Simulation-based assessment of robotic cardiac surgery skills: An international multicenter, cross-specialty trial.

Objective: This study aimed to investigate the validity of simulation-based assessment of robotic-assisted cardiac surgery skills using a wet lab model, focusing on the use of a time-based score (TBS) and modified Global Evaluative Assessment of Robotic Skills (mGEARS) score. Methods: We tested 3 wet lab tasks (atrial closure, mitral annular stitches, and internal thoracic artery [ITA] dissection) with both experienced robotic cardiac surgeons and novices from multiple European centers. The tasks were assessed using 2 tools: TBS and mGEARS score. Reliability, internal consistency, and the ability to discriminate between different levels of competence were evaluated. Results: The results demonstrated a high internal consistency for all 3 tasks using mGEARS assessment tool. The mGEARS score and TBS could reliably discriminate between different levels of competence for the atrial closure and mitral stitches tasks but not for the ITA harvesting task. A generalizability study also revealed that it was feasible to assess competency of the atrial closure and mitral stitches tasks using mGEARS but not the ITA dissection task. Pass/fail scores were established for each task using both TBS and mGEARS assessment tools. Conclusions: The study provides sufficient evidence for using TBS and mGEARS scores in evaluating robotic-assisted cardiac surgery skills in wet lab settings for intracardiac tasks. Combining both assessment tools enhances the evaluation of proficiency in robotic cardiac surgery, paving the way for standardized, evidence-based preclinical training and credentialing. Clinical trial registry number: NCT05043064.

Multiparametric Strategy to Predict Early Disease Decompensation in Asymptomatic Severe Aortic Regurgitation.

BACKGROUND: Use of the current echocardiography-based indications for aortic regurgitation (AR) surgery might result in late valve replacement at the stage of irreversible myocardial damage. Therefore, we aimed to identify simple models combining multiple echocardiography or magnetic resonance imaging (MRI)-derived indices and natriuretic peptides (BNP [brain natriuretic peptide] or NT-proBNP [N-terminnal pro-B type natriuretic peptide]) to predict early disease decompensation in asymptomatic severe AR. METHODS: This prospective and multicenter study included asymptomatic patients with severe AR, preserved left ventricular ejection fraction (>50%), and sinus rhythm. The echocardiography and MRI images were analyzed centrally in the CoreLab. The study end point was the onset of indication for aortic valve surgery as per current guidelines. RESULTS: The derivative cohort consisted of 127 asymptomatic patients (age 45±14 years, 84% males) with 41 (32%) end points during a median follow-up of 1375 (interquartile range, 1041-1783) days. In multivariable Cox regression analysis, age, BNP, 3-dimensional vena contracta area, MRI left ventricular end-diastolic volume index, regurgitant volume, and a fraction were identified as independent predictors of end point (all P<0.05). However, a combined model including one parameter of AR assessment (MRI regurgitant volume or regurgitant fraction or 3-dimensional vena contracta area), 1 parameter of left ventricular remodeling (MRI left ventricular end-diastolic volume index or echocardiography 2-dimensional global longitudinal strain or E wave), and BNP showed significantly higher predictive accuracy (area under the curve, 0.74-0.81) than any parameter alone (area under the curve, 0.61-0.72). These findings were confirmed in the validation cohort (n=100 patients, 38 end points). CONCLUSIONS: In asymptomatic severe AR, multimodality and multiparametric model combining 2 imaging indices with natriuretic peptides, showed high accuracy to identify early disease decompensation. Further prospective studies are warranted to explore the clinical benefit of implementing these models to guide patient management. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT02910349.

Case report: Robotic repair of unroofed coronary sinus.

Unroofed coronary sinus is a rare congenital heart disease caused by the partial or complete absence of the common wall between the coronary sinus and left atrium. When indicated for repair, it is done either percutaneously or surgically. Repair using a totally endoscopic robotic procedure is rarely performed nor reported in the literature. We report a case of a 47-year-old male who underwent a successful totally endoscopic robotic repair of this anomaly.

