Robotic Totally Endoscopic Coronary Bypass to the Left Anterior Descending Artery: Left Versus Right Internal Thoracic Artery Grafts.

INTRODUCTION: The left internal thoracic artery (LITA) is most commonly used to bypass the left anterior descending artery (LAD) given its well-established mortality benefit. In some cases, the grafting strategy necessitates placing the right internal thoracic artery (RITA) on the LAD. We compared outcomes in our robotic beating-heart totally endoscopic coronary bypass surgery (TECAB) population between patients receiving LITA versus RITA-LAD grafts. METHODS: We retrospectively reviewed patients undergoing robotic TECAB with skeletonized ITA conduits over 9 y. Outcomes were compared between those receiving LITA (Group-1) versus RITA (Group-2) grafts to the LAD (with/without other grafts). End points were early angiographic patency (in patients undergoing hybrid revascularization) and mid-term mortality/major adverse cardiac/cerebrovascular events. A propensity matched subanalysis was performed comparing only patients who received bilateral ITA grafting in each group. RESULTS: Society of Thoracic Surgeons predicted mortality risk score was higher in Group-2. Group-1 patients had lower incidence of multivessel disease (75% versus 96%, P ≤ 0.001). Early overall graft patency (97% versus 96%, P = 0.718) and LAD graft patency (98% versus 95%, P = 0.372) were equivalent. At mean 42-mo follow-up (longest 8.5 y), Group-1 had lower all-cause mortality but no difference in cardiac mortality or repeat revascularization. In the propensity matched subanalysis, mid-term outcomes were equivalent. CONCLUSIONS: Grafting the LAD with the LITA or RITA during robotic beating-heart TECAB resulted in similar early outcomes and angiographic patency. RITA-LAD patients were more likely to have multivessel disease and higher Society of Thoracic Surgeons risk and had higher all-cause mortality at mid-term analysis but no difference in major adverse cardiac/cerebrovascular events, including cardiac mortality.

Unilateral Pulmonary Edema After Robotically Assisted Mitral Valve Repair Requiring Veno-Venous Extracorporeal Membrane Oxygenation.

Unilateral pulmonary edema (UPE) is an uncommon yet potentially life-threatening complication of minimally invasive cardiac surgery (MICS). Most frequently described after robotically assisted mitral valve (MV) repair, it is characterized by right lung edema, hypoxemia, hypercapnia, pulmonary hypertension, and hemodynamic instability beginning minutes-to-hours after separation from cardiopulmonary bypass (CPB). The authors describe a severe case with refractory hypoxemia requiring veno-venous (VV) extracorporeal membrane oxygenation (ECMO) after robotically assisted MV repair.

Minimally invasive mitral valve surgery with or without robotics: Examining the evidence.

Minimally invasive mitral valve surgery can be performed with or without robotic assistance. In this issue of the journal, Zheng et al. compare between these two approaches in a propensity-matched study over a 5-year period and show that the two techniques have similar successful short and mid-term outcomes. Although we are proponents of the robotic approach, we agree with their conclusions and discuss in this commentary some of the previously published studies that have shown similar findings.

Robotic totally endoscopic triple bypass with bilateral internal mammary arteries and two different anastomotic techniques.

Robotic totally endoscopic coronary artery bypass (TECAB) offers several advantages over conventional sternotomy coronary artery bypass grafting. TECAB allows the increased use of bilateral internal mammary artery grafts independent of gender, body mass index or diabetes, minimizes the risk of wound infection, decreases the length of hospital stay, and improves the postoperative quality of life. Off-pump beating heart TECAB has been used to offer one or two grafts generally on the anterior wall. We describe our approach to perform beating heart, triple-vessel TECAB with targets on the lateral and posterolateral wall of the left ventricle.

Intrathecal Morphine for Analgesia in Minimally Invasive Cardiac Surgery: A Randomized, Placebo-controlled, Double-blinded Clinical Trial.

