Faculty Bibliography

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.

OBJECTIVES/OBJECTIVE:The full potential of robotics has not been achieved in terms of addressing the most challenging mitral valve (MV) cases. We outline our technique and report our early results with totally endoscopic robotic MV repair in a wide range of pathologies. METHODS:From May 2011 to August 2017, a dedicated team attempted totally endoscopic robotic MV repair in 500 MV regurgitation patients. Repair complexity was scored in 3 categories. We analysed our sequential case experience by quartiles. RESULTS:Patient mean age was 60.8 years (range 18-88). Aetiologies included: degenerative 382 (76.4%), functional 37 (7.4%), inflammatory 22 (4.4%) and others 59 (11.8%). Mitral annular calcification was present in 64 (12.8%) cases. Simple MV repair (annuloplasty alone or with 1 leaflet segment repair) was performed in 240 (48%) patients, complex (repair involving more than 1 segment on the same leaflet) in 140 (28%) patients and most complex (bileaflet repair or mitral annular calcification excision with atrioventricular groove repair) in 120 (24%) patients. Concomitant procedures included: left appendage closure (94.8%), patent foramen ovale/atrial septal defect (PFO/ASD) closure (19.6%), cryoablation (19.4%), tricuspid repair (6.2%) or hybrid percutaneous coronary revascularization (7.8%). The overall repair rate was 99.4%, with 0.6% early mortality and 1.2% stroke rate (0.2% permanent neurological deficit). Case complexity increased with our experience. Despite an increase in aortic occlusion and perfusion times (median 86.5 and 125 min) and a slight decrease in operating room extubation rate (overall 64%), length of hospital stay (median 4 days) and 30-day readmission rate (overall 3.6%) were not affected by the progressive inclusion of more complex cases. CONCLUSIONS:Totally endoscopic robotic MV repair performed by a dedicated team allows one to address the entire spectrum of pathological complexity and provides consistent results.

Recent improvements in 3D TEE post processing rendering techniques referred to as TrueVue (Philips Medical Systems, Andover, MA, USA). It allows for novel photorealistic imaging of cardiac structures including left atrial appendage (LAA) and its closure devices. Here we present TrueVue images of the LAA prior to and after LAA exclusion/occlusion using various percutaneous and surgical techniques. TrueVue may improve delineation of LAA anatomy prior to occlusion as well as visualization of occluder device position within the LAA.

OBJECTIVE:Advances in transcatheter aortic valve replacement have led to the consideration of tissue aortic valve replacement in younger patients. Part of this enthusiasm is the presumption that younger patients would have more flexibility in future treatment options, such as a primary surgical aortic valve replacement followed later by transcatheter aortic valve replacement(s) (valve-in-valve), vice versa, or other permutations. We created a microsimulation model using published longevity of tissue valves to predict the outcomes of patients after primary tissue surgical aortic valve replacement. METHODS:The model calculated survival by incorporating annual mortality (Social Security Administration) and mortality from re-replacements (Society of Thoracic Surgeons) in patients with surgical aortic valve replacement. Freedom from reoperation for structural valve degeneration incorporated best published data to determine the annual risk of re-replacement for structural valve degeneration based on implant duration and stratified by patient age. A constant rate of re-replacement for nonstructural valve degeneration indications was also incorporated. Each simulation was performed for 50,000 individuals. Kaplan-Meier curves were generated to represent survival. All simulations were run within the MATLAB environment (The MathWorks, Inc, Natick, Mass). RESULTS:Earlier decades of life at primary surgical aortic valve replacement were associated with higher incidences of re-replacements and especially multiple re-replacements. For those patients receiving a primary tissue surgical aortic valve replacement at age 50 years, 57.2% will require a second valve, 18.0% will require a third valve, and 1.6% will require a fourth valve with average operative mortalities of 2.9%, 4.8%, and 7.3%, respectively. A 50-year-old patient at primary surgical aortic valve replacement has a 13.1% chance of re-replacement before turning 60 years of age. CONCLUSIONS:Microsimulation incorporates changing hazards to estimate the risk of aortic valve re-replacement in patients undergoing tissue surgical aortic valve replacement and may be a starting point for patient education and healthcare economic planning.

OBJECTIVE:Medicare's Bundle Payment for Care Improvement(BPCI) Model 2 groups reimbursement for valve surgery into 90-day episodes of care(EOC) which include operative costs, inpatient stay, physician fees, post-acute care, and readmissions up to 90 days post-procedure. We analyzed our BPCI patients' 90-day outcomes to understand the late financial risks and implications of the bundle payment system for valve patients. METHODS:All BPCI valve patients from 10/2013 (start of risk-sharing phase) through 12/2015 were included. Readmissions were categorized as early (≤30 days) or late (31-90 days). Data were collected from institutional databases as well as Medicare claims. RESULTS:Analysis included 376 BPCI valve patients: 202 open and 174 transcatheter aortic valves (TAVR). TAVR patients were older (83.6 vs 73.8 years; p=0.001) and had higher STS predicted risk (7.1% vs 2.8%; p=0.001). Overall, 18.6% of patients (70/376) had one-or-more 90-day readmission, and total claims was on average 51% greater for these patients. Overall readmissions were more common among TAVR patients (22.4%(39/174) vs 15.3%(31/202),p=0.052) as was late readmission. TAVR patients had significantly higher late readmission claims, and early readmission was predictive of late readmission for TAVR patients only (p=0.04). CONCLUSION/CONCLUSIONS:Bundled claims for a 90-day episode of care are significantly increased in patients with readmissions. TAVR patients represent a high-risk group for late readmission, possibly a reflection of their chronic disease processes. Being able to identify patients at highest risk for 90-day readmission and the associated claims will be valuable as we enter into risk-bearing EOC agreements with Medicare.