Robot-assisted vs. conventional MIDCAB: A propensity-matched analysis.

Background: Robotic assistance (RA) in the harvesting of internal thoracic artery during minimally invasive direct coronary artery bypass grafting (MIDCAB) provides several potential benefits for surgeon and patient in comparison with conventional MIDCAB. The two technical options have not been thoroughly compared in the literature yet. We aimed to perform this in our cohort with the use of propensity-score matching (PSM). Methods: This was a retrospective comparison of all consecutive patients undergoing conventional MIDCAB (2005-2021) and RA-MIDCAB (2018-2021) at our institution with the use of PSM with 27 preoperative covariates. Results: Throughout the study period 603 patients underwent conventional and 132 patients underwent RA-MIDCAB. One hundred and thirty matched pairs were selected for further comparison. PSM successfully eliminated all preoperative differences. Patients after RA-MIDCAB had lower 24 h blood loss post-operatively (300 vs. 450 ml, p = 0.002). They had shorter artificial ventilation time (6 vs. 7 h, p = 0.018) and hospital stay (6 vs. 8 days, p < 0.001). There was no difference in the risk of perioperative complications, short-term and mid-term mortality between the groups. Conclusions: RA-MIDCAB is an attractive alternative to conventional MIDCAB. It is associated with lower post-operative blood loss and potentially faster rehabilitation after surgery. The mortality and the risk of perioperative complications are comparable among the groups.

Corrigendum: Robotic Cardiac Surgery in Europe: Status 2020.

[This corrects the article DOI: 10.3389/fcvm.2021.827515.].

The role of robotic technology in minimally invasive surgery for mitral valve disease.

INTRODUCTION: Robotic mitral valve surgery has developed for more than 20 years. The main purpose of robotic assistance is to use multiwristed instruments for surgical endothoracic maneuvers on the mitral valve without opening the chest. The surgeon controls the instruments remotely from a console but is virtually immersed into the operative field. AREAS COVERED: This review outlines indications and contraindication for the procedure. Intra- and postoperative results as available in the literature are reported. Further areas focus on the technological development, advances in surgical techniques, training methods, and learning curves. Finally we give an outlook on the potential future of this operation. EXPERT OPINION: Robotic assistance allows for the surgically least invasive form of mitral valve operations. All variations of robotic mitral valve repair and replacement are feasible and indications have recently been broadened. Improved dexterity of instrumentation, 3D and HD vision, introduction of a robotic left atrial retractor, and adjunct technology enable most complex forms of minimally invasive mitral valve interventions through ports on the patient's right chest wall. Application of robotics results in significantly reduced surgical trauma while maintaining safety and outcome standards in mitral valve surgery.

Robotic Cardiac Surgery in Europe: Status 2020.

BACKGROUND: European surgeons were the first worldwide to use robotic techniques in cardiac surgery and major steps in procedure development were taken in Europe. After a hype in the early 2000s case numbers decreased but due to technological improvements renewed interest can be noted. We assessed the current activities and outcomes in robotically assisted cardiac surgery on the European continent. METHODS: Data were collected in an international anonymized registry of 26 European centers with a robotic cardiac surgery program. RESULTS: During a 4-year period (2016-2019), 2,563 procedures were carried out [30.0% female, 58.5 (15.4) years old, EuroSCORE II 1.56 (1.74)], including robotically assisted coronary bypass grafting (n = 1266, 49.4%), robotic mitral or tricuspid valve surgery (n = 945, 36.9%), isolated atrial septal defect closure (n = 225, 8.8%), left atrial myxoma resection (n = 54, 2.1%), and other procedures (n = 73, 2.8%). The number of procedures doubled during the study period (from n = 435 in 2016 to n = 923 in 2019). The mean cardiopulmonary bypass time in pump assisted cases was 148.6 (63.5) min and the myocardial ischemic time was 88.7 (46.1) min. Conversion to larger thoracic incisions was required in 56 cases (2.2%). Perioperative rates of revision for bleeding, stroke, and mortality were 56 (2.2%), 6 (0.2 %), and 27 (1.1%), respectively. Median postoperative hospital length of stay was 6.6 (6.6) days. CONCLUSION: Robotic cardiac surgery case numbers in Europe are growing fast, including a large spectrum of procedures. Conversion rates are low and clinical outcomes are favorable, indicating safe conduct of these high-tech minimally invasive procedures.

