Concomitant Tricuspid Valve Surgery Is Not Associated With Increased Operative Risk During Robotic Mitral Valve Surgery.

OBJECTIVE: The aim of this study was to investigate the outcomes of robotic mitral valve surgery with and without concomitant tricuspid valve surgery. METHODS: Patients who underwent robotic mitral surgery between March 2010 and September 2022 were included. Patients were grouped according to the presence of concomitant tricuspid interventions. The groups were compared for baseline factors, operative parameters, and early postoperative outcomes. Age- and gender-matched groups were also compared for outcomes. RESULTS: The study included 285 robotic mitral surgery patients. There were 59 patients who underwent concomitant tricuspid interventions. In the concomitant tricuspid surgery group, cardiopulmonary bypass time (150.1 vs 128.4 min, P < 0.001) and cross-clamp time (99.2 vs 82.4 min, P < 0.001) were longer. Prolonged intubation was more frequent in the concomitant tricuspid intervention group (5.2% vs 0.5%, P = 0.029). The groups did not differ in terms of mortality, permanent pacemaker (PPM) requirement, or other morbidities. Perioperative outcomes were similar after matched group analysis. CONCLUSIONS: Operative mortality and early adverse outcomes did not increase with the addition of tricuspid intervention in our cohort of robotic mitral surgery patients. The robotic approach for mitral disease and coexisting tricuspid disease may offer safe results without an increased risk of postoperative PPM requirement.

Robotic-assisted minimally invasive multivessel coronary bypass surgery.

Robotic-assisted minimally invasive multiple vessel coronary bypass surgery is safe and can be performed with excellent results. In this video tutorial, we present our technique for robotic-assisted minimally invasive multivessel coronary artery bypass grafting, with complete coronary revascularization via a left anterior thoracotomy and guided by preoperative computed tomography.

Robot-Assisted Minimally Invasive Multivessel Coronary Bypass Guided by Computerized Tomography.

OBJECTIVE: Robot-assisted minimally invasive coronary bypass surgery is one of the least invasive approaches that offers multivessel revascularization and accelerated recovery. We investigated the benefits of computed tomography angiography (CTA) guidance in robotic coronary bypass (RCAB) by analyzing perioperative outcomes. METHODS: Between April 2022 and April 2023, 60 consecutive patients who underwent RCAB under preoperative CTA guidance were included. The intercostal space of the minithoractomy incision was determined based on the distance from the thoracotomy site to the midsection of the left anterior descending artery (LAD) on preoperative CTA. Peripheral vascular findings on preoperative CTA guided the decision for the cannulation site. Perioperative parameters and early outcomes were evaluated. RESULTS: The mean age of the patients was 62.3 ± 10.5 years, and 51 patients were male (85.0%). The mean number of revascularized vessels was 2.9 ± 1.1. Left thoracotomy guided by CTA measurements was performed in the fourth intercostal space in 37 patients (61.7%) and in the third intercostal space in the remaining patients. Axillary cannulation was performed in 28 (46.7%) patients because of prohibitive findings in the iliac vessels and aorta. All target coronary arteries with an indication for bypass were revascularized with CTA-guided RCAB. The left internal mammary artery (LIMA) was anastomosed to the LAD in all patients, and the LIMA was anastomosed sequentially to the diagonal artery in 17 patients (28.3%). No operative mortality or cerebrovascular event was observed. One patient underwent reoperation due to bleeding. CONCLUSIONS: Robot-assisted minimally invasive multiple-vessel coronary bypass under preoperative CTA guidance is safe and can be performed with excellent results.

Simple Tool for Bleeding Control During Minimally Invasive and Robotic Cardiac Surgery.

Achievement of complete hemostasis is a key element to success in cardiac surgery. Bleeding control is of utmost importance in minimally invasive and robotic cardiac surgery to avoid conversion, as major bleeding is one of the most common indications for conversion to sternotomy. Bleeding control with surgical techniques can be technically more difficult in robotic and minimally invasive cardiac surgery as access to the bleeding area is limited and it is harder to intervene compared with open cardiac surgery with sternotomy. We present in this case the achievement of hemostasis in a minimally invasive robotic mitral repair, without the employment of surgical techniques and with the aid of a surgical sealant.

Robotic-assisted mitral valve surgery without aortic cross-clamping: a safe and feasible technique.

