Sternal lifting technique for patients with sternal depression during robotic mitral repair.

INTRODUCTION: Traditional surgical methods have been difficult for patients with chest wall deformities, but the use of the Electrical Sternum Lifting System (ESLS) has made the surgery easier. MATERIALS AND SURGICAL TECHNIQUE: Patients with a sternum-to-vertebral distance of less than 80 mm on preoperative computed tomography (CT) scan routinely underwent sternal lift using the ESLS. The ESLS was effective in securing the operative field while suspending the sternum, allowing adequate observation of the left atrium, left ventricle, and the mitral valve, and safe mitral valve plasty. The use of the lifting device did not interfere with the robot arms, and the space between the sternum and vertebrae was widened with only a 3 mm wound to move the mitral valve surface in the sagittal plane, making the repair easy and accurate under robotic assistance. The effort to attach the ESLS was not difficult, and the postoperative cosmetic outcomes were excellent. Sixty-three out of 1002 patients (6.3%) underwent sternal elevation using ESLS. There were 19 males and 44 females with a mean age of 50.9 ± 14.0 years. The average of sternum-to-vertebral (S/V) distance was 72.4 ± 8.9 cm. Two patients had S/V distance of more than 80 mm but ESLS was used because of scoliosis.

Outcomes of Barlow mitral valve repaired by robot-assisted keyhole surgery.

Objective: To present our strategy and the clinical outcomes of robot-assisted Barlow mitral valve keyhole surgery. Methods: From May 2015 to March 2022, a total of 1281 patients underwent mitral valve repair at our institution, including 763 with robotics surgeries. Of these, 124 patients with Barlow mitral valve (49 ± 12 years, male/female ratio = 81:43) were treated using robotic assistance and included in this study. Results: All operations were completed using 3 to 5 keyholes. Neochordae implantation using the loop technique was the first option, and resection was performed only in cases with an intrinsic risk of developing systolic anterior motion. Neochordae implantation was performed in 118 cases (95.1%) using 6.6 ± 3.0 neochordae. Posterior leaflet resection was performed in 27 (21.7%) patients. Operation time was 177 ± 42 minutes, cardiopulmonary bypass time was 127 ± 25 minutes, and aorta crossclamp time was 76 ± 16 minutes. Blood transfusion was required in 5 cases (4%). None of the patients required a conversion to valve replacement. The postoperative complications included bleeding (n = 4), stroke (n = 1), and infection (n = 2). Mitral valve regurgitation 1 week after repair was none or trivial in 122 cases (98.3%), mild in 2 cases (1.7%), and more than moderate in 0 cases. Freedom from reoperation was 99.2% during the follow-up period of 36 ± 21 months. One patient required reoperation due to infective endocarditis. Conclusions: Robot-assisted keyhole surgery using the loop-first concept was adequate to help achieve satisfactory and safe perioperative outcomes for Barlow mitral valve.

Robotic Surgery for Triple Valve Insufficiency: A Case Report.

A 63-year-old woman was referred to our institution for surgical treatment of triple valve (aortic, mitral, and tricuspid) insufficiency and underwent a robot-assisted endoscopic procedure. Three intercostal ports were placed in the right lateral chest for robotic instruments and a retrograde cardioplegic cannula, and a 5 cm thoracotomy was made for the procedure, which was a mitral valve repair with neochords and ring annuloplasty, an aortic valve replacement with bioprosthetic valve, and a ring tricuspid annuloplasty. Surgery was successfully achieved without blood transfusion or any complications.

Multicenter Study of Surgical Ablation for Atrial Fibrillation in Aortic Valve Replacement.

There is controversy regarding appropriate surgical ablation procedures concomitant with nonmitral valve surgery. We retrospectively investigated the impact of surgical ablation for atrial fibrillation during aortic valve replacement between 2010 and 2015 in 16 institutions registered through the Japanese Society for Arrhythmia Surgery. Clinical data of 171 patients with paroxysmal and nonparoxysmal atrial fibrillation undergoing aortic valve replacement were collected and classified into full maze operation (n = 79), pulmonary vein isolation (PVI) (n = 56), and no surgical ablation (n = 36) groups. All patients were followed up and electrocardiograms were recorded in 68% at 2 years. The myocardial ischemia time was significantly longer in the maze group than the others during isolated aortic valve replacement (p ≤ 0.01), but there were no significant differences in 30-day or 2-year mortality rates between groups. The ratios of sinus rhythm at 2 years in paroxysmal and nonparoxysmal atrial fibrillation in the maze group versus PVI group were 87% versus 97%, respectively (p = 0.24) and 53% versus 42%, respectively (p = 0.47). No patients with nonparoxysmal atrial fibrillation in the no surgical ablation group maintained sinus rhythm at 2 years. In conclusion, both maze and PVI during aortic valve replacement are valuable strategies to restore sinus rhythm at 2 years and result in favorable early and midterm survival rates.