Persistent reduction of mitral regurgitation by implantation of a transannular mitral bridge: durability and effectiveness of the repair at 2 years-results of a prospective trial†.

OBJECTIVES: Ring annuloplasty reduces the septal-lateral diameter (SLD) indirectly by circumferential annular cinching and frequently results in the recurrence of mitral regurgitation (MR) in patients with functional MR (FMR). Our goal was to report the results from the trial and the 2-year post-trial surveillance data. We evaluated whether direct reduction of the SLD with a transannular mitral bridge could achieve significant and durable MR reduction in patients with FMR. METHODS: In a prospective trial, 34 consecutive patients with FMR had a mitral bridge implanted surgically. Primary end points were MR ≤1+ at 1, 3 and 6 months postimplant and freedom from subsequent surgical mitral valve repair or replacement. RESULTS: Thirty-two of 34 (94.1%) patients met the primary end points with MR ≤1+ at 6 months. At 2 years, there were no strokes or device-related adverse events. At 2 years, MR was reduced from 3.32 ± 0.47 to 0.50 ± 0.83 (P ≤ 0.001) with ≤1+ MR in 33/34 patients, including 4 reinterventions for periprosthetic recurrent MR ≥3 without mitral bridge explants or conventional mitral repair or replacement. At 2 years, the mean mitral gradient was 2.15 ± 0.82 mmHg; the mitral annular SLD decreased from 40.4 ± 2.91 mm to 28.9 ± 1.55 mm (P ≤ 0.001). The left ventricular ejection fraction increased (57.9 ± 10.4-62.4 ± 9.7%; P ≤ 0.001). The New York Heart Association functional class improved (2.19 ± 0.76-1.41 ± 0.61; P ≤ 0.001). CONCLUSIONS: The single-centre trial data indicate that direct reduction in the SLD with a mitral bridge is feasible, safe and efficacious in patients with FMR. Validation in a larger population of patients and comparison to conventional annuloplasty ring are necessary. CLINICAL TRIAL REGISTRATION NUMBER: NCT03511716.

Intravascular fasciitis leading to an aortic dissection. A case report.

Here we report on the case of a 61-year-old female with an accidental finding of intravascular fasciitis (IVF) affecting the ascending aorta in a specimen resected due to an acute aortic dissection. No infiltrative process of the aorta or surrounding soft tissues was grossly apparent. Microscopically, the lesion had poorly defined margins and was composed of plump spindle- and oval-shaped cells set in an abundant myxoid stroma. Immunohistochemically, cytoplasmic positivity for ß-catenin was observed and about 25% of cells were positive for calponin. The Ki-67 index was approximately 25% (increasing to about 50% in hot spot areas). Occasional isolated cells also showed positivity for alpha actin. Other markers were all negative in the tumor cells including; smooth muscle actin, desmin, h-caldesmon, D2-40, DOG1, S100 protein, CD34, CD31, ERG, melan A, HMB45, IgG, IgG4, ALK, cytokeratin AE1/AE3, and LCA. Intravascular fasciitis is a benign myofibroblastic proliferation which most commonly occurs in subcutaneous tissues and may mimic malignancy. To the best of our knowledge this is only the 2nd ever reported case of IVF affecting the aorta. Keywords: intravascular fasciitis - nodular fasciitis - soft tissue lesions - myofibroblasts - aorta.

