Faculty Bibliography

BACKGROUND:The benefits of fast-track extubation in the intensive care unit (ICU) after cardiac surgery are well established. Although extubation in the operating room (OR) is safe in carefully selected patients, widespread use of this strategy in cardiac surgery remains unproven. This study was designed to evaluate perioperative outcomes with OR vs ICU extubation in patients undergoing nonemergency, isolated coronary artery bypass grafting (CABG). METHODS:The Society of Thoracic Surgeons (STS) data for all single-center patients who underwent nonemergency isolated CABG over a 6-year interval were analyzed. Perioperative morbidity and mortality with ICU vs OR extubation were compared. RESULTS:Between January 1, 2017 and December 31, 2022, 1397 patients underwent nonemergency, isolated CABG; 891 (63.8%) of these patients were extubated in the ICU, and 506 (36.2%) were extubated in the OR. Propensity matching resulted in 414 pairs. In the propensity-matched cohort, there were no differences between the 2 groups in incidence of reintubation, reoperation for bleeding, total operative time, stroke or transient ischemic attack, renal failure, or 30-day mortality. OR-extubated patients had shorter ICU hours (14 hours vs 20 hours; P < .0001), shorter postoperative hospital length of stay (3 days vs 5 days; P < .0001), a greater likelihood of being discharged directly to home (97.3% vs 89.9%; P < .0001), and a lower 30-day readmission rate (1.7% vs 4.1%; P = .04). CONCLUSIONS:Routine extubation in the OR is a feasible and safe strategy for a broad spectrum of patients after nonemergency CABG, with no increase in perioperative morbidity or mortality. Wider adoption of routine OR extubation for nonemergency CABG is indicated.

OBJECTIVE/UNASSIGNED:Totally endoscopic intracardiac robotic surgery is generally limited to uncomplicated mitral valve surgery. With experience, our team has developed a more aggressive approach to robotic cardiac surgery that allows for repair of a broad spectrum of mitral valve pathologies. We report complex subvalvular procedural advancements associated with this approach secondary to enhanced team experience and capabilities. METHODS/UNASSIGNED:All robotic mitral procedures performed by a 2-surgeon team in a quaternary care medical center from July 2011 to May 2022 were reviewed. Natural language-processing techniques were used to analyze operative reports for subvalvular repair techniques. Complex subvalvular techniques included papillary muscle repositioning, division of secondary anterior leaflet chordae, septal myomectomy, division of aberrant left ventricular muscle band attachments, and left ventricular patch reconstruction. The surgical experience was divided into 2 periods: early robotic experience (pre-2018) versus late (2018 onwards). Baseline demographics, outcomes, and subvalvular techniques were analyzed and compared. RESULTS/UNASSIGNED: < .001)). CONCLUSIONS/UNASSIGNED:An experienced 2-surgeon team can perform progressively more complex robotic subvalvular repair techniques. These subvalvular techniques are a surrogate for team proficiency and capabilities.

Infective endocarditis (IE) is a life-threatening disease associated with in-hospital mortality of nearly one in five cases. IE can destroy valvular tissue, which may rarely progress to aneurysm formation, most commonly at the anterior leaflet in instances of mitral valve involvement. We present a remarkable case of a patient with IE and a rare complication of a ruptured aneurysm of the posterior leaflet of the mitral valve. Two- and Three-dimensional transesophageal echocardiography, intra-operative videography, and histopathologic analysis revealed disruption at this unusual location-at the junction of the P2 and P3 scallops, surrounded by an annular abscess.

