Faculty Bibliography

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.

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.