Outcomes of Surgical Bioprosthetic Aortic Valve Replacement in Patients Aged ≤65 and >65 Years.

BACKGROUND: Implantation of a bioprosthetic valve is a reasonable choice for patients aged > 65 years. For middle-aged patients there is less certainty about whether a mechanical or bioprosthetic valve is best. METHODS: The Pericardial Surgical Aortic Valve Replacement (PERIGON) Pivotal Trial is evaluating the safety and efficacy of the Avalus bioprosthesis (Medtronic). We evaluated clinical and echocardiographic outcomes through 5 years of follow-up, stratified by age ≤ 65 and >65 years. RESULTS: Two hundred seventy-one patients (24.2%) were ≤65 years old and 847 (75.8%) >65 years old. Most patients in both groups were men (217 [80.1%] vs 623 [73.6%], respectively; P = .031). Younger patients had a lower Society of Thoracic Surgeons risk of mortality (1.1% ± 0.9% vs 2.2% ± 1.4%, P < .001), better baseline New York Heart Association class (P = .004), and fewer comorbidities than older patients. At 5 years mortality was lower among younger than older patients (5.3% vs 14.0%, P < .001) and no cases of structural valve deterioration occurred in either group. Effective orifice area was similar between age groups (P = .11), and mean gradient was 13.9 ± 5.4 vs 12.0 ± 4.1 mm Hg (P < .001). Multivariable linear regression identified several parameters associated with mean aortic gradient at 5 years, including baseline age and mean aortic gradient, discharge stroke volume index and EOA, and implanted valve size. Ninety-five percent of patients were in New York Heart Association class I/II through 5 years in both age groups (P = .85). CONCLUSIONS: Findings from this analysis demonstrate satisfactory safety, hemodynamic performance, and durability of the Avalus bioprosthesis through a 5-year follow-up in patients aged ≤ 65 and >65 years.

A Case of Systolic Anterior Motion After Mitral Valve Repair Causing Hemolytic Anemia: Mechanism and Treatment.

Hemolytic anemia after mitral valve repair and ring annuloplasty is uncommon when compared with mitral valve replacement. In this report we present the case of a 67-year-old woman who had undergone mitral valve repair with a Duran band and developed hemolytic anemia. Most patients with severe hemolysis after mitral valve repair undergo reoperation. However, in the present case, the hemolysis was found to be secondary to systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction and was treated without the need for reoperation.

Dynamic Patient-Specific Three-Dimensional Simulation of Mitral Repair: Can We Practice Mitral Repair Preoperatively?

OBJECTIVE: Planned mitral repair strategies are generally established from preoperative echocardiography; however, specific details of the repair are often determined intraoperatively. We propose that three-dimensional printed, patient-specific, dynamic mitral valve models may help surgeons plan and trial all the details of a specific patient's mitral repair preoperatively. METHODS: Using preoperative echocardiography, segmentation, modeling software, and three-dimensional printing, we created dynamic, high-fidelity, patient-specific mitral valve models including the subvalvular apparatus. We assessed the accuracy of 10 patient mitral valve models anatomically and functionally in a heart phantom simulator, both objectively by blinded echocardiographic assessment, and subjectively by two mitral repair experts. After this, we attempted model mitral repair and compared the outcomes with postoperative echocardiography. RESULTS: Model measurements were accurate when compared with patients on anterior-posterior diameter, circumference, and anterior leaflet length; however, less accurate on posterior leaflet length. On subjective assessment, Likert scores were high at 3.8 ± 0.4 and 3.4 ± 0.7, suggesting good fidelity of the dynamic model echocardiogram and functional model in the phantom to the preoperative three-dimensional echocardiogram, respectively. Mitral repair was successful in all 10 models with significant reduction in mitral insufficiency. In two models, mitral repair was performed twice, using two different surgical techniques to assess which provided a better outcome. When compared with the actual patient mitral repair outcome, the repaired models compared favorably. CONCLUSIONS: Complex mitral valve modeling seems to predict an individual patient's mitral anatomy well, before surgery. Further investigation is required to determine whether deliberate preoperative practice can improve mitral repair outcomes.

