Innovations: Technology and Techniques in Cardiothoracic and Vascular Surgery

To assess early and late clinical outcomes in patients who underwent aortic valve repair surgery for aortic valve insufficiency, and to investigate predictors for recurrence.

Of 151 consecutive patients who underwent aortic valve repair surgery for varying degrees of aortic insufficiency (AI) in our department between 2004 and 2018, 60 (40%) underwent aortic root replacement, 71 (47%) aortic cusp plication, 31 (20%) subcommissural annuloplasty, 29 (19%) circular annuloplasty, and 28 (18%) autologous pericardial patch augmentation.

One patient died in the hospital (0.7%). Mean clinical and echocardiographic follow-up was 62±43 months (range 1 to 159) and 50 ± 40 months (range 1 to 158), respectively. The overall survival rate was 99.3% at 1 year and 98% at 5 years of follow-up. Seventeen patients (11.3%) had recurrent severe AI, and all of them underwent reoperation with a mean duration to reoperation of 35 ± 39 months. Risk factors for the development of recurrent significant AI (≥3) or reoperation, by univariable analysis, were unicuspid or bicuspid aortic valve (AV) (P = 0.018), the use of subcommissural annuloplasty (P = 0.010), the need for cusp repair (P = 0.001), and the use of pericardial patch augmentation (P < 0.001). By multivariable analysis only the use of pericardial patch augmentation emerged as a significant independent predictor for the development of recurrent significant AI (≥3) or reoperation (P = 0.020).

AV repair can be performed with low morbidity and mortality, with good early and late clinical outcomes. However, in our experience there was a significant rate of recurrent AI especially in patients who underwent cusp augmentation using glutaraldehyde-treated autologous pericardial patch.

Enhanced recovery pathways reduce length of stay and costs following lung resection. However, many fear that early discharge may lead to increased hospital readmissions. In this study, we aimed to determine whether early discharge was associated with increased readmission following anatomic lung resection.

Using the lung resection database approved by our institutional review board, we identified all patients undergoing minimally invasive lobectomy and segmentectomy between January 2010 and March 2017 at our institution, where an enhanced recovery pathway is well established. Thirty-day readmissions were compared between patients with short- and average length of stay, defined as 1 to 2 days and 3 to 5 days, respectively. Multivariable logistic regression analysis of patients matched by propensity scores was performed to determine odds of 30-day readmission for each group. Significance was set at P < 0.05.

A total of 296 patients met inclusion criteria. Unadjusted analysis revealed a 3-fold increased rate of readmission in the group with average length of stay (9%, n = 12) versus the group with short length of stay (3%, n = 5; P < 0.01). At baseline, patients with average length of stay had increased rates of preoperative chemotherapy (13%, n = 18 vs. 4%, n = 6; P < 0.01) and radiation (12%, n = 16 vs. 3%, n = 5). Patients with average length of stay also had higher rates of lobectomy (95%, n = 127 vs. 86%, n = 140; P = 0.02) and postoperative complications (31%, n = 41 vs. 4%, n = 7; P < 0.01). On multivariable analysis, patients with average length of stay had a 2.3-fold greater odds of readmission, which was not statistically significant (OR = 2.33; 95% CI, 0.60 to 9.02; P = 0.22).

Early discharge following minimally invasive anatomic lung resection does not increase the risk of hospital readmission in patients treated within an enhanced recovery pathway.

Minimally invasive CABG is making positive strides in the evolution of coronary artery bypass surgery. We carried out a retrospective study of the efficacy and outcomes of the usage of bilateral internal thoracic arteries in MICS CABG patients over a 6 year period using primary (MACCE) and secondary outcome measures and also carried out a subgroup analysis of patients with diabetes and methodology of revascularization, and with analogy to the SYNTAX trial of the relative risk.

