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

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.

Objective: An optimal valve replacement prosthesis demands durable leaflet technology, superior hemodynamic performance, and ease of use. Preclinical evaluation of polymer leaflets has historically demonstrated mechanical failure related to biodegradation. We present the preclinical evaluation of the novel TRIA™ polymer valve (Foldax, Salt Lake City, UT, USA) and a case report of TRIA mitral valve replacement.

Methods: A uniquely formulated, biostable, and biocompatible polymer (LifePolymer™ [LP], Foldax) has been designed to meet the functional demands of cardiac hemodynamics. Preclinical in vitro evaluation included biocompatibility testing, thrombogenicity testing, and toxicologic assessment followed by evaluation in the arteriovenous shunt of nonhuman primates and in the aortic position in sheep. Clinical evaluation of early human aortic and mitral implantation included computed tomography imaging and echocardiographic examination.

Results: In vitro studies of LP demonstrated no evidence of toxicity or tissue injury, no cytological injury in cell culture, and no intracutaneous sensitization. LP proved to be nonhemolytic by direct and extract methods, and complement activation was insignificant. Genotoxicity analysis proved LP to be nonmutagenic. All standard toxicologic assessments were within the margin of safety. Biostability was confirmed without polymer degradation or excessive comparative thrombogenicity. Ovine 6-month aortic valve explantation showed no leaflet calcification and minimal fibrinous depositions. An early human case example shows no evidence of leaflet thrombus formation at 6 months and a mean mitral gradient of 3 mm Hg at 12 months.

Conclusions: LP has met the requirements for a prosthetic polymer human heart valve. The surgical TRIA Mitral Valve has demonstrated promising early human clinical success, potentially facilitating a lifetime valve replacement strategy.

Objective: Pediatric mitral valve replacement remains a significant challenge due to the lack of growth-capable prostheses, often necessitating multiple reoperations. Partial heart transplantation (PHT) has shown promise in the semilunar position but has not been studied in the atrioventricular (AV) position. This study evaluates the feasibility and growth potential of AV PHT in an in vivo porcine model.

Methods: Three Yorkshire piglets underwent AV PHT, with the donor mitral valve implanted into the tricuspid position due to animal intraoperative tolerance limitations. The first 2 animals were used to refine surgical technique. The third piglet was designated for 2-month survival with serial echocardiographic monitoring. Donor valves were procured on the day of surgery to minimize ischemic time. Postoperative immunosuppression included tacrolimus, mycophenolate mofetil, and methylprednisolone.

Results: The survival animal tolerated the procedure well and remained clinically stable. Echocardiography demonstrated significant growth of the PHT mitral annulus from 2.0 cm to 4.3 cm, compared with 2.4 cm to 3.0 cm in the native annulus. The length of the PHT leaflet increased from 1.3 cm to 2.4 cm, whereas the length of the native leaflet increased from 1.1 cm to 1.9 cm. Nonprogressive moderate regurgitation was observed without stenosis. Gross examination confirmed excellent tissue integration without calcification or fibrosis.

Conclusions: This study demonstrates the in vivo feasibility and growth potential of AV PHT, representing a promising step toward growth-capable valve replacement for pediatric patients with irreparable mitral valve disease.