Faculty Bibliography

OBJECTIVE/UNASSIGNED:Prolonged intubation is associated with worse outcomes and longer intensive care unit (ICU) and hospital length of stay (LOS). Extubation in the operating room for patients undergoing isolated coronary artery bypass grafting is feasible, safe, and decreases ICU and hospital LOS. Aortic root and arch procedures are lengthy and often require circulatory arrest. Here, we present our experience with the safety and feasibility of operating room extubation following simple and complex aortic surgery. METHODS/UNASSIGNED:All consecutive patients who underwent aortic surgery from August 2023 to April 2025 were included in this descriptive study. We evaluated 30-day postoperative outcomes for patients who were extubated in the operating room and those in the ICU. Outcomes of interest were time to chair, ICU and hospital LOS, as well as reintubation and reoperation rates. RESULTS/UNASSIGNED:< .001). Thirty-day outcomes were excellent and comparable in both groups with no deaths or myocardial infarctions for operating room extubation compared with ICU extubation, respectively: atrial fibrillation (n = 49 [21.9%] vs n = 9 [60%]), stroke (n = 1 [0.4%]) vs n = 0), reoperation for bleeding (n = 1 vs n = 0), reintubation for respiratory failure (n = 0 vs n = 1), and 30-day readmission (n = 11 [4.9%] vs n = 2 [11.8%]). CONCLUSIONS/UNASSIGNED:Routine extubation in the operating room is safe and feasible for a wide variety of patients undergoing both simple and complex aortic surgery, even when most of them undergo circulatory arrest. Operating room extubation may accelerate recovery and early ICU and hospital discharge, without increasing readmission or morbidity.

OBJECTIVES/UNASSIGNED:Some patients with degenerative mitral valve regurgitation have incidental coronary artery disease. When these patients are referred to our robotic cardiac surgery program, they are offered robotic mitral valve surgery combined with staged percutaneous coronary intervention performed during the same hospital admission. The objective of this study is to compare this new "hybrid" approach with the "conventional" operation consisting of sternotomy mitral valve surgery with coronary artery bypass grafting performed as a single procedure. METHODS/UNASSIGNED:Between 2011 and 2024, 181 consecutive patients with degenerative mitral valve regurgitation and coronary artery disease underwent hybrid robotic mitral valve surgery + percutaneous coronary intervention (n = 79) or conventional sternotomy mitral valve surgery + coronary artery bypass grafting (n = 102) at a single high-volume quaternary care center. Information was prospectively entered into Society of Thoracic Surgeons, regional, and institutional data collection instruments. Survival was obtained from a National Death Index. RESULTS/UNASSIGNED:01). In the hybrid group, 92.4% (73/79) of percutaneous coronary interventions were performed after robotic mitral valve surgery and 58.7% (44/75) involved a single coronary distribution only. In the conventional group, 53.9% (55/102) coronary artery bypass grafting surgeries consisted of 1 distal anastomosis. In the hybrid group, the median hospital length of stay was shorter by 2 days. The 30-day mortality and 5-year survival were excellent and identical in both groups. CONCLUSIONS/UNASSIGNED:For patients with degenerative mitral valve regurgitation and coronary artery disease, a hybrid approach (robotic mitral valve surgery + percutaneous coronary intervention) provided enhanced postoperative outcomes with short- and mid-term survival comparable to the conventional operation (sternotomy mitral valve surgery + coronary artery bypass grafting).

BACKGROUND:Earlier intervention for mitral valve (MV) regurgitation leads to smaller left ventricles (LV) and potentially increases the risk of post-operative systolic anterior motion (SAM). We performed left ventricular outflow tract (LVOT) modification in patients with an increased risk of SAM. METHODS:From January 2019 to May 2024, 800 consecutive totally endoscopic robotic MV repairs (TERMVR) were performed. Based on pre-bypass TEE, post-operative SAM risk was graded as low(n=610,76.2%), moderate(n=144, 18%), or high(n=46, 5.8%). Patients with moderate or high risk of SAM were categorized as "increased risk of SAM". To prevent post-operative SAM, LVOT modification consisted in ventricular septal bulge(VSB) myectomy and/or septal myocardial trabeculations(SMT) resection. Operative notes, echocardiograms, and STS dataset were analyzed. RESULTS:Mean patient age was 63.8 years (range= 22-90); 45(5.6%) had prior cardiac surgery. Thirty-day mortality was 5(0.6%). A total of 190(23.8%) patients had an increased risk of SAM. LVOT modification was performed in the majority with increased risk of SAM (139/190, 73.2%) and in a minority with low risk of SAM (42/610,6.9%). In those undergoing LVOT modification(n=181), isolated VSB myectomy was performed in 140(77.3%), isolated SMT resection in 32(17.7%), and both in 9(5.0%). The anterior leaflet was never detached. One patient experienced transient SAM while on inotropes. There was no need for intraoperative MV repair revision for SAM. CONCLUSIONS:Currently, a significant proportion of MV repairs are at elevated risk of post-operative SAM. In our TERMVR experience, LVOT modification was performed with minimal morbidity and prevented any subsequent MV repair revision for SAM.

OBJECTIVE:Hybrid coronary revascularization is a clinical strategy that uses a combination of surgical revascularization and percutaneous coronary intervention (PCI). Data on the hybrid approach for coronary artery disease involving the left main (LM) are scarce. We analyzed our cohort of hybrid coronary revascularizations with minimally invasive direct coronary artery bypass (MIDCAB) using robotic left internal mammary artery harvesting and PCI for multivessel disease with and without LM involvement. METHODS:= 40, 64.5%). RESULTS:= 0.699). CONCLUSIONS:Hybrid robotic MIDCAB for patients with and without LM disease can be performed with acceptable results in selected patients. However, it is not possible to draw definitive conclusions regarding safety and efficacy compared with conventional coronary artery bypass grafting.

OBJECTIVE/UNASSIGNED:Surgical management of mitral annular calcification remains challenging. Our institution pursued a strategy of total mitral annular calcification resection with pericardial patch reconstruction of the left ventricle when primary atrioventricular groove closure was not possible. We present the short-term outcomes derived after implementing this strategy. METHODS/UNASSIGNED:A single-institution retrospective analysis included patients with significant mitral annular calcification undergoing totally endoscopic robotic mitral valve surgery between October 2009 and August 2023. Mitral valve repair was performed in patients with sufficient posterior leaflet length. Patients requiring pericardial patch ventriculoplasty were compared with those in whom primary atrioventricular groove closure was possible (non-pericardial patch ventriculoplasty). RESULTS/UNASSIGNED: = .52). CONCLUSIONS/UNASSIGNED:Totally endoscopic robotic mitral valve repair is a safe and feasible technique for the management of mitral annular calcification with promising results at 3 years. Patients who required atrioventricular groove pericardial patch reconstruction had similar outcomes to those in whom primary closure was possible.

We describe a rare but interesting complication of totally endoscopic robotic mitral valve repair in a patient with severe mitral regurgitation. The mitral valve was repaired robotically by standard techniques, and the intraoperative transesophageal echocardiogram demonstrated no residual mitral regurgitation. However, there was unexpected hypokinesia of the posterior and lateral walls of the left ventricle, with subsequent electrocardiography showing acute ST elevations of the lateral segment. Immediate cardiac catheterization revealed occlusion of the left circumflex artery. Aspiration thrombectomy was performed and a drug-eluting stent placed to restore the contour, thus preventing potential morbidity of the patient.