Contemporary suprasternal transcatheter aortic valve replacement: A multicenter experience using a simple, reliable alternative access approach.

OBJECTIVES: To describe outcomes after suprasternal (SS) transcatheter aortic valve replacement (TAVR) as a new alternative access approach. BACKGROUND: There still remains a cohort of the TAVR population who are not suitable for a transfemoral (TF) approach. SS-TAVR is a safe and effective alternative to TF-TAVR and has now become our preferred alternative access route. METHODS: We retrospectively reviewed all patients from New York Presbyterian Hospital, Columbia University Medical Center and Princeton Baptist Medical Center who underwent SS-TAVR from 2015 to July 2018. A total of 84 patients were included in the study. RESULTS: Technical success was achieved in all cases. Thirty-day survival was 98.8% (n = 83). There were minimal complications. Most notably, there were no transient ischemic attacks or strokes (0%, n = 0). Reexploration for bleeding was 3.6% (n = 3), and major bleeding was 1.7% (n = 1). We also achieved satisfactory results with a mean aortic valve gradient of 6.07 ± 3.79 mmHg and an aortic valve area of 2.21 ± 0.51 cm2 . No patients had anything more than mild paravalvular leak. The mean length of stay (LOS) in the intensive care unit was 1.42 ± 1.23 days, and hospital LOS was 4.20 ± 3.29 days. CONCLUSIONS: SS access for TAVR is an extremely important technique to have in any valve team's alternative access armamentarium. This technique can be safely and reliably reproduced with any standard hybrid operating room setup and no additional equipment, and it can be used with any commercially available valve system. In the current experience, minimal complications and excellent early term results were obtained.

Robotic mitral valve repair in a type B hemophiliac.

Hemophilia B is a rare X-linked recessive disorder that places surgical patients at an increased risk of bleeding. Patients with hemophilia are now achieving near-normal life expectancies and therefore the number of these patients requiring cardiac surgery due to the development of age-related cardiovascular disease may increase. We present the case of a young male with hemophilia B who was diagnosed with severe symptomatic mitral regurgitation and underwent successful robotic mitral valve repair. To our knowledge, this is the first report of a patient with hemophilia B who underwent robotic mitral valve repair.

Usefulness of two- and three-dimensional transesophageal echocardiography in combined mitral valve-in-valve implantation and paraprosthetic leak closure.

We demonstrate the usefulness of two- and live/real time three-dimensional transesophageal echocardiography in a procedure, which combined transcatheter mitral valve-in-valve deployment and paraprosthetic leak closure in the same setting using the less invasive transfemoral approach in an adult patient with bioprosthetic mitral valve degeneration. We also highlight the additive value of three-dimensional echocardiography over the two-dimensional technique.

Does pre-operative magnetic resonance imaging of the lumbar multifidus muscle predict clinical outcomes following lumbar spinal decompression for symptomatic spinal stenosis?

PURPOSE: To investigate whether pre-operative magnetic resonance imaging (MRI) of the lumbar multifidus muscle (LMM) would predict clinical outcomes following lumbar spinal decompression for symptomatic spinal stenosis. METHODS: A prospective cohort of patients with symptomatic neurogenic claudication, documented spinal stenosis on pre-operative MRI underwent spinal decompression. All subjects completed standardised outcome measures (Core Outcome Measures Index (COMI), Oswestry Disability Index (ODI v2.1) pre-operatively, 1 and 2 years post-surgery. Surgery was performed using a standardised lumbar spinous process osteotomy for access, followed by a decompression of the central canal, lateral recess and foraminal zones as indicated by the pre-operative MRI. Lumbar MRI scans were evaluated by two independent observers who assessed the axial CSA of the LMM bilaterally and the degree of muscle atrophy according to the Kader classification (2000). Changes in COMI and ODI scores at 1 and 2 years were investigated for statistically significant correlations with CSA of LMM and Kader grading. Statistical analyses utilised Student's t test, kappa coefficient for inter-observer agreement and Bland-Altman Limits of Agreement (BALOA). RESULTS: 66 patients (41 female) aged between 29 and 86 years underwent single-level decompression in 44, two-level decompression in 16 and three-level decompression in 6 cases. No significant correlation was observed between improvements in ODI and COMI relative to age, degree of stenosis, posterior fat thickness or psoas CSA. Those subjects with the greatest LMM atrophy relative to psoas CSA and L5 vertebral body area on pre-operative MRI had the least absolute improvement in both ODI and COMI scores (p = 0.006). CONCLUSIONS: Reduced LMM CSA (<8.5 cm2) and muscle atrophy were associated with less favourable outcomes following lumbar spinal decompression. Pre-operative CSA of LMM appeared to be a more reliable predictor of post-operative clinical outcomes compared to the Kader Grading Score. This is the first study to investigate the prognostic value of pre-operative MRI appearance and CSA of LMM with respect to post-operative outcome following lumbar decompression surgery. Healthy pre-operative LMM is associated with better outcomes following lumbar spinal decompression.

