Robot-Assisted Totally Endoscopic Mitral Valve Plasty and Coronary Artery Bypass Grafting.

We experienced 3 cases of port-access robot-assisted totally endoscopic technique for mitral valve repair and concomitant coronary artery bypass. The right internal mammary artery was harvested, mitral valve was fixed, and the right internal mammary artery to right coronary artery anastomosis was carried out on the arrested heart. The use of cardiac arrest and a V-shaped hook technique facilitated the coronary anastomosis and the da Vinci Firefly test (Intuitive Surgical Inc., Sunnyvale, CA) could confirm patency of the graft.

Robotic mitral valve plasty for isolated clefts of mitral valve leaflets.

A 21-year-old female patient referred to our institute had been suffering from severe mitral valve regurgitation due to a rare anomaly: a typical cleft at the posterior mitral leaflet and the other partial one at the anterior leaflet. We successfully fixed the mitral valve using the robot-assisted totally endoscopic technique which could perform suture closure of both leaflets and annuloplasty. This communication is the first report of the robotic and totally endoscopic procedure which could treat this rare mitral anomaly.

Novel Brain Protection Method for Zone 0 Endovascular Aortic Repair with Selective Cerebral Perfusion.

Objective: Zone 0 thoracic endovascular aortic repair (TEVAR) is associated with a high incidence of cerebral infarction mostly due to the embolic shower of a plaque from the aortic arch when the stent graft brushes against the aortic wall. Thus, it is important to develop a method for protecting the brain from such embolism. We report the outcomes of Zone 0 TEVAR with a novel brain protection method using selective cerebral perfusion under extracorporeal membrane oxygenation (ECMO). Materials and Methods: Two T-shaped grafts with ringed expanded polytetrafluoroethylene (ePTFE) were created using an 8-mm-ringed ePTFE anastomosed end-to-side with a 7-mm-ringed ePTFE. Carotid-carotid bypass and axillo-axillary bypass were established using these grafts. ECMO was connected to the grafts and the femoral vein. Bilateral carotid and axillary arteries were blocked, and cerebral perfusion was selectively maintained using ECMO. Total endovascular Zone 0 TEVAR was performed. The patency of brachiocephalic artery was maintained using the chimney or in situ fenestration technique. Results: Since August 2016, seven patients with aortic arch aneurysms underwent the procedure. The mortality rate was 0%. No neurological complications developed. Conclusion: This brain protection method using selective cerebral perfusion under ECMO is a safe method for Zone 0 TEVAR.

Combined robot-assisted mitral valve plasty and Nuss procedure via small ports.

Pectus excavatum (PE) can be associated with cardiac disorders that also require surgical repair. Totally endoscopic robot-assisted mitral valve plasty for mitral valve regurgitation was performed while elevating the sternum with the aid of our original electrical sternum lifting system. Then, the Nuss procedure was performed successfully via small incision. Simultaneous robot-assisted cardiac surgery and the Nuss procedure is effective. Sternal elevation during cardiac surgery is very important for a safe procedure. The Nuss technique prevents perioperative cardiac compression and allows for correction of the pectus deformity with good cosmetic and functional results.

[Minimally Invasive Cardiac Surgery for a Heart Tumor after Breast Cancer Therapy and Partial Lung Resection for Lung Cancer;Report of a Case].

Papillary fibroelastoma is a benign tumor of the heart, constituting less than 10% of heart tumors. When papillary fibroelastoma is diagnosed, surgical treatment must be considered because it may cause embolization such as myocardial infarction and strokes. We experienced a patient with papillary fibroelastoma of the tricuspid valve after total resection of the right breast for breast cancer and partial lung resection for lung cancer. Minimally invasive cardiac surgery (MICS) with right thoracotomy was perfomed to resect the tumor. Though median sternotomy is still the most widely used approach for cardiac tumor, MICS is a useful method for preventing sternal wound infection and promoting wound healing, particularly in a patient with high risk of wound infection like this case.

Successful Two-Stage Treatment for Coarctation of the Aorta-postductal Type and Aortic Regurgitation with Thoracic Endovascular Aortic Repair and Aortic Valve Replacement.

We herein report a case of a 20-year-old man with aortic regurgitation (AR), coarctation of the aorta (CoA), and patent ductus arteriosus (PDA). The preoperative ankle-brachial pressure index was 0.56 in bilateral extremities. Enhanced computed tomography revealed CoA-postductal type. We decided to perform a two-stage surgery: thoracic endovascular aortic repair (TEVAR) for CoA and PDA and then open surgery for AR. TEVAR was successfully performed with deployment of the stent graft at a 31-mm diameter subsequent to balloon dilation. At 8 days after TEVAR, the patient underwent aortic valve replacement via median sternotomy and was discharged without a complication.

