Clinical Impact of the Endo-aortic Clamp for Redo Mitral Valve Surgery.

Aim of this study was to compare redo MV surgery patients undergoing right mini-thoracotomy and EAC with redo MV patients undergoing surgery through other approaches. Redo MV patients from 7 European centers were analyzed. Primary endpoint was 30-day mortality; secondary endpoints were stroke, re-exploration, low cardiac output syndrome (LCOS), respiratory failure, and intensive care unit (ICU) and in-hospital length-of-stay. Forty-nine patients underwent right mini-thoracotomy and EAC (22.7%), and 167 (77.3%) underwent surgery through other approaches (112 sternotomy, 40 unclamped mini-thoracotomies, and 15 mini-thoracotomies with trans-thoracic clamp). Thirty-day mortality, stroke, re-exploration for bleeding, and weaning failure were comparable. The EAC group showed significant lower rate of LCOS (p = 0.03) and shorter ICU (p = 0.04) and in-hospital length of stay (p = 0.002). The EAC allows the surgeon to reach the aorta, to clamp it, and to deliver the cardioplegia with a "no-touch" technique, with significant improvement in outcomes.

Robotic-Assisted Minimally Invasive Direct Coronary Artery Bypass Grafting: A Surgical Technique.

In recent years, there has been a growing interest in robotic-assisted coronary artery revascularization in Europe. Two different types of surgery can be performed using a robotic platform: RA-MIDCAB, in which the mammary artery is harvested endoscopically with robotic assistance and off-pump bypass graft is achieved under direct vision through mini thoracotomy, and TE-CAB, completely robotically performed. We started the robotic cardiac surgery program for mitral valve disease in our hospital, Humanitas Gavazzeni (Bergamo, Italy), in 2019; and in 2021, we addressed our experience with RA-MIDCAB. After a learning curve period, we have developed our technique to optimize the benefits offered by the robotic platform, tailoring strategy to individual patients, based on preoperative radiological images.

Robotic-Assisted Epicardial Hybrid Ablation and Left Appendage Closure in Persistent Atrial Fibrillation: First European Experience.

Background: Pulmonary vein isolation is currently considered to be the gold standard for ablating paroxysmal atrial fibrillation. However, its efficacy is limited in patients with persistent atrial fibrillation. The convergent procedure has emerged as a hybrid ablation. This study aims, for the first time in the literature, to introduce a hybrid approach that includes epicardial ablation with cutting-edge robotic technology and subsequent electrophysiological study to verify and an endocardial ablation to complete the ablation lines. Methods: We present 18 cases of robotic-assisted epicardial hybrid ablation performed between April and December 2023 on patients with long-standing persistent atrial fibrillation (mean age: 64 ± 5 years; mean duration: 4 ± 2 years). All of the procedures were performed at "Humanitas Gavazzeni Hospital", Bergamo, Italy. Robot-assisted epicardial ablation performed using the "Epi-Sense AtriCure" device was guided by monitoring electrogram morphology and point-by-point impedance drop. This approach also included left atrial appendage occlusion and the disconnection of the ligament of Marshall. An electrophysiological study and endocardial ablation were planned three months after the procedure. Results: The procedure was successfully executed in all patients with no major complications and a mean operative time of 142 ± 22 min. None of the cases required conversion to full sternotomy or minithoracotomy. The procedure was performed in all cases without extracorporeal circulation and on a beating heart. Fifteen patients (83%) were extubated in the operating room. The length of stay in the intensive care unit was less than 24 h. Acute restoration of sinus rhythm was achieved in 12 out of the 18 patients (67%); the median duration of their hospital stay was two days. In the electrophysiological study, seven pts had sinus rhythm, two had atrial fibrillation, and one patient developed atrial flutter at 3-month follow-up. Patients underwent transcatheter ablation to complete the lesion set and, at the time of discharge, were all in sinus rhythm. Conclusions: In our initial experience, surgical atrial fibrillation ablation consisting of a unilateral thoracoscopic technique facilitated by a robotic platform and continuous EGM monitoring has proven to be safe and feasible. For the electrophysiological study at 3 months, completing the gaps in the surgical ablation lines could improve the clinical results of the technique in terms of sinus rhythm stability. However, mid- and long-term follow-up is required to demonstrate this.

