Optimal antiplatelet and antithrombotic regimen post-transcatheter aortic valve replacement.

BACKGROUND: There are limited data regarding optimal antiplatelet/antithrombotic therapy following transcatheter aortic valve replacement (TAVR). METHODS: In this single-centre retrospective study including TAVR patients from 2012 to 2020, ischemic and bleeding outcomes were compared between antiplatelet (dual antiplatelet [DAPT] vs. single antiplatelet [SAPT]) and oral anticoagulation (OAC) groups using incidence rate, Kaplan-Meier and Cox proportional hazards analysis. RESULTS: Total 492 patients (mean age 79.7 ± 7.7 years, 53.7% males, 83.5% Caucasian) were included. There was higher incidence of 1-year death or ischemia with DAPT vs. SAPT (23.6 vs. 14.8 per 100 patient-years [PY], incidence rate ratio [IRR] 1.60, 95% confidence interval [CI] 0.97-2.68, p = .05), especially in those without coronary artery disease (23.9 vs. 10.7 per 100 PY, IRR 2.24, 95% CI 1.10-4.47, p = .017). There was significantly higher major bleeding in those on OAC vs. no OAC (15 vs. 8 per 100 PY, IRR 1.87, 95% CI 1.10-3.11, p = .016), especially late (>1-year) bleeding (10.2 vs. 3.6 per 100 PY, IRR 2.81, 95% CI 1.33-5.92, p = .004). In multivariate analysis, DAPT was an independent predictor of death or ischemia (adjusted hazard ratio [aHR] 1.41, 95% CI 1.01-1.96, p = .041). OAC was an independent predictor of major bleeding (aHR 2.32, 95% CI 1.31-4.13, p = .004). CONCLUSIONS: There is signal to harm with routine use of DAPT post-TAVR. There is higher incidence of late bleeding post-TAVR with OAC, suggesting potential role for alternate antithrombotic strategies.

Unusual cause of myocardial infarction following transcatheter aortic valve replacement.

Key Clinical Message: Left coronary artery embolism from aortic valve leaflet tissue mass is a rare but potentially life-threatening complication following transcatheter aortic valve replacement. It is important for interventional cardiologists to be aware of this rare complication for rapid identification and prompt treatment which is the key to a successful outcome. Abstract: An 81-year-old female presented for elective transcatheter aortic valve replacement (TAVR) for severe low-flow low-gradient aortic stenosis. Immediately post-procedure, she developed unexplained, persistent hypotension. There was no bleeding. There was no aortic injury. Activated clotting time was in therapeutic range. Coronary angiography revealed hazy filling defects in left anterior descending and left circumflex. Intravascular ultrasound showed heterogeneous, hypoechoic mass with mild calcification consistent with embolized valve leaflet tissue. This was treated with emergent percutaneous coronary intervention with excellent results. Left coronary artery embolism from aortic valve leaflet tissue is a rare, but potentially life-threatening complication following TAVR. Prompt recognition is key to a successful outcome.

Robotic Resection of Left Atrial Myxoma With Cryoablation of Tumor Stalk.

The purpose of this report is to demonstrate robotic cryoablation of an atrial myxoma stalk as a method to prevent recurrence and preserve atrial tissue. A 38-year-old female patient was taken to the operating room, and an atrial myxoma abutting the left inferior pulmonary vein was resected robotically. This was followed by cryoablation of the tumor stalk instead of a full-thickness resection to prevent an extensive reconstruction. The operation resulted in the successful resection of an atrial myxoma with minimal length of stay. Follow-up at 3 months has shown no evidence of residual or recurrent tumor. Follow-up at 1 year is planned. Cryoablation of an atrial myxoma stalk, when resection would require complex reconstruction, is a useful tool in the armamentarium of a minimally invasive cardiac surgeon.

Transxiphoid Revascularization of the Anterior Descending Coronary Artery with the Left Mammary Artery.

