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Situs inversus totalis (SIT) with dextrocardia is a rare congenital anomaly that poses a surgical challenge. This case report presents the first known case of a totally 3D endoscopic mitral valve replacement (MVR), which was performed in a 75-year-old woman with SIT and severe functional mitral regurgitation. Despite the anatomical complexity, the procedure was successfully completed using a simplified three-port system and a 3D endoscope by requiring careful preoperative planning and intraoperative adaptation to the mirrored anatomy of SIT. This case report demonstrates the feasibility and potential benefits of totally endoscopic MVR in patients withSIT.

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We describe an upper mini-sternotomy for valve-sparing aortic root replacement in a teenager.

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OBJECTIVE: Myocardial bridging (MB) occurs when a coronary artery, commonly the left anterior descending (LAD), has an intramyocardial course. In symptomatic patients who fail medical therapy, surgical unroofing can provide symptomatic relief by improving coronary blood flow. We present a series of patients undergoing robotic totally endoscopic beating-heart MB unroofing. METHODS: There were 34 patients with an LAD-MB who failed medical therapy and underwent robotic totally endoscopic, off-pump unroofing between January 2017 and October 2023. Patients were evaluated by a multidisciplinary team and underwent provocative coronary angiography to confirm hemodynamic significance. We reviewed perioperative outcomes and contacted patients for midterm follow-up, including completion of a modified Seattle Angina Questionnaire (SAQ). RESULTS: The mean age was 48 ± 8 years, and 56% were female patients. One patient had prior septal myectomy via sternotomy. All patients had significant dobutamine Pd/Pa reduction on preoperative coronary angiography. One patient had atrial fibrillation and underwent concomitant ablation with left atrial appendage ligation. The mean procedure time was 140 ± 69 min. All were completed totally endoscopically off-pump without intraoperative conversions. The mean MB length was 4.5 ± 1.4 cm, and the mean depth was 1.6 ± 0.9 cm. Of the patients, 76% were extubated in the operating room. The mean intensive care unit and hospital length of stay were 0.97 ± 0.58 and 1.73 ± 1.1 days, respectively. There were no mortalities or strokes. There was 1 postoperative take-back for bleeding. At midterm follow-up (19 ± 14 months), 28 patients completed the SAQ; 86% reported "much less angina" during activity compared with before surgery, and 93% reported taking no antianginal medication since surgery. CONCLUSIONS: In appropriate patients with hemodynamically significant LAD-MB who fail medical therapy, robotic beating-heart unroofing is possible with good outcomes. Further studies are warranted.

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Background: Minimally invasive cardiac surgery offers numerous advantages that patients and surgeons desire. This surgical platform encompasses cannulation strategies for cardiopulmonary bypass, optimal surgical access points, and high-quality visualization techniques. Traditional peripheral cannulation methods, though convenient, possess inherent limitations and carry the potential for complications such as retrograde dissection, stroke, or neurologic sequelae. Conversely, central cannulation may be ideally suited to circumvent the disadvantages above. Fully video-assisted thoracoscopy cardiac surgery represents a state-of-the-art platform, offering surgeons an unparalleled surgical view. This analysis aimed to delineate the efficacy and safety of transthoracic central cannulation strategies and the surgical platform during fully video-assisted thoracoscopy cardiac surgery. Methods: Between October 2022 and February 2024, we identified a cohort of 85 consecutive patients with cardiopulmonary bypass undergoing fully video-assisted thoracoscopy cardiac surgery at our institutions. The patients' mean age was 41.09 ± 14.01 years, ranging from 18 to 75 years. The mean weight was 64.34 ± 10.59 kg (ranging from 49 to 103 kg). Congenital heart disease repair accounted for the highest proportion, with 43 cases (50.59%). Mitral valve surgery and left atrium Myxoma resections accounted for 29.41%. Specifically, this included 14 mitral valve repairs, five mitral valve replacements, and six left atrium myxoma resections. Aortic valve replacements constitute 20% of all cases. Results: A total of 85 adult patients underwent fully video-assisted thoracoscopy cardiac surgery. The average CPB time was 83.26 ± 28.26 min, while the aortic cross-clamp time averaged 51.87 ± 23.91 min. The total operation time (skin to skin) averaged 173.8 ± 37.08 min. The mean duration of mechanical ventilation was 5.58 ± 3.43 h, ICU stay was 20.04 ± 2.83 h (ranging from 15.5 to 34 h), and postoperative hospital stay was 5.55 ± 0.87 days. No patients required conversion to thoracotomy and unplanned reoperations due to various reasons. There were no in-hospital deaths, strokes, myocardial infarctions, aortic dissections, or renal failure. No patient developed wound soft tissue infection. Conclusions: Fully video-assisted thoracoscopy cardiac surgery utilizing central cannulation strategies is a reliable, cost-effective platform with a low risk of complications and a potential solution for patients facing contraindications for peripheral cannulation.