Rescue of False Lumen Frozen Elephant Trunk Deployment Intraoperatively.

Endovascular devices have become increasingly available, which has led to an increase in use of frozen elephant trunk stents for extended repair during type A aortic dissection. Frozen elephant trunk deployment is usually done under direct visualization of both the true and false lumen but rarely, the endograft can inadvertently end in the false lumen. This can lead to false lumen pressurization and end-organ malperfusion. Herein we describe a novel intraoperative rescue technique for misplaced frozen elephant trunk into the false lumen, easily executed in a standard operating room using transesophageal echocardiography and intravascular ultrasound guidance.

Plasma Exosome Hemoglobin Released During Surgery Is Associated With Cardiac Injury in Animal Model.

BACKGROUND: Patients with valvular heart disease require cardiopulmonary bypass and cardiac arrest. Here, we test the hypothesis that exosomal hemoglobin formed during cardiopulmonary bypass mediates acute cardiac injury in humans and in an animal model system. METHODS: Plasma exosomes were collected from arterial blood at baseline and 30 minutes after aortic cross-clamp release in 20 patients with primary mitral regurgitation and 7 with aortic stenosis. These exosomes were injected into Sprague-Dawley rats and studied at multiple times up to 30 days. Tissue was examined by hematoxylin and eosin stain, immunohistochemistry, transmission electron microscopy, and brain natriuretic peptide. RESULTS: Troponin I levels increased from 36 ± 88 ng/L to 3622 ± 3054 ng/L and correlated with exosome hemoglobin content (Spearman r = 0.7136, < .0001, n = 24). Injection of exosomes isolated 30 minutes after cross-clamp release into Sprague-Dawley rats resulted in cardiomyocyte myofibrillar loss at 3 days. Transmission electron microscopy demonstrated accumulation of electron dense particles of ferritin within cardiomyocytes, in the interstitial space, and within exosomes. At 21 days after injection, there was myofibrillar and myosin breakdown, interstitial fibrosis, elevated brain natriuretic peptide, and left ventricle diastolic dysfunction measured by echocardiography/Doppler. Pericardial fluid exosomal hemoglobin content is fourfold higher than simultaneous plasma exosome hemoglobin, suggesting a cardiac source of exosomal hemoglobin. CONCLUSIONS: Red blood cell and cardiac-derived exosomal hemoglobin may be involved in myocardial injury during cardiopulmonary bypass in patients with valvular heart disease.

Left Anterior Thoracotomy Minimally Invasive Aortic Valve Replacement Following Left Pneumonectomy.

We report the case of a 59-year-old man referred for aortic valve replacement for severe, symptomatic aortic insufficiency who underwent a minimally invasive left anterior thoracotomy aortic valve replacement. This approach was facilitated by his history of a left pneumonectomy for lung cancer 7 years prior to presentation, which resulted in a significant left mediastinal shift. The cannulation strategy and exposure were analogous to what would be expected from a standard right anterior thoracotomy minimally invasive aortic valve replacement. The minimally invasive approach allowed for early extubation and mobilization in a patient with moderate baseline pulmonary dysfunction.

Total Endovascular Arch Repair Using Needle Fenestration and Extracorporeal Membrane Oxygenation.

There remains a clinical need for endovascular repair of the ascending aorta and the aortic arch in patients who are prohibitively high risk for open surgical repair. Herein we present a case of a total endovascular arch repair by means of a novel technique for graft fenestration using a trans-septal needle with extracorporeal membrane oxygenation support. Although the use of trans-septal needle fenestration use has been described, the use in arch fenestrations has not. We present this case as an example of techniques that may be useful in the expanding landscape of endovascular ascending and arch repair.

Robot-assisted aortic valve surgery: State of the art and challenges for the future.

