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

Objective: Aortic valve replacement surgery (AVR) via median sternotomy (MS) is the standard surgical intervention used for AVR. However, the minimally invasive approach is becoming more widely adopted. This review focuses on quality of life (QoL) after minimally invasive AVR (MIAVR). The aim of this review is to comprehensively analyze the current body of evidence for QoL after MIAVR. A second aim is to determine whether a conclusion can be made based on the literature to indicate whether MIAVR is more beneficial to the patient compared with MS and should be the preferred approach.

Methods: A literature search was conducted in the PubMed database using relevant searches. Papers were either included or excluded based on their title. Through a cross-reference check from the papers identified by the search, further articles were identified. Initially, 375 manuscript titles and abstracts were screened, with 11 being included in this review.

Results: The 11 studies comparing postoperative QoL between MIAVR and MS were comprehensively analyzed. Three studies showed no significant differences between the groups; however, 8 identified better QoL after surgery in the MIAVR group. Three studies investigated pulmonary function after MIAVR and MS, concluding that MIAVR demonstrated superior pulmonary function.

Conclusions: Overall, MIAVR can be performed with acceptable postoperative QoL. However, the current literature is sparse, and it is not possible to say whether one approach is better than the other. MIAVR is certainly not inferior to MS in terms of QoL. Well-designed, randomized controlled trials are needed to draw more definitive conclusions.

Objective: Previous learning curve analyses of minimally invasive mitral valve (MV) repair have focused largely on early safety outcomes without including detailed mitral repair quality outcomes. This study investigates the learning curve of minimally invasive MV repair over a 15-year experience, focused on clinical outcomes and evidence-based technical failure endpoints.

Methods: All MV repair operations were performed by a single surgeon between May 2008 and February 2023. Patient data were stratified into 3 groups of tertiles. Failure endpoints were defined as postrepair residual mitral regurgitation ≥ mild and a 30-day composite outcome. Cumulative log-likelihood curves were constructed for minimally invasive MV repair using the primary outcomes as technical failure endpoints. Control limits were determined using previous analyses of the Society of Thoracic Surgeons database.

Results: A total of 362 consecutive patients across 15 years were included. Across tertiles, there was a significant trend toward shorter cross-clamp time (P < 0.001), cardiopulmonary bypass time (P < 0.001), and hospital length of stay (P = 0.005). Learning curve analysis demonstrated crossing of the lower threshold at ~60 patients for postrepair mitral regurgitation ≥ mild and ~85 patients for the 30-day composite outcome. The mean adjusted risk scores for both primary outcomes based on a multivariable logistic model demonstrated no significant differences across tertiles.

Conclusions: The estimated number of operations to achieve optimal repair outcomes and durability is ~60 to 85 patients. These data can improve the design of surgical training competencies, beyond avoidance of complications, and instead focus the learning curve on what is necessary to achieve optimal mitral repair outcomes.

Objective: Reverse hybrid coronary revascularization (RHCR) is the integration of percutaneous coronary intervention (PCI) followed by sternal-sparing coronary artery bypass grafting in patients with multivessel coronary artery disease (CAD). We sought to review our RHCR experience over a 10-year period using PCI first followed by robotic totally endoscopic coronary artery bypass (TECAB).

Methods: We reviewed the indications and outcomes in patients who underwent RHCR (PCI with drug-eluting stents first, followed by TECAB).

Results: From July 2013 to August 2024, 882 robotic TECAB procedures were performed at our institution. Of these, 60 patients underwent RHCR. The mean age of the patients was 66.7 ± 10 years, and 74% were male patients. The target vessel stented was the right coronary artery in 52 patients (87%), circumflex coronary artery in 10 patients (17%), and diagonal in 4 patients (7%). The average time from PCI to TECAB was 3.8 ± 1.64 months. A total of 35 patients (58%) underwent multivessel grafting, with 74% bilateral internal thoracic artery (ITA) use. The mean operative time was 253 ± 88 min, and the mean hospital length of stay was 2 ± 0.76 days. There were no conversions, perioperative strokes, or myocardial infarctions. At mean follow-up of 34 ± 27 months, cardiac-related mortality occurred in 1 patient. Freedom from major adverse cardiac or cerebrovascular events including repeat revascularization was 93%.

Conclusions: RHCR is safe and feasible in selected patients with multivessel CAD. In experienced hands, stenting first followed by robotic TECAB with left ITA or bilateral ITA grafts resulted in excellent early and midterm outcomes. Further studies are warranted.

Objective: To describe the technique and the results of left ventricular aneurysm (LVA) repair with simultaneous coronary artery bypass grafting (CABG) and/or mitral valve (MV) surgery through the left anterior thoracotomy.

Methods: Between October 2018 and June 2024, a cohort of 40 patients underwent repair for postinfarction LVA through left anterior thoracotomy. Simultaneous procedures included CABG (40 patients, 100%) and MV surgery (15 patients, 37.5%) and were performed through the same thoracotomy incision. The mean age of the patients was 61.4 ± 11.4 years (range, 33 to 82 years), the mean body mass index was 27.9 ± 4.3 kg/m² (range, 19.9 to 35.9 kg/m²), and the mean LV ejection fraction was 29.9% ± 8.6% (range, 10% to 55%). The surgical technique in all patients included peripheral cardiopulmonary bypass, minithoracotomy in the fourth intercostal space, aortic cross-clamping, and cold blood cardioplegia.

Results: Successful visualization and repair of the LVA and complete revascularization was achieved in all patients without conversion to sternotomy. The mean number of distal anastomoses per patient was 2.03 ± 1.12 (range, 1 to 5). The mean cardiopulmonary bypass time was 207 ± 51.0 min, and the mean cross-clamp time was 115.5 ± 28.7 min. The average intensive care unit stay was 2.1 ± 1.4 days (range, 1 to 8 days), and the total hospital stay was 6.8 ± 2.9 days (range, 4 to 14 days). No strokes, major complications, or hospital mortality were observed. The 30-day mortality included 1 patient.

Conclusions: LVA repair (isolated or combined with simultaneous cardiac surgical procedures) through the left anterior thoracotomy is shown to be efficient and safe in our experience.

Aortic arch replacement operations have undergone substantial evolution with technical advancements, notably the introduction of the frozen elephant trunk (FET) technique. The purpose of this state-of-the-art review is to detail our approach to contemporary aortic arch replacement with FET operations. First, we review the evolution of FET procedures over the years and discuss technical modifications, including cerebral perfusion options, to the aortic arch replacement with FET. We also discuss state-of-the-art technical considerations of head vessel reconstruction and management of the difficult left subclavian artery. We also discuss selected considerations related to the endovascular stent graft component, including landing zone management and when to consider extended distal aortic interventions. We briefly discuss potential complications of which the vigilant clinician should be aware, as well as highlight subtleties in managing aortic dissection compared with aortic aneurysms.