Objective: A 63-year-old man with severe asymmetric pectus excavatum (Haller index 3.55) presented with New York Heart Association class I symptoms, severe mitral regurgitation due to flail posterior leaflet, and preserved left ventricular (LV) function. Our goalwas to demonstrate a totally endoscopic robotic-assisted mitral repair.
Patient(s): Intraoperative transesophageal echocardiography confirmed severe mitral regurgitation with an anteriorly directed jet due to prolapse of the middle scallop of the posterior leaflet. Four ports were placed in the right chest for the da Vinci Xi surgical system (working, camera, left and right instruments), and cardiopulmonary bypass was instituted via femoral access with arterial and long venous cannulae. While preparing the pericardium, we noted that the right pulmonary veins entered the left atrium leftward of the sternum. An endoclamp was positioned with fluorescent guidance, and antegrade Del Nido cardioplegia was administered. Sondergaard's groove was opened and the left atrial appendage was oversewn with 2 layers of polytetrafluoroethylene sutures. With intracorporeal guidance, a 5th port for an atrial retractor was positioned to the right of the sternum, verifying that it could reach deep enough into the left chest. Analysis of lesions demonstrated a flail P2 leaflet and a globally myxoid mitral valve consistent with Barlow's disease. Although a 0-angle scope provided sufficient visualization of the valve and subvalvular regions, intermittent conflict existed between the instruments and the posterior sternum. A triangular excision of P2 was performed; abnormal chordae were excised below P2, and the defect was closed with polytetrafluoroethylene sutures. A 36-mm posterior annuloplasty band was attached with interrupted 2-0 braided sutures, and hydrostatic testing revealed no residual regurgitation.While the patient was being rewarmed, the endoclamp balloon was deflated while the LV and root were vented. The heart spontaneously returned to sinus rhythm, and the patient was weaned from cardiopulmonary bypass without inotropic support. Postoperative transesophageal echocardiography demonstrated preserved LV function and no residual regurgitation or gradient. The patient was extubated in the operating room and discharged on postoperative day 2.
Conclusion(s): Severe pectus excavatum can make right chest approaches difficult, even in a totally endoscopic robotic approach, but the lack of chest wall disruption allows a speedy recovery

Objective: A 75-year-old woman with New York Heart Association class II heart failure presented with severe mitral and tricuspid regurgitation. Eight years prior, the patient had a large right thoracotomy for resection of a pleural tumor. Our goal was to demonstrate a totally endoscopic resection of an unsuspected recurrent pleural tumor preceding concomitant mitral and tricuspid valve repair.
Method(s): After initially positioning the patient in the left decubitus position via a posterolateral approach, extensive adhesiolysis between the right lower lobe and the diaphragmrevealed a nonimaged 2- to 3-cmmass in the right lower lobe. Limited parenchymal resection was performed. The patient was repositioned in a supine position. Transesophageal echocardiography confirmed severe mitral regurgitation with moderate to severe tricuspid regurgitation. Five lateral thoracic ports were placed for the da Vinci Xi system. Cardiopulmonary bypass was instituted via femoral access with independent femoral and internal jugular venous lines. An endoballoon clamp was positioned with fluorescent guidance and antegrade del Nido cardioplegia was administered. Sondergaard's groove was opened, and the left atrial appendage was oversewn with 2 layers of polytetrafluoroethylene (PTFE) sutures. The mitral valve was nonmyxoid, inconsistent with Barlow's disease. Inspection confirmed mild prolapse of the anterior leaflet, numerous hypertrophied and calcified secondary chordae, and restriction of the posterior leaflet. Secondary chordae were excised below the A2-A3, P1-P2, and P2-P3 clefts. Small triangular excisions were performed at the A2-A3 and P1-P2 junctions, which were both reconstructed with a running PTFE suture. Hydrostatic testing revealed mild central insufficiency due to a lack of coaptation depth. Commissuroplasty was performed with a single PTFE suture, and the P2-P3 cleft was closed with a running PTFE suture. A 30-mmannuloplasty band was inserted. Final hydrostatic testing revealed excellent leaflet coaptation. The cavae were occluded with snares, and the tricuspid valve was exposed via a right atriotomy. A reduction tricuspid annuloplasty with a 26-mm band was performed. With the heart reperfused and the aortic root and left ventricle vented, the atriotomies were closed.
Result(s): Postoperative transesophageal echocardiography demonstrated preserved left ventricular function with trace mitral and tricuspid regurgitation. The patient was discharged on postoperative day 6. Final pathological analysis confirmed a completely resected benign solitary fibrous tumor.
Conclusion(s): A totally endoscopic approach to mitral and tricuspid valve repair can be performed safely and effectively in patients with a prior right thoracotomy