Risk Factors for Higher Postoperative Myocardial Injury in Minimally Invasive Mitral Valve Surgery Patients: A Cohort Study.

Background: Postoperative myocardial injury, as detected by an elevated concentration of high-sensitivity cardiac troponin I (hs-cTnI), is a common complication in cardiac surgery that may be linked to mortality. The primary aim of this study was to assess the risk factors associated with increased myocardial injury in patients undergoing minimally invasive mitral valve surgery. Methods: In this retrospective monocentric cohort study, we analyzed all patients who underwent elective minimally invasive mitral valve surgery between January 2019 and December 2022 and were subsequently admitted to our intensive care unit. The study population was divided into two groups based on the peak hs-cTnI level: the "lower myocardial injury" group comprised patients whose peak serum hs-cTnI level was less than 499 times the 99th percentile, while the "higher myocardial injury" group included those patients who exhibited hs-cTnI levels equal to or greater than 500 times the 99th percentile. A multivariable logistic regression analysis was performed to identify independent risk factors associated with higher myocardial injury. Results: In our final analysis, we enrolled 316 patients. Patients with higher myocardial injury (48; 15%) more frequently had a preoperative New York Heart Association (NYHA) class ≥3 compared to those with lower myocardial injury [33 (69%) vs. 128 (48%); p < 0.01-OR 2.41 (95% CI 1.24-4.64); p < 0.01]. Furthermore, cardiopulmonary bypass and aortic cross-clamp time were significantly longer in the higher myocardial injury group compared to the lower myocardial injury group [117 (91-145) vs. 86 (74-100) min; p < 0.01-OR 1.05 (95% CI 1.03-1.06); p < 0.01]. Moreover, patients who underwent robotic-assisted mitral valve surgery experienced lower myocardial injury rates [9 (19%) vs. 102 (38%); p = 0.01-OR 0.38 (95% CI 0.18-0.81); p = 0.01] than others. These findings remained consistent after adjustment in multivariate logistic regression. In terms of postoperative outcomes, patients with higher myocardial injury exhibited the highest lactate peak in the first 24 h, a higher incidence of postoperative acute kidney injury and a longer duration of mechanical ventilation. Although no patients died in either group, those with higher myocardial injury experienced a longer hospital length of stay. Conclusions: Higher myocardial injury is relatively common after minimally invasive mitral valve surgery. Prolonged aortic cross-clamp duration and higher NYHA class were independently associated with myocardial injury, while robotic-assisted mitral valve surgery was independently associated with lower postoperative myocardial injury.

Learning Curve Analysis of Robotic-Assisted Mitral Valve Repair with COVID-19 Exogenous Factor: A Single Center Experience.

Background and objective Renewed interest in robot-assisted cardiac procedures has been demonstrated by several studies. However, concerns have been raised about the need for a long and complex learning curve. In addition, the COVID-19 pandemic in 2020 might have affected the learning curve of these procedures. In this study, we investigated the impact of COVID-19 on the learning curve of robotic-assisted mitral valve surgery (RAMVS). The aim was to understand whether or not the benefits of RAMVS are compromised by its learning curve. Materials and Methods Between May 2019 and March 2023, 149 patients underwent RAMVS using the Da Vinci® X Surgical System at the Humanitas Gavazzeni Hospital, Bergamo, Italy. The selection of patients enrolled in the study was not influenced by case complexity. Regression models were used to formalize the learning curves, where preoperative data along with date of surgery and presence of COVID-19 were treated as the input covariates, while intraoperative and postoperative data were analyzed as output variables. Results The age of patients was 59.1 ± 13.3 years, and 70.5% were male. In total, 38.2% of the patients were operated on during the COVID-19 pandemic. The statistical analysis showed the positive impact of the learning curve on the trend of postoperative parameters, progressively reducing times and other key indicators. Focusing on the COVID-19 pandemic, statistical analysis did not recognize an impact on postoperative outcomes, although it became clear that variables not directly related to the intervention, especially ICU hours, were strongly influenced by hospital logistics during COVID-19. Conclusions Understanding the learning curve of robotic surgical procedures is essential to ensure their effectiveness and benefits. The learning curve involves not only surgeons but also other health care providers, and establishing a stable team in the early stage, as in our case, is important to shorten the duration. In fact, an exogenous factor such as the COVID-19 pandemic did not affect the robotic program despite the fact that the pandemic occurred early in the program.