BACKGROUND: Intrathecal morphine decreases postoperative pain in standard cardiac surgery. Its safety and effectiveness have not been adequately evaluated in minimally invasive cardiac surgery. The authors hypothesized that intrathecal morphine would decrease postoperative morphine consumption after minimally invasive cardiac surgery. METHODS: In this randomized, placebo-controlled, double-blinded clinical trial, patients undergoing robotic totally endoscopic coronary artery bypass received either intrathecal morphine (5 mcg/kg) or intrathecal saline before surgery. The primary outcome was postoperative morphine equivalent consumption in the first 24 h after surgery; secondary outcomes included pain scores, side effects, and patient satisfaction. Pain was assessed via visual analog scale at 1, 2, 6, 12, 24, and 48 h after intensive care unit arrival. Opioid-related side effects (nausea/vomiting, pruritus, urinary retention, respiratory depression) were assessed daily. Patient satisfaction was evaluated with the Revised American Pain Society Outcome Questionnaire. RESULTS: Seventy-nine patients were randomized to receive intrathecal morphine (n = 37) or intrathecal placebo (n = 42), with 70 analyzed (morphine 33, placebo 37). Intrathecal morphine patients required significantly less median (25th to 75th percentile) morphine equivalents compared to placebo during first postoperative 24 h (28 [16 to 46] mg vs. 59 [41 to 79] mg; difference, -28 [95% CI, -40 to -18]; P < 0.001) and second postoperative 24 h (0 [0 to 2] mg vs. 5 [0 to 6] mg; difference, -3.3 [95% CI, -5 to 0]; P < 0.001), exhibited significantly lower visual analog scale pain scores at rest and cough at all postoperative timepoints (overall treatment effect, -4.1 [95% CI, -4.9 to -3.3] and -4.7 [95% CI, -5.5 to -3.9], respectively; P < 0.001), and percent time in severe pain (10 [0 to 40] vs. 40 [20 to 70]; P = 0.003) during the postoperative period. Mild nausea was more common in the intrathecal morphine group (36% vs. 8%; P = 0.004). CONCLUSIONS: When given before induction of anesthesia for totally endoscopic coronary artery bypass, intrathecal morphine decreases use of postoperative opioids and produces significant postoperative analgesia for 48 h.

Cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on health care and cardiac surgery. We report cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic. METHODS: A detailed survey was sent to recruit participating adult cardiac surgery centers in North America. Data regarding cardiac surgeons' perceptions and changes in practice were analyzed. RESULTS: Our study comprises 67 institutions with diverse geographic distribution across North America. Nurses were most likely to be redeployed (88%), followed by advanced care practitioners (69%), trainees (28%), and surgeons (25%). Examining surgeon concerns in regard to COVID-19, they were most worried with exposing their family to COVID-19 (81%), followed by contracting COVID-19 (68%), running out of personal protective equipment (PPE) (28%), and hospital resources (28%). In terms of PPE conservation strategies among users of N95 respirators, nearly half were recycling via decontamination with ultraviolet light (49%), followed by sterilization with heat (13%) and at home or with other modalities (13%). Reuse of N95 respirators for 1 day (22%), 1 week (21%) or 1 month (6%) was reported. There were differences in adoption of methods to conserve N95 respirators based on institutional pandemic phase and COVID-19 burden, with higher COVID-19 burden institutions more likely to resort to PPE conservation strategies. CONCLUSIONS: The present study demonstrates the impact of COVID-19 on North American cardiac surgeons. Our study should stimulate further discussions to identify optimal solutions to improve workforce preparedness for subsequent surges, as well as facilitate the navigation of future healthcare crises.

Techniques for Robotic-Assisted Surgical Myocardial Revascularization.

The two current strategies for robotic-assisted, surgical myocardial revascularization are minimally invasive direct coronary artery bypass (MIDCAB) and totally endoscopic coronary artery bypass grafting (TECAB). We discuss the rationale underlying the benefits of robotic assistance in surgical myocardial revascularization, and detail the technical steps to safely and effectively perform these two procedures.

Multi-arterial and total-arterial coronary revascularization: Past, present, and future perspective.

