Feasibility of Robotic Mitral Valve Repair Using Barbed Nonabsorbable Sutures: A Preliminary Single-Center Experience.

OBJECTIVE: Barbed nonabsorbable sutures have been widely adopted for tissue closure in noncardiac robotic surgery to improve intraoperative efficiency. Here, we examine the profile in robotic mitral valve repair (rMVR), which utilized barbed nonabsorbable sutures. To our knowledge, this is the first report to describe clinical outcomes for rMVR with barbed nonabsorbable sutures. METHODS: A retrospective review identified 90 patients who underwent rMVR using barbed nonabsorbable sutures at our center between 2019 and 2021. The primary outcome measure was dehiscence, while other relevant outcomes included 30-day readmission and 30-day mortality. RESULTS: In addition to fixation of the mitral annuloplasty band, barbed nonabsorbable sutures were employed commonly in concomitant pericardiectomy closure (100.0%, 90 of 90), atriotomy closure (100.0%, 90 of 90), and left atrial appendage closure (if eligible; 98.8%, 83 of 84). One patient who underwent mitral valve annuloplasty using only barbed nonabsorbable suture required reoperation for annuloplasty ring dehiscence. Immediate postoperative ring dehiscence was not observed in any patients after the routine reinforcement of barbed nonabsorbable sutures with everting pledgeted polyester sutures, and no additional patients required reoperation for suture-related complications. Clinical signs of dehiscence were not observed after pericardiectomy, atriotomy, or left atrial appendage closure with barbed nonabsorbable sutures. The 30-day readmission rate was 3.3% (3 of 90), and 30-day mortality was 0% (0 of 90). CONCLUSIONS: These data suggest the initial feasibility of barbed nonabsorbable sutures in robotic cardiac surgery, specifically within rMVR. Further research is necessary to explore the long-term safety and efficacy profile of such approach.

Feasibility of Postoperative Day One or Day Two Discharge After Robotic Cardiac Surgery.

INTRODUCTION: The robotic platform reduces the invasiveness of cardiac surgical procedures, thus facilitating earlier discharge in select patients. We sought to evaluate the characteristics, perioperative management, and early outcomes of patients who underwent postoperative day 1 or 2 (POD1-2) discharge after robotic cardiac surgery at our institution. METHODS: Retrospective review of 169 patients who underwent robotic cardiac surgery at our facility between 2019 and 2021 identified 57 patients discharged early on POD1 (n = 19) or POD2 (n = 38) and 112 patients who underwent standard discharge (POD3 or later). Relevant data were extracted and compared. RESULTS: In the early discharge group, median patient age was 62 [IQR: 55, 66] (IQR = interquartile range) years, and 70.2% (40/57) were male. Median Society of Thoracic Surgeons predictive risk of mortality score was 0.36 [IQR: 0.25, 0.56] %. The most common procedures performed were mitral valve repair [66.6%, (38/57)], atrial mass resection [10.5% (6/57)], and coronary artery bypass grafting [10.5% (6/57)]. The only significant differences between the POD1 and POD2 groups were shorter operative time, higher rate of in-operating room extubation, and shorter ICU length of stay in the POD1 group. Lower in-hospital morbidity and comparable 30-day mortality and readmission rates were observed between the early and standard discharge groups. CONCLUSIONS: POD1-2 discharge after various robotic cardiac operations afforded lower morbidity and similar 30-day readmission and mortality rates compared to discharge on POD3 or later. Our findings support the feasibility of POD1-2 discharge after robotic cardiac surgery for patients with low preoperative risk, an uncomplicated postoperative course, and appropriate postoperative management protocols.

Current status and future directions in the development and optimization of thoracic and abdominal artificial organs.

INTRODUCTION: Artificial organs are engineered devices with the capacity to be implanted or integrated into a living body to replace a failing organ, or to duplicate or augment one or multiple functions of the diseased organ. AREAS COVERED: We evaluate the present landscape and future possibilities of artificial organ engineering by exploring the spectrum of four distinguishable device features: mobility, compatibility, functionality, and material composition. These mechanical and functional differences provide the framework through which we examine the current status and future possibilities of the abdominal and thoracic artificial organs. EXPERT OPINION: Transforming the artificial organs landscape in ways that expand the scope of existing device capabilities and improve the clinical utility of artificial organs will require making improvements upon existing technologies and multidisciplinary cooperation to create and discover new capacities.

Routine endoscopic robotic cardiac tumor resection using an 8-mm working port and percutaneous cannulation.