Reason and Timing for Conversion to Sternotomy in Robotic-Assisted Coronary Artery Bypass Grafting and Patient Outcomes.

OBJECTIVE: Conversion to sternotomy is a primary bailout method for robotically assisted coronary artery bypass grafting procedures. The aims of this study were to identify the primary reasons for conversion from robotically assisted coronary artery bypass grafting to sternotomy and to evaluate the in-hospital outcomes in such patients. METHODS: Prospectively collected data from February 2004 to April 2017 were reviewed for 72 patients (56 men; mean age = 63.8 years) who required conversion to sternotomy during a robotically assisted coronary artery bypass grafting procedure with planned endoscopic left internal thoracic artery harvest and anastomosis to the left anterior descending on the beating heart. RESULTS: The overall rate of conversion was 12.4% (72/581). Conversions occurred either during attempted endoscopic left internal thoracic artery harvest (31.9%), during endoscopic left anterior descending isolation (40.3%), during manual isolation and anastomosis of the left anterior descending (19.4%), or after anastomosis due to unsatisfactory flow (8.3%). Overall, the most common reason for conversion was an intramyocardial left anterior descending (43.1%). The median stay in the intensive care unit was 1 day (range = 0-20) and the median hospital length of stay was 5 days (range = 3-43). In-hospital complications included new atrial fibrillation (16.7%), need for blood transfusion (20.8%), mediastinitis (4.2%), postoperative myocardial infarction (2.8%), exploration for bleeding (2.8%), and 1 in-hospital death. CONCLUSIONS: The reasons for conversion were primarily related to anatomical factors that created difficulties for endoscopic left internal thoracic artery harvesting and left anterior descending identification. Patients who required conversion to sternotomy from robotically assisted coronary artery bypass grafting demonstrated acceptable outcomes and low complication rates.

A Prospective Randomized Study of Endoscopic Versus Conventional Harvesting of the Radial Artery.

OBJECTIVE: The aims of the study were to determine whether endoscopic harvesting of the radial artery (RA) reduces morbidity due to pain, infection, and disability with improvement in satisfaction and cosmesis compared to the conventional technique and (2) to compare the 6-month angiographic patency of the RA harvested conventionally and endoscopically. METHODS: In a prospective randomized study, 119 patients undergoing coronary artery bypass grafting using the RA were randomized to have RA harvested either conventionally (n = 59) or endoscopically (n = 60). RESULTS: Radial artery harvest time (open wound time) was significantly reduced in the endoscopic group (36.5 ± 9.4 vs 57.7 ± 9.4 minutes, P < 0.001). Only one patient developed wound infection (1.6%) in the endoscopic group compared with six patients (10.2%), P = 0.061, in the conventional group. Although this was not statistically significant, clinically this was relevant in terms of reduction in postoperative morbidity. Postoperative pain in the arm incision was significantly lower in the endoscopic group at postoperative day 2 (P < 0.001) and at discharge (P < 0.001) and similar to the conventional open group at 6 weeks' follow-up (P = 0.103). Overall patient satisfaction and cosmesis were significantly better in the endoscopic group at postoperative day 2 (P < 0.001), at discharge (P < 0.001), and at 6 weeks' follow-up (P < 0.001). There was no difference in the arm disability postoperatively (P = 0.505) between the two groups. Six-month angiographic assessment of 23 patients (12 endoscopic and 11 open) revealed no difference in the patency rate (10/12 in endoscopic and 9/11 in open group). CONCLUSIONS: Endoscopic RA harvesting reduced the incidence of postoperative wound infection and wound pain and improved patient satisfaction and cosmesis compared with conventional harvesting technique. There was no difference in the 6-month angiographic patency of the RA harvested conventionally and endoscopically.

