Sternal lifting technique for patients with sternal depression during robotic mitral repair.

INTRODUCTION: Traditional surgical methods have been difficult for patients with chest wall deformities, but the use of the Electrical Sternum Lifting System (ESLS) has made the surgery easier. MATERIALS AND SURGICAL TECHNIQUE: Patients with a sternum-to-vertebral distance of less than 80 mm on preoperative computed tomography (CT) scan routinely underwent sternal lift using the ESLS. The ESLS was effective in securing the operative field while suspending the sternum, allowing adequate observation of the left atrium, left ventricle, and the mitral valve, and safe mitral valve plasty. The use of the lifting device did not interfere with the robot arms, and the space between the sternum and vertebrae was widened with only a 3 mm wound to move the mitral valve surface in the sagittal plane, making the repair easy and accurate under robotic assistance. The effort to attach the ESLS was not difficult, and the postoperative cosmetic outcomes were excellent. Sixty-three out of 1002 patients (6.3%) underwent sternal elevation using ESLS. There were 19 males and 44 females with a mean age of 50.9 ± 14.0 years. The average of sternum-to-vertebral (S/V) distance was 72.4 ± 8.9 cm. Two patients had S/V distance of more than 80 mm but ESLS was used because of scoliosis.

Outcomes of Barlow mitral valve repaired by robot-assisted keyhole surgery.

Objective: To present our strategy and the clinical outcomes of robot-assisted Barlow mitral valve keyhole surgery. Methods: From May 2015 to March 2022, a total of 1281 patients underwent mitral valve repair at our institution, including 763 with robotics surgeries. Of these, 124 patients with Barlow mitral valve (49 ± 12 years, male/female ratio = 81:43) were treated using robotic assistance and included in this study. Results: All operations were completed using 3 to 5 keyholes. Neochordae implantation using the loop technique was the first option, and resection was performed only in cases with an intrinsic risk of developing systolic anterior motion. Neochordae implantation was performed in 118 cases (95.1%) using 6.6 ± 3.0 neochordae. Posterior leaflet resection was performed in 27 (21.7%) patients. Operation time was 177 ± 42 minutes, cardiopulmonary bypass time was 127 ± 25 minutes, and aorta crossclamp time was 76 ± 16 minutes. Blood transfusion was required in 5 cases (4%). None of the patients required a conversion to valve replacement. The postoperative complications included bleeding (n = 4), stroke (n = 1), and infection (n = 2). Mitral valve regurgitation 1 week after repair was none or trivial in 122 cases (98.3%), mild in 2 cases (1.7%), and more than moderate in 0 cases. Freedom from reoperation was 99.2% during the follow-up period of 36 ± 21 months. One patient required reoperation due to infective endocarditis. Conclusions: Robot-assisted keyhole surgery using the loop-first concept was adequate to help achieve satisfactory and safe perioperative outcomes for Barlow mitral valve.

Robotic Surgery for Triple Valve Insufficiency: A Case Report.

A 63-year-old woman was referred to our institution for surgical treatment of triple valve (aortic, mitral, and tricuspid) insufficiency and underwent a robot-assisted endoscopic procedure. Three intercostal ports were placed in the right lateral chest for robotic instruments and a retrograde cardioplegic cannula, and a 5 cm thoracotomy was made for the procedure, which was a mitral valve repair with neochords and ring annuloplasty, an aortic valve replacement with bioprosthetic valve, and a ring tricuspid annuloplasty. Surgery was successfully achieved without blood transfusion or any complications.

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.

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.

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.

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.

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.

Prolonged Cross-Clamping During Aortic Valve Replacement Is an Independent Predictor of Postoperative Morbidity and Mortality: Analysis of the Japan Cardiovascular Surgery Database.

BACKGROUND: The present study aimed to determine whether aortic cross-clamp duration (ACCD) was directly related to postoperative morbidity and mortality rates and to identify the inflection point of ACCD for increased mortality and morbidity rates in patients who had undergone isolated aortic valve replacement (AVR) for aortic stenosis. METHODS: From the Japan Cardiovascular Surgery Database, we extracted data from 16,272 patients with AS who underwent isolated AVR between January 2008 and December 2012. We evaluated postoperative mortality and morbidity rates after stratifying patients into five groups based on ACCD (<60 minutes, ≥60 to <90 minutes, ≥90 to <120 minutes, ≥120 to <150 minutes, and ≥150 minutes). RESULTS: The overall hospital mortality rate was 2.8%. Multivariate logistic analysis revealed that the odds ratio for operative mortality increased as ACCD incrementally increased and was markedly higher for ACCD of 150 minutes or longer (odds ratio, 2.68; 95% confidence interval, 1.66 to 4.32; p < 0.001). There were significant increases in risks of reoperation for bleeding for ACCD of120 minutes or longer, stroke for ACCD of 60 minutes or longer, deep sternal infection for ACCD of 120 minutes or longer, ventilation for more than 24 hours for ACCD of 90 minutes or longer, and new requirement for dialysis for ACCD of 150 minutes or longer. CONCLUSIONS: Prolonged ACCD offers an independent predictor of postoperative morbidity and mortality after isolated AVR for AS despite recent technologic advances and surgical refinements.