Robot-Assisted Totally Endoscopic Mitral Valve Plasty and Coronary Artery Bypass Grafting.

We experienced 3 cases of port-access robot-assisted totally endoscopic technique for mitral valve repair and concomitant coronary artery bypass. The right internal mammary artery was harvested, mitral valve was fixed, and the right internal mammary artery to right coronary artery anastomosis was carried out on the arrested heart. The use of cardiac arrest and a V-shaped hook technique facilitated the coronary anastomosis and the da Vinci Firefly test (Intuitive Surgical Inc., Sunnyvale, CA) could confirm patency of the graft.

Robotic mitral valve plasty for isolated clefts of mitral valve leaflets.

A 21-year-old female patient referred to our institute had been suffering from severe mitral valve regurgitation due to a rare anomaly: a typical cleft at the posterior mitral leaflet and the other partial one at the anterior leaflet. We successfully fixed the mitral valve using the robot-assisted totally endoscopic technique which could perform suture closure of both leaflets and annuloplasty. This communication is the first report of the robotic and totally endoscopic procedure which could treat this rare mitral anomaly.

Thoracoscopic infrared ablation to create a box lesion as a treatment for atrial fibrillation.

BACKGROUND: Creating a box lesion in the posterior wall of the left atrium from the epicardial side of the beating heart remains a challenge. Although a transmural lesion can be created by applying radiofrequency (RF) energy at clampable sites, it is still difficult to create a transmural lesion at unclampable sites because the inner blood flow in the unclampable free wall weakens the thermal effect on the outside. Our aim was to apply the newly developed infrared coagulator to create linear transmural lesions on the beating heart thoracoscopically to treat atrial fibrillation (AF). CASE PRESENTATION: A 71-year-old male was referred to our hospital with a diagnosis of hypertrophic cardiomyopathy and permanent atrial fibrillation. The patient was first diagnosed with atrial fibrillation 20 years before. Direct current cardioversion had been performed every few years a total of four times, but sinus rhythm restoration had always been temporary. On February 27, 2020, thoracoscopic PV isolation together with infrared roof- and bottom-line ablation to create a box lesion and left atrial appendage amputation (LAAA) were performed. The coagulator could be applied to clinical thoracoscopic surgery to successfully create a box lesion without any complication. The patient restored a regular sinus rhythm, it has been maintained for eleven months, and there have been no adverse events. CONCLUSIONS: The infrared coagulator might have enough potential to create transmural lesions on the beating heart in thoracoscopic AF surgery.

Bilateral endoscopic technique for left atrial appendectomy and robot-assisted mitral valve repair.

We report a bilateral thoracoscopic technique in which robot-assisted mitral valve repair was achieved concomitantly with stapler division of the large left atrial appendage. The patient was a 65-year-old male with severe mitral regurgitation, paroxysmal atrial fibrillation and a large-sized atrial appendage. Closure of the appendage was completed off-pump using a left thoracoscopic stapler-division technique previous to right thoracoscopic robot-assisted mitral valve repair and cryoablation. Complete closure of the appendage was confirmed in thoracoscopic views. The bilateral thoracoscopic technique could be preferable for the minimally invasive treatment of mitral valvular disease and concomitant large-sized atrial appendage management.

Combined robot-assisted mitral valve plasty and Nuss procedure via small ports.

Pectus excavatum (PE) can be associated with cardiac disorders that also require surgical repair. Totally endoscopic robot-assisted mitral valve plasty for mitral valve regurgitation was performed while elevating the sternum with the aid of our original electrical sternum lifting system. Then, the Nuss procedure was performed successfully via small incision. Simultaneous robot-assisted cardiac surgery and the Nuss procedure is effective. Sternal elevation during cardiac surgery is very important for a safe procedure. The Nuss technique prevents perioperative cardiac compression and allows for correction of the pectus deformity with good cosmetic and functional results.