OBJECTIVE: Prior studies have demonstrated robotic excision of cardiac tumors as a safe and effective treatment option. The procedure is performed with five incisions: three robotic arm ports, one atrial retractor port, and one working port. We report our unique initial experience in robotic tumor removal. To our knowledge, this is one of the first reports demonstrating cardiac myxoma and fibroelastoma removal with use of exclusively 8-mm ports. METHODS: All data for robotic cardiac tumor resection at our institution from June 2019 to December 2021 were retrospectively collected; 18 cases were included, including 13 cardiac myxomas and five fibroelastomas. Baseline demographics, intraoperative characteristics, and surgical outcomes were recorded. Descriptive statistics were calculated; continuous variables were reported as median [interquartile range], and categorical variables were reported as percentages. RESULTS: Median patient age was 64 [55, 70] years old. The cohort consisted of primarily female (67%) and white (83%) patients. Median body mass index was 26.3 [23.0, 31.5] kg/m2 . 11% of patients were current tobacco users and 50% had hypertension. All patients underwent myxoma or fibroelastoma removal with the use of five 8-mm robotic ports. Each patient underwent percutaneous cannulation via the femoral arteries. Aortic occlusion was achieved via an endoaortic balloon (67%) or transthoracic cross-clamp (33%). Cross-clamp time was 30 [26, 41] minutes. Concomitant procedures performed during myxoma removal included patent foramen ovale closure (28%), mitral valve repair (8%), left atrial appendage closure (8%), Cox-maze procedure (6%), and coronary artery bypass grafting (6%). All cardiac tumors were packaged with use of the endo-bag and subsequently removed through the working port. Maximal myxoma and fibroelastoma diameters were 2.5 [1.7, 3.5] and 0.6 [0.4, 0.7] cm, respectively. Procedural cardiopulmonary bypass time was 77 [65, 84] minutes. No intraoperative mortality, reoperation for bleeding, or postoperative cardiac issues were recorded. One in-hospital mortality occurred as the result of a thrombotic event in the context of a hypercoagulable state unrelated to the patient's operation. No other mortalities were observed at 30 days. Hospital length of stay was 4.5 [3.0, 7.8] days. CONCLUSIONS: In our study, the robotic platform facilitated safe and effective cardiac tumor excision. Our results highlight the efficacy of 8-mm port sizing and the concurrent use of other minimally invasive techniques, including percutaneous cannulation, in this patient population. In general, patients prefer the least invasive treatment option available. Our findings emphasize the importance of training cardiac surgeons to perform robotic procedures using the least invasive means possible to provide patients with various options for their treatment.

Totally Endoscopic Robot-Assisted Aortic Valve Replacement and Complex Mitral Valve Repair: The Lateral Approach.

A 76-year-old male patient was referred to our institution with moderate-to-severe aortic and mitral insufficiency. The patient underwent totally endoscopic robot-assisted aortic valve replacement and mitral valve repair. In this article, we present our lateral approach to the robotic double valve surgery.

Low diagnostic yield in follow-up MR imaging in patients with spontaneous intracerebral hemorrhage with a negative initial MRI.

PURPOSE: Follow-up MRI/MRA is historically obtained as outpatient when patients with a spontaneous intracerebral hemorrhage (ICH) have an initial MRI/MRA that is negative for an underlying structural lesion. However, the utility of repeating MR imaging in a delayed fashion remains uncertain. METHODS: We retrospectively reviewed 396 patients with spontaneous ICH admitted at our institution between 2015 and 2017 and selected those whose initial MRI/MRA was negative for an underlying structural lesion and those who underwent follow-up MR imaging in a delayed fashion. RESULTS: A total of 113 patients met the study criteria. The average age of those with negative follow-up MRI/MRA was 65.0 ± 12.6 (IQR: 55.0-74.0) years old. None of the 113 patients with a negative inpatient MRI/MRA had an underlying structural lesion on follow-up MRI/MRA (0%, 95% CI 0.0-0.032, p < 0.001). The mean time of the follow-up imaging from the initial study was 105.7 days (median: 62 days; IQR: 42.5-100.5). Of the 113, 83 (73.5%) underwent follow-up MRI with and without gadolinium, while 30 (26.5%) patients did not receive gadolinium. CONCLUSION: Delayed follow-up MRI in patients with a negative initial MRI/MRA for workup of spontaneous ICH was not diagnostic in any of the patients included in the study. Our study suggests that a routine follow-up MRI for this patient population is not necessary.