BACKGROUND AND AIM OF THE STUDY: Although abundant biological, clinical, and scientific evidence exists on the superiority of multi-arterial (MAR) and total-arterial revascularization (TAR) over the conventional strategy with a single internal thoracic artery, only 10% of patients undergoing coronary artery bypass grafting (CABG) in the United States receives a second arterial conduit, and only 5% of patients receives TAR. METHODS AND RESULTS: In January 2020, the authors performed comprehensive search to identify studies that evaluated MAR and TAR strategies through the MEDLINE database. CONCLUSIONS: In this paper, the authors reviewed the literature on the historical and current evidence in favor of MAR and TAR, thus underlying why current CABG practice needs qualitative improvement.

Robotic endoscopic mitral valve repair with the endoballoon in a patient with right aortic arch.

We describe a patient with right aortic arch who underwent robotic endoscopic mitral valve repair with the endoballoon for severe mitral regurgitation. We review the important issues when performing totally endoscopic robotic surgery in a case with such congenital aortic anomaly that must be appreciated to ensure safe surgery in this situation.

Robotic totally endoscopic off-pump unroofing of left anterior descending coronary artery myocardial bridge: A report of two cases.

Myocardial bridge occurs when the myocardium courses external to an intramyocardial coronary artery, most commonly, the left anterior descending artery. The presentation can range from an asymptomatic, incidental finding to myocardial infarction, and sudden cardiac death. We report two cases of symptomatic MBs, which were treated with surgical unroofing, using a totally endoscopic robotic-assisted off-pump approach.

Robotic totally endoscopic excision of aortic valve papillary fibroelastoma: The least invasive approach.

INTRODUCTION: Papillary fibroelastomas (PFEs) are a rare subtype of benign primary cardiac tumors, which are most commonly found on the aortic valve (AV). They have the potential to cause severe adverse clinical consequences, thus prompting surgical excision in the majority of cases. In this article, we report on a series of 5 PFEs resected from the AV using a robotic-assisted sternal-sparing approach, and review of the literature on this approach. To our knowledge, this is the largest reported series of robotic-assisted sternal-sparing AV-PFE resections. MATERIALS AND METHODS: From May 2016 until November 2018, 5 patients at our institution underwent removal of a papillary fibroelastoma from the aortic valve using a totally endoscopic robotic-assisted approach. After obtaining institutional IRB approval, we retrospectively reviewed their data for this report. We additionally contacted the patients to acquire a last clinical follow up for this study. Results In this series of 5 patients who underwent robotic totally endoscopic excision of AV PFE, all patients had successful removal of their tumor with no significant morbidity or mortality. All 5 patients were seen at a 30-day follow-up office visit, at which time they had recovered from surgery and were back to full activity. At a mean of 24 months all patients were doing well and free of symptoms with no evidence of tumor recurrence on repeat echo evaluation. DISCUSSION: This is a series of 5 patients with AV-associated PFEs who underwent robotic totally-endoscopic excision without rib-spreading or conversion to sternotomy. This report demonstrated the successful application of robotic-assisted technology in aortic valve pathology. All PFEs were successfully removed without valve repair or replacement. We were able to offer a safe, curative, minimally-invasive surgical excision option for this group of patients. CONCLUSION: Our patients in this cohort demonstrated the well-established benefits of robotic sternal-sparing cardiac surgery, including excellent intra and postoperative outcomes and accelerated recovery.

Predictors of blood transfusion use in robotic beating-heart totally endoscopic coronary artery bypass with anastomotic connectors.