Thoracoscopic stapler-closure of left atrial appendage and epicardial clamp-isolation of pulmonary veins in a patient with non-valvular atrial fibrillation and short bowel: a case report.

BACKGROUND: Thromboembolic occlusion of the superior mesenteric artery (SMA) is a serious event in patients with atrial fibrillation (AF). Extensive bowel resection is frequently required, and the resulting short bowel syndrome hampers the intake of anticoagulant or anti-arrhythmic medication. CASE SUMMARY: We report the case of thoracoscopic surgery consisting of stapler-closure of the left atrial appendage and bilateral epicardial clamp-isolation of the pulmonary veins performed in a 66-year-old male patient with symptomatic persistent non-valvular AF who became unable to take in anticoagulants or anti-arrhythmic drugs because of thromboembolic SMA occlusion and subsequent total resection of the small intestine. The patient has been free from thromboembolic or arrhythmic symptoms during 6 months of follow-up despite taking no anticoagulant or anti-arrhythmic drugs. Electrocardiographic monitoring demonstrated a stable sinus rhythm for 48 h at postoperative Months 3 and 6. Echocardiography manifested an improvement of the left ventricular ejection fraction from a preoperative value of 44-69% at postoperative Month 6. DISCUSSION: The present technique may contribute to treating patients with symptomatic non-valvular AF and a complication similar to that of the present case.

Epicardial Left Atrial Appendage Exclusion Reduces Blood Pressure in Patients With Atrial Fibrillation and Hypertension.

BACKGROUND: Percutaneous left atrial appendage exclusion (LAAE) has evolved as an alternative strategy for stroke prevention in atrial fibrillation (AF). Recent observational data have suggested that epicardial LAAE can have substantial impact on arrhythmia burden and hemodynamic profile. OBJECTIVES: The authors aimed to study the impact of epicardial versus endocardial LAAE on systemic blood pressure in hypertensive AF patients. METHODS: This was a prospective, nonrandomized study comparing 247 patients who underwent epicardial LAAE with 124 patients with endocardial exclusion. Clinical outcomes were measured at 3 months and 1 year. Primary outcome was improvement in systolic blood pressure (SBP) between both groups compared with baseline. Secondary outcome included changes in diastolic pressures (DBP), serum electrolytes, and creatinine. RESULTS: There was no significant difference in baseline SBP between epicardial and endocardial groups. SBP was significantly lower in the epicardial group both at 3 months (122 ± 11.8 mm Hg vs. 129.7 ± 8.2 mm Hg; p < 0.001) and 1 year (123 ± 11.6 mm Hg vs. 132.2 ± 8.8 mm Hg; p < 0.001) compared with the endocardial group. An adjusted multivariate linear mixed effects model demonstrated that epicardial LAAE significantly decreased SBP by 7.4 mm Hg at 3 months and by 8.9 mm Hg at 1 year (p < 0.0001). There was a trend toward lower DBP with epicardial LAAE at 3 months by 1.3 mm Hg (p = 0.2) and at 1 year by 1.8 mm Hg (p = 0.09). There was no significant difference in serum electrolytes and creatinine between both groups. CONCLUSIONS: In hypertensive AF patients, epicardial LAAE significantly decreases SBP both at 3 and 12 months compared with endocardial exclusion.

[Staged Hybrid Treatment for a Coronary Artery Pseudoaneurysm after Percutaneous Coronary Intervention;Report of a Case].

We herein report a case of a coronary artery pseudoaneurysm caused by previous catheter intervention, who was treated with a staged hybrid procedure of coronary artery bypass grafting (CABG) and subsequent percutaneous catheter intervention. A 59-year-old man underwent an urgent percutaneous coronary stent placement for acute myocardial infarction at segment 1 of the right coronary artery, where later coronary pseudoaneurysm developed. Prior to closure of the aneurysm by covered stent placement, he underwent CABG to segment 3 using the right internal thoracic artery graft, in case the implanted covered stent should acutely thrombose in the future. The graft flow was increased by producing an artificial stenosis just proximal to the anastomosis. The present technique would be a safe and viable option of therapeutic strategy to fix coronary artery pseudoaneurysms that have been formed at the proximal segment of main coronary arteries.

En Bloc Left Pulmonary Vein and Appendage Isolation in Thoracoscopic Surgery for Atrial Fibrillation.