Consequences of Hybrid Procedure Addition to Robotic-Assisted Direct Coronary Artery Bypass.

OBJECTIVE: Patients postcoronary artery revascularization surgery often receives blood product transfusion, which could delay their intensive care unit and hospital discharge. We investigated our robotic-assisted direct coronary artery bypass (RADCAB) transfusion rate to determine whether performing the minimal invasive coronary surgery with percutaneous coronary intervention in one stage would increase the incidence of blood transfusion, morbidity, and length of stay. METHODS: Between November 2003 and November 2015, 483 consecutive patients underwent RADCAB surgery. They were divided into two groups. Group 1 (147 patients; mean ± SD age, 61.2 ± 11 years; 23% females) underwent robotic-assisted hybrid coronary artery revascularization with left internal thoracic artery to the left anterior descending coronary artery with percutaneous coronary intervention to a nonleft anterior descending coronary artery vessel in the same stage. Group 2 (336 patients; mean ± SD age, 61.2 ± 10.5 years; 25% females) underwent nonhybrid RADCAB. Early and late postoperative follow-up at mean ± SD of 83.6 ± 11.1 months was obtained. RESULTS: Blood transfusion rate in group 1 was statistically different, as illustrated in Table 2. Based on the intraoperative cardiac catheterization, the incidence of graft revision was higher in the nonhybrid group. There was no difference between the two groups in terms of renal failure, neurological complication, prolonged mechanical ventilation, and gastrointestinal bleed. CONCLUSIONS: Despite similar preoperative demographics in the two groups, we have observed a significant difference in the blood transfusion rate in group 1. However, this did not lead into a statistically significant re-exploration rate for bleeding. Hence, we assume that dual antiplatelet therapy usage in the hybrid group might be the cause of the increase in blood transfusion rate. Nevertheless, it did not affect postoperative morbidity and length of hospital stay. A randomized multicenter clinical trial is needed.

Endoscopic Conduit Harvest in Coronary Artery Bypass Grafting Surgery: An ISMICS Systematic Review and Consensus Conference Statements.

OBJECTIVE: The purpose of this consensus conference was to develop and update evidence-informed consensus statements and recommendations on harvesting saphenous vein and radial artery via an open as compared with endoscopic technique by systematically reviewing and performing a meta-analysis of randomized and nonrandomized clinical trials. METHODS: All randomized controlled trials and nonrandomized controlled trials included in the first the International Society for Minimally Invasive Cardiothoracic Surgery Consensus Conference and Statements, in 2005 up to November 30, 2015, were included in a systematic review and meta-analysis. Based on the resultant, 76 studies (23 randomized controlled trials and 53 nonrandomized controlled trials) on 281,459 patients analyzed, consensus statements, and recommendations were generated comparing the risks and benefits of endoscopic versus open conduit harvesting for patients undergoing coronary artery bypass grafting. RESULTS: Compared with open vein harvest, it is reasonable to perform endoscopic vein harvest of saphenous vein to reduce wound-related complications, postoperative length of stay, and outpatient wound management resources and to increase patient satisfaction (class I, level A). Based on the quality of the conduit and major adverse cardiac events as well as 6-month angiographic patency, endoscopic vein harvest was noninferior to open harvest. It is reasonable to perform endoscopic radial artery harvest to reduce wound-related complication and to increase patient satisfaction (class I, level B-R and B-NR, respectively) with reduction in major adverse cardiac events and noninferior patency rate at 1 and 3 to 5 years (class III, level B-R). CONCLUSIONS: Based on the consensus statements, the consensus panel recommends (class I, level B) that endoscopic saphenous vein and radial artery harvesting should be the standard of care for patients who require these conduits for coronary revascularization.

Ultrafast Track Robotic-Assisted Minimally Invasive Coronary Artery Surgical Revascularization.

