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Restricted accessOtherFirst published November, 2018pp. 379-380
Restricted accessEditorialFirst published November, 2018pp. 381-382
Restricted accessReview articleFirst published November, 2018pp. 383-390Untreated atrial fibrillation is associated with an increased risk of all-cause mortality and morbidity. Despite the current guidelines recommending surgical ablation of atrial fibrillation at the time of coronary artery bypass surgery, most patients with concomitant atrial fibrillation and coronary artery disease do not receive surgical ablation for their atrial fibrillation. This review reports the efficacy of different surgical ablation techniques used for the treatment of atrial fibrillation during coronary artery bypass. PubMed was systematically searched for studies reporting outcomes of concomitant surgical ablation in coronary artery bypass patients between January 2002 and March 2018. Data were independently extracted and analyzed by two investigators. Twenty-four studies were included. Twelve studies exclusively reported outcomes of surgical ablation in patients undergoing coronary artery bypass, whereas the remaining 12 reported outcomes of concomitant cardiac surgery with subgroup analysis. Only four studies performed the concomitant Cox-Maze procedure. Freedom from atrial tachyarrhythmia was reported as high as 98% at 1 year and 76% at 5 years with Cox-Maze procedure, whereas lesser lesion sets had more variable outcomes, ranging from 35% to 93%. In most studies, the addition of surgical ablation was not associated with increased morbidity and mortality. Although the Cox-Maze procedure had the greatest short- and long-term success rates, most studies comprising the evidence documenting the safety and efficacy of adding surgical ablation were of low or moderate quality. There was a great deal of heterogeneity among study populations, follow-up times, methods, and definition of failure. To establish a consensus regarding a surgical ablation technique for atrial fibrillation in coronary artery bypass population, larger multicenter randomized controlled studies need to be designed.
Restricted accessReview articleFirst published November, 2018pp. 391-403Great advances have been made in the surgical management of esophageal disease since the first description of esophageal resection in 1913. We are in the era of minimally invasive esophagectomy. The current three main approaches to an esophagectomy are the Ivor Lewis technique, McKeown technique, and the transhiatal approach to esophagectomy. These operations were associated with a high morbidity and mortality. The recent advances in minimally invasive surgical techniques have greatly improved the outcomes of these surgical procedures. This article reviews the literature and describes the various techniques available for performing minimally invasive esophagectomy and robot-assisted esophagectomies, the history behind the development of these techniques, the variations, and the contemporary outcomes after such procedures.
Restricted accessResearch articleFirst published November, 2018pp. 404-416The aim of the study was to compare hemodynamic and perioperative outcomes of stented against stentless aortic valve replacement in patients with small aortic root (21 mm or less).
A comprehensive search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing stentless to stented bioprosthetic valves in small aortic root patients. Odds ratios, weighted mean differences, or standardized mean differences and their 95% confidence intervals were analyzed.
A total of seven studies with a total of 965 patients fulfilled the inclusion
criteria. There was no significant difference in preoperative baselines
including mean age between both groups (
Stentless aortic valves offer superior short-term hemodynamic outcomes in patients with small aortic root when compared with stented aortic valves. Although both groups have similar perioperative complications rates, stentless valves bring about a shorter hospital stay. A further large multicenter randomized controlled trial should address the longer-term benefit of stentless aortic valve over stented valve.
Restricted accessResearch articleFirst published November, 2018pp. 417-422Robotic-assisted surgery is increasingly being used in thoracic surgery. Currently, the Integrated Thoracic Surgery Residency Program lacks a standardized curriculum or requirement for training residents in robotic-assisted thoracic surgery. In most circumstances, because of the lack of formal residency training in robotic surgery, hospitals are requiring additional training, mentorship, and formal proctoring of cases before granting credentials to perform robotic-assisted surgery. Therefore, there is necessity for residents in Integrated Thoracic Surgery Residency Program to have early exposure and formal training on the robotic platform. We propose a curriculum that can be incorporated into such programs that would satisfy both training needs and hospital credential requirements.
We surveyed all 26 Integrated Thoracic Surgery Residency Program Directors in the United States. We also performed a PubMed literature search using the key word “robotic surgery training curriculum.” We reviewed various robotic surgery training curricula and evaluation tools used by urology, obstetrics gynecology, and general surgery training programs. We then designed a proposed curriculum geared toward thoracic Integrated Thoracic Surgery Residency Program adopted from our credentialing experience, literature review, and survey consensus.
Of the 26 programs surveyed, we received 17 responses. Most Integrated Thoracic Surgery Residency Program directors believe that it is important to introduce robotic surgery training during residency. Our proposed curriculum is integrated during postgraduate years 2 to 6. In the preclinical stage postgraduate years 2 to 3, residents are required to complete introductory online modules, virtual reality simulator training, and in-house workshops. During clinical stage (postgraduate years 4–6), the resident will serve as a supervised bedside assistant and progress to a console surgeon. Each case will have defined steps that the resident must demonstrate competency. Evaluation will be based on standardized guidelines.