Comparative myocardial protection of endoaortic balloon versus external clamp in minimally invasive mitral valve surgery.

AIMS: Minimally invasive mitral valve surgery leads to shorter postoperative recovery time, cosmetic advantages and significant pain reduction compared with the standard sternotomy approach. Both an external aortic clamp and an endoaortic balloon occlusion can be used to manage the ascending aorta and the myocardial protection. In this study, we aimed to compare these two strategies in terms of effectiveness of myocardial protection and associated early postoperative outcomes. METHODS: We investigated the retrospective records of prospectively collected data of patients treated by minimally invasive mitral valve surgery from March 2014 to June 2019. A total of 180 cases (78 in the external aortic clamp group and 102 in the endoaortic balloon clamp group) were collected. A propensity weighting analysis was adopted to adjust for baseline variables. RESULTS: The endoaortic balloon clamp presented higher EuroSCORE II (higher reoperative surgery rate). The intra- and postoperative data were similar between the two groups: the postoperative troponin-I levels, peak of serum lactates and rate of myocardial infarction were also comparable. The endoaortic clamp group recorded longer operative, cardiopulmonary bypass and cross-clamp times. The external clamp group showed a higher rate of postoperative atrial fibrillation and conduction block. CONCLUSIONS: In experienced centers, the use of the endoaortic balloon clamp is safe, reproducible and comparable to the external aortic clamp regarding the effectiveness of myocardial protection: its employment might facilitate minimally invasive mitral valve surgery.

Evaluation of robotic-assisted mitral surgery in a contemporary experience.

AIMS: To evaluate the safety/effectiveness of a recently established robotic-assisted mitral surgery program. METHODS: Cohort study with prospective collection of clinical data of 59 consecutive recipients (May 2019-August 2021) of robotic-assisted (fourth-generation platform, DaVinci X) mitral valve repair for degenerative disease, using a totally endoscopic technique. Patients' selection was based on defined anatomical and clinical criteria. We established a dedicated multidisciplinary protocol to facilitate postoperative fast-tracking, and a systematic in-house clinical and echocardiographic follow-up at 3, 6, and 12 postoperative months. RESULTS: All patients (89.8% men, average age 58 ±â€Š12 years) received mitral valve repair; there was no operative mortality, one conversion to sternotomy (1.7%) and one stroke (1.7%). Extubation within the operative theater occurred in 28.8%; average mechanical ventilation time and ICU stay was 2.8 ±â€Š4.1 and 32.5 ±â€Š15.8 h (after exclusion of one outlier, learning-curve period, suffering from perioperative stroke); average postoperative hospital stay was 6.8 ±â€Š3.4 days and 96.6% of patients were discharged home. One patient was transfused (1.7%); there were no other complications. Follow-up revealed stability of the results of mitral repair, with one (1.7%) persistent (>2+/4+) mitral regurgitation, and stability of coaptation height over time. We observed optimal functional results (class I was 98% at 3 months and 96% at 12 months). Quarterly case load consistently increased during the experience. CONCLUSION: This initial experience suggests the reliability and clinical safety of a recently established local robotic-assisted mitral surgery. This strategy can facilitate faster postoperative recovery, and its positioning in the therapeutic armamentarium needs to be defined.

Less invasive aortic valve replacement using the trifecta bioprosthesis.