First Major Clinical Outcomes of Totally Endoscopic Robotic Mitral Valve Repair in Japan　- A Single-Center Experience.

BACKGROUND: In 2018, Japan became the first country to have robotic cardiac surgery covered under the national health insurance. The number of patients undergoing robotic mitral valve (MV) repair has been estimated to increase remarkably, but no reports in Japan have yet described the outcomes of robotic MV repair. This study aimed to analyze the early clinical outcomes of patients undergoing totally endoscopic robotic MV repair (TERMVR) as a landmark national study for this procedure.Methods and Results:A total of 213 patients (152 men; mean age, 55±11 years) underwent TERMVR during May 2014 to December 2018. Preoperative demographics, operative profiles, and postoperative outcomes, including follow-up echocardiography, were analyzed. Successful TERMVR was achieved in all patients. Operation, cardiopulmonary bypass, and aortic cross-clamp times were 192±49.8, 127±23.8, and 70.1±16.2 min, respectively. Intraoperative transfusion was performed in 20 patients (10%). There were no in-hospital deaths. All patients were alive during the median follow-up period of 255 days (interquartile range, 32.5-208 days). Freedom from recurrence of MR >grade 2+ was 97.3%, 95.0%, and 90.7% at 6, 12, and 24 months, respectively. CONCLUSIONS: TERMVR is an effective and safe procedure with acceptable early postoperative outcomes.

Nonresectional Simplified Folding Technique in Robotic Mitral Valve Plasty: Comparison with Leaflet Resection Technique.

OBJECTIVE: The mitral valve plasty (MVP) technique for degenerative disease is typically leaflet resection and suturing. However, this technique is time consuming and unreproducible. To overcome this disadvantage, we developed a nonresectional folding technique, which is fast and reproducible. In this report, we examine our new folding technique in robotic MVP. METHODS: The new folding technique was performed in 10 patients (age 56 ± 15 years), and the conventional resection and suturing (RS) technique was performed in 22 patients (age 53 ± 8 years). In our new folding technique, we used two sutures to fold the prolapsed leaflet to the left ventricle side. The first folding suture line is a land mark, and the second line adjusts the height of the posterior leaflet to the anterior leaflet so that sufficient coaptation depth can be obtained. RESULTS: MVP was successful in all patients. In the folding technique group, the operation time, cardiopulmonary bypass time, and cross clamp time was faster than the conventional RS technique group (188 ± 31, 97 ± 32, and 55 ± 3 min, versus 242 ± 51, 137 ± 25, and 70 ± 15 min; P < .05). Hospital stays were significantly shorter in the folding technique group (13 ± 2 days versus 17 ± 7 days; P < .05). All patients were discharged without complications. The post-echocardiography revealed no mitral valve regurgitation in any patient. CONCLUSION: The new folding technique facilitated efficient MVP for posterior leaflet prolapse in mitral valve regurgitation, without the need for the resection of the leaflet.

Robotic mitral valve plasty for mitral regurgitation after blunt chest trauma in Barlow's disease.

We successfully treated a case of mitral regurgitation due to chest trauma in Barlow's disease. A 71-year-old man was admitted with severe mitral regurgitation after blunt compression of the chest by a heavy object 5 months earlier. Preoperative examination revealed wide chordae tendineae rupture and myxomatous changes to the bileaflets. Neo-chordae reconstruction of the anterior mitral leaflet using loop technique, triangular resection of the posterior mitral leaflet, and ring annuloplasty was performed via surgical robot. Robotic mitral valve plasty for severe mitral regurgitation due to chest trauma in Barlow's disease was achieved safely with good clinical and excellent cosmetic results.

Hybrid treatment combining robotic coronary artery bypass grafting and percutaneous catheter radiofrequency ablation.

Isolated coronary artery bypass grafting associated with atrial fibrillation is routinely performed through a sternotomy, and cardiac arrest. Advancements in this surgical approach have led to better cosmesis, a quick postoperative recovery, with the same postoperative results. We report a case of a novel, less invasive hybrid treatment combining robot-assisted coronary artery bypass grafting and percutaneous radiofrequency catheter ablation.

Surgical Repair for the Treatment of Pulmonary Vein Stenosis After Radiofrequency Ablation.