Revascularization of the coronary arteries, via open sternotomy and on cardiopulmonary bypass, remains the most common cardiac surgical procedure in the United States. Patients, and cardiologists, seek an alternative to dividing the sternum while reaping the advantages of left internal mammary artery (LIMA) revascularization of the diseased left anterior descending (LAD) coronary artery. We describe a strictly transxiphoid mammary artery liberation with anastomosis to the anterior descending (TRAX CABG) without sternal division. Of the 26 patients who underwent attempted TRAX CABG, 18 had nonsternotomy LIMA-to-LAD revascularization with completion angiogram to document bypass patency. TRAX CABG offers surgeons a minimally invasive alternative to trans-sternal LIMA-to-LAD in select patients. Conversion to traditional sternotomy has limited unanticipated morbidity and completion angiogram confirms procedural success.

Thoracoscopic robot-assisted extended thymectomy in the human cadaver.

METHODS: Thoracoscopic robot-assisted extended thymectomy was performed in a human cadaver. The technique utilized the da Vinci surgical system inserted through the subxiphoid approach with the sternum lifted upward (anteriorly). A small subxiphoid incision and two additional thoracoports were made in the chest wall, and the sternum was lifted by a new lifting retractor system. RESULTS: This method provided sufficient view and working space in the anterior mediastinum. A complete thymectomy was performed with facility. The robotic system provides superior optics and allows for enhanced dexterity. CONCLUSIONS: Minimally invasive robotic-assisted thymectomy is an effective procedure and may add benefits for both surgeon and patients.

Thoracoscopic robot-assisted extended thymectomy in human cadaver.

Thoracoscopic robot-assisted extended thymectomy was performed in a human cadaver. The technique utilized the da Vinci surgical system inserted through the subxiphoid approach with the sternum lifted upward (anteriorly). A small subxiphoid incision and two additional thoracoports were made in the chest wall, and the sternum was lifted by a new lifting retractor system. This method provided sufficient view and working space in the anterior mediastinum. Complete thymectomy was performed with facility. The robotic system provides superior optics and allows for enhanced dexterity. Minimally invasive robotic-assisted thymectomy is an effective procedure and may add benefits for both surgeon and patients.

Port-access atrium retractors for totally endoscopic mitral valve surgery: theTornado Retractor, the Butterfly Retractor, and the Semiautomatic Butterfly Retractor.

INTRODUCTION: We developed three types of new atrial retractors that facilitate totally endoscopic mitral valve surgery. TECHNIQUE: Tornado Retractor: This retractor, which is made of rigid thick wire has a unique appearance, and can be inserted atraumatically through a 3-mm skin incision. Butterfly Retractor: This retractor consists of two parts: a rigid thick rod and foldable blades. When unfolded, the blades have a width of 35 x 55 mm, but they can be inserted thorough the 15-mm thoracoport when folded. Semiautomatic Butterfly Retractor: This retractor has a wired foldable blade and a specially designed rod containing a spring. It can be inserted when closed through the 15-mm thoracoport, and the blades can be opened and fixed automatically after being placed in the thoracic cavity, and the surgeon can remove it through the port easily. These retractors were evaluated in the totally endoscopic robotic mitral valve repairs with human fresh frozen cadavers using the da Vinci Surgical System. CONCLUSION: All the retractors allowed easier access to the heart and provided superior mitral valve presentation without impinging on the robotic arms.

How to do it: importance of left atrial side retraction in robotic and minimally invasive mitral valve surgery.

A customized transthoracic atrial retractor was previously developed for robotic and minimally invasive mitral valve surgery, but it has sometimes failed to provide sufficient exposure of the mitral valve because some atrial tissues push away the operative field from the right side. This report describes 3 new atrial side retractors (the foldaway retractor, the spoon retractor, and the wired retractor) and their use in performing robotic mitral valve repair in fresh frozen human cadavers. These retractors provided exceptional and consistent exposure of the left atrium in robotic and minimally invasive mitral valve surgery in human cadavers without causing traumatic injury, and these retractors should be useful in live patients because they will be used in arrested hearts.

Suprasternal Transcatheter Aortic Valve Replacement in Patients With Marginal Femoral Access.

