Cardiovascular computed tomography for the detection of quadricuspid aortic valve: A case report.

Aortic regurgitation (AR) represents a significant cause of morbidity and mortality. Due to its low cost and widespread availability, echocardiography remains the frontline for aortic valve (AV) assessment. However, poor sonographic windows may limit the assessment of valve morphology with this technique. Cardiovascular computed tomography (CCT) is increasingly utilized prior to structural AV interventions. Due to its excellent spatial resolution, CCT provides exceptional characterization of aortic leaflets. Accordingly, we present a case of a quadricuspid valve diagnosed by CCT. Here, CCT led to a new diagnosis of quadricuspid valve, highlighting the potential for CCT for the characterization of aortic leaflet morphology. CCT may be particularly useful in patients with contraindications to transesophageal echocardiography or those undergoing structural or robotic interventions.

Postoperative Day 1 Discharge After Robotic Totally Endoscopic Coronary Bypass: The Ultimate in Enhanced Recovery After Surgery.

OBJECTIVE: The benefits of Enhanced Recovery After Surgery (ERAS) protocols are being recognized in multiple surgical specialties, including following coronary bypass surgery to improve quality of care and decrease costs. We developed a fast-track discharge protocol for patients undergoing robotic totally endoscopic coronary bypass surgery (TECAB) to be discharged on postoperative day (POD) 1, the subjects of this study. METHODS: In a retrospective study of 720 patients undergoing robotic beating-heart TECAB over 8 years at our institution, 93 patients were selected for a fast-track POD1 discharge protocol. We compared the outcomes of this group to the remaining 627 patients who were discharged per standard protocol (non-POD1 discharge). RESULTS: The early discharge group was significantly younger, had lower Society of Thoracic Surgeons (STS) risk of mortality, and had a lower prevalence of obesity, diabetes, and chronic kidney disease. Patients discharged on POD1 were more often extubated in the operating room (56% vs 42%, P = 0.010). The readmission rate for the early discharge group was 3.2%, which was similar to the readmission rate of 6.7% for the standard discharge protocol group (P = 0.329). Time to return to work was shorter in the early discharge group, although it did not quite reach statistical significance (12 vs 18 days, P = 0.051). There was no difference in midterm cardiac mortality. CONCLUSIONS: Early discharge on POD1 after robotic TECAB is appropriate in selected patients and is associated with low readmission rates and a trend towards earlier return to work. Patients suitable for this "ultrafast-track" approach were more likely to be younger, have lower STS risk, and fewer comorbidities.

Multi-spectrum robotic cardiac surgery: Early outcomes.

Objective: The robotic cardiac surgery program at our current institution began in 2013 with an experienced and dedicated team. This review analyzes early outcomes in the first 1103 patients. Methods: We reviewed all robotic procedures between July 2013 and February 2021. Primary outcomes were mortality and perioperative morbidity. Our robotic approach is totally endoscopic for all cases: off-pump for coronary and epicardial procedures, and on-pump with the endoballoon for mitral valve and other intracardiac procedures. Results: There were 1103 robotic-assisted cardiac surgeries over 7 years. A total of 585 (53%) were off-pump totally endoscopic coronary artery bypasses, 399 (36%) intracardiac cases (including isolated and concomitant mitral valve procedures, isolated tricuspid valve repair, CryoMaze, atrial or ventricular septal defect repair, benign cardiac tumor, septal myectomy, partial anomalous pulmonary venous drainage, and aortic valve replacement); 80 (7%) epicardial electrophysiology-related procedures (epicardial atrial fibrillation ablation, left atrial appendage ligation, lead placement, and ventricular tachycardia ablation); and 39 (4%) other epicardial procedures (pericardiectomy, unroofing myocardial bridge). Mortality was 1.2% (observed/expected ratio, 0.7). In the totally endoscopic coronary artery bypass and intracardiac groups, mortality was 1.0% (observed/expected, 0.6) and 1.5% (observed/expected, 0.87), respectively. There were 8 conversions to sternotomy (0.7%) and 24 (2.2%) take-backs for bleeding. Mean hospital and intensive care unit lengths of stay were 2.74 ± 1.26 days and 1.28 ± 0.57 days, respectively. Conclusions: This experience demonstrates that a robotic endoscopic approach can safely be used in a multitude of cardiac surgical procedures both on- and off-pump with excellent early outcomes. An experienced surgeon and team are necessary. Longer-term follow-up is warranted.