[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.

Fasudil Is an Effective Graft Vasodilator for Gastroepiploic Artery in Coronary Artery Bypass Grafting.

OBJECTIVE: The gastroepiploic artery (GEA) has been used as an alternative arterial in situ graft for coronary artery bypass grafting (CABG). However, because of the large individual differences and the spastic nature of the GEA, caution has to be exercised during harvesting. We evaluated the usefulness of fasudil, a Rho kinase inhibitor, as a vasodilator for right GEA (RGEA) graft after harvesting, compared with the conventional agents papaverine and verapamil-nitroglycerin. METHODS: Between June 2009 and January 2013, 30 patients with ischemic heart disease who underwent isolated CABG using RGEA graft were randomly assigned to fasudil (n = 10), papaverine (n = 10), or verapamil-nitroglycerin (n = 10) group. Fasudil (2.67 mmol/L), papaverine (1.0 mmol/L) mixed with heparinized blood, or verapamil-nitroglycerin (30 µmol/L each) was injected intraluminally into the RGEA graft after harvesting. Right GEA graft free flow (GFF), hemodynamic changes, and histopathology of RGEA were evaluated. RESULTS: Intraluminal injection of fasudil increased GFF significantly (P < 0.001) and markedly from 41.5 ± 31.5 mL/min at baseline to 149.3 ± 46.7 mL/min after injection. Papaverine increased GFF (P < 0.001) from 40.0 ± 35.8 to 64.9 ± 33.7 mL/min, and verapamil-nitroglycerin also increased GFF (P < 0.001) from 38.8 ± 32.1 to 79.0 ± 35.2 mL/min. The GFF was significantly higher (P = 0.001) in the fasudil group than in the other two groups. Histopathologically, fasudil treatment markedly increased the diameter of RGEA graft, while maintaining integrity of the multiple elastic lamellae. Blood pressure did not change significantly after drug injection in all groups. CONCLUSIONS: Fasudil is more potent than papaverine or verapamil-nitroglycerin in increasing GFF of RGEA graft for CABG.

Impact of real-time three-dimensional transesophageal echocardiography on procedural success for mitral valve repair.

BACKGROUND: For mitral valve repair, minimally invasive cardiac surgery as well as transcatheter valvular intervention have been developed. Under these conditions, three-dimensional transesophageal echocardiography (3D-TEE) plays a key role for planning the surgical treatment strategy. However, few data exist regarding the role of 3D-TEE in mitral valve repair. Therefore, we examined the impact of 3D-TEE on procedural success of mitral valve repair. METHODS AND RESULTS: We examined 86 consecutive patients who underwent mitral valve repair for degenerative mitral valve prolapse. Among them, 39 patients were examined by only two-dimensional transesophageal echocardiography (2D-TEE) and 47 patients underwent 3D-TEE in addition to 2D-TEE. The cardiac surgeons and physicians discussed the repair procedure preoperatively with the echocardiographic images. As a result, 18 patients of the 2D-TEE group and 37 patients of the 3D-TEE group underwent mitral valve repair by small thoracotomy including robotic approach. Simple repair was done in 21 with 2D-TEE and 21 with 3D-TEE and complex repair was done in 18 with 2D-TEE and 26 with 3D-TEE. Importantly, three patients with 2D-TEE before surgery had to undergo reoperation due to recurrent severe mitral regurgitation with dehiscence of the annuloplasty rings, although none with 3D-TEE did. CONCLUSIONS: These results demonstrate that 3D-TEE is helpful in assessing the morphology of mitral apparatus and complexity of mitral valve repair, particularly in minimally invasive cardiac surgery including robotic ones. We would suggest that sonographers, cardiologists, and cardiac surgeons should be familiar with 3D-TEE and work together throughout the perioperative period for better outcomes.

[Minimally Invasive Aortic Valve Replacement for Aortic Stenosis after Renal Transplantation;Report of a Case].

A 41-year-old man was referred to our department for surgical treatment for aortic stenosis 7 years after renal transplantation. He had been diagnosed with aortic stenosis by echocardiography a year before. He had syncopal attack during exercise 2 months before and surgical treatment had been indicated. We successfully performed aortic valve replacement via right mini-thoracotomy in the 4th intercostal space. Cardiac surgery after renal transplantation is rare and many complications may happen. Minimally invasive cardiac surgery is considerated to be useful in minimizing mediastinitis in patients on immune suppressants.