BACKGROUND: We sought to identify the independent predictors of blood transfusion requirement in robotic beating-heart patients with totally endoscopic coronary artery bypass (TECAB). METHODS: We retrospectively reviewed patients undergoing TECAB with distal anastomotic connectors from July 2013 to May 2017 at our institution. The cohorts were divided into patients who received a blood transfusion (BT group) and patients who did not (non-blood transfusion [NBT] group). RESULTS: Two-hundred seventy-four consecutive patients underwent TECAB, and 47 patients (17%; BT group) received BT. The BT group had a lower preoperative hemoglobin level and a higher rate of preoperative risk profiles and higher society of thoracic surgeons (STS) predicted the risk of mortality. Kaplan Meier analysis showed decreased 1-year survival in the BT group compared with the NBT group (90.9% vs 96.4%; logrank, 0.017). The Youden index identified a preoperative hemoglobin cutoff value of 12.2 g/dL (sensitivity 60.9%, specificity 79.3%) and operative time of 300 minutes (sensitivity 61.7%, specificity 59.0%) for BT requirement. Multivariate logistic regression analysis identified a preoperative hemoglobin <12.2 g/dL (odds ratio, 6.03; 95% confidence interval, 3.01-12.1) and an operative time >300 minutes (odds ratio, 2.15; 95% confidence interval, 1.07-4.33) as independent factors associated with BT requirement. CONCLUSIONS: We found that preoperative hemoglobin and operative time were independent predictors of BT requirement during robotic beating-heart TECAB. These data would help to select patients to minimize perioperative BT as well as predict outcomes after this procedure.

3D echocardiographic analysis of aortic annulus for transcatheter aortic valve replacement using novel aortic valve quantification software: Comparison with computed tomography.

BACKGROUND: With the increasing use of transcatheter aortic valve replacement (TAVR) in patients with aortic stenosis (AS), computed tomography (CT) remains the standard for annulus sizing. However, 3D transesophageal echocardiography (TEE) has been an alternative in patients with contraindications to CT. We sought to (1) test the feasibility, accuracy, and reproducibility of prototype 3DTEE analysis software (Philips) for aortic annular measurements and (2) compare the new approach to the existing echocardiographic techniques. METHODS: We prospectively studied 52 patients who underwent gated contrast CT, procedural 3DTEE, and TAVR. 3DTEE images were analyzed using novel semi-automated software designed for 3D measurements of the aortic root, which uses multiplanar reconstruction, similar to CT analysis. Aortic annulus measurements included area, perimeter, and diameter calculations from these measurements. The results were compared to CT-derived values. Additionally, 3D echocardiographic measurements (3D planimetry and mitral valve analysis software adapted for the aortic valve) were also compared to the CT reference values. RESULTS: 3DTEE image quality was sufficient in 90% of patients for aortic annulus measurements using the new software, which were in good agreement with CT (r-values: .89-.91) and small (<4%) inter-modality nonsignificant biases. Repeated measurements showed <10% measurements variability. The new 3D analysis was the more accurate and reproducible of the existing echocardiographic techniques. CONCLUSIONS: Novel semi-automated 3DTEE analysis software can accurately measure aortic annulus in patients with severe AS undergoing TAVR, in better agreement with CT than the existing methodology. Accordingly, intra-procedural TEE could potentially replace CT in patients where CT carries significant risk.

Late Manifestation of Coronary Sinus and Left Atrial Perforation of a Left Ventricular Pacemaker Lead at Extraction.

A 56-year-old man presented for lead extraction of a left ventricular (LV) lead that had been deactivated due to hiccups and of a right ventricular (RV) lead with a high threshold. Pus was noted upon entering the pocket. The right atrial and RV leads were extracted, but traction on the LV lead caused ischemia and was not performed. An echocardiogram demonstrated the lead in the left atrium and a robotic-assisted thoracotomy was used to remove the lead that had unroofed the coronary sinus, gone into the left atrium, and perforated through the free wall into the pericardium.

Routine External Iliac Artery Cannulation in Robotic Cardiac Surgery: Role of the Corona "Vitae" in Distal Limb Perfusion.