[The current state and future of care of patients with congenital heart defects]. / Soucasný stav a budoucnost péce o nemocné s vrozeným srdecními vadami.

Care of patients with congenital heart diseases in Czech Republic does not have only important history, falling to the prewar period, but especially systematic and long-term work with excellent results in pediatric patients. With improvements in the care of these patients also improves their survival with the need for continuous care in adulthood including reoperation, catheter ablations incisional tachycardias and other specialized procedures in difficult heart morphology. The article is a reflection and an appeal to all responsible professionals, organizers and payers of health care, how to proceed and provide specialized training, continuity of care for these patients, including proposed organizational changes and outlines the need for further development in this important medical field.

[Operation of Ebstein anomaly in adulthood - our experience]. / Operace Ebsteinovy anomálie v dospelém veku - nase zkusenosti.

INTRODUCTION: The outcome of the operation of the Ebstein anomaly in adulthood depends on the experience of the surgical team. METHODS AND RESULTS: We operated 38 adult patients with Ebstein anomaly at the age of 34.8 ± 12.7 (19-63) years at the Department of Cardiac Surgery, Hospital Na Homolce, Prague, in the period of 2005-2013. The majority of patients (71 %) had Ebstein anomaly type C or D. The 30-days postoperative mortality was 5.2 %. In the long-term follow-up 2 other patients died. Tricuspid valve repair was performed in 45 %, bioprosthesis was implanted in 53 %. Concomitant bi-directional cavo-pulmonary anastomosis was performed in 31.5 %, mitral valve repair in 8 %, closure of atrial communication in 83 %, right-sided MAZE or istmus cryo-ablation in 39 %. After the operation we found improvement of the functional NYHA class (from 2.2 ± 0.7 to 1.7 ± 0.6; p < 0.0001) as well as decrease of tricuspid regurgitation (from grade 3.8 ± 0.4 to 0.9 ± 1; p < 0.0001). The ejection fraction of the right ventricle (RVEF) improved in 86 % of patients, in 14 % RVEF decreased or did not change (RVEF before operation 36 ± 10.5 %, after operation 42 ± 9.5 %, p = 0.001). In the long-term follow-up we found dysfunction of the tricuspid valve repair in 12 % and degeneration of the bioprosthesis in 15 %. Among 86 adult patients with Ebstein anomaly from our database the mortality was significantly higher in unoperated compared to operated patients (26 % vs 12 %, p = 0.006). Patients with cyanosis had high mortality regardless of surgery (40 % with and 83 % without operation). Reoperation after surgery in childhood or adulthood was necessary in 20 % of adults. CONCLUSION: The adult patients with Ebstein anomaly should be examined in a specialized center even if the symptoms are mild. The operation should be performed by a team with good results and experience in surgery and post-operative care in Ebstein anomaly. According to our knowledge Hospital Na Homolce represents such specialized center for Czech Republic.

Single-site access robot-assisted epicardial mapping with a snake robot: preparation and first clinical experience.

CardioARM, a highly flexible "snakelike" medical robotic system (Medrobotics, Raynham, MA), has been developed to allow physicians to view, access, and perform complex procedures intrapericardially on the beating heart through a single-access port. Transthoracic epicardial catheter mapping and ablation has emerged as a strategy to treat arrhythmias, particularly ventricular arrhythmias, originating from the epicardial surface. The aim of our investigation was to determine whether the CardioARM could be used to diagnose and treat ventricular tachycardia (VT) of epicardial origin. Animal and clinical studies of the CardioARM flexible robot were performed in hybrid surgical-electrophysiology settings. In a porcine model study, single-port pericardial access, navigation, mapping, and ablation were performed in nine animals. The device was then used in a small, single-center feasibility clinical study. Three patients, all with drug-refractory VT and multiple failed endocardial ablation attempts, underwent epicardial mapping with the flexible robot. In all nine animals, navigation, mapping, and ablation were successful without hemodynamic compromise. In the human study, all three patients demonstrated a favorable safety profile, with no major adverse events through a 30-day follow-up. Two cases achieved technical success, in which an electroanatomic map of the epicardial ventricle surface was created; in the third case, blood obscured visualization. These results, although based on a limited number of experimental animals and patients, show promise and suggest that further clinical investigation on the use of the flexible robot in patients requiring epicardial mapping of VT is warranted.

