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

Objective: Partial heart transplantation (PHT) is a new procedure that delivers growing heart valve implants for children. However, awareness, attitudes, and perceptions of health care professionals regarding PHT remain unexplored.

Methods: A national survey was conducted among members of the Congenital Heart Surgical Society, pediatric cardiac intensive care unit (ICU) directors, medical students, and organ procurement organization (OPO) representatives. The survey measured their awareness, perceptions, and attitudes toward PHT. Perceptions and attitudes were measured using a 5-point Likert scale. Statistical comparisons in ranked responses between survey questions were calculated using two-way analysis of variance, with multiple comparisons assessed by a Tukey post hoc test.

Results: There were responses from 95 medical students (12.1%), 32 congenital cardiac surgeons (10.26%), 21 pediatric ICU directors (16.8%), and representatives from 8 OPOs (15%). Prior to survey distribution, 20% of students were aware of PHT. In contrast, almost all congenital heart surgeons (96.88%) and pediatric cardiologists (100%) were aware of PHT. Although surgeons and cardiologists understand the concepts of PHT, cardiologists were less likely to recommend and inform their patients about the procedure if they meet the criteria (Likert scale scores of 4.68 vs 3.14, P = 0.01 and 4.38 vs 3.69, P = 0.01, respectively). Surgeon and cardiologist perceptions regarding the use of PHT for different patient age groups were significantly different (P < 0.001).

Conclusions: Even though PHT is a relatively recent innovation, it is well known among pediatric cardiac surgeons and pediatric intensive care directors.

Objective: Whether minimally invasive aortic valve replacement (MIAVR) offers an advantage over conventional AVR (CAVR) remains a matter of debate. Although some studies have suggested better postoperative outcomes with MIAVR, technical challenges and longer operative times remain major obstacles to the adoption of these techniques. In this meta-analysis, we compare the reported immediate postoperative outcomes of both approaches.

Methods: Cochrane, MEDLINE, and Embase^® databases were searched from inception until January 2022 for studies reporting immediate postoperative outcomes of MIAVR and CAVR. Studies were excluded if they reported on concomitant procedures or enrolled pediatric patients. Random-effects meta-analysis was performed using the restricted maximum likelihood estimator with Hartung-Knapp adjustment.

Results: The literature search yielded 3,921 articles, of which 75 were included in this meta-analysis. The most common techniques were ministernotomy and minithoracotomy. MIAVR was associated with lower 30-day mortality than CAVR (odds ratio [OR] = 0.65, 95% confidence interval [CI]: 0.54 to 0.78, I² = 0%, P < 0.001). The length of stay (LOS) in the hospital (standardized mean difference [SMD] = -0.44, 95% CI: -0.61 to -0.26, P < 0.001) and in the intensive care unit (SMD = -0.36, 95% CI: -0.57 to -0.15, P < 0.001) were shorter for MIAVR. Individual comparisons of ministernotomy and minithoracotomy to CAVR also yielded similar results. However, aortic cross-clamping and cardiopulmonary bypass times were longer for MIAVR.

Conclusions: Our meta-analysis suggests that minimally invasive approaches to AVR may provide advantages beyond cosmesis. Despite longer operative times, MIAVR was associated with earlier recovery and shorter hospital LOS. These findings were consistent for both minithoracotomy and ministernotomy.

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.