Simple frameshifts in minimally invasive surgery postoperative pain management significantly reduce opiate prescriptions.

INTRODUCTION: To evaluate the impact of an 'opt-in' non-narcotic postoperative pain regimen on narcotic utilization and patient-reported pain scores. MATERIALS AND METHODS: A prospective, non-blinded pre- and post-interventional trial was conducted, including a lead-in period for baseline evaluation. The intervention group received a new pain protocol prioritizing non-narcotic medications, an 'opt-in' requirement for opiates, and standardized patient education. Study outcomes included opiate prescription and utilization (measured in Morphine Equivalent Doses) and reported pain scores on postoperative day (POD) 1, discharge and follow up. RESULTS: At discharge, 70% fewer patients were prescribed any opioids (ARR: -0.7; p < 0.001); the amount prescribed was reduced by 95% (pre-intervention 69.3 mg versus post-intervention 3.5 mg, p < 0.001). Mean opioids used following discharge decreased by 76% (14.7 mg versus 3.5 mg, p = 0.011). In a subgroup analysis of robotic prostatectomies, there was a 95% reduction in mean opioids prescribed at discharge (64.6 mg versus 3.2 mg, p < 0.001) and 82% reduction in utilization over entire postoperative course (87.6 mg versus 15.7 mg, p = 0.001). There was no significant difference in pain scores between intervention groups at POD 1, discharge and follow up for patients (entire cohort and post-prostatectomy). CONCLUSION: A standardized pain protocol with 'opt-in' requirements for opiate prescription, emphasis on non-narcotic medications, and patient education, resulted in significant reductions in opioid use. Simple frameshifts in pain management can yield significant gains in the opioid epidemic.

Acute ischaemic stroke interventions: large vessel occlusion and beyond.

Care for acute ischaemic stroke is one of the most rapidly evolving fields due to the robust outcomes achieved by mechanical thrombectomy. Large vessel occlusion (LVO) accounts for up to 38% of acute ischaemic stroke and comes with devastating outcomes for patients, families and society in the pre-intervention era. A paradigm shift and a breakthrough brought mechanical thrombectomy back into the spotlight for acute ischaemic stroke; this was because five randomised controlled trials from several countries concluded that mechanical thrombectomy for acute stroke offered overwhelming benefits. This review article will present a comprehensive overview of LVO management, techniques and devices used, and the future of stroke therapy. In addition, we review our institution experience of mechanical thrombectomy for posterior and distal circulation occlusion.

Two PTP receptors mediate CSPG inhibition by convergent and divergent signaling pathways in neurons.

Receptor protein tyrosine phosphatase σ (PTPσ) and its subfamily member LAR act as transmembrane receptors that mediate growth inhibition of chondroitin sulfate proteoglycans (CSPGs). Inhibition of either receptor increases axon growth into and beyond scar tissues after CNS injury. However, it is unclear why neurons express two similar CSPG receptors, nor whether they use the same or different intracellular pathways. We have now studied the signaling pathways of these two receptors using N2A cells and primary neurons derived from knockout mice. We demonstrate that both receptors share certain signaling pathways (RhoA, Akt and Erk), but also use distinct signals to mediate CSPG actions. Activation of PTPσ by CSPGs selectively inactivated CRMP2, APC, S6 kinase and CREB. By contrast LAR activation inactivated PKCζ, cofilin and LKB1. For the first time, we propose a model of the signaling pathways downstream of these two CSPG receptors. We also demonstrate that deleting both receptors exhibits additive enhancement of axon growth in adult neuronal cultures in vitro. Our findings elucidate the novel downstream pathways of CSPGs and suggest potential synergy of blocking their two PTP receptors.

Methylglyoxal-induced neuroinflammatory response in in vitro astrocytic cultures and hippocampus of experimental animals.