OBJECTIVE: Contemporary anesthetic techniques have enabled shorter sedation and early extubation in off-pump and minimally invasive coronary artery bypass (CABG) surgery. Robotic-assisted CABG represents the optimal surgical approach for ultrafast track anesthesia, with patients able to bypass the cardiac surgical intensive care unit with recovery in the postanesthesia care unit (PACU) and inpatient ward. METHODS: In-hospital postoperative outcomes from ninety patients who underwent either elective or urgent robotically-assisted CABG at our institution were reviewed. These patients were carefully selected by a multidisciplinary team to undergo fast-track anesthesia: extubation in the operating room, 4-hour recovery in the postanesthesia care unit and transfer to the inpatient ward. Intrathecal, paravertebral local, and patient-controlled anesthesia techniques were used to facilitate transition to oral analgesics. RESULTS: Average patient age was 61 ± 9 years. Sixty-six patients (73%) were male. Seventy cases were elective, and 20 patients required urgent revascularization. All patients underwent intraoperative angiography after graft construction, which revealed Fitzgibbon class A grafts. There were no in-hospital mortalities. One patient required re-exploration for bleeding, through the same minimally invasive incision, did not require conversion to sternotomy for bleeding, and was transferred to the intensive care unit postexploration for bleeding for standard postoperative care. Postoperative complications were limited to one superficial wound infection. The mean hospital length of stay was 3.5 ± 1.17 days. CONCLUSIONS: In patients undergoing robotic-assisted CABG, ultrafast-track cardiac surgery with immediate postprocedure extubation and transfer to the inpatient ward has been demonstrated to be safe with no increase in perioperative morbidity or mortality. It requires a dedicated heart team with a carefully selected group of patients. Avoiding cardiac surgical intensive care unit expedites recovery, with possible avoidance of infection and early discharge from hospital.

Is the Future of Coronary Arterial Revascularization a Hybrid Approach?: The Canadian Experience Across Three Centers.

OBJECTIVE: Hybrid coronary revascularization offers and combines the advantages of both surgical and percutaneous revascularization and eliminates at the same time the disadvantages of both procedures. The objective of this study was to assess graft and stent patency at 6 months, rate of bleeding, intensive care unit and hospital stay, rate of reintervention, and long-term clinical follow-up. METHODS: From March 2004 to November 2015, a total of 203 patients underwent robotic-assisted minimally invasive direct coronary artery bypass graft of the left internal thoracic artery to the left anterior descending artery and PCI of a non-left anterior descending vessel in a single or two stage, at three different centers. Patients underwent 6-month angiographic follow-up. The mean ± SD clinical follow-up was 77.82 ± 41.4 months. RESULTS: Successful hybrid coronary revascularization occurred in 196 of the 203 patients. One hundred forty-six patients underwent simultaneous surgical and percutaneous intervention. Nineteen patients underwent PCI before surgery, and 38 patient underwent PCI after surgery. No in-hospital mortality occurred. The mean ± SD ICU stay was 1 ± 1 days and the mean ± SD hospital stay was 5 ± 2 days. Only 13.3% of the patients required a blood transfusion. Six-month angiographic follow-up has been performed in the 95 patients, and it demonstrated a left internal thoracic artery anastomotic patency of 97.9% and stent patency of 92.6%. A total of 77.8 ± 41.4-month clinical follow-up demonstrated 95.1% survival, 92.6% freedom from angina, and 90.7% freedom from any form of coronary revascularization. CONCLUSIONS: Hybrid coronary revascularization seems to be a promising and safe revascularization strategy. It provides selected patients with an alternative, functionally complete revascularization with minimal surgical trauma and good long-term clinical outcomes.

Phantom study of an ultrasound guidance system for transcatheter aortic valve implantation.