Radiofrequency ablation procedures for atrial fibrillation are occasionally associated with pulmonary vein stenosis (PVS). A common treatment for PVS is catheter intervention; however, because of the high restenosis rate, it is not suitable for young patients. The case presented herein is of a young male patient with severe bilateral PVS who underwent successful surgical pulmonary vein repair by sutureless technique. The stenotic lesions of the pulmonary veins were dissected and were covered using autologous pericardium. An enhanced computed tomographic scan revealed that all the pulmonary veins were widely patent after 6 months from the operation.

Hyperkalemic arrest and the aortic no-touch technique in minimally invasive atrial septal defect closure in adults.

To avoid aortic cross-clamping and cardioplegic ischaemia, we propose the induction of hyperkalemic arrest and using aortic no-touch technique in minimally invasive atrial septal defect (ASD) closure. Twenty-eight patients were included in this study. After establishment of cardiopulmonary bypass, potassium was administered to induce hyperkalemic arrest. The mean dose of injected potassium was 1.2 ± 0.45 mEq/kg. Following the direct closure of the ASD, potassium was filtered out using a hemodialyzer. At the end of the operation, serum potassium was normalized to 4.1 ± 0.5 mEq/l. The mean arrest time was 11 ± 4.4 min without complications. Hyperkalemic arrest in combination with aortic no-touch technique is safe and efficacious in minimally invasive ASD closure.

A Novel Treatment Using an Intraventricular Stent Graft for Postinfarction Ventricular Septal Rupture in a Porcine Model.

OBJECTIVE: Ventricular septal rupture (VSR) is a severe complication of acute myocardial infarction, and the conventional technique for repair is associated with high operative mortality. A novel intraventricular stent graft (IVSG) device was tested as a less invasive treatment for VSR; it does not require cardiopulmonary bypass, cardiac arrest, or left ventricular incision. Its effectiveness was assessed using animal experiments. METHODS: Six pigs were placed on cardiopulmonary bypass. The VSR model was created by making a hole in the interventricular septum via the right ventricle. Animals were weaned off the bypass. The sheath encasing the device was advanced over the guidewire, and the IVSG was placed in the left ventricle. Before and after rupture creation and after device deployment, left ventriculography was performed, hemodynamic data were collected, and Qp/Qs values were measured. RESULTS: All procedures were completed safely. The left-to-right shunt seen after rupture creation disappeared after device deployment. The pulmonary-to-systemic blood flow ratio after rupture was 3.35 ± 1.00, decreasing significantly to 1.09 ± 0.10 after device deployment (P = 0.007). Hemodynamic instability after rupture creation improved dramatically after deployment. CONCLUSIONS: The use of our new IVSG in this VSR animal experiment model significantly decreased the left-to-right shunt. The new device was able to control the acute heart failure associated with VSR with a minimally invasive procedure during the hyperacute phase of heart failure. Potential improvements in VSR treatment outcomes are expected with its clinical application.

[Emergency Thoracic Endovascular Aortic Repair of Ruptured Kommerell's Diverticulum with an Acute Aortic Dissection].

This case report describes emergency thoracic endovascular aortic repair (TEVAR) of a ruptured Kommerell's diverticulum associated with a type B acute aortic dissection in a patient with a right aortic arch. A 64-year-old male was admitted with symptoms of sudden paraplegia and shock. The computed tomography imaging showed right aortic arch anomaly, with mirror image branching of the major arteries. The aorta was dissected from the origin of the right subclavian artery to the terminal aorta, with a thrombosed false lumen. Rupture was found in a 6.3 cm aneurysm located in the distal arch, which was diagnosed as Kommerell's diverticulum. We performed emergency TEVAR, and the aneurysm was successfully excluded using deployment of a Gore Tag stent-graft. At 3 months' follow-up, the patient was doing well and showed shrinkage of the aneurysm was confirmed. TEVAR is considered to be a suitable procedure for an emergency aortic catastrophe even in patients with aortic anomaly.

Two-Port Robotic Cardiac Surgery (TROCS) for Atrial Septal Defect (ASD) Using Cross-Arm Technique--TROCS ASD Repair.

BACKGROUND: We successfully performed totally endoscopic atrial septal defect (ASD) repair via 2 ports, and we named this procedure two-port robotic cardiac surgery (TROCS).Methods and Results:A 51-year-old woman with secundum ASD underwent robot-assisted ASD repair under ventricle fibrillation without aortic cross-clamping. Two ports were placed in the right side of the chest, and 1 port was for the robotic endoscope. Two robotic instruments were inserted through another port and crossed while preventing them from colliding. CONCLUSIONS: TROCS ASD repair using a cross-arm technique was achieved safely with good clinical results and excellent cosmetic results.

Robotic resection of dual accessory mitral valve tissue in an adult patient.