Diabetes mellitus is characterized by chronic hyperglycemia and its diverse complications. Hyperglycemia is associated with inflammatory responses in different organs and diabetic patients have a higher risk of developing neurodegenerative disorders. Methylglyoxal is a reactive advanced glycation end product precursor that accumulates in diabetic patients. It induces various stress responses in the central nervous system and causes neuronal dysfunction. Astrocytes are actively involved in maintaining neuronal homeostasis and possibly play a role in protecting the brain against neurodegeneration. However it is not clear whether methylglyoxal exerts any adverse effects towards these astrocytes. In the present study we investigated the effects of methylglyoxal in astrocytic cultures and hippocampi of experimental animals. The cells from the astrocytic line DITNC1 were treated with methylglyoxal for 1 to 24 h. For the in vivo model, 3 months old C57BL/6 mice were treated with methylglyoxal solution for 6 weeks by intraperitoneal injection. Following the treatment, both astrocytes and hippocampi were harvested for MTT assay, Western blot and real time PCR analyses. We found that methylglyoxal induced astrogliosis in DITNC1 astrocytic cultures and C57BL/6 mice. Further, activation of the pro-inflammatory JNK signaling pathway and its downstream effectors c-Jun were observed. Furthermore, increased gene expression of pro-inflammatory cytokines and astrocytic markers were observed from real time PCR analyses. In addition, inhibition of JNK activities resulted in down-regulation of TNF-α gene expression in methylglyoxal treated astrocytes. Our results suggest that methylglyoxal may contribute to the progression of diabetes related neurodegeneration through JNK pathway activation in astrocytes and the subsequent neuroinflammatory responses in the central nervous system.

Ginsenosides attenuate methylglyoxal-induced impairment of insulin signaling and subsequent apoptosis in primary astrocytes.

Diabetes mellitus (DM), which is characterized by chronic hyperglycemia, is known to increase the risk of neurodegeneration. In type 2 diabetes, hyperglycemia could cause insulin resistance and neurodegeneration in various cells including neurons and astrocytes. Hyperglycemia is also known to result in the formation of advanced glycation end-products (AGE) Methylglyoxal (MG) is one of the most reactive AGE precursors in which its abnormal accumulation is usually found in diabetic patients and induces neuronal cell death in central nervous system. Ginseng is a herb that has been widely used to treat various diseases in traditional Chinese medicine. Ginsenosides, the pharmacologically active component isolated from ginseng, have been shown to have cryoprotective effects in different neural cells. In the present study we investigated the effects of MG in disturbing insulin signaling and leading to further cellular apoptosis in rat primary astrocytes. Furthermore, the protective effects of different subtypes of ginsenosides were studied. From the results, impairment of insulin signaling was found in astrocytes under MG treatment. Moreover, cleavage of caspase and Poly ADP ribose polymerase (PARP) was observed in line with insulin signaling disruption, showing the neurotoxic effects of MG towards astrocytes. The effects of ginsenosides in MG treated astrocytes were also investigated. After treatment, ginsenosides Rd and R-Rh2 were shown to ameliorate the cell viability of MG-treated astrocytes. In addition, Rd and R-Rh2 could improve insulin signaling and inhibit apoptosis, indicating that Rd, R-Rh2 and related compounds may have therapeutic potential in treating diabetes-induced neurodegeneration.

Modulation of endoplasmic reticulum chaperone GRP78 by high glucose in hippocampus of streptozotocin-induced diabetic mice and C6 astrocytic cells.

Diabetes mellitus is known to increase the risk of neurodegeneration, and both diseases are reported to be linked to dysfunction of endoplasmic reticulum (ER). Astrocytes are important in the defense mechanism of central nervous system (CNS), with great ability of tolerating accumulation of toxic substances and sensitivity in Ca(2+) homeostasis which are two key functions of ER. Here, we investigated the modulation of the glucose-regulated protein 78 (GRP78) in streptozotocin (STZ)-induced diabetic mice and C6 cells cultured in high glucose condition. Our results showed that more reactive astrocytes were presented in the hippocampus of STZ-induced diabetic mice. Simultaneously, decrease of GRP78 expression was found in the astrocytes of diabetic mice hippocampus. In in vitro study, C6 cells were treated with high glucose to investigate the role of high glucose in GRP78 modulation in astrocytic cells. GRP78 as well as other chaperones like GRP94, calreticulin and calnexin, transcription levels were down-regulated after high glucose treatment. Also C6 cells challenged with 48h high glucose were activated, as indicated by increased level of glial fibrillary acidic protein (GFAP). Activated C6 cells simultaneously exhibited significant decrease of GRP78 level and was followed by reduced phosphorylation of Akt. Moreover, unfolded protein response was induced as an early event, which was marked by the induction of CHOP with high glucose treatment, followed by the reduction of GRP78 after 48h. Finally, the upsurge of ROS production was found in high glucose treated C6 cells and chelation of ROS could partially restore the GRP78 expression. Taken together, these data provide evidences that high glucose induced astrocytic activation in both in vivo and in vitro diabetic models, in which modulation of GRP78 would be an important event in this activation.