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

Enhancing recovery protocols seek to optimize multiple aspects of care throughout the patient's perioperative cardiac surgery journey. Fast-track recovery protocols, specifically those involving earlier extubation, have been among the early methods to enhance a patient's recovery. However, how early these protocols should be implemented after surgery remains a source of ongoing controversy. Strong opinions exist on whether it is appropriate to extubate patients after cardiac surgery in the operating room (OR). Although OR extubation may offer benefits such as reduced intensive care unit length of stay and resource utilization, there are concerns regarding safety, patient selection, and inconsistent outcomes, which have raised significant controversy. This review aims to discuss the reasons why a team may consider exploring extubation in the OR and provide a practical approach for the interdisciplinary team seeking to implement this practice in appropriately selected patients.

Objective: Robotic navigational bronchoscopy and endobronchial ultrasound have augmented diagnostic yield and localization of challenging pulmonary nodules. However, there is a paucity of literature regarding its role in decision-making during single-anesthesia bronchoscopy and resection (SABAR). We aim to describe our experience of SABAR via shape-sensing robotic navigational bronchoscopy (SSRNB).

Methods: A retrospective observational chart review was performed of adult patients who underwent SSRNB between August 2020 and April 2022. Diagnostic yield, localization success, treatment timelines, and cost were analyzed. Patients were categorized on the preoperative intent of SABAR for either localization or diagnostic yield. Localization was intended in nonpalpable peripheral nodules and multifocal nodules, whereas diagnostic yield was intended in deep nodules and multifocal nodules.

Results: A total of 73 patients and 96 nodules were analyzed. The average age was 67 years, with 43 of 73 (59%) being female. Approximately 58 of 73 patients (80%) identified as current or former smokers, and 12 of 73 (16.4%) had a history of lung cancer. The average tumor size was 1.4 cm. Localization confirmed by fluorescence imaging was achieved in 56 of 56 patients (100%) with localization intent and 76 of 76 (100%) of the entire sample. Successful diagnostic yield was obtained in 20 of 26 patients (76.9%) with biopsy intent who then underwent immediate resection. Diagnostic yield for the entire sample was 47 of 76 (61.8%). Eight of 14 benign nodules identified by SSRNB were resected due to persistent concern and concordant. Surgical resection occurred within 30 days of initial consultation for 50 of 73 patients (70%). A total variable cost saving of $4,000 was observed in SABAR relative to separate procedures.

Conclusions: This novel study demonstrates that SABAR with SSRNB is an effective way to intraoperatively localize and potentially diagnose difficult lung nodules during planned resection. This efficacy accelerates treatment timelines and decreases hospital costs. Future studies are warranted to delineate patient populations who would benefit most from SABAR using SSRNB.

Objective: Minimally invasive mitral valve surgery (MIMVS) is being increasingly adopted worldwide. Pivotal to the safe conduct of the procedure is optimal visualization to allow detailed valve analysis and assessment of reparability. Positioning of conventional transthoracic left atrial retractors used during MIMVS may be time-consuming and can result in a limited view or thoracic bleeding. The aim of this study was to evaluate the safety and efficacy of the FlexCrown™ retractor by Geister (Tuttlingen, Germany), an innovative self-expandable left atrial retractor, during MIMVS.

Methods: A retrospective analysis was performed of 245 patients at 2 mitral specialist centers from January 2017 to July 2022. All patients underwent MIMVS via a right minianterolateral thoracotomy using the FlexCrown retractor.

Results: There were 129 female (53%) and 116 male (47%) patients with a mean age of 67 ± 10 years. The etiology of the mitral valve pathology was stenosis in 11% of patients (n = 27), regurgitation in 80% (n = 196), and mixed in 9% (n = 22). The device was used for both mitral valve repair (n = 125) and replacement (n = 120). There were no cases of tissue damage, dislodgement, or migration of the FlexCrown retractor. The postoperative transthoracic echocardiogram showed no or trivial mitral regurgitation in 90% of patients (n = 220).

Conclusions: The FlexCrown self-expandable left atrial retractor by Geister allows excellent and safe exposure of the mitral valve with fast deployment and removal during MIMVS. The use of this innovative retractor may represent a helpful alternative to conventional left atrial retractors.

Objective: Isolated tricuspid valve (TV) surgery remains underused despite guideline recommendations. This underuse may be related to perceived high risk in comorbid patients but also to high reported needs for postoperative permanent pacemaker implantation (PPI). It is conceivable that PPI can be prevented by operating on the beating heart (BH). We conducted a systematic review and meta-analysis assessing the influence of BH versus arrested heart (AH) technique on short-term and long-term outcomes after isolated TV surgery with a specific focus on PPI requirements.

Methods: Three databases were assessed. The primary outcome was the rate of postoperative PPI. Secondary endpoints included short-term and long-term survival, cardiopulmonary bypass (CPB) and procedural duration, intensive care unit (ICU) and hospital stay, and postoperative stroke incidence. Hazard ratios, odds ratios, and 95% confidence intervals were calculated. A pooled Kaplan-Meier survival curve after reconstruction analysis was generated for the endpoint of long-term survival. Random-effects models were used.

Results: A total of 1,157 studies were identified. Six observational studies from different countries were included in the analysis. The cohorts receiving either BH or AH technique for isolated TV surgery showed no significant differences in the rate of PPI (range: 6.3% to 18.2%) or any secondary outcomes, including short-term and long-term survival, CPB and procedural duration, ICU and hospital stay, or stroke incidence.

Conclusions: Our meta-analysis suggests that performing TV surgery on the BH is not likely to be associated with a reduced risk of postoperative PPI or with different incidences of major clinical endpoints.

Objective: To evaluate the impact of a novel multidisciplinary initiative, known as the Multimodal ENhanced Discharge (MEND), on length of stay (LOS) for patients undergoing minimally invasive coronary artery bypass grafting (MICS CABG).

Methods: The MEND program aims to optimize the patient's preoperative condition and increase preparedness, provide individualized perioperative care, and ensure early postdischarge follow-up to support active recovery and facilitate early discharge. This single-center, retrospective analysis reviewed LOS and readmission data for 198 consecutive patients who underwent MICS CABG by a single surgeon. Of these, 91 patients received routine care (RC) and 107 patients received care through the MEND program.

Results: The median ward (non-intensive care unit) LOS was significantly shorter by 33% in the MEND group versus the RC group (2 vs 3 days, P < 0.001), resulting in a 40% shorter median total hospital LOS in the MEND group versus the RC group (2 vs 5 days, P < 0.001). Readmission rates were 14.3% for RC and 6.6% in the MEND group (P = 0.12).

Conclusions: Implementation of the MEND program in patients undergoing MICS CABG was associated with significantly shorter overall hospital LOS without an increase in readmission rates. No statistically significant differences in baseline characteristics between the RC and MEND cohorts were observed. These findings suggest MEND is an effective and generalizable program for optimizing recovery. Ultimately, this model of care has the potential to positively affect health care costs, improve surgical wait times, and expand capacity in MICS CABG programs.