OBJECTIVE: Recently, the PARTNER 2A trial reported results of transcatheter aortic valve replacement versus surgical aortic valve replacement in 2032 intermediate-risk patients at 2 years. Two hundred thirty-six patients (24%) required an access route other than transfemoral. Compared with transfemoral and surgical aortic valve replacement, nontransfemoral transcatheter aortic valve replacement was associated with a numerically higher rate of death and disabling stroke at 30 days. This underscores the need for a better alternative surgical approach for patients with marginal femoral access. We reviewed our multicenter experience with minimally invasive suprasternal transcatheter aortic valve replacement. METHODS: Consecutive patients with symptomatic severe aortic stenosis at high or intermediate risk for surgical aortic valve replacement underwent suprasternal transcatheter aortic valve replacement. A commercially available transcatheter heart valve was deployed under fluoroscopic guidance through the innominate artery or ascending aorta. Using a 3-cm skin incision just above the sternal notch, the Aegis Transit System (Aegis Surgical Ltd, Galway, Ireland) provided illuminated access to the mediastinum without bone disruption. Through a purse-string suture placed in the innominate artery or ascending aorta, transcatheter aortic valve replacement proceeded similarly to the direct aortic approach. RESULTS: Thirty patients at six medical centers successfully underwent suprasternal transcatheter aortic valve replacement. Implanted valves included 2 CoreValve and 12 Evolut-R (Medtronic, Inc, Minneapolis, MN USA), as well as 10 SAPIEN 3 and 6 SAPIEN XT (Edwards Lifesciences, Corp, Irvine, CA USA) with sizes ranging from 23 to 31 mm. Median procedure time was 90 minutes and median hospital stay was 4 days. Postoperatively, new permanent pacemaker (n = 3) was the most common Vascular Academic Research Consortium 2 complication. CONCLUSIONS: These data demonstrate the early clinical feasibility of suprasternal transcatheter aortic valve replacement. Key advantages of this approach include direct access to the innominate artery and ascending aorta, precise sheath control, and confident arterial closure. Additional experience is warranted to confirm these favorable results.

Factors Associated with Discharge to a Skilled Nursing Facility after Transcatheter Aortic Valve Replacement Surgery.

An assumption regarding transcatheter aortic valve replacement (TAVR), a minimally invasive procedure for treating aortic stenosis, is that patients remain at, or near baseline and soon return to their presurgical home to resume activities of daily living. However, this does not consistently occur. The purpose of this study was to identify preoperative factors that optimally predict discharge to a skilled nursing facility (SNF) after TAVR. Delineation of these conditions is an important step in developing a risk stratification model to assist in making informed decisions. Data was extracted from the American College of Cardiology (ACC) transcatheter valve therapy (TVT) registry and the Society of Thoracic Surgeons (STS) database on 285 patients discharged from 2012⁻2017 at a tertiary referral heart institute located in the southeastern region of the United States. An analysis of assessment, clinical and demographic variables was used to estimate relative risk (RR) of discharge to a SNF. The majority of participants were female (55%) and white (84%), with a median age of 82 years (interquartile range = 9). Approximately 27% (n = 77) were discharged to a SNF. Age > 75 years (RR = 2.3, p = 0.0026), female (RR = 1.6, p = 0.019), 5-meter walk test (5MWT) >7 s (RR = 2.0, p = 0.0002) and not using home oxygen (RR = 2.9, p = 0.0084) were identified as independent predictive factors for discharge to a SNF. We report a parsimonious risk-stratification model that estimates the probability of being discharged to a SNF following TAVR. Our findings will facilitate making informed treatment decisions regarding this older patient population.

Mirror glasses for minimally invasive surgery.

INTRODUCTION: The operator performing minimally invasive surgery is prevented from seeing the whole field with both eyes by the restricted small thoracotomy incision. To overcome this problem, we developed mirror glasses. METHODS: Use of these glasses was evaluated in terms of the time required for threading of sutures with endoscopic forceps. Three surgeon ligated thread a suture five times with and without use of the glasses in the box, and the mean time was calculated for each surgeon. RESULTS: The time required for ligation (mean +/- SD) was 24.2 +/- 2.9 s with mirror glasses and 27.0 +/- 2.5 s without the glasses (p = 0.01). CONCLUSION: The mirror glasses may be found useful for fine manipulation for minimally invasive surgery.

How I do it: self-retaining atrial retractors for robotic and minimally invasive mitral valve surgery.

