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

Objective: We conducted a systematic review of all available evidence on the feasibility and safety of minimally invasive coronary artery bypass grafting (MICS CABG) in patients with multivessel coronary artery disease (CAD).

Methods: A systematic literature search in PubMed, MEDLINE via Ovid, Embase, Scopus, and Web of Science was performed to identify all relevant studies evaluating outcomes of MICS CABG among patients with multivessel CAD and including at least 15 patients with no restriction on the publication date.

Results: A total of 881 studies were identified, of which 26 studies met the eligibility criteria. The studies included a total of 7,556 patients. The average patient age was 63.3 years (range 49.5 to 69.0 years), male patients were an average of 77.8% (54.0% to 89.8%), and body mass index was 29.8 kg/m² (24.5 to 30.1 kg/m²). Early mortality and stroke were on average 0.6% (range 0% to 2.0%) and 0.4% (range 0% to 1.3%), respectively. The average number of grafts was 2.8 (range 2.1 to 3.7). The average length of hospital stay was 5.6 days (range 3.1 to 9.3 days).

Conclusions: MICS CABG appears to be a safe method in well-selected patients with multivessel CAD. This approach is concentrated at dedicated centers, and there is no widespread application, although it has potential to be widely applicable as an alternative for surgical revascularization. However, large randomized controlled studies with longer follow-up are still required to compare the outcomes with conventional CABG and other revascularization strategies.

Objective: Throughout Europe, the interest in implementing robot-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) has been growing. However, concerns about additional costs have emerged concurrently. In this analysis, we aim to provide a comparison of the cumulative perioperative costs of RA-MIDCAB, on-pump coronary artery bypass grafting (CABG), and off-pump CABG (OPCAB).

Methods: We conducted a propensity score-matched analysis comparing patients undergoing RA-MIDCAB with those undergoing CABG or OPCAB at our institution from January 2016 to December 2021. After matching, we analyzed the combined intraoperative surgical costs and 30-day postoperative costs. We first compared RA-MIDCAB costs to CABG and then to OPCAB separately. Violin plots illustrated the cost distribution among individual patients. Total cost uncertainty was estimated using 1,000 bootstrapping iterations.

Results: Seventy-nine RA-MIDCAB patients were matched to 158 CABG patients, and 80 RA-MIDCAB patients were matched to 149 OPCAB patients. Considering both surgical and clinical outcomes, RA-MIDCAB yielded an average cost of €17,121 per patient (€16,781 to €33,294), CABG was €16,571 per patient (€16,664 to €41,860), and OPCAB was €15,463 per patient (€10,895 to €57,867). After bootstrap iterations, RA-MIDCAB was found to be €472 (2.8%) and €1,599 (10.3%) more expensive per patient than CABG and OPCAB, respectively.

Conclusions: In The Netherlands, the adoption of RA-MIDCAB did not show a significant economic impact on hospital resources. The additional robotic costs for the surgery were almost entirely offset by the cost savings during the postoperative hospital stay. However, these comparisons may differ when considering hybrid coronary revascularization with its additional percutaneous coronary intervention costs.

Objective: This study assessed the impact of digital chest drainage systems for patients undergoing video-assisted thoracoscopic surgery (VATS) pleurodesis for primary spontaneous pneumothorax (PSP) as compared with conventional chest drainage.

Methods: A retrospective analysis of patients who underwent VATS pleurodesis for PSP was conducted. The primary outcome was pneumothorax recurrence, while secondary outcomes included time to mobilization, degree of lung expansion, drainage duration, and length of hospital stay. These measures were expressed as average treatment effect and subsequently compared after propensity score adjustment.

Results: In total, 125 consecutive patients over a 64-month period were analyzed, with 55 patients in the digital drainage system group and 70 patients in the conventional drainage system group. After propensity score adjustment, the use of a digital drainage system was significantly associated with earlier mobilization (-2.22 days, P < 0.001) and lower rate of recurrence (-11.2%, P = 0.049).

Conclusions: The digital drainage system facilitated earlier postoperative free mobilization and resulted in lower pneumothorax recurrence rates.

Objective: Myocardial bridging (MB) occurs when a coronary artery, commonly the left anterior descending (LAD), has an intramyocardial course. In symptomatic patients who fail medical therapy, surgical unroofing can provide symptomatic relief by improving coronary blood flow. We present a series of patients undergoing robotic totally endoscopic beating-heart MB unroofing.

Methods: There were 34 patients with an LAD-MB who failed medical therapy and underwent robotic totally endoscopic, off-pump unroofing between January 2017 and October 2023. Patients were evaluated by a multidisciplinary team and underwent provocative coronary angiography to confirm hemodynamic significance. We reviewed perioperative outcomes and contacted patients for midterm follow-up, including completion of a modified Seattle Angina Questionnaire (SAQ).

Results: The mean age was 48 ± 8 years, and 56% were female patients. One patient had prior septal myectomy via sternotomy. All patients had significant dobutamine Pd/Pa reduction on preoperative coronary angiography. One patient had atrial fibrillation and underwent concomitant ablation with left atrial appendage ligation. The mean procedure time was 140 ± 69 min. All were completed totally endoscopically off-pump without intraoperative conversions. The mean MB length was 4.5 ± 1.4 cm, and the mean depth was 1.6 ± 0.9 cm. Of the patients, 76% were extubated in the operating room. The mean intensive care unit and hospital length of stay were 0.97 ± 0.58 and 1.73 ± 1.1 days, respectively. There were no mortalities or strokes. There was 1 postoperative take-back for bleeding. At midterm follow-up (19 ± 14 months), 28 patients completed the SAQ; 86% reported "much less angina" during activity compared with before surgery, and 93% reported taking no antianginal medication since surgery.

Conclusions: In appropriate patients with hemodynamically significant LAD-MB who fail medical therapy, robotic beating-heart unroofing is possible with good outcomes. Further studies are warranted.

We convened a group of cardiac surgeons, intensivists, and anesthesiologists with extensive experience in minimally invasive cardiac surgery (MICS) and perioperative care to identify the essential elements of a MICS program and the relationship with Enhanced Recovery After Surgery (ERAS). The MICS incision should minimize tissue invasion without compromising surgical goals. MICS also requires safe management of hemodynamics and preservation of cardiac function, which we have termed myocardial management. Finally, comprehensive perioperative care through an ERAS program should be provided to allow patients to achieve optimal recovery. Therefore, we propose that MICS requires 3 elements: (1) a less invasive surgical incision (non-full sternotomy), (2) optimized myocardial management, and (3) ERAS. We contend that the full benefit of MICS can be achieved only by also utilizing an ERAS platform.