The presence of isolated accessory mitral valve tissue (AMVT) is extremely rare in adults. We successfully performed robot-assisted resection of dual AMVT that was attached to the papillary muscle and anterior mitral leaflet. Echocardiography was invaluable for identifying the most suitable approach. The short-axis view on echocardiography revealed the precise location where the AMVT was attached. The robotic operation enabled fine visualization; we clearly observed the AMVT and removed its entire extra structure. The patient recovered well and was discharged 3 days after the operation. To the best of our knowledge, this is the first report of successful robotic AMVT resection.

A novel coronary active perfusion system using a conventional intra-aortic balloon pump for off-pump coronary artery bypass grafting.

OBJECTIVE: It is important for coronary active perfusion systems to avoid myocardial ischemia during off-pump coronary artery bypass grafting. We have developed a new concept for a perfusion system to pump blood based on changes in helium gas volume. This system uses a conventional intra-aortic balloon pump to activate the perfusion pump. Our study used basic and animal experiments to investigate the most suitable system for coronary perfusion using this new concept. METHODS: A conventional intra-aortic balloon pump was used to supply power. A device for perfusion was developed with a balloon placed inside a stiff syringe barrel. The device was connected to the helium gas line of the intra-aortic balloon pump. Changes in flow with changes in augmentation level were noted when volumes outside and within the balloon were changed. Six pigs with occlusion of the left anterior descending artery were used for system validation, with monitoring to identify changes in hemodynamics and cardiac enzyme levels. RESULTS: In the basic experiment, an 80-mL outside volume and 3.0-mL inner volume resulted in the greatest percentage change in flow rate with respect to changes in augmentation. In the animal experiment, the new coronary active perfusion system prevented myocardial ischemia during coronary occlusion. CONCLUSIONS: We clarified the most suitable method for our new coronary active perfusion system. Using this system, safe anastomosis was consistently performed in animal experiments. Clinically, off-pump coronary artery bypass may potentially be performed more safely and easily using this new system.

Fasudil is a superior vasodilator for the internal thoracic artery in coronary surgery.

BACKGROUND: The internal thoracic artery (ITA) is a very useful conduit for coronary artery bypass artery (CABG), with excellent long-term patency. With the purpose to dilate the ITA graft and increase graft free flow (GFF) intraoperatively, we evaluated the usefulness of intraluminal injection of fasudil, a Rho-kinase inhibitor, in comparison to the conventional graft dilating agent, papaverine. METHODS: Between June 2011 and January 2012, 30 patients with ischemic heart disease who underwent isolated CABG using ITA were enrolled. The patients were randomly assigned to 2 groups: the fasudil group (n = 15) in which fasudil solution 0.9 mg/dL was injected into the ITA, and the papaverine group (n = 15) in which papaverine solution (0.4 mg/mL) mixed with heparinized blood was used. Outcome measures were left ITA GFF, heart rate, and mean blood pressure during flow measurements, and histopathologic examination of the ITA. RESULTS: In the fasudil group, GFF increased significantly (p < 0.01) from 19.7 ± 15.2 mL/minute at baseline to 66.9 ± 31.7 mL/minute after fasudil injection. In the papaverine group, GFF increased significantly (p < 0.01) from 22.9 ± 17.3 mL/minute at baseline to 44.8 ± 26.7 mL/minute after papaverine injection. Blood pressure and heart rate did not change significantly after drug injection in both groups. The GFF was significantly higher (p = 0.038) in fasudil-treated ITA than in papaverine-treated ITA. Histopathologically, the diameter of the ITA was markedly increased after fasudil injection. Elastica van Gieson staining showed that the multiple elastic lamellae structure was intact. CONCLUSIONS: Fasudil exhibited very potent vasodilatory effect on the ITA compared with conventional papaverine resulting in increased GFF. This agent is a useful graft dilating agent.

Novel sternum lifting technique for robotic internal thoracic artery graft harvesting.

Internal thoracic artery (ITA) harvesting using the robotic system usually requires artificially induced capnothorax to provide visualization and working space, but this procedure has the disadvantage of deteriorating the hemodynamics. We developed an electrical sternum lifting system (ESLS) for robotic ITA harvesting, which is robust and can be finely adjusted, capable of lifting the sternum for a maximum of 5 to 10 cm. Using a mechanical sternum lifting device significantly (P < 0.01) shortened the time of ITA harvesting from a mean ± SD of 55.5 ± 24.1 minutes to 33.0 ± 15.7 minutes. No patient using the ESLS required induced capnothorax. Our novel ESLS provides a good operative field of view and allows ITA harvesting without inducing capnothorax.