Background: The primary objective of this study was to evaluate the safety and feasibility of robotic-assisted mitral valve surgery without aortic cross-clamping. Methods: From January 2010 to September 2022, 28 patients underwent robotic-assisted mitral valve surgery without aortic cross-clamping in our center using DaVinci Robotic Systems. Clinical data during the perioperative period and early outcomes of the patients were recorded. Results: Most patients were in New York Heart Association (NYHA) class II and III. Mean age and EuroScore II of the patients were 71.5 ± 13.5 and 8.4 ± 3.7 respectively. The patients underwent either mitral valve replacement (n = 16, 57.1%) or mitral valve repair (n = 12, 42.9%). Concomitant procedures were performed including tricuspid valve repair, tricuspid valve replacement, PFO closure, left atrial appendage ligation, left atrial appendage thrombectomy and cryoablation for atrial fibrillation. Mean CPB times were 140.9 ± 44.6 and mean fibrillatory arrest duration was 76.6 ± 18.4. Mean duration of ICU stay was 32.5 ± 28.8 h and mean duration of hospital stay 9.8 ± 8.3 days. One patient (3.6%) underwent revision due to bleeding. New onset renal failure was observed in one (3.6%) patient and postoperative stroke in one (3.6%) patient. Postoperative early mortality was observed in two (7.1%) patients. Conclusions: Robotic-assisted mitral valve surgery without cross-clamping is a safe and feasible technique in high-risk patients undergoing redo mitral surgery with severe adhesions as well as in primary mitral valve cases that are complicated with ascending aortic calcification.

Pulmonary artery sarcoma treated with pulmonary endarterectomy and leaflet reconstruction using Ozaki technique.

Pulmonary arterial intimal sarcomas (PAIS) are rare malignancies with a poor prognosis. Sarcomas present with signs and symptoms mimicking pulmonary thromboembolic disease, delaying the diagnosis. We present a 29-year-old male patient diagnosed with PAIS in the right and main pulmonary arteries extending to the left pulmonary leaflet. The patient was treated with pulmonary endarterectomy and pulmonary leaflet reconstruction using the Ozaki technique.

Robotic mitral valve replacement; results from the world's largest series.

Background: This study evaluates the clinical outcome of patients with robotic mitral valve replacement (MVR). Methods: Between January 2010 and April 2022, 117 consecutive patients underwent robotic MVR with or without additional cardiac procedures. All procedures were completed by a single surgical team with Da Vinci Robotic Systems. Perioperative variables and early clinical outcomes were recorded. Results: Mean age and EuroScore II of the patients were 57.1±12.9 and 5.1±5.7, respectively. Isolated MVR was performed in 55 (47.0%) patients and combined cardiac procedures were performed in 62 (53.0%) patients. Additional procedures included: ablation for atrial fibrillation, tricuspid valve replacement, tricuspid valve repair, left atrial appendix ligation, patent foramen ovale closure, left atrial thrombectomy and septal myectomy for hypertrophic obstructive cardiomyopathy. Mean cardiopulmonary bypass time and cross clamp time were 143±54 and 93±37 minutes, respectively. Mean intensive care unit stay time was 26.5±26.0 hours. Postoperative stroke was observed in one (0.9%) patient and new onset renal failure was observed in two (1.7%) patients. Perioperative and postoperative early mortality was observed in three (2.6%) patients, which was lower than expected. Conclusions: Robotic MVR is feasible and can be performed with good early postoperative outcomes. A majority of the patients require additional cardiac procedures.

Transatrial balloon atrial septostomy to facilitate weaning off venoarterial ECMO after pulmonary endarterectomy.

Atrial septostomy has been the last resort in the management of patients with the right ventricular failure related to pulmonary hypertension before lung transplantation. In this paper, we present a simple and safe technique (transatrial approach) for balloon atrial septostomy in a patient who required central venoarterial extracorporeal membrane oxygenation after pulmonary endarterectomy.

Critical limb ischemia patients clinically improving with medical treatment have lower neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios.

OBJECTIVES: Inflammation is a component in the pathogenesis of critical limb ischemia. We aimed to assess how inflammation affects response to treatment in patients treated for critical limb ischemia using neutrophil-to-lymphocyte (NLR) and platelet-to-lymphocytes ratios (PLR) as markers of inflammation. METHODS: Patients in a single tertiary cardiovascular center with critical limb ischemia unsuitable for surgical or interventional revascularization were retrospectively identified. Data were collected on medical history for risk factors, previous surgical or endovascular revascularization, and outcome. A standard regimen of low molecular weight heparin, aspirin, statins, iloprost infusions, and a standard pain medication protocol were applied to each patient per hospital protocol. Patients with improvement in ischemic pain and healed ulcers made up the responders group and cases with no worsening pain or ulcer size or progression to minor or major amputations made up the non-responders group. Responders and Non-responders were compared for risk factors including pretreatment NLR and PLR. RESULTS: 268 included patients who were not candidates for surgical or endovascular revascularization were identified. Responders had significantly lower pretreatment NLR (4.48 vs 8.47, p < 0.001) and PLR (162.19 vs 225.43, p = 0.001) values. After controlling for associated risk factors NLR ≥ 4.63 (p < 0.001) and PLR ≥ 151.24 (p = 0.016) were independently associated with no response to treatment. CONCLUSIONS: Neutrophil-to-lymphocyte ratio and platelet-to-lymphocytes ratio are markers of inflammation that are reduced in patients improving with medical treatment suggesting a decreased state of inflammation before treatment in responding patients.