Range and distribution of NT-proBNP values in stable corrected congenital heart disease of various types.

BACKGROUND: Elevated levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) are an expected finding in many adults with congenital heart disease (ACHD) but no reports have described the range of values within different diagnostic groups. METHODS: Between the years 2003 and 2011 we measured NT-proBNP in consecutive ACHD patients attending the outpatient department. Further NT-proBNP analysis was performed on 705 blood samples from 394 stable patients with the defect corrected. The results were compared among different diagnostic groups and with a control group of healthy volunteers. RESULTS: The median value of NT-proBNP in the whole cohort was signifinatly higher than in the control group (211 vs 42 pg/mL; P < 0.0001). The median value of NT-proBNP in pg/mL and the percentage of normal NT-proBNP values in the listed diagnostic groups were as follows: coarctation of the aorta (COA), 97 (64%); pulmonary stenosis (PS),160 (48%); secundum atrial septal defect (ASD), 254 (44%); incomplete atrioventricular septal defect (AVSD), 211 (32%); ventricular septal defect (VSD), 154 (58%); tetralogy of Fallot (TOF), 177 (38%); transposition of the great arteries (TGA) after Mustard, 237 (20%) or Senning correction, 143 (39%); Ebstein anomaly 287, (26%); pulmonary atresia (PA), 327 (18%); and complex defects after Fontan procedure, 184 (31%). CONCLUSIONS: Normal levels of NT-proBNP were found most often in patients after the correction of coarctation of the aorta and ventricular septal defect with the highest levels found in pulmonary atresia and Ebstein anomaly. Our results may serve as reference values for different ACHD groups.

[Six-year experience with cardiac surgery in adults with congenital heart disease]. / Sestileté zkusenosti s operacemi vrozených srdecních vad u dospelých.

BACKGROUND: Increasing number of adults with congenital heart disease (ACHD) require reoperation or primary repair. To define risk and outcome of operations of ACHD performed in adult cardiac surgery. METHODS: Between 2005-2010 we operated on 459 patients with ACHD, aged 40.4 +/- 15 years. Operations of ACHD represented 9.5% of 4854 cardiac operations in our department. RESULTS: The 30-days mortality was 1.1%, hospital mortality was 1.52%, long-term mortality among discharged patients was 1.3%. Reoperations after surgery in childhood represented 39%, repeated reoperations 9%, operations of 3 or 4 valves 2.6%. Robotic surgery or minithoracotomy was performed in 9%. Pulmonary hypertension was present in 11.3%, NYHA III-IV in 30%. The risk factors of mortality were: NYHA class III-IV (p < 0.001), cyanosis (p < 0.001), severe systolic dysfunction of left (p = 0.006) or right ventricle (p < 0.001).We did not confirm increased risk in older patients, women, pulmonary hypertension, reoperations and operations of 3-4 valves. CONCLUSIONS: Excellent surgical results among older adults with CHD were achieved by the co-operation of paediatric cardiac surgeon within the experienced centre for adult cardiac surgery. The highest risk was found in patients with NYHA class Ill-IV, cyanosis and ventricular dysfunction.

Arch replacement and downstream stent grafting in complex aortic dissection: first results of an international registry.

