Eligibility for Minimally Invasive Coronary Artery Bypass Examination of Epicardial Adipose Tissue Using Computed Tomography

Objective: A variable that necessitates conversion to a conventional full-sternotomy coronary artery bypass procedure from a robotic-assisted endoscopic single-vessel small thoracotomy is the inability to visualize the left anterior descending coronary artery within the surrounding epicardial adipose tissue using the endoscopic camera. The purpose of this study was to determine whether anatomical properties of the epicardial adipose tissue examined using preoperative computed tomography (CT) images are able to predict and thus reduce the need for intraoperative conversion based on effective preoperative exclusion criteria. Methods: Retrospective analysis of patient preoperative CT angiography scans from both converted (n = 17) and successful robotic-assisted (n = 17) procedures was performed. Where possible, measurements of epicardial adipose tissue were acquired from axial slices, at the most accessible segment of the left anterior descending coronary artery. Results: Results indicate that patients who successfully underwent the endoscopic single-vessel small thoracotomy procedure (mean +/- SD depth, 4.9 +/- 1.9 mm) had significantly less epicardial adipose tissue (38%, P = 0.002) overlying the vessel toward the lateral chest wall than those who were converted to the full-sternotomy approach intraoperatively (mean +/- SD depth, 7.9 +/- 3.2 mm). Using this as a retrospective exclusion criterion reduces the conversion rate for this group by 47%, while maintaining a high specificity (94%). No significant differences exist between the two groups with respect to the remaining epicardial adipose tissue measurements or body mass index. Conclusions: The addition of CT angiography measurements of the epicardial adipose tissue overlying the left anterior descending coronary artery may enhance preoperative surgical planning for this procedure, thereby reducing the instances of procedural changes

Minimally Invasive Surgical Therapies for Atrial Fibrillation

Atrial fibrillation is the most common sustained arrhythmia and is associated with significant risks of thromboembolism, stroke, congestive heart failure, and death. There have been major advances in the management of atrial fibrillation including pharmacologic therapies, antithrombotic therapies, and ablation techniques. Surgery for atrial fibrillation, including both concomitant and stand-alone interventions, is an effective therapy to restore sinus rhythm. Minimally invasive surgical ablation is an emerging field that aims for the superior results of the traditional Cox-Maze procedure through a less invasive operation with lower morbidity, quicker recovery, and improved patient satisfaction. These novel techniques utilize endoscopic or minithoracotomy approaches with various energy sources to achieve electrical isolation of the pulmonary veins in addition to other ablation lines. We review advancements in minimally invasive techniques for atrial fibrillation surgery, including management of the left atrial appendage

Effect of lipid-lowering medications in patients with coronary artery bypass grafting surgery outcomes

Background: Increased life expectancy and improved medical technology allow increasing numbers of elderly patients to undergo cardiac surgery. Elderly patients may be at greater risk of postoperative morbidity and mortality. Complications can lead to worsened quality of life, shortened life expectancy and higher healthcare costs. Reducing perioperative complications, especially severe adverse events, is key to improving outcomes in patients undergoing cardiac surgery. The objective of this study is to determine whether perioperative lipid-lowering medication use is associated with a reduced risk of complications and mortality after coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). Methods: After IRB approval, we reviewed charts of 9,518 patients who underwent cardiac surgery with CPB at three medical centers between July 2001 and June 2015. The relationship between perioperative lipid-lowering treatment and postoperative outcome was investigated. 3,988 patients who underwent CABG met inclusion criteria and were analyzed. Patients were divided into lipid-lowering or non-lipid-lowering treatment groups. Results: A total of 3,988 patients were included in the final analysis. Compared to the patients without lipid-lowering medications, the patients with lipid-lowering medications had lower postoperative neurologic complications and overall mortality (P \u3c 0.05). Propensity weighted risk-adjustment showed that lipid-lowering medication reduced in-hospital total complications (odds ratio (OR) = 0.856; 95% CI 0.781-0.938; P \u3c 0.001); all neurologic complications (OR = 0.572; 95% CI 0.441-0.739; P \u3c 0.001) including stroke (OR = 0.481; 95% CI 0.349-0.654; P \u3c 0.001); in-hospital mortality (OR = 0.616; 95% CI 0.432-0.869; P = 0.006; P \u3c 0.001); and overall mortality (OR = 0.723; 95% CI 0.634-0.824; P \u3c 0.001). In addition, the results indicated postoperative lipid-lowering medication use was associated with improved long-term survival in this patient population. Conclusions: Perioperative lipid-lowering medication use was associated with significantly reduced postoperative adverse events and improved overall outcome in elderly patients undergoing CABG surgery with CPB

Emergent Percutaneous Rotational Atherectomy to Bailout Surgical Transapical Aortic Valve Implantation: A Successful Case of Heart Team Turnaround.