A guidance system using transesophageal echocardiography and magnetic tracking is presented which avoids the use of nephrotoxic contrast agents and ionizing radiation required for traditional fluoroscopically guided procedures. The aortic valve is identified in tracked biplane transesophageal echocardiography and used to guide stent deployment in a mixed reality environment. Additionally, a transapical delivery tool with intracardiac echocardiography capable of monitoring stent deployment was created. This system resulted in a deployment depth error of 3.4mm in a phantom. This was further improved to 2.3mm with the custom-made delivery tool. In comparison, the variability in deployment depth for traditional fluoroscopic guidance was estimated at 3.4mm.

Complete Obliteration of the Left Atrial Appendage: An Analysis of Epicardial Excision and Novel Pericardial Patch Exclusion.

OBJECTIVE: Conventional epicardial excision is believed to be the most effective method of surgically obliterating the left atrial appendage (LAA), although incomplete resection and residual LAA volume may undermine its effectiveness. We sought to compare the impact of conventional epicardial excision with a novel LAA pericardial patch exclusion on residual LAA volume. METHODS: We performed LAA obliteration using pericardial patch exclusion, followed by conventional epicardial excision, in 27 cadaveric hearts. After each procedure, residual LAA volume was measured by two different techniques and compared with baseline volume. There was no difference in baseline LAA volume between each procedure. RESULTS: Procedural success was achieved in all hearts. Conventional epicardial excision left a residual LAA volume of 0.95 mL (24%), as compared with pericardial patch exclusion, which left a residual volume of 0.17 mL (4%, P = 0.0001). Further analysis of fixed and fresh hearts showed that reduction of LAA volume was more pronounced in the fresh hearts, suggesting effectiveness in live patients. Neither technique resulted in any significant change in the endocardial shape of the LAA orifice or injury to the circumflex artery. CONCLUSIONS: Conventional epicardial excision of the LAA results in significantly more residual LAA volume, which may have important implications in persistent stroke risk. Pericardial patch exclusion seems to achieve near-total elimination of the LAA and may be a superior surgical option.

An Early Canadian Experience With the Correx Automated Coring and Apical Connector Device for Aortic Valve Bypass.

OBJECTIVE: Aortic valve replacement is the standard of care for severe, symptomatic aortic valve stenosis (AS); however, anatomy or pre-existing comorbidities may preclude conventional or alternative transcatheter approaches. Aortic valve bypass (AVB) may be performed as a salvage procedure for the relief of symptomatic aortic stenosis in patients who are not suitable candidates for aortic valve replacement. METHODS: At our institution, seven patients underwent AVB using the Correx automated coring and apical connector system. All patients had severe AS with New York Heart Association functional class 3 symptoms and were not candidates for conventional or transcatheter approaches. Via a left anterolateral thoracotomy to access the descending aorta and left ventricular apex, we used the Correx system (Correx, Waltham, MA USA) to anastomose a valve conduit to the left ventricular apex proximally and the descending aorta distally. Three patients required cardiopulmonary bypass. RESULTS: In all seven patients, the automated coring and apical connector was successfully deployed. There were two in-hospital deaths in this series. Immediately postoperatively and at 3 months, there was a significant reduction in mean and peak valve gradients, and all surviving patients performed at New York Heart Association functional class 1. CONCLUSIONS: Aortic valve bypass seems to be an acceptable alternative for the treatment of severe AS in high-risk patients who are not candidates for aortic valve replacement. The Correx automated system may improve the clinical applicability and surgical reproducibility of AVB in appropriately selected patients in which conventional or transcatheter aortic valve replacement is not a feasible options.

Analysis of the learning curve in telerobotic, beating heart coronary artery bypass grafting: a 90 patient experience.