Nine hundred and forty patients underwent multivessel MICS CABG via a left mini-thoracotomy from August 2011 to September 2017 and complete revascularization was done using the left internal thoracic artery–right internal thoracic artery Y (LITA–RITA Y) composite conduit. Efficacy and outcomes were evaluated by primary (MACCE) and secondary outcome measures including total length of stay, return to full physical activity, and quality of life. Propensity score matched analyses were carried out in diabetics, in the methodology of revascularization (MICS OPCABG vs. MICS ONCABG), and by comparison to the SYNTAX trial for relative risk. Mean follow-up was 2.9 years (maximum was 5.6 years).

Out of the 940 patients, 843 (89.6%) were diabetic and 97 (10.4%) were nondiabetic. Average grafts were 3.2. There were 9 mortalities (0.9%). The average ICU and hospital stay was 40 ± 12 hours and 3.1 days. Ten patients (1.06%) required reintervention by angioplasty. A total of 99.3% patients were free from major adverse cardiac and cerebrovascular events (MACCE) at follow-up. Mean follow-up was 33 months and 846 (90%) of the patients were followed up. Based on propensity score–matched groups, patients who had their surgery done by MICS ONCABG (beating heart technique) had greater mean number of grafts and hospital length of stay and had significantly longer ICU stay, extubation in OR and blood loss in comparison to patients who had their CABG done by the MICS OPCABG technique. The new technique has shown favorable risk reduction in comparison to both the arms of the SYNTAX trial.

The safety, efficacy and outcomes of minimally invasive CABG evaluated by primary (MACCE) and secondary outcomes and quality-of-life measures have been good in this study, especially in diabetics, and have shown results better than conventional CABG. The learning curve can be safely negotiated by using peripheral cardiopulmonary bypass assistance and comparison with the SYNTAX trial has shown a relative reduction in all-cause risk.

We sought to investigate outcomes after left ventricular assist device (LVAD) implantation in advanced heart failure patients stratified by race.

Patients who had LVADs inserted at a single center as a bridge to transplant (BTT) or destination therapy (DT) were divided into 3 groups based on race: Caucasian, African American (AA), and Hispanic. Postoperative outcomes including complications, discharge disposition, and survival at defined time points were compared. Cox proportional hazards were used to identify factors associated with 1-year all-cause survival.

A total of 158 patients who had LVADs as BTT (n = 63) and DT (n = 95) were studied. Of these, 56% (n = 89) were Caucasians, 35% (n = 55) were AA, and 9% (n = 14) were Hispanics. AA patients had higher BMI and lower socioeconomic status and educational level, and were more likely to be single or divorced. Operative outcomes were similar among all 3 groups. Unadjusted 30-day, 6-month, 1-year, and 2-year survival rates for Caucasians versus AA versus Hispanics were 82% versus 89% versus 93%, P = 0.339; 74% versus 80% versus 71%, P = 0.596; 67% versus 76% versus 71%, P = 0.511; and 56% versus 62% versus 68%, P = 0.797. On multivariate analysis, device-related infection, malfunction, and abnormal rhythm were factors associated with overall all-cause mortality.

AA patients who undergo LVAD implantation as BTT or DT have lower socioeconomic status and educational level compared to their Caucasian or Hispanic counterparts. These differences, however, do not translate into postimplant survival outcomes.

Limited data is available about the effect of implanted valve size on prosthesis–patient mismatch (PPM) incidence and aortic gradient (AG) after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). We compared PPM incidence and postprocedural AG between TAVR and SAVR patients considering the impact of implanted valve size.

From March 20, 2012, to September 30, 2015, 563 consecutive patients underwent TAVR (n = 419) or isolated SAVR (n = 144). Postprocedural transthoracic echocardiography was obtained within 30 days; AG, effective orifice area (EOA), and EOA index were calculated.