BACKGROUND: We evaluated the safety and rhythm control effectiveness in en bloc isolation of the left pulmonary vein (PV) and appendage conducted as part of the thoracoscopic procedure for bilateral PV isolation, non-PV ablation, and appendage closure for atrial fibrillation (AF). METHODS: Procedural safety was evaluated by reviewing the surgical records. Rhythm control was examined in accordance with the Heart Rhythm Society guidelines at postoperative months 1, 3, 6, and 12, and yearly thereafter. The sinus rhythm rates at postoperative years 1 and 2 were compared with the corresponding data from our previous procedure without the en bloc technique. RESULTS: Starting in 2014, the en bloc technique was applied to 238 nonvalvular AF patients and successfully performed in all but 23 patients. The mean operation time was 88 minutes. There were no hospital deaths or major procedure-related complications. The mean follow-up period was 1.7 years. The sinus rhythm rates at postoperative years 1 and 2 were 85% and 80% in paroxysmal, 76% and 70% in persistent, and 67% and 61% in long-standing persistent AF, respectively, without antiarrhythmic drug use. Compared with the previous procedure (n = 324), sinus rhythm rates were higher in long-standing persistent AF (67% vs 50% at 1 year and 61% vs 40% at 2 years; p = 0.04). No patients suffered cardiogenic thromboembolisms without anticoagulation. CONCLUSIONS: Thoracoscopic en bloc left PV and appendage isolation was safely achieved in most patients. Using this technique may contribute to better rhythm control results than not using it in cases of long-standing persistent AF.

Thoracoscopic stapler-and-loop technique for left atrial appendage closure in nonvalvular atrial fibrillation: Mid-term outcomes in 201 patients.

BACKGROUND: Left atrial appendage (LAA) closure can be an alternative to oral anticoagulation to prevent cardiogenic thromboembolisms in patients with nonvalvular atrial fibrillation. OBJECTIVE: The purpose of this study was to retrospectively evaluate the safety, completeness, and mid-term prevention of our thoracoscopic stapler-and-loop technique for LAA closure. METHODS: Patients operated on between October 2008 and February 2017 were reviewed. Endoscopic stapler and ligation loops were used. Patients received 1 month of anticoagulation before discontinuation. Hospital death and procedure-related major complications (thromboembolism, hemorrhagic events, phrenic palsy) were the primary composite endpoint for safety, and cardiogenic thromboembolisms were the endpoint for prevention. Brain magnetic resonance imaging investigated new thromboembolic spots 1 year after surgery. RESULTS: There were 201 patients (118 men, 83 women) with a mean age of 74 years (range 68-94) years, mean CHA2DS2-VASc score (± SD) 4.1 ±1.4, and mean HAS-BLED score 2.9 ± 1.0. Mean operation time was 28 minutes. All LAAs were removed, and intraoperative transesophageal echocardiography confirmed completeness of the closure in each patient. No hospital deaths or major procedure-related complications occurred. Follow-up results for 198 patients (98%) over a mean period of 48 months (range 12-110) revealed that 2 patients developed cardiogenic thromboembolisms (0.25 event per 100 patient-years). Magnetic resonance imaging of 51 patients with a mean CHA2DS2-VASc score of 4.7 ± 1.6 revealed 1 new small spot in each of 2 patients (3.9%; 3.9 spots per 100 patient-years). CONCLUSION: Our thoracoscopic stapler-and-loop technique swiftly, safely, and completely closed LAAs in patients with nonvalvular atrial fibrillation and provided acceptable mid-term prevention without anticoagulation.

[A case of cardiogenic embolism, which occurred under appropriate warfarin use, treated with thoracoscopic left atrial appendectomy].

A 74-year-old man with a past medical history of bradycardiac atrial fibrillation and an old cerebral infarction presented with dysarthria. He had been treated with warfarin and PT-INR on admission was 2.0. MRI of the head revealed an acute ischemic stroke involving the cerebellum and left occipital lobe. Because transesophageal cardiac echography showed a thrombus in the left atrial appendage, anticoagulant treatment with warfarin and heparin was initiated. The thrombus was enlarging; therefore, we changed the anticoagulant therapy to apixaban with heparin on day 11. On day 17, a hemorrhagic cerebral infarction occurred. After the hemorrhage diminished, we treated him with warfarin aiming for a PT-INR between 3 and 4. The thrombus gradually shrank and disappeared on day 110. Finally, a thoracoscopic left atrial appendectomy was performed as a secondary prevention, with no recurrence till date.

