. Patient demographics, preoperative characteristics, disease progression, operative details, and outcomes were analyzed. The primary outcome was 30-day mortality. Secondary outcomes were 30-day readmission, length of stay, and adverse events. Descriptive and summative statistics were used to describe clinical data and examine differences in outcomes of patients with primary versus secondary etiology using bivariate analyses.

Results: Twenty-four patients were divided into 2 arms, primary TV pathology and secondary dysfunction due to comorbid cardiac conditions. The overall mortality was 8.3%. Major complications, including respiratory failure, renal failure, and reoperation were 12.5%, 8.3%, and 8.3%, respectively. No permanent pacemakers were required, and the 30-day readmission rate was 4.5%.

Conclusions: Reoperative robotic TV surgery is a safe and viable alternative to traditional sternotomy for both primary and secondary TV pathology. TV repair and replacement are possible using the minimally invasive technique. The morbidity and mortality rates are acceptable when compared with traditional approaches with decreased need for pacemaker placement in the minimally invasive approach.

Objective: Hypertrophic obstructive cardiomyopathy (HOCM) develops in at least 1 out of 715 young adults. Patients who are refractory to medical therapy qualify for septal myectomy. Due to anatomy, serious complications such as ventricular septal defect and heart block may occur. Establishing cardiovascular magnetic resonance (CMR)-based 3-dimensional (3D) models as part of preoperative planning and training has the potential to decrease procedure-related complications and improve results.

Methods: CMR images were used to segment cardiac structures. Left ventricular wall thickness was calculated and projected on top of the in silico model. A 3D model was printed with a red layer indicating a wall thickness exceeding 15 mm and used for preoperative resection planning and patient counseling. To provide preoperative patient-specific in situ simulation, the planned resection volume was replaced with silicone in a second model. For perioperative quality control, resected silicone was compared with resected myocardial tissue. The impact of the models was evaluated descriptively through consultation of both the cardiothoracic surgeon and patients and through patient outcomes.

Results: Three-dimensional in silico and 3D-printed heart models of 5 patients were established preoperatively. Since the introduction of the models in October 2020, the surgeon feels better prepared, more confident, and less difficulty with making decisions. In addition, patients feel better informed preoperatively.

Conclusions: Using 3D heart models optimized preoperative planning and training, intraoperative quality control, and patient consultation. Reduction of procedure-related complications and clinical outcome should be studied in larger cohorts.

Objective: To evaluate the safety and efficacy of surgical repair for patients diagnosed with simple congenital heart defects (CHD) using the minimally invasive right vertical infra-axillary minithoracotomy (RVIAT) approach.

Methods: We retrospectively reviewed the clinical data of consecutive patients who underwent minimally invasive RVIAT for repair of CHD between August 2019 and August 2022. There were 382 patients who underwent 8 primary procedures and were included in this study.

Results: The median age of the patients was 16.2 (interquartile range [IQR], 7.2 to 41.9) months, and the median weight of the patients was 8.8 (IQR, 6.5 to 14) kg. The preoperative diagnoses were as follows: ventricular septal defect, atrial septal defect, partial anomalous pulmonary venous return, partial atrioventricular septal defect, cor triatriatum, complete atrioventricular septal defect, and myxoma. The mean aortic cross-clamp time, bypass time, and operation time were 45.4 ± 19.3 min, 65.6 ± 23.1 min, and 154.5 ± 29.7 min, respectively. There was no in-hospital mortality or conversion to median sternotomy. Two patients (0.5%) required early reoperation; 1 due to postoperative bleeding and 1 for permanent pacemaker implantation. Other complications included trivial residual shunts (23 of 382, 6%), pleural effusion (3 of 382, 0.8%), pneumothorax (0.8%), and wound infection (4 of 382, 1%). There were 2 late noncardiac deaths. Late reoperation was performed on 1 patient with progressive aortic valve regurgitation who required aortic valvuloplasty.

Conclusions: RVIAT is a minimally invasive approach that can be safely performed on patients with simple CHDs. RVIAT may be a good alternative approach for median sternotomy and cardiac intervention.

Objective: Impella 5.5 (Abiomed, Danvers, MA, USA) is a temporary mechanical circulatory support device used for patients in cardiogenic shock. This review provides a comprehensive overview of the device's clinical effectiveness, safety profile, patient outcomes, and relevant procedural considerations.

Methods: We conducted a systematic review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines using the PubMed/MEDLINE database. The search query included articles available from October 6, 2022, through January 13, 2023. Our initial search identified 75 studies. All records were screened by 2 independent reviewers using the Covidence software for adherence to our inclusion criteria, and 8 retrospective cohort studies were identified as appropriate for inclusion.

Results: Across the included studies, the sample size ranged from 4 to 275, with predominantly male cohorts. Indications for Impella support varied, and the duration of support ranged from 9.8 to 70 days. Overall, Impella support appeared to be associated with favorable survival rates and manageable complications in various patient populations. Complications associated with Impella use included bleeding, stroke, and device malfunctions. Two studies compared prolonged and Food and Drug Administration-approved Impella support, showing similar outcomes and adverse events.

Conclusions: Impella 5.5 continues to be an attractive option for bridging patients to definitive therapy. Survival during and after Impella 5.5 was favorable for patients regardless of initial indication. However, device use was associated with several important complications, which calls for judicious use and a precontemplated exit strategy. Limitations of this literature review include biases inherent to the retrospective studies included, such as selection and publication bias.