A total of 381 patients in TAVR group and 82 patients in SAVR group were included. Mean preoperative AG and mean aortic valve area were not significantly different between the 2 groups. Postprocedural AG was significantly lower in TAVR than SAVR group, 7.74 ± 5.39 versus 14.27 ± 8.16 (P < 0.001). Between patients who had TAVR and SAVR with a valve size ≤23 mm, SAVR patients were 3 times more likely to have greater than mild AG after the procedure, OR: 3.1 (95% CI, 1.1 to 8.9) (P < 0.001). PPM incidence was significantly higher in SAVR group than TAVR group, 44 (53.7%) versus 112 (29.4%), OR = 2.8 (95% CI, 1.7 to 4.5) (P < 0.001). The PPM incidence was also higher in SAVR group than TAVR group among those who had the procedures with a valve size ≤23 mm, 35 (64.8%) versus 56 (47.9%), OR = 2 (95% CI, 1.1 to 3.9) (P = 0.048). Postprocedural outcomes were comparable between the 2 groups.

In comparison to SAVR, TAVR is associated with less PPM and lower AG, especially in patients receiving a valve size ≤23 mm.

The majority of minimally invasive surgical aortic valve replacements (MIAVRs) are performed at high-volume cardiac surgery centers. However, outcomes at lower volume federal facilities are not yet reported in the literature and not captured in the national Society of Thoracic Surgeons (STS) database. Our study objective was to describe the evolution of MIAVR at a Veterans Affairs Medical Center (VAMC).

A single-center retrospective cohort study was performed of 114 patients who underwent MIAVR for isolated aortic valvular disease between January 2011 and August 2018. Preoperative STS risk factors were determined and perioperative outcomes were analyzed.

By 2016, 100% of isolated surgical aortic valve replacements were performed as MIAVRs at our VAMC. Introduction of automatic knot-fastening devices, single-shot del Nido cardioplegia, and rapid deployment valves decreased aortic cross-clamp (AXC) times from a median of 96 (interquartile range [IQR]: 84 to 103) to 53 minutes (38 to 61, P < 0.001, Kruskal–Wallis). Thirty-day mortality was 0.9%. Median length of hospital stay was 9 days (7 to 13). Postoperative atrial fibrillation occurred in 54% of patients, stroke occurred in 1.8% of patients, and 7.1% of patients required permanent pacemakers. Transition to rapid deployment valves decreased postoperative mean pressure gradient from median 14 mmHg (10 to 17) to 7 mmHg (4.7 to 10, P < 0.001, Mann–Whitney). At median 1.5-year follow-up echocardiogram, mean gradient was 10.8 mmHg with mild paravalvular leak rate of 1.8%.

Facilitating technologies decreased operative times during MIAVR adoption at our VAMC. For patients with isolated aortic valve pathology, MIAVR can be performed with low morbidity and mortality at lower volume federal institutions, with outcomes comparable to those reported from higher volume centers.

The learning curve and the advantages of transitioning to robotic-assisted lobectomy by a surgeon who is proficient in thoracoscopic lobectomy is currently unknown. The cost of robotic lobectomy has been reported to be higher than thoracoscopic lobectomy and there is no significant decrease in hospital length of stay.

This is a retrospective review of 228 patients diagnosed with lung carcinoma who underwent minimally invasive lobectomy from March 2014 to May 2018. A total of 114 patients underwent thoracoscopic lobectomy and 114 patients underwent robotic-assisted lobectomy. The data collected included patient demographics, tumor characteristics, morbidity, mortality, operative times, and hospital length of stay.

A total of 114 patients underwent thoracoscopic lobectomy and 114 patients underwent robotic-assisted lobectomy. The patients in each group were similar in age, gender, smoking status, FEV-1, tumor histology, and pathologic stage. The mortality and complication rates were similar. The mean number of total lymph nodes and N2 lymph nodes were significantly higher in the robotic lobectomy group (P < 0.0001). The mean operative time was shorter in the robotic group. The median hospital length of stay (4 days) was similar between the 2 groups (P = 0.99).

The results of this report suggest that thoracoscopic and robotic-assisted lobectomy have similar outcomes when a surgeon proficient in the thoracoscopic technique completely transitions to the robotic-assisted technique. The learning curve was relatively accelerated in this single-surgeon experience. There may be an advantage for robotic-assisted lobectomy in the total number of lymph nodes harvested.