OBJECTIVE:Mitral annular calcification is underdiagnosed in patients with mitral regurgitation. After excision, it may require reconstruction of the atrioventricular groove and decreases the probability of valve repair. We reviewed the safety and efficacy of totally endoscopic robotic mitral valve repair in the presence of mitral annular calcification, with an emphasis on pathology and repair techniques. METHODS:Between May 2011 and August 2017, the same 2-surgeon team attempted totally endoscopic robotic mitral valve repair in 64 mitral annular calcification cases, accounting for 12.8% of our experience. Mitral annular calcification associated with a calcified posterior leaflet was not considered for totally endoscopic robotic mitral valve repair. When possible, the mitral annular calcification was excised en bloc using electrocautery, the posterior leaflet separated from the mitral annular calcification and spared, the atrioventricular groove was reconstructed, the posterior leaflet was reattached to the neoannulus, and the repair was completed with annuloplasty. RESULTS:The median age of patients was 65 years, with 21 (32.8%) aged less than 60 years, and 34 (53.1%) were women. The etiology was Barlow's disease in 54 patients (84%). Repair was converted to replacement in 2 patients (3.1%). Cryoablation was performed in 8 patients (12.5%), hybrid percutaneous coronary intervention was performed in 5 patients (7.8%), and tricuspid annuloplasty was performed in 2 patients (3.1%). Median aortic occlusion was 122 minutes, excluding cases with concomitant tricuspid repair. Thirty-three patients (52%) were extubated in the operating room. The median length of stay was 4 days. Residual mitral regurgitation on discharge transthoracic echocardiogram was none to mild in all patients. None of the patients had a perioperative stroke or needed a pacemaker. Thirty-day mortality was 2 (3.1%). CONCLUSIONS:Mitral annular calcification is present in a significant percentage of patients with mitral regurgitation, especially in Barlow's disease, including younger patients. By using a variety of repair techniques, totally endoscopic robotic mitral valve repair can be performed safely and effectively in most mitral annular calcification cases with a noncalcified posterior leaflet.

This is a response to the papers in the May/June issue of Innovations focused on robotic techniques in cardiac and thoracic surgery. Successful robotic surgery relies on a high level of preparation and communication from each member of the operating room. The lack of a team approach can result in not only failure to establish and/or sustain a robotic program, but more importantly, in serious consequences at the detriment to patient care and safety. While these are salient points, the authors of this commentary wish to highlight that the first robot-assisted mitral valve surgery in North America was performed at NYU Langone Health using the Zeus robotic surgical system. Although that robotic platform had several disadvantages that limited its clinical advancement, an appreciation for this history in robotic cardiac surgery is important if we as cardiothoracic surgeons seek to move toward a future of expanding robotic surgery within the ever-changing landscape of cardiac surgery.

This summarizes the incidence of septo-octogenarian patients in our robotic mitral experience and provides comparative outcomes to STS predicted models of mortality, stroke, and shortened length of stay, demonstrating that elderly patients (≥70 years) matched STS benchmarks and outperforming STS predicted short length of stay in this study population. NYHA = New York Heart Association. PCI = percutaneous coronary intervention. LOS = length of stay. STS = Society of Thoracic Surgeons. Advanced age confers higher STS predicted risks of mortality (PROM) and longer hospital lengths of stay (LOS) in patients undergoing mitral valve surgery; some consider it a contraindication to robotic-assisted approaches. We analyzed the feasibility and safety of totally endoscopic robotic mitral valve surgery (TERMS) in patients≥70 years. From 5/11 to 4/18, 570 consecutive patients underwent TERMS by the same two-surgeon team utilizing the da Vinci Xi Surgical System. Differences in patient demographics, intra-operative variables, and outcomes were analyzed between septo-octogenarian (patients≥70 years) and younger patients (<70 years). Patients requiring LV patch reconstruction following mitral annular calcification resection were excluded. For those patients with STS predicted risk scores (n=439), our outcomes were compared to those STS predictions. Patients≥70 comprised 25% of our TERMS cohort. Patients≥70 had higher rates of pre-operative atrial fibrillation and congestive heart failure, and significantly higher STS PROM. Patients≥70 had greater incidence of concomitant cryoablation, hybrid percutaneous coronary intervention, and tricuspid repair. Patients≥70 did not have longer cardiopulmonary bypass or aortic occlusion times. Thirty-day mortality was similar between groups (p=0.151). Median LOS was one day longer for patients≥70, 4 vs 3 days (p<0.001). Short LOS (<6 days) was achieved in 72% of patients≥70, markedly outperforming the STS predicted rates (36%). Advanced age is not a limiting factor for robotic mitral valve surgery in most patients. TERMS in patients≥70 years matched STS benchmark performance outcomes and provided excellent recovery as evidenced by the short LOS (<6 days) experienced by the majority of septo-octogenarian patients.