Robotic off-pump totally endoscopic coronary artery bypass in the current era: report of 544 patients.

OBJECTIVES: Robotic off-pump totally endoscopic coronary artery bypass (TECAB) is the least invasive form of surgical coronary revascularization. It has proved to be highly effective and safe. Its benefits are well-established and include fewer complications, shorter hospital stay and quicker return to normal activities. TECAB has undergone 2 decades of technological advancement to include multivessel grafting, a beating-heart approach and successful completion in multiple patient groups in experienced hands. The aim of this report was to examine outcomes of robotic off-pump TECAB at our institution over 7 years. METHODS: Data from 544 patients undergoing TECAB between July 2013 and August 2020 were retrospectively examined. The C-Port Flex-A distal anastomotic device was used for the majority of grafts (70%). Yearly follow-up was conducted. Angiographic early patency data were reviewed for patients undergoing hybrid revascularization. RESULTS: The mean age was 66 years, with 1.7% mean STS risk. Fifty-six percentage had multivessel TECAB. There was 1 conversion to sternotomy, and 46% extubation in the Operating Room (OR). Mortality was 0.9%. Early graft patency was 97%. At mid-term follow-up at 38 months, cardiac mortality was 2.7% and freedom from major adverse cardiac events was 92.5%. CONCLUSIONS: We conclude that robotic beating-heart TECAB in the current era is safe and effective with excellent outcomes and comparable early angiographic patency to standard coronary artery bypass grafting surgery when performed frequently by an experienced team. This procedure was completed in our hands both with and without an anastomotic device. Longer-term studies are warranted.

Angiographic patency after robotic beating heart totally endoscopic coronary artery bypass grafting facilitated by automated distal anastomotic connectors.

OBJECTIVES: Robotic totally endoscopic coronary artery bypass (TECAB) on the beating heart has been facilitated in our experience using distal coronary anastomotic connectors. In this study, we retrospectively reviewed graft patency in all robotic TECAB patients who underwent formal angiography at our current institution over a 5-year period. METHODS: Between July 2013 and June 2018, 361 consecutive patients underwent robotic beating-heart TECAB. Of these patients, 121 had a follow-up angiogram, which assessed graft patency. Eighty-four patients had an angiogram as part of planned hybrid procedures and 37 patients underwent an unplanned angiogram for clinical indications. Retrospective analysis of angiographic patency and clinical outcomes was performed. RESULTS: The mean Society of Thoracic Surgeons predicted risk of mortality was 1.8%. Single-vessel bypass was performed in 40 (33%) patients and multivessel grafting in 81 (67%). Average flow (ml/min) and pulsatility index in the grafts was 74.7 ± 39.1 and 1.42 ± 0.52, respectively. The number of grafts evaluated was 204 (130 left internal mammary artery and 74 right internal mammary artery grafts). The median time to angiography was 1.0 and 16.0 months and graft patency was 98% and 91% in the hybrid and non-hybrid groups, respectively. Overall graft patency was 95.6% (left internal mammary artery = 96%; right internal mammary artery = 93%). Left internal mammary artery to left anterior descending artery graft patency was 97%. Clinical follow-up was available for 316 (88%) patients at mean 22.5 ± 15.1 months. Freedom from major adverse cardiac events at 2 years was 92%. CONCLUSIONS: In this consecutive series of patients undergoing formal angiography after robotic single and multivessel TECAB, we found satisfactory graft patency and 2-year clinical outcomes. Longer-term follow-up is warranted.

Prevalence of mitral annular disjunction in patients with mitral valve prolapse and severe regurgitation.