OBJECTIVES: Arch replacement combined with antegrade stent grafting of the descending aorta represents a hybrid surgical approach for extensive thoracic aortic disease. This multicentre study evaluates the early results of this method in complex aortic dissection (AD). METHODS: Retrospective data acquisition was achieved by institution of an international registry. A hybrid stent graft with integrated vascular prosthesis for arch replacement (E-vita open®) was used. From January 2005 to March 2009, 106 patients (mean age 57; 77% male) with complex AD (55 acute, 51 chronic) were studied. RESULTS: As many as 49/106 (46%) patients underwent emergency surgery. Stent-graft deployment and arch replacement (95 total, 11 subtotal) were performed under hypothermic circulatory arrest (HCA (8±6min) and selective antegrade cerebral perfusion (SACP) (74±23min). Stent-graft placement into the true lumen was successful in all but one case (99%). Ascending aortic replacement was performed in 91/106 (86%), aortic valve repair/replacement in 49/106 (46%), coronary artery bypass grafting (CABG) in 17/106 (16%) and mitral valve repair in 2/106 (2%). Cardiopulmonary bypass (CPB) and cardiac arrest times were 242±64 and 144±44min, respectively. In-hospital mortality was 12% (13/106; six acute, seven chronic AD) and new strokes observed in 5/106 (5%). The false lumen (FL) was evaluated in 96/106 (91%) patients postoperatively. At first follow-up computed tomography (CT)-examination, thoracic FL thrombosis was 93% (76 complete, 13 partial) and 58% (31 complete, 25 partial) in the thoraco-abdominal aorta. CONCLUSIONS: By combining arch replacement with downstream stent grafting, one-stage repair of complex aortic dissection with almost unanimous thoracic FL thrombosis can be achieved at acceptable perioperative risk.

Multicenter early experience with extended aortic repair in acute aortic dissection: is simultaneous descending stent grafting justified?

OBJECTIVE: In acute type A aortic dissection, the extension of repair to downstream aorta has been controversially discussed. We present the early results of a multicenter study using a hybrid stent graft prosthesis. METHODS: Between January 2005 and January 2010, the data from 191 patients after combined proximal aortic replacement and antegrade stent grafting were collected in the database of the International E-vita open Registry. Of the 191 patients, 68 underwent surgery for acute aortic dissection and were included in the present study. Hypothermic circulatory arrest and selective cerebral perfusion were routinely used. Computed aortic imaging was performed for false lumen evaluation during follow-up. RESULTS: The in-hospital mortality rate was 13% (9/68). Along the stent graft, the rate of immediate complete false lumen thrombosis was 86% (51/59) and increased during follow-up (23 ± 17 months) to 94% (46/49). Distally, complete or partial false lumen thrombosis was initially observed in 61% (36/59) and in 82% (40/49) after follow-up. The 1- and 3-year actuarial survival rate was 82% and 74%, respectively. CONCLUSIONS: Extended thoracic aortic repair of acute aortic dissection with a hybrid stent graft is feasible at acceptable early mortality and promotes false lumen thrombosis around the stent graft and below.

Aortic dissection and rupture in a 16-year-old girl with Turner syndrome following previous progression of aortic dilation.

Aortic dissection occurs in Turner syndrome with substantially higher frequency in comparison to the general population, and its prevention is one of the main aims of cardiologic follow-up. Findings of cystic medial necrosis in the aortic wall and a high prevalence of aortic dilation suggest that a form of aortopathy exists in Turner syndrome. However, little is known about natural development of aortic dilation prior to dissection. We present a 16-year-old girl with Turner syndrome with a bicuspid aortic valve, aortic stenosis, and dilation of ascending aorta, who underwent annual echocardiographic examinations from early childhood. Significant progressions of proximal aortic dilation occurred twice at the age of 10 and 15 years. Thereafter, another rapid progression was observed during 8 months and within 3 weeks preceding dissection. Acute aortic dissection was diagnosed while the girl was waiting for elective surgery. She was successfully operated. Frequent estimations of aortic diameter in Turner patients with abnormal findings may help to anticipate this life-threatening event. Additionally, we learned that rapid progression of aortic dilation should lead to immediate surgery to prevent more risky urgent intervention following the dissection.