Objectives. The safety and effectiveness of the Trifecta GT bioprosthesis (introduced in 2016) in less invasive aortic valve replacement are scarcely investigated. Our aim was to evaluate the immediate and initial follow-up results of this device in the context of less invasive surgery. We discuss patient-specific strategies for the selection of the surgical approach. Methods. A retrospective review of 133 patients undergoing AVR with the Trifecta GT through three less invasive accesses (UMS, Upper ministernotomy; RMS, Reversed ministernotomy; RAMT, Right anterior minithoracotomy) was performed. In-hospital, follow-up and hemodynamic performance (PPM, Patient-prosthesis mismatch) data were collected. Results. Among patients, 79% received UMS, 11% RMS and 10% RAMT. Selection of approach was based on preoperative anatomical analysis (CT-scan) and planned concomitant procedures. There was no operative mortality, no valve-related adverse events. There were 36 concomitant procedures. No significant intergroup differences occurred in cardiopulmonary bypass, aortic clamp, mechanical ventilation time, ICU stay and average bleeding. There were two cases of moderate PPM (1.5%) and no instances of severe PPM; there were no significant (≥2/4) perivalvular leaks. Average mean gradient at discharge was 8 ± 3 mmHg. At follow-up (average: 2.5 ± 0.9 years, 100% complete, 315 patient years) there was no mortality and no valve-related adverse event. Hemodynamic performance was maintained at follow-up. Conclusions. The optimal device for less invasive AVR needs to be individualized, as well as the selection of the surgical approach. The use of the Trifecta GT bioprosthesis appears to be reproductible whatever less invasive approach is employed, with confirmed excellent hemodynamic performance.

Corrigendum: Robotic Cardiac Surgery in Europe: Status 2020.

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

[Towards the age of computer-assisted surgery: how to establish a robotic-assisted mitral surgery program with a last-generation platform]. / Verso l'era della chirurgia computer-assistita: come iniziare un programma di chirurgia robotica della valvola mitrale.

Mitral valve therapy is rapidly evolving. In this context, there is a clear evolution towards the diffusion of minimally invasive techniques for surgical mitral valve replacement or repair, namely in the context of primary mitral regurgitation. The robotic-assisted mitral surgery strategy allows the greatest reduction in surgical trauma to the patients, as well as improved ergonomics and video-assistance for performance of the mitral procedure. We currently observe a rapid diffusion of robotic-assisted mitral valve surgery across Europe, which rightfully forms part of the treatment modalities available to multidisciplinary Mitral Teams. However, the development of a robotic cardiac surgery program should be established maintaining reproducibility and patient safety. Adequate training and preparation are essential to initiate and sustain a robotic-assisted mitral valve surgery program. Herein, we address its main steps: fundamentals, multidisciplinary approach, risk management, team management, development and consolidation. We also present the initial clinical results in our Center, and analyze some learning-curve aspects.

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.

Robotic Mitral Valve Repair Through Nonresectional Posterior Leaflet Remodeling.

The nonresectional posterior leaflet remodeling technique through free margin running suture (FMRS) has been recently introduced for the management of complex degenerative lesions of the posterior mitral leaflet. It aims at providing a novel tool in the mitral surgeon's armamentarium to improve the reproducibility and durability of repair, namely in cases characterized by more severe degenerative disease (Barlow and extensive fibroelastic deficiency lesions). Although FMRS can be performed through any surgical access, its features render it particularly adapted to minimally invasive mitral surgery. We describe for the first time the characteristics of FMRS in the context of robotic-assisted mitral repair. A stepwise approach is employed for presentation. The diffusion of robotic-assisted mitral repair has been limited by both economic and reproducibility issues; we hypothesize that FMRS may be helpful in improving the reproducibility of minimally invasive and robotic-assisted mitral surgery. We also discuss the initial clinical results of FMRS.

Continued follow-up of the free margin running suture technique for mitral repair.