BACKGROUND: Recent articles have commented on the "learning curve" in robotic-assisted coronary artery bypass grafting. We systematically studied this phenomenon using standard statistical and cumulative sum (CUSUM) failure methods. METHODS: Ninety patients underwent internal thoracic artery (ITA) takedown and an attempt at ITA to coronary bypass on the beating heart using the Zeus telerobotic system from September 1999 to December 2001. The rates of mortality and 11 predefined major complications were compared in five quintiles of 18 consecutive patients each and a CUSUM curve was generated for the entire cohort. RESULTS: All patients but one underwent successful endoscopic ITA takedown. Thirteen patients had a totally endoscopic anastomosis, whereas in 61 a small mini-thoracotomy or mini-sternotomy was used. Sixteen patients (17.8%) were converted electively to a sternotomy: 11 patients underwent off-pump and 5 patients on-pump surgery. There were no deaths; 13 patients (14.4%) incurred one or more of the 11 major complication(s), including 5, 1, 2, 3, and 2 in each of the five quintiles (p = 0.39). Standard statistical analyses identified a significant decrease in operating room time (p < 0.0001), as well as a decrease in the incidence of an occluded graft or wrong vessel grafted from quintiles 1 to 5 (p = 0.03). On CUSUM analysis, the failure curve was steep for the first 18 to 20 patients, before moderating its slope for the remainder of the experience. CONCLUSIONS: Robotic ITA to coronary bypass on the beating heart has a moderately steep learning curve, which is mitigated by further experience. CUSUM analysis complimented standard statistical methods in detecting a cluster of suboptimal results during the early experience with this procedure.

Intraoperative left atrial ablation (for atrial fibrillation) using a new argon cryocatheter: early clinical experience.

PURPOSE: Recently surgical treatment of atrial fibrillation has gained more popularity and presently is being performed in large numbers of patients. This report describes our early experience in treatment of patients with chronic or paroxysmal atrial fibrillation with a new tool for left atrial cryoablation. DESCRIPTION: From July 2002 through January 2003, 28 patients underwent left atrial cryoablation with the Surgifrost CryoCath. Patients underwent cryotherapy as an isolated procedure (n = 1), in combination with mitral valve surgery (n = 13), or with other surgical procedures (n = 14). In all patients contiguous lesion lines to the orifices of the pulmonary veins connected to the mitral annulus and the atriotomy were created. Surgery was performed through a conventional sternotomy in 8 patients (29%) and a right lateral minithoracotomy using video-assistance in 20 patients (71%). EVALUATION: Postoperatively sinus rhythm was restored in 27 patients (96%). At discharge 82% (23/28) of patients were in sinus rhythm and 18% (5/28) were in atrial fibrillation. Four patients (14%) required pacemaker implantation. There was no in-hospital mortality. At 6-months follow-up (19/28 patients) all were alive and 74% were in stable sinus rhythm, New York Heart Association functional class was 1.2 +/- 0.4. CONCLUSIONS: As indicated by our small and early patient cohort left atrial cryoablation with the Surgifrost argon cryocatheter is effective for the treatment of atrial fibrillation. This new device is technically easy to handle, it can be applied through a median sternotomy or lateral minithoracotomy. Long-term follow-up is necessary to evaluate further rhythm outcome.

Limitations for manual and telemanipulator-assisted motion tracking--implications for endoscopic beating-heart surgery.

