Annals of cardiothoracic surgery最新文献

Background: After the US Food and Drug Administration (FDA) approved the Thoraflex Hybrid device in April 2022, hybrid devices to facilitate total arch replacement (TAR) became commercially available in the United States. However, little is known about how the Thoraflex device has been used since then. We present our experience (2016-2025) with this device.

Methods: At our practice, 62 patients [median age, 65 (54-73) years] underwent frozen elephant trunk (FET) TAR with the Thoraflex device: 14 under an investigational device exemption (IDE) (2016-2018) and 48 after FDA approval (2022-2025). Both Ante-Flo (straight) and Plexus (branched) models were used.

Results: Patients with aortic dissection were common (n=38; 61%). Many patients had prior open or endovascular aortic repair (n=28; 45%). Initial cannulation was commonly done via the innominate artery (n=30; 48%) or the right axillary artery (n=22; 36%). Both branched and island strategies were used to reattach the brachiocephalic arteries. Selectively, left subclavian artery (LSCA) bypass was performed before TAR in 18 patients (29%). The distal anastomosis was performed proximal to the LSCA in 27 repairs (43%). A short (10-cm) endograft extension was used in most cases (n=49; 79%). Eight (13%) patients underwent concomitant aortic root replacement. Overall, four patients (7%) had operative deaths, and three (5%) were discharged with stroke or persistent need for renal dialysis. Two patients had spinal cord deficits that resolved before discharge. Twenty-five downstream extensions (12 open, 13 endovascular) were needed in 22 patients; two patients underwent more than one repair. After discharge, seven additional patients died within one year of surgery.

Conclusions: TAR is a complex procedure. Patients requiring such repair tend to have substantial disease that often eventually necessitates subsequent downstream aortic repair, especially when dissection is present. Using the Thoraflex Hybrid device in TAR results in good early outcomes and provides a reliable base for extension.

The evolution of surgical replacement of the aortic arch has been shaped by advances in surgical techniques and ancillary technologies. From the early pioneering attempts in the 1950s by Ho Ju Lin, Cooley, and DeBakey, which preceded the advent of cardiopulmonary bypass (CPB), the development of perfusion, cerebral protection, and surgical techniques, along with the evolution of prosthetic grafts, has progressively enabled surgeons to address these challenging conditions with greater confidence. Despite these remarkable advancements, aortic arch surgery still remains one of the most technically challenging procedures in cardiac surgery. A major turning point was the introduction of the elephant trunk technique by Borst in 1983. This approach allowed for staged treatment of diffuse aneurysmal disease, including both degenerative and post-dissection cases, and reduced the overall surgical risk across multiple procedures. Initially met with skepticism, the technique has since been universally adopted by centers specializing in aortic pathology. At the same time, numerous modifications to the technique have emerged. Each modification has addressed specific technical challenges or enabled the integration of new technologies. The development of the Siena graft in the early 2000s was driven by the need to harness the growing potential of endovascular devices, which had been evolving since the 1990s, and to address critical technical issues. These included the use of multi-branched prostheses and the introduction of an anastomotic collar to facilitate secure distal anastomoses, even in less-than-ideal anatomical conditions. The design of the Siena graft, now widely adopted by most manufacturers for arch grafts, required close collaboration with industry partners to ensure a reliable product from its inception. Today, the Siena graft remains a highly relevant platform for the treatment of diffuse aneurysmal disease that requires the elephant trunk technique. This paper describes the evolution and design of the graft, the technical approach, including pitfalls and safeguards, and our clinical experience.

Background: The natural history of aortic valve disease commonly eventuates in percutaneous or open surgical treatment. Percutaneous treatment has been expanding its indication from high-risk patients to low- and moderate-risk patients; however, there are certain groups of patients who are not good candidates for percutaneous treatment, such as those with bicuspid valve disease or pure aortic regurgitation patients. Robotic surgery, as an evolution from traditional approaches, has been gradually expanding its indications in cardiac surgery. The use of a lateral approach, common to robotic mitral procedures, may become a valid alternative for several patients undergoing aortic valve procedures. The aim of the present study was to evaluate and discuss the characteristics, challenges and early results of a newly created robotic aortic valve replacement program.

Methods: This was a retrospective study analysing prospectively collected data of all patients who have undergone robotic aortic valve replacement (RAVR) in Hospital Clínic Barcelona from December 2021 to October 2024.

Results: Since December 2021, 25 consecutive patients have undergone RAVR. Sixty-eight percent of the cohort were males and the median age was 66 years [interquartile range (IQR), 58.5-71.8 years]. Severe aortic stenosis was the predominant lesion in 76% of patients, and degenerative calcification was the aetiology in 52% of patients. Median cardiopulmonary bypass time was 129 minutes (IQR, 113-145.5 minutes) and median ischemic time was 91 minutes (IQR, 78-105 minutes). Three patients required a re-exploration for bleeding, which was performed through the same approach, and one patient suffered an ischemic cerebro-vascular accident (CVA) with complete recovery. Median intensive care unit (ICU) length of stay and hospital length of stay were 1 and 4 days, respectively.

Conclusions: Our initial experience shows that expanding a robotic program to include RAVR is feasible, safe, and can provide excellent clinical outcomes in selected patients.

Right lateral access robotic aortic valve replacement (RAVR) may represent a significant advancement in minimally invasive cardiac surgery. This review examines RAVR's development, technical specifications, clinical outcomes, and future trajectory in cardiac surgery. Multicenter RAVR experiences have demonstrated promising results with low rates of operative mortality (0.9%), stroke (0.9%), and permanent pacemaker placement (2.9%). In propensity-matched comparisons with transcatheter aortic valve replacement (TAVR), RAVR had significantly lower rates of paravalvular leak (0.7% vs. 21.5%) and one-year mortality (1.4% vs. 12.5%). With a 3-cm working incision at the level of the anterior axillary line, the lateral access approach offers distinct advantages including improved surgical visualization, reduced tissue trauma, and standardization potential across various cardiac procedures. While learning curve considerations exist, these are minimal for experienced robotic mitral teams. RAVR programs have expanded to include implementation of complex procedures such as aortic root enlargement. As robotic systems become more prevalent and surgical expertise grows, RAVR shows promise to evolve from an innovative technique to a standard therapeutic option in aortic valve surgery. This evolution, supported by growing clinical evidence and technological advancement, positions RAVR as a potentially transformative development in cardiac surgery, offering patients the benefits of minimally invasive approaches while maintaining the durability of traditional surgical valve replacement.

The application of robotic cardiac surgery has long been considered the pinnacle of surgical care for an isolated procedure. This has been for good reason, as the quality and reproducibility of isolated procedures like mitral valve (MV) repair and robotic-assisted, minimally invasive, direct coronary artery bypass have grown steadily across the globe with shrinking learning curves. Once a robotic team's learning curve has crested, however, additional opportunities may be explored that may include concomitant procedures. Following the core surgical principles of safety and procedural homogeneity with open operations, robotic cardiac surgery may be extended in a stepwise fashion to multi-valve operations, concomitant maze procedures, aortic root enlargement, septal myectomy, and even valve and coronary bypass operations, all via the same transaxillary working incision. We will review the development and operative techniques of concomitant procedures that may be utilized in conjunction with robotic aortic valve replacement (RAVR).