OBJECTIVES: The free margin running suture (FMRS) technique was recently proposed to treat complex degenerative mitral lesions. Limited follow-up data are available. We evaluated the midterm reliability of this technique and the associated mitral valve parameters using rest/stress echocardiography. METHODS: One-hundred-eight consecutive patients at 2 European centres were included. Prospective follow-up was performed (266.1 patient-years, average duration 2.5 ± 2.5 years). Echocardiographic scans at rest were obtained for all patients at hospital discharge and at follow-up. Stress echocardiography was also performed in 17 patients. RESULTS: There were no operative deaths. FMRS was performed through a right minithoracotomy in 86.1% of patients, with a robotic-assisted technique in 5.6% and through a sternotomy in 8.3%. Bileaflet disease was noted in 31.4%. One patient (0.9%) presented a 2+/4+ residual mitral regurgitation at discharge; lower-degree or no residual regurgitation was noted in the remaining patients. At the follow-up examination, 1 patient (0.9%) presented with a 2+/4+ mitral regurgitation. Coaptation length at discharge versus that at follow-up was 1.3 ± 0.2 vs 1.3 ± 0.1 cm (P = 0.13); the average transmitral gradient was 4.8 ± 1.5 vs 3.5 ± 0.9 mmHg (P < 0.001). In a subpopulation, follow-up echocardiography indicated that the average transmitral gradient at rest versus that at peak effort was 3.2 ± 0.7 vs 5.1 ± 1.3 mmHg (P < 0.001), with no appearance of significant mitral regurgitation and marginally significant increases in pulmonary artery systolic pressures (P = 0.049). CONCLUSIONS: Data indicate effectiveness and reproducibility of FMRS, with stability of valve function at midterm. FMRS was also associated with promising outcomes in diastolic performance both at rest and during exercise.

Versatility of endoaortic balloon occlusion device for less invasive management of complex and reoperative cardiac cases.

Heart Teams are increasingly confronted with decision-making in anatomically and clinically complex surgical candidates. Herein, we discuss the versatility of the endoaortic occlusion device (Intraclude; Edwards Lifesciences Inc) for the management of a various array of complex primary and reoperative cardiac cases. Three clinical scenarios are illustrated (ascending aortic pseudoaneurysm, mitral valve surgery after previous CABG, extensive thoracic aortic surgery with continuous visceral perfusion), suggesting the effectiveness of the patient-specific strategy to minimize operative morbidity. Evolution of surgical techniques needs to be considered in decision-making among alternative treatment strategies.

Strategy-specific durability of mitral valve repair through the video-assisted right minithoracotomy approach.

AIMS: We sought to analyze the early and follow-up results of minimally invasive video-assisted mitral valve repair. With particular focus on degenerative disease, results were stratified according to type of lesion, strategy of repair and surgical technique. METHODS: We retrospectively built a database over 241 patients who received mitral repair for severe regurgitation through right minithoracotomy in the 2009-17 period. Cause was degenerative in 92.1%, restrictive in 5.8% and mixed in the remainders. Clinical and echocardiographic follow-up (98.7% complete, average duration 2.9 years ±â€Š1.4) was obtained through contact of in-house and territorial cardiologists. Recurrent mitral regurgitation at follow-up was defined as being at least mild-to-moderate (2+). RESULTS: Operative mortality was 1.7%, and related to the technique in one case. Five-year actuarial survival was 95% ±â€Š2; there was no valve-related death and one reoperation. At follow-up, we observed eight cases of 2+ regurgitation and one instance of 4+ regurgitation (4-year actuarial freedom: 92% ±â€Š4). Freedom from recurrent regurgitation was significantly lower in the 'restrictive' subgroup vs. the 'degenerative' subgroup (P = 0.02); no statistically significant difference in freedom from recurrence was observed among patients who received mitral repair using a 'resect' vs. 'nonresection' strategy (P = 0.46), and in those who received the Totally Endoscopic technique (endoaortic balloon occlusion, no costal spreading) vs. controls (external aortic clamp, costal spreading) (P = 0.98). CONCLUSION: Durability of minimally invasive mitral repair is optimal. Nonresection repair techniques are at least noninferior to previous approaches based on leaflet resection.

Surgical treatment of left ventricular echinococcosis through the HeartPort technique.

Echinococcal lesions rarely involve the heart; nonetheless, echinococcal cysts of the left ventricular myocardium often demand surgical treatment due to the risk of rupture and anaphylaxis. Herein, an echinococcal cyst of the anteroapical left ventricular wall was managed through small left anterior thoracotomy; repair was achieved under cardioplegic arrest (endoaortic balloon occlusion) with an uneventful course. We discuss the usefulness of such a less invasive approach for the depicted lesion (minimized manipulation of the heart and reduced surgical aggressiveness) and for other lesions involving the apical/lateral LV region.