Faculty Bibliography

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).

OBJECTIVE/UNASSIGNED:During septal myectomy, once the heart is arrested and drained of blood on cardiopulmonary bypass, transesophageal echocardiography can no longer assess septal thickness. In the present study, we evaluated the effectiveness of on-pump intracardiac echocardiography (OPIE) for real-time intraoperative septal thickness assessment in patients with preoperative thickness ≤2.0 cm. Our hypothesis was that OPIE measurements would be conconcordant with the pre- and postcardiopulmonary bypass transesophageal echocardiography measurements that are at present the primary operative guides. METHODS/UNASSIGNED:We retrospectively reviewed patients with hypertrophic cardiomyopathy and septal thickness ≤2.0 cm on transthoracic echocardiography who underwent septal myectomy from July 2017 to July 2024. The OPIE probe was introduced into the left-ventricular chamber during cardioplegic arrest, with repeated measurements to assess the depth and adequacy of resection. Septal thickness was evaluated pre-myectomy using transthoracic echocardiography, cardiac magnetic resonance imaging, transesophageal echocardiography, and OPIE. Lin's concordance correlation coefficients and Bland-Altman analyses were used to evaluate agreement between modalities. RESULTS/UNASSIGNED:A total of 220 patients were included with preoperative thickness ≤2.0, 56 of whom underwent myectomy with OPIE guidance. Preresection transesophageal echocardiography and OPIE demonstrated the strongest agreement of all the imaging modalities (Lin's concordance correlation coefficient, 0.81; 95% CI, 0.72-0.88), with minimal bias (-0.73) and the narrowest limits of agreement (-3.76, +2.31]. OPIE-derived resection thickness estimates were tightly clustered. In the OPIE cohort, there was 1 ventricular septal defect (1.8%) and no 30-day mortality. CONCLUSIONS/UNASSIGNED:OPIE is a reliable tool for intraoperative assessment of septal thickness, particularly in patients with mild hypertrophy.

OBJECTIVE/UNASSIGNED:The arterial switch operation (ASO) is the standard repair for d-transposition of the greater arteries, although coronary reimplantation remains technically complex and carries the risk of both early and late complications. Coronary ostial plasty for late stenosis has been described using various patch materials, each with its own advantages and limitations. However, the optimal patch material remains unclear. METHODS/UNASSIGNED:We report 2 cases of symptomatic late left main coronary artery (LMCA) stenosis after ASO in young adults with complex coronary artery. Both patients underwent coronary ostial plasty in which a femoral artery homograft patch was used. The patients' preoperative presentation, imaging findings, operative details, and postoperative course are reviewed. RESULTS/UNASSIGNED:Case 1 was a 22-year-old man with a single coronary artery arising from the right anterior sinus and >75% LMCA ostial stenosis. Case 2 was a 25-year-old young man with interarterial LMCA atresia and collateralization from a dominant right coronary artery. In both cases, surgical repair involved extending the aortotomy into the LMCA and performing ostial plasty using a femoral artery homograft patch. Both patients had uneventful recoveries and remain asymptomatic with excellent functional status. CONCLUSIONS/UNASSIGNED:Late coronary artery stenosis is a recognized complication after ASO, particularly in patients with complex coronary anatomy. Although multiple patch materials have been used for ostial plasty, each has drawbacks. Femoral artery homograft may represent a promising alternative in these challenging anatomical settings.

The Society of Thoracic Surgeons (STS) 2026 Expert Consensus Pathway on Robotic Cardiac Training outlines principles for the safe initial introduction and subsequent expansion of robotic cardiac programs. The 25-year history of robotic cardiac surgery has established safety and efficacy while providing multiple innovations. There is currently a unique opportunity to coalesce best practices and evidence to inform a recent global surge in interest in incorporating robotic techniques into standard cardiac surgical practice. This consensus is a collaborative effort between the STS Workforce on Evidence Based Surgery, the STS Robotic Cardiac Surgery Taskforce, and multinational leaders in robotic cardiac surgery that aims to standardize initial core principles of preparatory elements, followed by 4 phases of robotic cardiac training to proceed from program commencement to mastery.

OBJECTIVE:Surgery for mitral valve disease in patients with mitral annular calcification (MAC) remains challenging. There is no consensus on the ideal management strategy or patient selection, and perioperative and periprocedural morbidity and mortality rates remain high. The recent surge of patients presenting with MAC has been accompanied by increased interest in MAC surgery and interventions. This expert consensus document is meant to provide a simplified outline for managing MAC, including patient selection, imaging, and surgical and transcatheter therapeutic options, with a particular focus on conventional surgical techniques and hybrid approaches. METHODS:The American Association for Thoracic Surgery Clinical Practice Standards Committee assembled an international panel of cardiac surgeons and structural heart interventionalists with established expertise in the field of MAC. A comprehensive literature review was performed by the panel and a medical librarian. Clinical recommendations were developed utilizing a modified Delphi method. RESULTS:Expert consensus was reached on 33 recommendations, with class of recommendation and level of evidence, for each of 5 main topics: (1) preoperative evaluation for patients with MAC, patient selection, and indications for intervention; (2) standard surgical techniques in MAC; (3) hybrid procedures in MAC; (4) transcatheter MAC interventions; and (5) complications and bailout of MAC surgery and interventions. CONCLUSIONS:Despite the complexity and heterogenicity of patients presenting with MAC, consensus on several key recommendations was reached by this American Association for Thoracic Surgery expert panel. These recommendations provide guidance for cardiac surgeons and structural heart interventionists in treating most patients who present with MAC.