OBJECTIVE: Femoral artery cannulation is the most commonly used approach for cardiopulmonary bypass (CPB) in robotic cardiac procedures. However, without adding a distal perfusion cannula, leg ischemia can occur in up to 11.5% of patients. There is a well-described 2 to 4 mm size arterial branch that originates from the medial side of the external iliac artery or inferior epigastric artery, immediately above the inguinal ligament, and connects to the obturator artery. Therefore, it was historically named the corona mortis, which means "crown of death" in Latin. When peripheral cannulation is performed above this branch in the external iliac artery, we consider it a corona "vitae" because of its role as a limb-saving collateral. We report herein our standard technique of peripheral cannulation without the need of a distal perfusion cannula and preventing limb ischemia. METHODS: We included all patients who underwent robotic cardiac surgery with peripheral cannulation over a 16-month period at our institution. We cannulated just above the level of the inguinal ligament through a 2 to 3 cm transverse skin incision. The incidence of limb ischemia and vascular complications was recorded and analyzed. RESULTS: During the study period, 133 patients underwent robotic cardiac procedures with peripheral "external iliac" CPB. The size of the cannula was 21F or larger in 73% and 23F in 54% of the patients. No leg ischemia or femoral artery complications requiring additional intervention occurred. CONCLUSIONS: External iliac cannulation can be successfully performed in robot-assisted cardiac surgery using relatively large cannulas without the need of a distal limb perfusion catheter, with good results. In our view, given the importance of the corona mortis ("crown of death" in Latin) in perfusing the limb during CPB, we propose a new name for this artery in robotic cardiac surgery, namely, the corona vitae ("crown of life" in Latin).

Robotic unroofing of myocardial bridge of the left anterior descending coronary artery in a patient with hypertrophic obstructive cardiomyopathy and previous septal myectomy.

A 56-year-old female diagnosed with hypertrophic obstructive cardiomyopathy and myocardial bridge (MB) of the left anterior descending (LAD) coronary artery underwent septal myectomy with resolution of her left ventricular outflow tract gradient. She had ongoing refractory symptoms of exertional angina and fatigue for over a decade and finally presented to our clinic to be re-evaluated for treatment. Provocative angiographic testing confirmed significant ischemia secondary to LAD MB. She underwent robotic totally endoscopic off pump unroofing of the LAD MB with complete relief of her symptoms and return to full activity. We conclude that patients undergoing septal myectomy for hypertrophic obstructive cardiomyopathy should be evaluated for MB and undergo unroofing of the bridge at the time of surgery. Learning objective: A myocardial bridge (MB) is a condition in which a coronary artery, most often the left anterior descending, takes an intramuscular route and is covered by the myocardium leading to compression and potential ischemia. This case report adds to the growing body of evidence supporting the significance of considering MB in the overall management of hypertrophic obstructive cardiomyopathy, and the symptomatic relief that a patient can obtain from an unroofing procedure.

A Retrospective Evaluation of Endo-Aortic Balloon Occlusion Compared to External Clamping in Minimally Invasive Mitral Valve Surgery.

We compare outcomes of endo-aortic balloon occlusion (EABO) vs external aortic clamping (EAC) in patients undergoing minimally invasive mitral valve surgery (MIMVS) in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database. Adults undergoing mitral valve surgery (July 2017-December 2018) were identified within the STS database (N = 60,607). Total 7,978 patients underwent a minimally invasive approach (including robotically assisted). About 1,163 EABO patients were 1:1 propensity-matched to EAC patients using exact matching on age, sex, and type of mitral procedure, and propensity score average matching for 16 other risk indicators. Early outcomes were compared. Categorical variables were compared using logistic regression; hospital and intensive care unit length of stay were compared using negative binomial regression. In the matched cohort, mean age was 62 years; 35.9% were female, and 86% underwent mitral valve repair. Cardiopulmonary bypass time was shorter for EABO vs EAC group (125.0 ± 53.0 vs 134.0 ± 67.0 minutes, P = 0.0009). There was one aortic dissection in the EAC group and none in the EABO group (P value > 0.31), and no statistically significant differences in cross-clamp time, major intraoperative bleeding, perioperative mortality, stroke, new onset of atrial fibrillation, postoperative acute kidney injury, success of repair. Median hospital LOS was shorter for EABO vs EAC procedures (4 vs 5 days, P < 0.0001). In this large, retrospective, STS database propensity-matched analysis ofpatients undergoing MIMVS, we observed similar safety outcomes for EABO and EAC, including no aortic dissections in the EABO group. The EABO group showed slightly shorter CPB times and hospital LOS.