[Thoracoscopic Left Atrial Appendectomy for a Patient with Thrombus in the Left Atrial Appendage after Anticoagulation Therapy;Report of a Case].

Thoracoscopic left atrial appendectomy for patients with non-valvular atrial fibrillation has been suggested as a new approach for preventing cardiogenic thromboembolism. While this procedure is effective in patients who suffer from thromboembolism even with anticoagulation therapy, it is contraindicated in patients with an existing left atrial appendage thrombus. We herein report a case of 61-yearold female with atrial fibrillation and recurrent cardiogenic thromboembolism. Left atrial appendage thrombus had been detected even under anticoagulation therapy. We decided to strengthen anticoagulation therapy and successfully resolved the left atrial appendage thrombus. Thus, thoracoscopic left atrial appendectomy was performed safely, and thromboembolism has never occurred since the operation.

[Total Endoscopic Left Atrial Appendectomy for Valvular Atrial Fibrillation;Report of a Case].

Total endoscopic left atrial appendectomy for non-valvular atrial fibrillation(Af) has been reported to be a safe and effective procedure to prevent cardiogenic thromboembolism and also discontinue oral anticoagulant therapy. On the other hand, open-heart surgery is generally indicated for valvular Af. We report the case of a 67-year-old male patient with valvular Af and recurrent episodes of cardiogenic thromboembolism who underwent total endoscopic left atrial appendectomy. He was diagnosed as having mitral valve stenosis and scheduled for surgery, but presented with cerebellar hemorrhage after warfarin was replaced with heparin in the preoperative phase. Consequently, the operation was cancelled. The case was considered as a good relative indication for total endoscopic left atrial appendectomy, which does not need a cardiopulmonary bypass, to prevent future cardiogenic thromboembolism. The operation was performed and the postoperative course was uneventful.

Thoracoscopic stand-alone left atrial appendectomy for thromboembolism prevention in nonvalvular atrial fibrillation.

OBJECTIVES: This study sought to evaluate thoracoscopic stand-alone left atrial appendectomy for thromboembolism prevention in nonvalvular atrial fibrillation (AF). BACKGROUND: Closing the left atrial appendage (LAA) is an efficacious alternative to oral anticoagulation as prevention against AF-induced thromboembolism, provided that the procedure is safe and complete. METHODS: Thirty patients (mean age, 74 ± 5.0 years) who had had thromboembolisms were selected. A subgroup of 21 patients (mean age, 75 years; mean CHA2DS2 VASc score, 4.5) urgently needed an alternative treatment to anticoagulation: warfarin was contraindicated due to hemorrhagic side effects in 13, the international normalized ratio was uncontrollable in 7, and transient ischemic attacks had developed immediately after the warfarin dose was reduced for oncological treatment in 1. The LAA was thoracoscopically excised with an endoscopic cutter. RESULTS: Thoracoscopic appendectomy (mean operating time, 32 min, switched to mini-thoracotomy in 2 cases) led to no mortality and no major complications. Three-month post-operative 3-dimensional enhanced computed tomography, performed with patients' consent, confirmed the completeness of the appendectomy. Patients have been followed for 1 to 38 months (mean, 16 ± 9.7 months [18 ± 9.4 months for the subgroup]). One patient died of breast cancer 28 months after surgery. Despite discontinued anticoagulation, no patients have experienced recurrence of thromboembolism. CONCLUSIONS: Thoracoscopic stand-alone appendectomy is potentially safe and may allow surgeons to achieve relatively simple, complete LAA closure. Further experience may demonstrate this technique to be a viable option for thromboembolism prevention in nonvalvular AF.

Type A aortic dissection with transient myocardial ischemia caused by intimal flap inverting into the left ventricle.

A 41-year-old man with sudden onset of chest oppression and downslope ST depression was diagnosed as having type A aortic dissection with angina pectoris and aortic regurgitation. Intraoperative transesophageal echocardiogram (TEE) showed intimal flap inverting into the left ventricle through the aortic valve. This case was rare in that transient myocardial ischemia was induced not by dissection of the aortic root reaching the coronary ostia but by back-and-forth movement of the intimal flap, covering the coronary ostia and interrupting the coronary artery flow. TEE was important for correct diagnosis.