Mitral annular disjunction (MAD) is routinely diagnosed by cardiac imaging, mostly by echocardiography, and shown to be a risk factor for ventricular arrhythmias. While MAD is associated with mitral valve (MV) prolapse (MVP), it is unknown which patients with MAD are at higher risk and which additional imaging features may help identify them. The value of cardiac computed tomography (CCT) for the diagnosis of MAD is unknown. Accordingly, we aimed to: (1) develop a standardized CCT approach to identify MAD in patients with MVP and severe mitral regurgitation (MR); (2) determine its prevalence and identify features that are associated with MAD in this population. We retrospectively studied 90 patients (age 63 ± 12 years) with MVP and severe MR, who had pre-operative CCT (256-slice scanner) of sufficient quality for analysis. The presence and degree of MAD was assessed by rotating the view plane around the MV center to visualize disjunction along the annulus. Additionally, detailed measurements of MV apparatus and left heart chambers were performed. Univariate logistic regression analysis was performed to determine which parameters were associated with MAD. MAD was identified in 18 patients (20%), and it was typically located adjacent to a prolapsed or flail mitral leaflet scallop. Of these patients, 75% had maximum MAD distance > 4.8 mm and 90% > 3.8 mm. Female gender was most strongly associated with MAD (p = 0.04). Additionally, smaller end-diastolic mitral annulus area (p = 0.045) and longer posterior leaflet (p = 0.03) were associated with greater MAD. No association was seen between MAD and left ventricular size and function, left atrial size, and papillary muscle geometry. CCT can be used to readily detect MAD, by taking advantage of the 3D nature of this modality. A significant portion of MVP patients referred for mitral valve repair have MAD. The presence of MAD is associated with female gender, smaller annulus size and greater posterior leaflet length.

Robotic cardiac surgery impact of a new patient-side assistant on outcomes.

OBJECTIVE: Very few studies have focused on the experience of the patient-side assistant in robotic cardiac surgery. We investigated whether the retirement of a highly experienced robotic patient-side assistant and replacement with a new assistant had an effect on surgical outcomes. METHODS: In 4/2016, the established patient-side assistant retired after spending 8 months training a new patient-side assistant. A retrospective analysis of 216 patients was performed; 108 patients over a 9 month period just prior to arrival of the new patient-side assistant (Group 1), and 108 patients over 8 months just subsequent to departure of the established assistant (Group 2). Case distribution, pre-operative characteristics, and surgical outcomes were collected and compared. RESULTS: Case volume increased in Group 2 with the new assistant. The mean age and rate of pre-op CVA for Group 1 was lower, but, otherwise, patient demographics were not significantly different. Group 1 had more intracardiac cases and group 2 had more triple-vessel TECABs. Overall operative time was not different between the two groups. Perioperative outcomes including hospital length of stay major adverse cardiovascular events and mortality were similar between the two groups. CONCLUSIONS: We conclude that the transition to a new robotic cardiac surgical patient-side assistant does not have to affect the progress of a busy robotic program. If adequate time for training and gradual assumption of responsibility is ensured, it is feasible to make this transition without loss of volume or compromise in patient outcomes.

Robotic totally endoscopic excision of aortic valve papillary fibroelastoma: The least invasive approach.

INTRODUCTION: Papillary fibroelastomas (PFEs) are a rare subtype of benign primary cardiac tumors, which are most commonly found on the aortic valve (AV). They have the potential to cause severe adverse clinical consequences, thus prompting surgical excision in the majority of cases. In this article, we report on a series of 5 PFEs resected from the AV using a robotic-assisted sternal-sparing approach, and review of the literature on this approach. To our knowledge, this is the largest reported series of robotic-assisted sternal-sparing AV-PFE resections. MATERIALS AND METHODS: From May 2016 until November 2018, 5 patients at our institution underwent removal of a papillary fibroelastoma from the aortic valve using a totally endoscopic robotic-assisted approach. After obtaining institutional IRB approval, we retrospectively reviewed their data for this report. We additionally contacted the patients to acquire a last clinical follow up for this study. Results In this series of 5 patients who underwent robotic totally endoscopic excision of AV PFE, all patients had successful removal of their tumor with no significant morbidity or mortality. All 5 patients were seen at a 30-day follow-up office visit, at which time they had recovered from surgery and were back to full activity. At a mean of 24 months all patients were doing well and free of symptoms with no evidence of tumor recurrence on repeat echo evaluation. DISCUSSION: This is a series of 5 patients with AV-associated PFEs who underwent robotic totally-endoscopic excision without rib-spreading or conversion to sternotomy. This report demonstrated the successful application of robotic-assisted technology in aortic valve pathology. All PFEs were successfully removed without valve repair or replacement. We were able to offer a safe, curative, minimally-invasive surgical excision option for this group of patients. CONCLUSION: Our patients in this cohort demonstrated the well-established benefits of robotic sternal-sparing cardiac surgery, including excellent intra and postoperative outcomes and accelerated recovery.