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OBJECTIVES: We compared the outcomes of a right mini-thoracotomy (RMT) versus those of a sternotomy for concomitant mitral and tricuspid valve surgery and surgical ablation. METHODS: We analysed patients who underwent concomitant mitral and tricuspid valve surgery and surgical ablation at a single institution (mean follow-up: 7 years) after propensity score matching. The primary and secondary outcomes were all-cause death, composite major adverse events (including stroke, reoperation, readmission, permanent pacemaker insertion) and recurrence of atrial fibrillation (A-fib). A subgroup analysis was performed. RESULTS: A total of 797 procedures (mean age: 61.6 years; RMT: 45.2%; female: 66.5%; mitral valve repair: 33.6%) were done; 267 pairs were matched. The 5- and 10-year overall survival in the matched cohort was 92.7% and 86.9% for the RMT group and 92.1% and 83.1% for the sternotomy group (P = 0.879). Significant differences were not observed in major adverse events (P = 0.273; hazard ratio: 0.76) and A-fib recurrence (P = 0.080; hazard ratio: 0.72). The RMT group had lower rates of postoperative low cardiac output syndrome (P = 0.019) and acute renal failure (P = 0.003). Atrial fibrillation high-risk factors (including long-standing A-fib, enlarged left atrium, old age) exhibited significant interactions (P for interaction = 0.002) with the approach regarding A-fib recurrence. CONCLUSIONS: In this study, an RMT exhibited no significant differences in long-term outcomes compared to a sternotomy, but it could remain a clinically reasonable option. Patients with a high risk of A-fib may have favourable ablation outcomes with a sternotomy.

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Objective: A sternum-sparing approach of minimally invasive total coronary revascularization via left anterior thoracotomy demonstrated promising early outcomes in unselected patients with coronary artery multivessel disease. Follow-up data are still missing. Methods: From November 2019 to September 2023, coronary artery bypass grafting via left anterior minithoracotomy on cardiopulmonary bypass and cardioplegic cardiac arrest was performed as a routine procedure in 392 consecutive, nonemergency patients (345 men; 67.0 ± 9.9 years; range, 32-88 years). All patients had multivessel coronary artery disease (77.6% 3-vessel-disease, 22.4% 2-vessel-disease, and 32.9% left main stenosis). Patients at old age (older than a 80 years, 12.5%), with severe left ventricular dysfunction (ejection fraction <30%, 7.9%), diabetes mellitus (34.9%), massive obesity (body mass index > 35, 8.9%), and chronic lung disease (17.1%) were included. Mean European System for Cardiac Operative Risk Evaluation II score was 2.9 ± 2.8. Mean midterm follow-up (100%) was 15.2 ± 10.7 months (range, 0.1-39.5 months). Results: Left internal thoracic artery (99.0%), radial artery (70.4%), and saphenous vein grafts (57.4%) were used, and 70.4% of patients received at least 2 arterial grafts. A total of 3.0 ± 0.8 anastomoses (range, 2-5 anastomoses) per patient were performed to revascularize the territories of left anterior descending (98.7%), circumflex (91.6%), and right coronary (70.9%) artery. Complete anatomical revascularization was achieved in 95.1%. At follow-up, all-cause-mortality, myocardial infarction, repeat revascularization, and stroke was 3.1%, 1.5%, 5.4%, and 0.7%, respectively. Overall major adverse cardiac and cerebrovascular events rate was 8.7%. Conclusions: This is the first report of midterm follow-up after routine sternum-sparing total coronary revascularization via left anterior thoracotomy for multivessel coronary artery disease with a high rate of multiple arterial grafting and complete anatomical revascularization. Outcome was favorable and similar to that of contemporary conventional coronary artery bypass grafting.