Robotic cardiac surgery was FDA-approved in 2002 and since then several different procedures have been performed to facilitate a truly minimally invasive approach. The use of robotics in aortic valve surgery, however, is still in its infancy. In this article, we report our clinical experience and chronological development with robot-assisted aortic valve surgery. This includes a description of how robotic assistance was gradually integrated during right mini-thoracotomy aortic valve replacement, a series of cases in which the robot was docked for parts of the procedure, a single case of a totally endoscopic robot-assisted aortic valve replacement with a stentless valve, and three cases of aortic valve papillary fibroelastoma resections. All of these were performed safely with early postoperative recovery and excellent clinical results. Additionally, we review the latest literature describing robot-assisted aortic valve surgery. Finally, we describe current issues, and challenges for robot-assisted aortic valve surgery.

Minimally Invasive Redo Mitral Valve Replacement Using a Robotic-Assisted Approach.

Minimally invasive, robotic-assisted cardiac surgery has been shown to decrease transfusion rates, decrease wound infection rates, shorten hospital length of stay, and allow for a faster return to full activity compared with traditional sternotomy approaches. However, its application has chiefly been limited to primary, isolated procedures such as primary mitral valve repair or replacement. We describe the first reported use of a robotic surgery platform to perform reoperative mitral valve replacement using a minimally invasive, totally endoscopic, port-access approach.

Application of an Epicardial Left Atrial Appendage Occlusion Device by a Robotic-Assisted, Right Chest Approach.

Closure of the left atrial appendage (LAA) has become a standard part of any mitral valve operation because it is thought to reduce the potential for late thrombus development and for embolic events. To date, surgeons performing robotic mitral valve operations have been limited to an endocardial approach to LAA closure. However, oversewing the orifice of the LAA is time consuming and lengthens the cross-clamp time, and failures to obtain permanent closure have been reported. We describe our technique for an epicardial approach that is safe and efficient and that gives a secure closure of the LAA.

Minimally Invasive Mitral Valve Surgery III: Training and Robotic-Assisted Approaches.

Minimally invasive mitral valve operations are increasingly common in the United States, but robotic-assisted approaches have not been widely adopted for a variety of reasons. This expert opinion reviews the state of the art and defines best practices, training, and techniques for developing a successful robotics program.

Minimally Invasive Mitral Valve Surgery I: Patient Selection, Evaluation, and Planning.

Widespread adoption of minimally invasive mitral valve repair and replacement may be fostered by practice consensus and standardization. This expert opinion, first of a 3-part series, outlines current best practices in patient evaluation and selection for minimally invasive mitral valve procedures, and discusses preoperative planning for cannulation and myocardial protection.

Minimally Invasive Mitral Valve Surgery II: Surgical Technique and Postoperative Management.

Techniques for minimally invasive mitral valve repair and replacement continue to evolve. This expert opinion, the second of a 3-part series, outlines current best practices for nonrobotic, minimally invasive mitral valve procedures, and for postoperative care after minimally invasive mitral valve surgery.

Concurrent Minimally Invasive Aortic Valve Replacement and Coronary Artery Bypass via Limited Right Anterior Thoracotomy.

An 89-year-old man and an 80-year-old woman were treated surgically for critical aortic stenosis secondary to senile calcific aortic disease and high-grade calcified lesions in the ostium of the right coronary artery. Minimally invasive aortic valve replacement and concurrent coronary artery bypass grafting were performed concurrently through a 5-cm right anterior thoracotomy in the second intercostal space. Surgery was uncomplicated in both cases, with no adverse events. Both patients were alive and well at midterm follow-up. Concurrent minimally invasive aortic valve replacement and coronary artery bypass grafting can be performed successfully through a limited right anterior thoracotomy.

Web-based telerehabilitation for the upper extremity after stroke.

Stroke is a leading cause of disability in the United States and yet little technology is currently available for individuals with stroke to practice and monitor rehabilitation therapy on their own. This paper provides a detailed design description of a telerehabilitation system for arm and hand therapy following stroke. The system consists of a Web-based library of status tests, therapy games, and progress charts, and can be used with a variety of input devices, including a low-cost force-feedback joystick capable of assisting or resisting in movement. Data from home-based usage by a chronic stroke subject are presented that demonstrate the feasibility of using the system to direct a therapy program, mechanically assist in movement, and track improvements in movement ability.

TACT imaging of primary caries.

