Annals of cardiothoracic surgery最新文献

The introduction of robotic surgical devices nearly two decades ago led to a significant reduction in the invasiveness of cardiac procedures. The further worldwide implementation of robotic surgical devices in cardiac surgery, especially coronary artery bypass grafting and mitral valve repair or replacement, has, however, been stalled by numerous challenges. First, there is the high complexity of the procedures that involve a significant learning curve; second, there is the significant cost of robotic surgical devices. Furthermore, significant changes in the medical device regulation have occurred in recent years, hindering further technological development and the emergence of new players on the market. Finally, clinical evidence regarding the benefits of robotic-cardiac procedures remains scarce at this time. We invited all players active in or planning to throw themselves into robotic-assisted cardiac surgery to discuss these challenges in a semi-structured interview. Two promising and ambitious companies showed interest in participating in this project: Medicaroid and SS Innovations. The main conclusions from the interview are that both companies aim (I) to launch an affordable alternative compared to the current robotic surgical devices, (II) to further develop their robotic devices based on the opinion of physicians, and (III) to engage in overcoming the steep learning curve correlated with robotic-assisted cardiac procedures.

Background: Coronary artery bypass grafting (CABG) has significantly reduced the morbidity and mortality of patients suffering from ischemic heart disease over its six decades of practice. In recent years, minimally invasive techniques have been increasingly described and utilized, with the promise of providing patients with the same standard of care without the need for the traditional full sternotomy, and in select cases without cardiopulmonary bypass, and thus providing improved recovery metrics. The present systematic review and meta-analysis sought to determine the outcomes of all patients receiving robotic-assisted CABG in an Atlantic patient demographic.

Methods: The methods for this systematic review and meta-analysis adhered to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement. Four databases were searched, using appropriate search terminology. Meta-analysis using proportions or means, as appropriate, were applied, and were presented as per routine practice. Kaplan-Meier curves were digitized and aggregated using previously reported, validated techniques. Quality assessment and risk of bias of each study were assessed systematically. Patient populations were subcategorized as per established technical definitions.

Results: Thirty-five studies were identified through the literature search, with three studies having subgroupings appropriate for separate analysis (yielding 42 data points maximally). A total of 9,078 patients (69% male), with a mean age of 62.3 years, were identified across the study period. On actuarial assessment, survival at yearly assessment from 1-, 2-, 3-, 4- and 5-yearly intervals was determined to be 95%, 94%, 92%, 90%, and 88%, respectively.

Conclusions: The present systematic review and meta-analysis demonstrated that short-term mortality, operative time, and admission [intensive care unit (ICU) and overall length of stay] outcomes were encouraging in the Atlantic demographic. Freedom from long-term mortality assessment of a smaller cohort showed encouraging results. A major caveat to the present analysis is the high degree of heterogeneity in the reporting of data. Analysis of future randomized controlled trials will be vital in establishing these procedures as commonplace.

Background: Hybrid coronary revascularization (HCR) is a well-established technique for treating multi-vessel coronary disease. There remains a paucity of discussion assessing the efficacy of HCR with respect to the timing of the surgical component relative to that of the percutaneous coronary intervention (PCI).

Methods: A retrospective review was undertaken of our prospectively collected database from January 2009 to December 2019. Of 395 HCR patients analyzed, we examined the outcomes of 109 pairs of propensity-matched patients who either underwent robotic-assisted minimally-invasive direct coronary artery bypass (MIDCAB) first, or who had PCI prior to surgery.

Results: Thirty-day mortality was 0.25% (1 death) for the entire cohort. Mid-term survival for the total 'MIDCAB-first' group was 94.1% (17 deaths), not significantly different to that for the 'PCI-first' cohort (8 deaths, 92.7%), and this was also statistically comparable after propensity matching. Perioperative morbidity was not different between patient groups. Freedom from major adverse cardiac and cerebrovascular events (MACCE) and the incidence of repeat revascularization was similar between the two groups at up to 11-year follow-up. Elevated serum creatinine independently predicted increased MACCE for all patients, irrespective of the sequence of HCR revascularization employed.

Conclusions: In appropriately selected patients with multi-vessel coronary disease, HCR is associated with excellent short and longer-term results, irrespective of whether the MIDCAB or PCI procedure is performed first.

Robotic coronary artery bypass grafting (CABG) has emerged as a promising minimally invasive surgical technique for the treatment of coronary artery disease. This paper provides an in-depth analysis of the anesthetic management for robotic CABG. Challenges associated with robotic CABG are discussed and various anesthetic techniques, perioperative elements and pain management modalities that can contribute to enhanced patient recovery are explored.

Coronary artery bypass grafting (CABG) is the treatment of choice for coronary artery disease. The traditional method of performing CABG via a full sternotomy has its drawbacks, including increased postoperative morbidity, a higher incidence of complications, and extended hospitalizations. Although minimally invasive and robotic-assisted technology offer promising alternatives, they have not gained wide acceptance, largely because of the limited amount of literature supporting hybrid and robotic-assisted CABG. Since 2005, Lankenau Heart Institute's cardiothoracic surgical team has been developing and refining for selected patients a method for coronary revascularization that involves robotic harvesting of the left internal mammary artery (LIMA) and beating heart surgery through a limited minithoracotomy. This technique precisely places the robotic endoscopic port over the target site of the left anterior descending (LAD) artery. The LIMA is harvested using the enhanced visualization and precision of the robotic platform. The robotic instruments are then removed, and the endoscopic port site is slightly enlarged to become the minithoracotomy, allowing for LIMA-to-LAD anastomosis. The other two robotic ports are used for drains, eliminating the need for additional incisions. The method has been used in over 2,850 patients. The method has been used in over 2,850 patients. This article describes in detail our standardized technique for robotic-assisted minimally invasive direct coronary artery bypass (R-MIDCAB).

Robotic coronary and intra-cardiac surgery has been available for more than 25 years. In this period, multiple studies have demonstrated the beneficial effects of robotic surgery over conventional open surgery. Throughout the years, technical developments have enabled us to perform totally endoscopic coronary artery bypass (TECAB) grafting. But these techniques remained in the hands of a small group of pioneers because of a lack of structured training programs and the absence of long-term results at that time. Currently, a renewed interest and a wide dispersion of robotic platforms, thanks to use of robotics in other disciplines, has led to an exponential increase in robotic cardiac centers both in Europe and USA. Nonetheless, this increase was slowed down in Europe as a result of the uncertainty introduced by the implementation of a revised regulatory framework for medical devices [Regulation 2017/745, 'Medical Device Regulation' ('MDR')]. The MDR was introduced with the goal of increasing patient safety and supporting innovation. Implementing the MDR has proven to be exceptionally challenging and risks to the supply of essential devices have been identified. Changes to both regulatory and market dynamics led to a circumstance where the only available robotic platform for cardiac surgery decided to cease marketing of essential accessories for conducting surgery. This resulted in the disappearance of dedicated tools such as the Endowrist stabilizer, essential for TECAB, and the atrial retractor which is essential for intra-cardiac surgery. In the mean-time, further clinical evidence was published demonstrating the superiority of robotic cardiac surgery over other minimally invasive approaches. This has demonstrated the need to better define the clinical evidence requirements for regulatory purposes to ensure that dedicated tools for evidence-based interventions in robotic coronary surgery remain available such that TECAB can continue in Europe.