Benefit of Robotic Beating-Heart Totally Endoscopic Coronary Artery Bypass in Octogenarians.

OBJECTIVE: An important advantage of robotic beating-heart totally endoscopic coronary artery bypass (TECAB) is early functional recovery, in which fragile patients like octogenarians (age >80 years) benefit most. The aim of this study was to investigate the safety and feasibility of TECAB in octogenarians. METHODS: We retrospectively reviewed patients undergoing TECAB from July 2013 to September 2017 at our institution. Perioperative outcomes of octogenarian patients and that of younger patients were compared. RESULTS: Of 308 patients who underwent TECAB, 28 patients (9.1%) were octogenarians (mean age 83.8 ± 3.0 years). Octogenarians had a higher rate of hypertension and atrial fibrillation compared to younger patients. TECAB was successfully performed without conversion to any larger incisions in octogenarians. Mean operative time (299 ± 83 minutes vs 281 ± 89 minutes, P = 0.309) and the rate of multivessel bypass (60.7% vs 58.2%, P = 0.798) were similar between octogenarians and younger patients. New atrial fibrillation was observed more frequently in octogenarians compared to younger patients (35.7% vs 18.6%, P = 0.031). Mean length of hospital stay was similar between the 2 groups (octogenarians: 3.9 ± 1.8 days vs younger patients: 3.5 ± 3.0 days, P = 0.475). Twenty-two octogenarians (78.6%) were discharged directly to home. In-hospital mortality was zero in octogenarians. CONCLUSIONS: Robotic beating-heart TECAB had favorable results in octogenarians with acceptable morbidity and mortality and excellent short length of stay similar to younger patients.

Predictors of blood transfusion use in robotic beating-heart totally endoscopic coronary artery bypass with anastomotic connectors.

BACKGROUND: We sought to identify the independent predictors of blood transfusion requirement in robotic beating-heart patients with totally endoscopic coronary artery bypass (TECAB). METHODS: We retrospectively reviewed patients undergoing TECAB with distal anastomotic connectors from July 2013 to May 2017 at our institution. The cohorts were divided into patients who received a blood transfusion (BT group) and patients who did not (non-blood transfusion [NBT] group). RESULTS: Two-hundred seventy-four consecutive patients underwent TECAB, and 47 patients (17%; BT group) received BT. The BT group had a lower preoperative hemoglobin level and a higher rate of preoperative risk profiles and higher society of thoracic surgeons (STS) predicted the risk of mortality. Kaplan Meier analysis showed decreased 1-year survival in the BT group compared with the NBT group (90.9% vs 96.4%; logrank, 0.017). The Youden index identified a preoperative hemoglobin cutoff value of 12.2 g/dL (sensitivity 60.9%, specificity 79.3%) and operative time of 300 minutes (sensitivity 61.7%, specificity 59.0%) for BT requirement. Multivariate logistic regression analysis identified a preoperative hemoglobin <12.2 g/dL (odds ratio, 6.03; 95% confidence interval, 3.01-12.1) and an operative time >300 minutes (odds ratio, 2.15; 95% confidence interval, 1.07-4.33) as independent factors associated with BT requirement. CONCLUSIONS: We found that preoperative hemoglobin and operative time were independent predictors of BT requirement during robotic beating-heart TECAB. These data would help to select patients to minimize perioperative BT as well as predict outcomes after this procedure.

Robotic-Assisted Total Pericardiectomy for Acute Relapsing Pericarditis: A Case Report.