Successful surgery, particularly on the heart valves, is dependent on excellent and consistent exposure of the operative field. In this report, we describe 2 types of new atrial retractors designed for robotic and minimally invasive mitral valve surgery. These simple and easy-to-handle atrial retractors provide exceptional and consistent exposure of the left atrium in robotic and minimally invasive mitral valve surgery and prevent traumatic injury.

Echocardiographic measurements alone do not provide accurate non-invasive selection of annuloplasty band size for robotic mitral valve repair.

BACKGROUND AND AIM OF THE STUDY: Successful mitral valve repair (MVP) is dependent on accurate annuloplasty band sizing. This is difficult and time-consuming when performed via port-access, or through a 4-cm minithoracotomy used in robotically assisted MVP. With the goal of moving toward a less-invasive approach and minimizing cross-clamp time, an attempt was made to determine annuloplasty band size using transesophageal echocardiography (TEE) alone. METHODS: The intertrigonal distance (ITD) was determined by dividing the left ventricular outflow tract diameter (LVOT: measured on standard midesophageal aortic valve long-axis view) by 0.8. The ITD was compared to a nomogram developed to select the best Cosgrove-Edwards annuloplasty band size. RESULTS: Between July and October, 2004, 11 patients (mean age 52.6 +/- 17.9 years; four Barlow's valves with bileaflet prolapse, four posterior leaflet prolapses, one anterior leaflet prolapse, one rheumatic, one dilated annulus) undergoing robotically assisted MVP had the annuloplasty band chosen using TEE alone. Seven patients (63.6%) had no or mild mitral regurgitation (MR) on postoperative TEE. Three patients (27.2%) had some systolic anterior motion (SAM), with one (Barlow's valve) requiring a second repair (same operation). One patient (9.1%, rheumatic) had grade 2+ MR on postoperative TEE. CONCLUSION: In this small case series, a substantial proportion of patients had suboptimal immediate postoperative results. This suggests that selection of the annuloplasty band should not be based on a single echocardiographic variable as it depends on the etiology of the MR, and other dimensions of the mitral valve. Further studies are ongoing to develop a non-invasive method for the selection of annuloplasty band size.

Robot-Assisted Partial Atrioventricular Canal Defect Repair and Cryo-Maze Procedure.

Atrial septal defect is one of the most common congenital heart anomalies in adults. Patients with partial atrioventricular canal defects, previously known as ostium primum atrial septal defect, usually present at an early age, and only a few reach adulthood without surgical correction. Herein, we describe a young woman who presented with an ostium primum defect and severe symptomatic mitral and tricuspid regurgitation with paroxysmal atrial fibrillation. A complex repair was successfully done through a left atrial approach using robot-assistance.

Robotic mitral valve surgery: a United States multicenter trial.

OBJECTIVE: In a prospective phase II Food and Drug Administration trial, robotic mitral valve repairs were performed in 112 patients at 10 centers by using the da Vinci surgical system. The safety of performing valve repairs with computerized telemanipulation was studied. METHODS: After institutional review board approval, informed consent was obtained. Patients had moderate to severe mitral regurgitation. Operative technique included peripheral cardiopulmonary bypass, a 4- to 5-cm right minithoracotomy, a transthoracic aortic crossclamp, and antegrade cardioplegia. The successful study end point was grade 0 or 1 mitral regurgitation by transthoracic echocardiography at 1 month after surgery. RESULTS: Valve repairs included quadrangular resections, sliding plasties, edge-to-edge approximations, and both chordal transfers and replacements. The average age was 56.4 +/- 0.09 years (mean +/- SEM). There were 77 (68.8%) men and 35 (31.2%) women. Valve pathology was myxomatous degeneration in 105 (91.1%), and 103 (92.0%) had type II leaflet prolapse. Leaflet repair times averaged 36.7 +/- 0.2 minutes, with annuloplasty times of 39.6 +/- 0.1 minutes. Total robot, aortic crossclamp, and cardiopulmonary bypass times were 77.9 +/- 0.3 minutes, 2.1 +/- 0.1 hours, and 2.8 +/- 0.1 hours, respectively. On 1-month transthoracic echocardiography, 9 (8.0%) had grade 2 mitral regurgitation, and 6 (5.4%) of these had reoperations (5 replacements and 1 repair). There were no deaths, strokes, or device-related complications. CONCLUSIONS: Multiple surgical teams performed robotic mitral valve repairs safely early in development of this procedure, with a reoperation rate of 5.4%. Advancements in robotic design and adjunctive technologies may help in the evolution of this minimally invasive technique by decreasing operative times.