The neutrophil-lymphocyte ratio and the platelet-lymphocyte ratio correlate with thrombus burden in deep venous thrombosis.

OBJECTIVE: Deep venous thrombosis (DVT) is associated with a state of increased inflammation at the time of diagnosis as either a cause or consequence. The neutrophil-lymphocyte ratio (NLR) and the platelet-lymphocyte ratio (PLR) are easy-to-obtain, low-cost biomarkers of systemic inflammation. The objective of this study was to determine whether these two ratios at the time of diagnosis can be an indicator of thrombus burden in terms of thrombus location in DVT. METHODS: Patients with a diagnosis of DVT confirmed with venous Doppler ultrasound in a single referral center for cardiovascular diseases between 2014 and 2018 were retrospectively analyzed. Of 1852 patients, 933 with blood counts at time of diagnosis were included. The NLR and PLR were calculated from blood count results. Patients were categorized according to the level of thrombus and the number of vein segments involved as evidenced by Doppler ultrasound findings. RESULTS: Iliac, femoral, popliteal, and crural groups had a mean NLR of 5.07, 4.18, 3.59, and 3.24, respectively (P = .002), and a mean PLR of 1.82 × 107, 1.76 × 107, 1.47 × 107, and 1.64 × 107, respectively (P = .011). Patients with proximal DVT had a higher mean NLR (4.40 ± 4.28 vs 3.54 ± 3.55; P = .05) and PLR (1.77 × 107 ± 1.3 × 107 vs 1.49 × 107 ± 1.08 × 107; P = .03) than patients with distal DVT. NLR increased with the number of vein segments involved (P = .001), but this correlation did not exist with PLR (P = .097). CONCLUSIONS: A state of inflammation, demonstrated by NLR and PLR, at the time of diagnosis in DVT patients correlates with disease burden in terms of thrombus location. Further studies are required to assess the clinical value of NLR and PLR at the bedside.

Cost of Healthcare Associated With Deep Vein Thrombosis in Patients Treated With Warfarin in Turkey: 2010-2013 Database Analysis of a Tertiary Care Center.

OBJECTIVES: To evaluate the cost of healthcare with respect to the quality of anticoagulation in patients with deep vein thrombosis (DVT) treated with warfarin in daily practice via the database analysis of a tertiary care center in the period 2010 to 2013. METHODS: Of 258 307 records in total, 42 582 unique patients with DVT and 32 012 patients with international normalized ratio (INR) measurements were included. Overall, 6720 unique patients with DVT diagnosis and one or more INR measurements were identified, and the records of 4377 out of 6720 unique patients were validated and included in the analysis data set. The cost analysis was based on direct medical costs from the payer's perspective. Cost items were related to healthcare resource utilization (inpatient and outpatient services) during the study period, which provided a basis for calculation of per-patient, outpatient, inpatient, and total direct medical costs. RESULTS: Mean outpatient, inpatient, and total hospital admission costs were $578, $2195, and $2785, respectively, for patients with time in the therapeutic range of 70% or more, whereas the same costs were $571, $2163, and $3192, respectively, for patients with time in the therapeutic range of less than 70%. CONCLUSIONS: Our findings for a retrospective cohort of patients with DVT undergoing warfarin therapy reveal that patients spent 70% or more, as opposed to less than 70%, of follow-up time within the therapeutic INR range and that outpatient care, as opposed to inpatient care, was associated with lower healthcare costs. Given the significant contribution that hospital stay makes to the cost burden of DVT, our findings also highlight the association between poor warfarin anticoagulant control and increased hospitalization costs.

A case of a large Chiari network mimicking a right atrial thrombus.

The Chiari network is described as a reticulated network of fibers connected to the Eustachian valve identified as the embryological remnant of the right valve of the sinus venosus. It is an incidental finding without any significant pathophysiological consequences. However, the presence of the Chiari network in the right atrium obliges the physician to differentiate from other right atrial pathologies. We present a case of a large Chiari network mimicking a right atrial thrombus with incidental finding in a 76-year-old man undergoing coronary artery bypass surgery.