Acute, relapsing pericarditis is an uncommon potential complication of any cardiothoracic intervention. If medical management fails to mitigate recurrent symptoms, robotic total pericardiectomy can be performed as a definitive therapeutic option. A 33-year-old woman had severely symptomatic, persistent pericarditis, which began 3 weeks after pacemaker placement for tachy-brady syndrome. After failure of pharmacologic treatment, a robot-assisted total pericardiectomy was performed with a drastic improvement in symptoms. Considering that this case of pericarditis was inflammatory (nonconstrictive), a radical excisional approach to all the pericardium was undertaken in order to prevent relapse of symptoms. A bilateral endoscopic off-pump robot-assisted approach was used to completely and fully excise both the anterior and posterior pericardium. In conclusion, we present a case of acute relapsing pericarditis in a very symptomatic patient who failed medical therapy and underwent a robotic totally endoscopic radical pericardiectomy with excellent results. We believe that this technique allows for total pericardiectomy using the least invasive approach and should be considered in the management of this rare but potentially debilitating condition.

Robotic totally endoscopic off-pump unroofing of left anterior descending coronary artery myocardial bridge: A report of two cases.

Myocardial bridge occurs when the myocardium courses external to an intramyocardial coronary artery, most commonly, the left anterior descending artery. The presentation can range from an asymptomatic, incidental finding to myocardial infarction, and sudden cardiac death. We report two cases of symptomatic MBs, which were treated with surgical unroofing, using a totally endoscopic robotic-assisted off-pump approach.

Robotic Multivessel Endoscopic Coronary Bypass: Impact of a Beating-Heart Approach With Connectors.

BACKGROUND: Most robotic coronary bypass operations are single-vessel procedures. Very few centers perform totally endoscopic coronary artery bypass (TECAB), and even fewer perform multivessel grafting endoscopically. We hypothesized that a robotic beating-heart approach using distal anastomotic connectors facilitates multivessel TECAB with similar safety and efficacy to single-vessel TECAB. METHODS: We reviewed patients undergoing robotic TECAB at our institution between July 2013 and March 2018. There were 344 consecutive patients divided into two groups: multivessel (MV, group 1), and single-vessel (SV, group 2). We interrogated our prospectively collected database for preoperative, intraoperative, and postoperative outcomes to compare the groups. RESULTS: There were 197 patients in group 1 and 147 patients in group 2. Mean Society of Thoracic Surgeons scores were 1.69% ± 2.4% and 1.96% ± 3.5%, respectively (p = 0.389). Patients in group 1 were older, 67 ± 9.4 versus 63 ± 11.2 years (p < 0.001) and had more triple-vessel disease, 135 (69%) versus 31 (21%; p < 0.001). In group 1, 174 patients (88%) had bilateral internal mammary artery grafts and 13% had triple-vessel TECAB. Mean hospital stay was 3.07 ± 1.2 days in group 1 and 2.81 ± 1.4 days in group 2 (p = 0.072), and overall mortality was 1.45% (2.0% and 0.7%, respectively; p = 0.268). Graft patency (mean, 7 months) was 95.6% (151 of 158 grafts) in group 1 and 94.9% (37 of 39 grafts) in group 2 (p = 0.896). CONCLUSIONS: Multivessel grafting is feasible during robotic beating-heart connector TECAB with good outcomes. We found no significant difference in mortality, hospital stay, midterm major adverse cardiac events, and interim graft patency compared with single-vessel TECAB. Further studies are warranted.

Hybrid coronary revascularization: Midterm outcomes of robotic multivessel bypass and percutaneous interventions.