Acute effects of suction retraction on atrial hemodynamics and histology.

OBJECTIVES: In minimally invasive and robotic mitral valve surgery, a blade retractor is used to elevate the left atrial roof, which often distorts tissue and impairs visualization. We tested the hemodynamic and histologic changes of intra-atrial suction, using a new suction retractor that may improve stabilization and visualization. METHODS: Swine were divided into 3 equal (n = 4) groups: blade retractor, suction retractor, and arrested heart control. Left atrial ultrasonic crystals were used to record ejection fractions. After cardioplegic arrest, the atrium was opened and sampled for preretractor histology. Retractors remained in place for 1 hour, followed by postretractor histologic sampling. Controls were crossclamped for an equivalent time and postarrest histologic data obtained. Animals were weaned from bypass, data were collected for 4 hours, and postsacrifice atrial histologic samples were obtained. RESULTS: The main effect due to treatment was not statistically significant ( P = .52) between the 3 groups, with the 4-hour average ejection fraction for blade retractor, suction retractor, and control being statistically equivalent at 33.3% +/- 8.3, 35.3% +/- 12.1, and 40.8% +/- 9.9 (mean +/- standard deviation), respectively. Histology showed equivalent amounts of myocyte fragmentation, interstitial edema, eosinophilia, and wavy fibers between blade retraction and suction retraction, while the latter showed slightly increased amounts of hemorrhage. CONCLUSIONS: Atrial endocardial suction retraction appears to be safe with no acute changes in the left atrial ejection fraction or significant acute histologic differences, compared to blade retraction. Furthermore, intra-atrial suction may be applicable to procedures other than minimally invasive and robotic mitral valve repair for providing improved stabilization.

Reexamining contraindications for minimally invasive mitral valve surgery.

Historically, contraindications to minimally invasive or robotic mitral valve surgery have included prior mastectomy, thoracic reconstruction, or chest radiation. However, we believe that by granting flexibility in the choice of skin incision site while performing careful dissection, surgeons can provide these patients the outstanding results afforded by a minithoracotomy. We present a patient who had undergone a prior mastectomy and radiation treatment in whom we performed a minimally invasive mitral valve repair through a right-sided minithoracotomy using the previous mastectomy incision.

Angiogenic growth factor response to acute systemic exercise in human skeletal muscle.

We investigated whether acute systemic exercise increases vascular endothelial growth factor (VEGF), VEGF receptor (KDR and Flt-1) mRNA, and VEGF protein in sedentary humans. Twelve sedentary subjects were recruited and performed 1 h of acute, cycle ergometer exercise at 50% of maximal oxygen consumption. Muscle biopsies were obtained from the vastus lateralis before exercise and at 0, 2, and 4 h postexercise. Acute exercise significantly increased VEGF mRNA at 2 and 4 h and increased KDR and Flt-1 mRNA at 4 h postexercise. The sustained increase in VEGF mRNA through 4 h and the increases in KDR and Flt-1 at 4 h are different from their respective time course responses in rats. In contrast to the increase in VEGF mRNA postexercise, VEGF protein levels were decreased at 0 h postexercise. These results provide evidence in humans that 1) VEGF, KDR, and Flt-1 mRNA are increased by acute systemic exercise; 2) the time course of the VEGF, KDR, and Flt-1 mRNA responses are different from those previously reported in rats (Gavin TP and Wagner PD. Acta Physiol Scand 175: 201-209, 2002); and 3) VEGF protein is decreased immediately after exercise.

A technique for evaluating competitive flow for intraoperative decision making in coronary artery surgery.

The effect of native coronary competitive flow on the patency of arterial and saphenous vein grafts is controversial. We use a simple intraoperative technique to evaluate competitive flow that allows us to make informed intraoperative decisions regarding anastomotic quality, vessel runoff, and competing native coronary blood flow.