Expansion and utilization of robotic assistance in thoracic surgery have increased. Our proposed curriculum aims to enable Integrated Thoracic Surgery Residency Program residents to achieve competency in robotic-assisted thoracic surgery and to facilitate the acquirement of hospital privileges when they enter practice.
Restricted accessResearch articleFirst published November, 2018pp. 423-427Conversion to sternotomy is a primary bailout method for robotically assisted coronary artery bypass grafting procedures. The aims of this study were to identify the primary reasons for conversion from robotically assisted coronary artery bypass grafting to sternotomy and to evaluate the in-hospital outcomes in such patients.
Prospectively collected data from February 2004 to April 2017 were reviewed for 72 patients (56 men; mean age = 63.8 years) who required conversion to sternotomy during a robotically assisted coronary artery bypass grafting procedure with planned endoscopic left internal thoracic artery harvest and anastomosis to the left anterior descending on the beating heart.
The overall rate of conversion was 12.4% (72/581). Conversions occurred either during attempted endoscopic left internal thoracic artery harvest (31.9%), during endoscopic left anterior descending isolation (40.3%), during manual isolation and anastomosis of the left anterior descending (19.4%), or after anastomosis due to unsatisfactory flow (8.3%). Overall, the most common reason for conversion was an intramyocardial left anterior descending (43.1%). The median stay in the intensive care unit was 1 day (range = 0–20) and the median hospital length of stay was 5 days (range = 3–43). In-hospital complications included new atrial fibrillation (16.7%), need for blood transfusion (20.8%), mediastinitis (4.2%), postoperative myocardial infarction (2.8%), exploration for bleeding (2.8%), and 1 in-hospital death.
The reasons for conversion were primarily related to anatomical factors that created difficulties for endoscopic left internal thoracic artery harvesting and left anterior descending identification. Patients who required conversion to sternotomy from robotically assisted coronary artery bypass grafting demonstrated acceptable outcomes and low complication rates.
Restricted accessResearch articleFirst published November, 2018pp. 428-432Subaortic membrane is an anatomical intracardiac anomaly that may cause discrete subaortic stenosis and aortic insufficiency. Patients requiring subaortic membrane resection may benefit from a minimally invasive approach; however, subaortic membranes are typically resected through a median sternotomy. We present our initial clinical experience of adult patients who have undergone a mini-thoracotomy subaortic membrane resection.
Eight patients who underwent an elective subaortic membrane resection performed through a mini-thoracotomy were retrospectively reviewed. A 5-cm mini-thoracotomy incision was made in the 2nd intercostal space; a videoscope was inserted through a separate incision within the same interspace. Cardiopulmonary bypass (CPB) was instituted via central arterial and peripheral venous cannulation and an aortotomy was made. The subaortic membrane was resected with shafted instruments. The left ventricular outflow tract was inspected and CPB was weaned. Thirty-day mortality, intensive care and hospital length of stay, ventilation time, operative times, postoperative morbidity, and need for additional procedures were evaluated.
The median CPB and cross-clamp times were 60 and 42 minutes, respectively.
The median time to extubation was 3.6 hours. The median intensive care unit
and hospital stay were 22 hours and 3 days, respectively. The postoperative
left ventricular outflow tract mean gradients decreased significantly (26.5
vs. 9.4 mm Hg,
Subaortic membranes can be resected through a mini-thoracotomy approach with excellent clinical results.
Restricted accessResearch articleFirst published November, 2018pp. 433-437Approximately 50% of patients with severe symptomatic mitral regurgitation are deemed too high risk for surgery. The MitraClip procedure is a viable option for this population. Our goal was to assess outcomes and survival of patients who underwent the MitraClip procedure at an institution where mitral valve surgery is routinely performed.
A retrospective study of patients undergoing the MitraClip procedure was performed. Baseline characteristics, perioperative outcomes, and follow-up echocardiographic and clinical outcomes were examined. Primary end point was survival. Secondary end points included technical failure (residual 3/4+ mitral regurgitation), reoperation, New York Heart Association symptoms, 30-day mortality, and other clinical outcomes. Predictors of mortality were determined using multivariable regression analysis.
Fifty consecutive patients underwent the MitraClip procedure during the
4-year period. The average age was 83, the Society of Thoracic Surgeons
predicted risk of mortality mean was 9.4%, 88% (44/50) had New York Heart
Association III/IV symptoms, 86% (43/50) had 4+ mitral regurgitation, and
72% (36/50) had degenerative mitral disease etiology. Echocardiographic data
(median [interquartile range] follow-up = 43 [26–392]) showed that 86%
(43/50) of patients had 2+ or less mitral regurgitation. Sixty percent
(24/40) had New York Heart Association I/II symptoms at last follow-up.