OBJECTIVE: The purpose of this study was to investigate the outcomes of patients undergoing advanced hybrid coronary revascularization, defined as robotic beating-heart multivessel totally endoscopic coronary artery bypass combined with percutaneous coronary intervention. METHODS: This is a retrospective study. Among 308 consecutive patients who underwent totally endoscopic coronary artery bypass, 57 who underwent advanced hybrid coronary revascularization (mean age, 65.6 years) from July 2013 to September 2017 were included. Midterm survival and freedom from major adverse cardiac events, including death, myocardial infarction, and repeat revascularization, were analyzed. RESULTS: Multivessel totally endoscopic coronary artery bypass was successfully performed without conversion to thoracotomy. Bilateral internal thoracic artery grafting was used in 50 patients (87.7%). The mean operative time was 318.4 ± 51.0 minutes. The mean length of hospital stay was 3.0 ± 1.3 days. There was no 30-day mortality. Percutaneous coronary intervention was planned after totally endoscopic coronary artery bypass in 51 patients (89.4%). The target lesions were the right coronary artery only in 38 patients, the left circumflex artery only in 4 patients, and multiple lesions in 13 patients. Eventually, 2 patients did not receive percutaneous coronary intervention. Percutaneous coronary intervention attempt was unsuccessful in 8 lesions. Patency of the left/right internal thoracic artery was 95.2% (60/63) and 95.7% (45/47), respectively. Graft patency was 95.2% (40/42) in the left circumflex artery and 93.3% (14/15) in the diagonal branch. Three-year survival was 92.8%, and 3-year freedom from major adverse cardiac events was 80.2%. CONCLUSIONS: Advanced hybrid coronary revascularization is a safe and less-invasive approach with short hospital stay and good midterm outcomes.

Is robotic beating heart totally endoscopic coronary artery bypass feasible for BMI > 35 morbidly obese patients?

BACKGROUND: We investigated the outcomes of morbidly obese patients after robotic beating heart totally endoscopic coronary artery bypass (BH-TECAB). METHODS: This is a retrospective single center study. From July 2013 to December 2016, the outcomes of patients undergoing BH-TECAB were reviewed. RESULTS: A total of 234 patients underwent BH-TECAB (172 male, mean age 65.2 years). There were 43 morbidly obese patients defined as body mass index (BMI) greater than 35, and 191 non-morbidly obese patients. Postoperative complications, or mortality in morbidly obese and other patients were similar except for prolonged ventilation >24 h (11.6% vs 2.1%, P = 0.008). CONCLUSIONS: Morbidly obese patients had an increased incidence of prolonged ventilation after BH-TECAB, but an otherwise reasonably low morbidity and mortality similar to patients with a lower BMI. We believe that adoption of robotics technology allows for BH-TECAB and can lead to improved outcomes in this high-risk population.

Robotic Beating Heart Totally Endoscopic Coronary Artery Bypass in Higher-Risk Patients: Can It be Done Safely?

OBJECTIVE: Patients with a high Society of Thoracic Surgeons (STS) predicted risk of mortality undergoing coronary artery bypass surgery are known to have worse outcomes. Less invasive approaches have been shown to improve morbidity and mortality for these patients. In this study, we examined perioperative outcomes in higher-risk patients undergoing robotic totally endoscopic beating heart coronary artery bypass surgery. METHODS: The STS predicted risk of mortality was reviewed for patients undergoing robotic totally endoscopic beating heart coronary artery bypass surgery at our institution between January 2013 and May 2017. We identified a higher-risk cohort (n = 50) and compared them to a lower-risk cohort (n = 220) during the same period. The higher-risk group was formed from patients with the 50 highest STS scores. Perioperative data were collected retrospectively. RESULTS: There were 50 patients in the higher-risk group (mean STS score = 7.05 ± 4.9, mean age = 73 years) and 220 patients in the lower-risk group (mean STS score = 0.89 ± 0.6, mean age = 64 years). The higher-risk group had significantly greater rates of renal insufficiency, peripheral vascular disease, and lower ejection fraction. The incidence of postoperative re-exploration for bleeding, stroke, myocardial infarction, and prolonged ventilation was similar. Perioperative blood transfusion and hospital length of stay were greater in the higher-risk group. Mortality was lower in the higher-risk group (0% vs 1.8% P = 0.045). Cardiac-related mortality was similar at midterm follow-up. CONCLUSIONS: We conclude that beating heart totally endoscopic beating heart coronary artery bypass surgery can be performed in patients with a higher STS predicted risk of mortality with excellent outcomes. Further studies are warranted to evaluate long-term results of totally endoscopic beating heart coronary artery bypass surgery in this challenging group of patients.