OBJECTIVE: Tuned-aperture computed tomography, a new method for creating 3-D radiographic information based on optical aperture theory, was evaluated for diagnostic efficacy in primary caries detection. STUDY DESIGN: Sixty-four extracted teeth with 89 carious lesions were imaged with D-speed film, direct digital, and TACT modalities. A commercially available, 8-bit, charge-coupled device was used in the later two modalities. Six trained observers were asked to identify the presence or absence and depth of interproximal and occlusal lesions for all three modalities. The teeth were sectioned and examined microscopically to determine ground truth. Logistic regression analysis was performed for all three imaging systems for the detection task. Analysis of variance was used for depth determination. Detection of lesion, depth of lesion accuracy, and time for diagnosis were also examined. RESULTS: For caries detection TACT and film were not different (p = 0.2216) with the Wald statistic. Film and TACT were significantly more accurate than the digital system (p = 0.0001). Scheffe's post hoc test revealed that TACT and film were more accurate than the direct digital system for determining lesion depth (p = 0.05) but not statistically different when compared with each other. The detection data were substantiated further by receiver operating characteristic analysis that demonstrated similar statistical relationships. Time required per diagnosis was not shown to be statistically different among the three imaging modalities. CONCLUSIONS: We conclude for caries detection and depth determination that TACT could not be distinguished from film despite the significant relative loss of information capacity in the charge-coupled device receptor. The relatively poorer performance yielded by the digital control images suggests that increased information capacity associated with more modern charge-coupled device detectors may improve diagnostic performance for both direct digital and TACT displays over that demonstrated in this investigation.

Robotic repair of sinus venosus atrial septal defect with partial anomalous pulmonary venous return and persistent left superior vena cava.

The presence of partial anomalous pulmonary venous return and/or persistent left superior vena cava (LSVC) is usually viewed as a contraindication for robotic repair of complex atrial septal defects, such as those of the sinus venosus type. Three patients, aged 29, 73, and 23 years, successfully underwent totally endoscopic, robotic-assisted repair of sinus venosus-type atrial septal defect with partial anomalous pulmonary venous return and persistent LSVC. Two different techniques--direct cannulation or placement of a sump sucker--were successfully used to manage venous return from the persistent LSVC.

Concomitant robotic mitral and tricuspid valve repair: technique and early experience.

BACKGROUND: Robotic mitral valve repair has been successfully performed since the late 1990s, but concomitant robotic tricuspid repair has not yet been widely adopted. We report our first 5 years' experience with concomitant robotic mitral-tricuspid valve repair. METHODS: Records were reviewed for all patients who underwent concomitant robotic mitral-tricuspid valve repair in a single practice. Cardiopulmonary bypass was performed with femoral cannulation, antegrade and retrograde cardioplegia, and aortic cross-clamping by balloon occlusion. Access was through 5 ports. Tricuspid repair techniques included De Vega, modified De Vega with annuloplasty band, and annuloplasty band with interrupted suture repair. RESULTS: From August 2006 to December 2011, 50 patients underwent concomitant robotic mitral-tricuspid valve repair. The mean age was 73.4±9.3 years, and all patients had mitral or tricuspid regurgitation grades of 2+ or greater preoperatively. Cross-clamp and cardiopulmonary bypass times decreased significantly with surgeon experience. There were no conversions to sternotomy and one conversion to mitral valve replacement. Six patients required reexploration for bleeding or hemothorax, most of them early in the series. There were no infections, no intraoperative strokes, and no new-onset acute renal failure requiring dialysis. Two postoperative strokes resolved completely. Two patients experienced nitinol clip fracture and mitral ring dehiscence requiring reoperation. There were 2 early deaths. All patients had regurgitation grades of less than 2 at follow-up (p < 0.001). CONCLUSIONS: Combined robotic mitral-tricuspid valve repair can be performed safely and reproducibly, with acceptable early results. Long-term follow-up will be needed to establish this as an alternative to traditional sternotomy approaches.

A case of odontogenic brain abscess arising from covert dental sepsis.

Odontogenic infections can spread to any organ of the body and in some cases cause life threatening infections. We report a case of multiple odontogenic brain abscesses resulting from undetected tooth decay. Whereas most odontogenic brain abscesses occur following dental treatment, this report documents brain abscesses prior to dental treatment, signifying the dangers of covert dental infections. This case report updates the literature on the topic of odontogenic brain abscesses.