How I perform totally endoscopic robotic mitral valve repair.

A sixty-two-year-old male presented with significant symptoms related to severe mitral regurgitation with posterior leaflet flail and prolapse on transesophageal echocardiogram (TEE). Preoperative computed tomography (CT) angiography showed normal caliber thoracoabdominal aorta and patent access vessels. The patient underwent totally endoscopic robotic mitral valve repair (rMVr) with left atrial CryoMAZE procedure

Orthopedic Principles to Facilitate Enhanced Recovery After Cardiac Surgery

Enhanced recovery after surgery (ERAS) protocols recognize early postoperative mobilization as a driver of faster postoperative recovery, return to normal activities, and improved long-term patient outcomes. For patients undergoing open cardiac surgery, an opportunity for facilitating earlier mobilization and a return to normal activity lies in the use of improved techniques to stabilize the sternal osteotomy. By following the key orthopedic principles of approximation, compression, and rigid fixation, a more nuanced approach to sternal precaution protocols is possible, which may enable earlier patient mobilization, physical rehabilitation, and recovery

Minimally Invasive Mitral Valve Surgery III: Training and Robotic-Assisted Approaches.

Minimally invasive mitral valve operations are increasingly common in the United States, but robotic-assisted approaches have not been widely adopted for a variety of reasons. This expert opinion reviews the state of the art and defines best practices, training, and techniques for developing a successful robotics program

Minimally Invasive Mitral Valve Surgery I: Patient Selection, Evaluation, and Planning.

Widespread adoption of minimally invasive mitral valve repair and replacement may be fostered by practice consensus and standardization. This expert opinion, first of a 3-part series, outlines current best practices in patient evaluation and selection for minimally invasive mitral valve procedures, and discusses preoperative planning for cannulation and myocardial protection

Minimally Invasive Mitral Valve Surgery II: Surgical Technique and Postoperative Management.

Techniques for minimally invasive mitral valve repair and replacement continue to evolve. This expert opinion, the second of a 3-part series, outlines current best practices for nonrobotic, minimally invasive mitral valve procedures, and for postoperative care after minimally invasive mitral valve surgery

Robotic Versus Conventional Sternotomy Mitral Valve Surgery: A Systematic Review and Meta-Analysis

Background: Robotic-assisted mitral valve surgery (RMVS) is becoming an increasingly performed procedure in cardiac surgery, however, its true safety and efficacy compared to the gold standard conventional sternotomy approach [conventional sternotomy mitral valve surgery (CSMVS)] remains debated. The aim of this meta-analysis was to provide a comprehensive analysis of all available literature comparing RMVS to CSMVS. Methods: An electronic search of five databases was performed to identify all relevant studies comparing RMVS to CSMVS. Pre-defined primary outcomes of interest included all-cause mortality, cerebrovascular accidents (CVA) and re-operation for bleeding. Secondary outcomes of interest included cross clamp time, cardiopulmonary bypass (CPB) time, intensive care unit (ICU) and hospital length of stay (LOS), postoperative atrial fibrillation (POAF) and red blood cell (RBC) transfusion. Results:The search strategy identified fourteen studies qualifying for inclusion in this meta-analysis comparing RMVS to CSMVS. The outcomes of 6,341 patients (2,804 RMVS and 3,537 CSMVS) were included. RMVS had significantly lower mortality when compared to CSMVS group in both the unmatched [odds ratio (OR) 0.33; 95% confidence interval (CI): 0.19–0.57; P Conclusions: Current evidence on comparative outcomes of RMVS and CSMVS is limited with only lowquality studies currently available. This present meta-analysis suggests that RMVS may have lower mortality and shorter ICU and hospital LOS, however CSMVS may be associated with significantly shorter cross clamp and CPB times. Further analysis of high-quality studies with randomized data is required to verify these results

Systematic Review and Meta-Analysis of Mid-Term Survival, Reoperation, and Recurrent Mitral Regurgitation for Robotic-Assisted Mitral Valve Repair