Does Robotic Beating Heart Connector Totally Endoscopic Coronary Artery Bypass Bridge the Gender Gap in Coronary Bypass Surgery?

OBJECTIVE: Previous studies have shown that women carry a higher risk of morbidity and mortality after coronary artery bypass surgery. We investigated gender differences in risk factors and outcomes in our patients undergoing robotic beating heart connector totally endoscopic coronary artery bypass. METHODS: From July 2013 to April 2017, patients undergoing connector totally endoscopic coronary artery bypass were reviewed. We compared the outcomes of men versus women. RESULTS: A total of 192 men and 71 women underwent connector totally endoscopic coronary artery bypass. The mean ± SD age was 65.4 ± 10.6 years. The Society of Thoracic Surgeons score was higher in women than men (median = 1.46 vs 0.73, P = 0.001), and women had a higher rate of peripheral vascular disease (22.5% vs 9.9%, P = 0.007). Intraoperative data in women and men were similar except for the rate of multi-vessel connector totally endoscopic coronary artery bypass and the rate of bilateral internal mammary artery use, which were both lower in women (49.3% vs 64.6%, P = 0.024, and 42.3% vs 56.8%, P = 0.036, respectively). The mean ± SD length of hospital stay (women vs men: 3.99 ± 4.00 vs 3.39 ± 2.42, P = 0.324) was comparable. The 30-day mortality in women and men was 0% (0/71) and 2.1% (4/192), respectively (P = 0.577). The morbidity and mortality of single- or multi-vessel connector totally endoscopic coronary artery bypass were similar between men and women. CONCLUSIONS: We conclude that the morbidity and mortality in women after robotic beating heart connector totally endoscopic coronary artery bypass in our center were similar to those seen in men.

Morbid Obesity Does not Increase Morbidity or Mortality in Robotic Cardiac Surgery.

OBJECTIVE: Morbid obesity (body mass index ≥ 35 kg/m) usually confers a higher perioperative risk in cardiac surgery. Robotic cardiac surgery may have many advantages for these high-risk patients. METHODS: We retrospectively reviewed patients undergoing robotic cardiac surgery from July 2013 to April 2017 at our institution. We compared the outcomes of morbidly obese patients versus nonobese patients. RESULTS: A total of 486 patients underwent robotic cardiac surgery (322 men, median age = 65 years). The robotic procedures were the following: totally endoscopic beating heart coronary artery bypass (n = 263), mitral valve surgery (n = 138), arrhythmia surgery (n = 33), adult congenital surgery (n = 16), pericardiectomy (n = 11), and others (n = 25). The cohorts were divided into the following: normal weight (body mass index < 25, n = 123), overweight (body mass index = 25 to < 30, n = 182), obesity (body mass index = 30 to < 35, n = 105), and morbid obesity (body mass index ≥ 35, n = 76). Morbidly obese patients had a higher rate of hypertension, dyslipidemia, and diabetes mellitus compared with normal or overweight patients. There were no significant differences in morbidity, mean length of intensive care unit stay (2.10 ± 4.27 days), and hospital stay (4.48 ± 5.61 days) among the groups. In-hospital mortality was 1.4% (7/486) with nonsignificant difference. CONCLUSIONS: Outcomes of robotic heart surgery in morbidly obese patients in our center were acceptable. Over a broad range of cardiac surgical procedures, morbid obesity was not associated with increased morbidity or mortality when these procedures were performed using a robotic approach. These findings can be beneficial in managing this challenging group of patients.

Redo Robotic Endoscopic Beating Heart Coronary Bypass (TECAB) After Previous TECAB.

Redo-totally endoscopic coronary artery bypass (TECAB) after previous TECAB to our knowledge has never been reported in the literature. We present a case report of a 65-year-old gentleman who underwent a second beating-heart TECAB with the right internal mammary artery (IMA) to the obtuse marginal branch, following previous TECAB (left IMA-diagonal/left anterior descending). An extensive experience in robotic coronary operation and anastomotic devices contributed to the successful outcome in this patient. We conclude that prior TECAB is not a contraindication to redo-TECAB as long as an IMA conduit is available and left lung adhesions are not prohibitive.