Predictors of mortality were higher Society of Thoracic Surgeons predicted
risk of mortality (
Many patients with mitral valve regurgitation who are high risk for open surgery can be treated with the MitraClip procedure. In our study, most patients (86%) had a technically successful operation and postoperative outcomes including survival were acceptable.
Restricted accessResearch articleFirst published November, 2018pp. 438-444A robotic-assisted approach potentially has many advantages for cardiac reoperation, which include sternum-sparing and three-dimensional visualization leading to precise adhesiolysis and excellent exposure in a limited field.
We retrospectively reviewed our patients undergoing robotic cardiac reoperation (redo group) from July 2013 to April 2017 at our institution and compared with our patients undergoing standard robotic surgery (nonredo group). In the reoperative cases, a thoracoscope was inserted through a 5-mm port placed away from the previous scar. Another 5-mm port was inserted under direct vision to make space for one or two robotic arms, and further precise dissection was performed robotically.
A total of 486 patients underwent robotic-assisted cardiac surgery. There
were 36 patients who had one or more previous cardiac surgeries (42
surgeries). Although the mean operative and cardiopulmonary bypass time were
longer in the redo group (median = 351 minutes vs. 289 minutes and 219
minutes vs. 178 minutes,
Robotic cardiac reoperation is feasible with acceptable clinical outcomes including a low mortality rate similar to standard robotic surgery in our hands. Robotic assistance may have the potential to minimize morbidity and mortality.
Restricted accessCase reportFirst published November, 2018pp. 445-447Cor triatriatum sinister is an uncommon cardiac abnormality characterized by a membrane that divides the left atrium into two chambers. Definitive management requires surgical resection, traditionally through sternotomy. Minimally invasive reparative techniques are associated with reduced blood loss, shorter hospitalization, faster recovery time, and improved cosmesis with excellent patient satisfaction. We present a 29-year-old woman with cor triatriatum sinister and associated atrial septal defect who underwent successful minimally invasive repair through a right periareolar approach.
Restricted accessCase reportFirst published November, 2018pp. 448-450Different case series have been published demonstrating the feasibility of endovascular repair of the ascending aorta in selected patients deemed unfit for open surgery. However, the use of commercially available stent graft in the ascending aorta remains off-label, and their excessive length often prevents their deployment in the ascending aorta. Here we report a case of successful primary endovascular repair of the ascending aorta using a physician modified off-the-shelf device.
Restricted accessCase reportFirst published November, 2018pp. 451-454We report a case of 53-year-old woman with the parathyroid adenoma (PA) located in the aortopulmonary window with an aberrant right subclavian artery. Her preoperative calcium level was 11.3 mg/dL (reference range = 8.8–10.6 mg/dL). The parathyroid hormone level was significantly elevated at 127.4 pg/mL (reference range = 12–88 pg/mL) as measured on immunoradiometric assay. Dual-phase technetium-99m–labeled sestamibi parathyroid scintigraphy and fluorine-18 18F-fluorocholine positron emission tomography/computed tomography revealed a mediastinal tumor measuring 3 × 5 × 6 mm located anterolateral to the aortopulmonary window. Minimally invasive removal of PA was performed through 3.5-cm reverse J-shaped partial upper sternotomy to the third intercostal space. Postoperative recovery was uneventful, and serum calcium and parathyroid hormone levels normalized within 24 hours of surgery. Our case represents the rare occurrence of a mediastinal PA associated with aberrant right subclavian artery treated with targeted minimally invasive approach using different imaging modalities including technetium-99m–sestamibi scintigraphy and fluorine-18 18F-fluorocholine positron emission tomography/computed tomography, and intraoperative use of gamma probe for precise localization PA.
Restricted accessCase reportFirst published November, 2018pp. 455-457Traditionally, pacing leads are placed transvenously, although smaller pediatric patients who require permanent pacemakers may benefit from delaying tranvenous lead placement until they are larger. Alternative, minimally invasive atrioventricular pacing options have not previously existed for this patient population, leaving many of these children with large sternotomies or thoracotomies. Using three port sites and an adjustable shaft dual-needle suturing device, we placed a steroid-eluting, sew-on epicardial lead on the right atrium of a 9-year-old patient. This is one of the earliest reported cases of a minimally invasive technique for sew-on epicardial lead placement on the atrium of a child. Although based on a single case, we believe that this approach is safe, reliable, and reproducible and that it can be used to place leads on any aspect of the heart. Adoption of this technique will allow for earlier atrioventricular pacing, which may decrease the incidence of pacemaker syndrome, and thus improve overall outcomes in this patient population.