Transcatheter aortic valve implantation (TAVI) is an established treatment for severe aortic stenosis (AS) in patients with elevated surgical risk. Concomitant coronary artery disease affects 55-70% of patients with severe AS. Percutaneous coronary intervention in patients with TAVI can be challenging. We report a case of acute coronary obstruction immediately following transapical TAVI deployment requiring emergent rotational atherectomy

A chance-constrained programming approach to preoperative planning of robotic cardiac surgery under task-level uncertainty

In this paper, a novel formulation for robust surgical planning of robotics-assisted minimally invasive cardiac surgery based on patient-specific preoperative images is proposed. In this context, robustness is quantified in terms of the likelihood of intraoperative collisions and of joint limit violations. The proposed approach provides a more accurate and complete formulation than existing deterministic approaches in addressing uncertainty at the task level. Moreover, it is demonstrated that the dexterity of robotic arms can be quantified as a cross-entropy term. The resulting planning problem is rendered as a chance-constrained entropy maximization problem seeking a plan with the least susceptibility toward uncertainty at the task level, while maximizing the dexterity (cross-entropy term). By such treatment of uncertainty at the task level, spatial uncertainty pertaining to mismatches between the patient-specific anatomical model and that of the actual intraoperative situation is also indirectly addressed. As a solution method, the unscented transform is adopted to efficiently transform the resulting chance-constrained entropy maximization problem into a constrained nonlinear program without resorting to computationally expensive particle-based methods

Comparison of outcomes of root replacement procedures and supracoronary techniques for surgical repair of acute aortic dissection.

BACKGROUND: Surgical approach to type A acute aortic dissection (AADA) is usually dictated by the presenting anatomy. We compared long-term outcomes of AADA repaired with a root replacement versus a supracoronary tube graft, regardless of the proximal extent of the intimal tear. METHODS: A single-centre, retrospective cohort of consecutive patients undergoing repair of AADA between December 1999 and March 2012 were stratified based on the proximal surgical procedure performed: supracoronary tube graft or root replacement. Imaging, chart reviews and clinical follow-ups were analyzed to identify the presenting anatomy and clinical outcomes. RESULTS: We included the cases of 75 patients in our analysis: 54 received a supracoronary tube graft and 21 received a root replacement. The proximal tear was identified below the sinotubular junction in all patients in the root group and in 61% of patients in the supracoronary group. We detected no differences between the groups for in-hospital mortality, length of stay, or complications. However, the root group had significantly increased renal failure (0% v. 9.5%, p = 0.018), cardiopulmonary bypass time (198.4 ± 80.0 min v. 316.5 ± 102.5 min, p < 0.001), cross-clamp time (91.6 ± 34.9 min v. 191.3 ± 52.8 min, p < 0.001), duration of surgery (457.5 ± 129.9 min v. 611.6 ± 197.8 min, p < 0.001), and platelet transfusions (8.1 ± 7.6 v. 12.8 ± 8.7 units, p = 0.021) than the supracoronary group. Long-term follow-up demonstrated a greater incidence of 2+ aortic regurgitation among patients in the supracoronary group than the root group (29.7% v. 0.0%, p = 0.006); however, there was no difference between the groups in symptoms or reoperation. CONCLUSION: In AADA, aortic root replacement involves a longer procedure with increased risk of early renal impairment. Long-term follow-up identified significantly more aortic regurgitation and root dilation in the supracoronary group than the root group, with a trend toward worse long-term survival. However, we found no difference between the groups in mortality, reoperation or New York Heart Association class

Clinical and economic outcomes after sternotomy for cardiac surgery with skin closure through 2-octyl cyanoacrylate plus polymer mesh tape versus absorbable sutures plus waterproof wound dressings: a retrospective cohort study.

BACKGROUND: To compare clinical and economic outcomes after sternotomy for cardiac surgery with skin closure through 2-octyl cyanoacrylate plus polymer mesh tape (2OPMT) versus conventional absorbable sutures plus waterproof wound dressings (CSWWD). METHODS: Retrospective study using the Premier Healthcare Database. Patients undergoing a cardiac surgery requiring sternotomy with 2OPMT or CSWWD were included. Primary outcome was 60-day cumulative incidence of diagnosis for wound complications (infection, dehiscence). Secondary outcomes were index admission hospital length of stay (LOS), total hospital-borne costs, discharge status, and 60-day cumulative incidences of inpatient readmission and reoperation. After propensity score matching, outcomes were compared between the 2OPMT and CSWWD groups using bivariate multilevel mixed-effects generalized linear models. RESULTS: Overall, 7,901 2OPMT patients and 10,775 CSWWD patients were eligible for study. After propensity score matching on 68 variables, each group comprised 5,338 patients (total study N = 10,676). The 2OPMT and CSWWD groups did not differ significantly in terms of the 60-day cumulative incidences of wound complication (3.47% vs 3.47%, p = 0.996), inpatient readmission (12.6% vs. 13.6%, p = 0.354), and reoperation (10.3% vs 10.1%, p = 0.808), as well as discharge to home versus non-home setting (77.2% vs. 75.1%), p = 0.254. However, the 2OPMT group had significantly lower LOS (9.2 days vs 10.6 days, p < 0.001) and total hospital-borne costs (50,174 vs 60,526, p < 0.001). CONCLUSIONS: This large observational study provides evidence that sternotomy skin closure with 2OPMT is associated with nearly identical 60-day cumulative incidence of wound complication as compared with CSWWD, while exhibiting a significant association with lower LOS and total hospital-borne costs. Trial registration Not applicable