Background: Over the past two decades surgical approaches for mitral valve (MV) disease have evolved with the advent of minimally invasive techniques. Robotic mitral valve repair (RMVr) safety and efficacy has been well documented, however, mid- to long-term data are limited. The aim of this review was to provide a comprehensive analysis of the available mid- to long-term data for RMVr. Methods: Electronic searches of five databases were performed to identify all relevant studies reporting minimum five-year data on RMVr. Pre-defined primary outcomes of interest were overall survival, freedom from MV reoperation and from moderate or worse mitral regurgitation (MR) at five years or more post-RMVr. A meta-analysis of proportions or means was performed, utilizing a random effects model, to present the data. Kaplan-Meier curves were aggregated using reconstructed individual patient data. Results: Nine studies totaling 3,300 patients undergoing RMVr were identified. Rates of overall survival at 1-, 5- and 10-year were 99.2%, 97.4% and 92.3%, respectively. Freedom from MV reoperation at eight-years post RMVr was 95.0%. Freedom from moderate or worse MR at seven years was 86.0%. Rates of early post-operative complications were low with only 0.2% all-cause mortality and 1.0% cerebrovascular accident. Reoperation for bleeding was low at 2.2% and successful RMVr was 99.8%. Mean intensive care unit and hospital stay were 22.4 hours and 5.2 days, respectively. Conclusions: RMVr is a safe procedure with low rates of early mortality and other complications. It can be performed with low complication rates in high volume, experienced centers. Evaluation of available mid-term data post-RMVr suggests favorable rates of overall survival, freedom from MV reoperation and from moderate or worse MR recurrence

Robotically Assisted Mitral Valve Repair—Port-Only Totally Endoscopic Approach

Robotic mitral valve repair (MVR) is an emerging option to treat degenerative valve disease. Compared to open thoracotomy, robotic mitral valve surgery has been shown to afford decreased postoperative length of stay with comparable rates of mortality and morbidity. Among the variety of techniques for robotic MVR, the totally endoscopic approach remains the least invasive method to date. In this report, we describe our technique for totally endoscopic robotically-assisted MVR. In particular, we seek to highlight the use of several unique techniques in MVR. Percutaneous cannulation with use of the endoballoon is employed for cardiopulmonary bypass (CPB), thus avoiding traditional aortic cross-clamping. Moreover, intercostal nerve cryoanesthesia is performed from T3–T9 to reduce post-operative pain and aid in reducing opioid management. Barbed, nonabsorbable sutures are used throughout the procedure (for left atrial appendage closure, mitral valve annuloplasty band placement, left atrial closure, pericardial re-approximation), eliminating the need for knot-tying at several steps. We also detail the installation of two sets of neochords for mitral regurgitation and the fastening of the mitral annuloplasty band. Finally, we would like to highlight the small size of each port used in the case (eight millimeters maximum diameter). Taken together, these features of the robotic platform make it notable for its minimally invasive approach to MVR

Hall Normalization Constants for the Bures Volumes of the n-State Quantum Systems

We report the results of certain integrations of quantum-theoretic interest, relying, in this regard, upon recently developed parameterizations of Boya et al of the n x n density matrices, in terms of squared components of the unit (n-1)-sphere and the n x n unitary matrices. Firstly, we express the normalized volume elements of the Bures (minimal monotone) metric for n = 2 and 3, obtaining thereby "Bures prior probability distributions" over the two- and three-state systems. Then, as an essential first step in extending these results to n > 3, we determine that the "Hall normalization constant" (C_{n}) for the marginal Bures prior probability distribution over the (n-1)-dimensional simplex of the n eigenvalues of the n x n density matrices is, for n = 4, equal to 71680/pi^2. Since we also find that C_{3} = 35/pi, it follows that C_{4} is simply equal to 2^{11} C_{3}/pi. (C_{2} itself is known to equal 2/pi.) The constant C_{5} is also found. It too is associated with a remarkably simple decompositon, involving the product of the eight consecutive prime numbers from 2 to 23. We also preliminarily investigate several cases, n > 5, with the use of quasi-Monte Carlo integration. We hope that the various analyses reported will prove useful in deriving a general formula (which evidence suggests will involve the Bernoulli numbers) for the Hall normalization constant for arbitrary n. This would have diverse applications, including quantum inference and universal quantum coding.Comment: 14 pages, LaTeX, 6 postscript figures. Revised version to appear in J. Phys. A. We make a few slight changes from the previous version, but also add a subsection (III G) in which several variations of the basic problem are newly studied. Rather strong evidence is adduced that the Hall constants are related to partial sums of denominators of the even-indexed Bernoulli numbers, although a general formula is still lackin