BACKGROUND: Surgical performance is limited by human factors. Beating-heart surgery requires full dexterity and motion tracking. Currently techniques for total endoscopic beating-heart bypass grafting using telemanipulation systems are being developed. The aim of this study was to assess the limitations for manual and telemanipulator-assisted motion tracking using the da Vinci telemanipulator system. METHODS: To simulate beating-heart conditions an endoscopic trainer was developed. Twenty subjects were asked to touch targets manually and with telemanipulator assistance with different patterns of increasing index of difficulty (resting model, unstabilized, and stabilized model with a frequency of 35, 60, and 90 beats per minute). In addition one task was performed using different scaling ratios on a resting model. The times between hits as well as errors were electronically recorded. RESULTS: There was no significant impact of various frequencies and amplitudes for manual tracking. The average values for the delay (k(m)[ms]) and information-processing (c(m) [ms/bit]) constants for the manual tasks were 201 ms and 86 ms/bit respectively. Both the delay constant (k(t) = 630 ms; p < 0.0005) and the information-processing constant (c(t) = 250 ms/bit; p < 0.0005) were increased for the telemanipulator-assisted tasks at rest. When working on moving targets telemanipulator-assisted tracking required significantly more time and led to more errors. At a frequency of 90 beats per minute telemanipulator-assisted tracking became more difficult. CONCLUSIONS: Endoscopic beating-heart bypass grafting requires optimal stabilization to avoid inaccuracies due to incomplete motion tracking. At higher frequencies telemanipulator-assisted tracking became more difficult, demonstrating the technical limits of current telemanipulator technology.

Evaluating the effect of three-dimensional visualization on force application and performance time during robotics-assisted mitral valve repair.

OBJECTIVE: The purpose of this study was to determine the effect of three-dimensional (3D) binocular, stereoscopic, and two-dimensional (2D) monocular visualization on robotics-assisted mitral valve annuloplasty versus conventional techniques in an ex vivo animal model. In addition, we sought to determine whether these effects were consistent between novices and experts in robotics-assisted cardiac surgery. METHODS: A cardiac surgery test-bed was constructed to measure forces applied during mitral valve annuloplasty. Sutures were passed through the porcine mitral valve annulus by the participants with different levels of experience in robotics-assisted surgery and tied in place using both robotics-assisted and conventional surgery techniques. RESULTS: The mean time for both the experts and the novices using 3D visualization was significantly less than that required using 2D vision (P < 0.001). However, there was no significant difference in the maximum force applied by the novices to the mitral valve during suturing (P = 0.7) and suture tying (P = 0.6) using either 2D or 3D visualization. The mean time required and forces applied by both the experts and the novices were significantly less using the conventional surgical technique than when using the robotic system with either 2D or 3D vision (P < 0.001). CONCLUSIONS: Despite high-quality binocular images, both the experts and the novices applied significantly more force to the cardiac tissue during 3D robotics-assisted mitral valve annuloplasty than during conventional open mitral valve annuloplasty. This finding suggests that 3D visualization does not fully compensate for the absence of haptic feedback in robotics-assisted cardiac surgery.

Investigating perioperative heart migration during robot-assisted coronary artery bypass grafting interventions.

OBJECTIVE: : For robot-assisted coronary artery bypass graft interventions, surgeons typically use a preoperative thoracic computed tomography scan of the patient to plan the procedure. However, the cardiac anatomy is prone to changes induced perioperatively in the effort to access the heart and surgical targets, which, in turn, may invalidate the initial plan. This article presents a method to estimate the perioperative heart migration, information which can be further exploited to refine the preoperative surgical plan. METHODS: : Tracked transesophageal ultrasound images of four patients' hearts were acquired at each stage in the procedure: before lung deflation, after lung deflation, and after both lung deflation and CO2 thoracic insufflation. Anatomic features of interest-the mitral and aortic valves-were identified from each dataset, and their movement between the different procedure stages was recorded and used to estimate the global heart displacement. Moreover, the local morphology of the features of interest was investigated to provide insight on the extent of the deformation the heart has undergone during the workflow. RESULTS: : The study suggested that the heart does undergo substantial displacement-on the order of 10 to 15 mm in each direction (axial, coronal, and sagittal) after lung deflation and CO2 thoracic insufflation. However, no significant differences (P > 0.1) were observed in the morphologic characteristics of the features of interest across the multiple workflow stages, suggesting that local deformations occur at a much smaller scale compared with the global migration. CONCLUSIONS: : The quantification of the perioperatively induced changes is critical to track the displacement of the heart and surgical targets. The recorded migration patterns should not be ignored but rather be used to update the surgical plan to better suit the intraoperative environment.