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Introduction: Enhanced Recovery After Surgery (ERAS) prioritizes faster functional recovery after major surgery. An important aspect of postoperative ERAS is decreasing morbidity and immobility, which can result from prolonged critical care. Using current clinical data, our aim was to analyze whether a six-hour monitoring period after Minimally Invasive Cardiac Surgery (MICS) might be sufficient to recognize major postoperative complications in a future Fast Track pathway. Additionally, we sought to investigate whether it could be possible to deescalate the setting of postoperative monitoring. Methods: 358 patients received MICS and were deemed suitable for an ERAS protocol between 01/2021 and 03/2023 at our institution. Of these, 297 patients could be successfully extubated on-table, were transferred to IMC or ICU in stable condition and therefore served as study cohort. Outcomes of interest were incidence and timing of Major Adverse Cardiac Events (MACE; death, myocardial infarction requiring revascularization, stroke), bleeding requiring reexploration and Fast Track-associated complications (reintubation and readmission to ICU). Results: Patients' median age was 63 years (IQR 55-70) and 65% were male. 189 (64%) patients received anterolateral mini-thoracotomy, primarily for mitral and/or tricuspid valve surgery (n = 177). 108 (36%) patients had partial upper sternotomy, primarily for aortic valve repair/replacement (n = 79) and aortic surgery (n = 17). 90% of patients were normotensive without need for vasopressors within 6 h postoperatively, 82% of patients were transferred to the general ward on postoperative day 1 (POD). Two (0.7%) MACE events occurred, as well as 4 (1.3%) postoperative bleeding events requiring reexploration. Of these complications, only one event occurred before transfer to the ward - all others took place on or after POD 1. There was one instance of reintubation and two of readmission to ICU. Conclusions: If MICS patients can be successfully extubated on-table and are hemodynamically stable, major postoperative complications were rare in our single-center experience and primarily occurred after transfer to the ward. Therefore, in well selected MICS patients with uncomplicated intraoperative course, monitoring for six hours, possibly outside of an ICU, followed by transfer to the ward appears to be a feasible theoretical concept without negative impact on patient safety.

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Transmitral myectomy for hypertrophic obstructive cardiomyopathy is compatible with minimally invasive surgery compared with traditional transaortic access. It has often been performed in conjunction with mitral valve replacement or temporary detachment of the anterior leaflet from its annulus. We present a novel approach: longitudinal incision at the midline of the anterior mitral leaflet for septal myectomy. The procedure is ideally conducted endoscopically or robotically through the right chest. Cardiopulmonary bypass is established in the usual manner. After cardioplegic arrest, the mitral valve is exposed, and the anterior mitral leaflet is incised longitudinally at the midline. Both parts of the leaflet are tentatively fixed to the atrial wall with sutures to keep them open. Using the look-up mode of a 30° scope, the right cusp of the aortic valve is observed. Myectomy is initiated close to the aortic annulus using the pure-cut mode of electrocautery and scissors, then extended apically as necessary. After myectomy, the anterior leaflet is reapproximated with interrupted sutures. This technique is simpler than the detachment of the anterior leaflet and does not require patch materials that could lead to durability issues for the reconstruction of the anterior leaflet.

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OBJECTIVE: To evaluate the outcomes of minimally invasive cardiac surgery (MICS) compared with the sternotomy approach for Jehovah's Witness (JW) patients who cannot receive blood transfusions DESIGN: This was a retrospective observational study. SETTING: The study was conducted at a specialized cardiovascular intervention and surgery institute. PARTICIPANTS: The study cohort comprised JW patients undergoing cardiac surgery between September 2016 and July 2022. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: Patients (n = 63) were divided into MICS (n = 19) and sternotomy (n = 44) groups, and clinical outcomes were analyzed. There was no difference in types of operation except coronary bypass grafting (n = 1 [5.3%] in the MICS group v n = 20 [45.5%] in the sternotomy group; p = 0.005). There were no between-group differences in early mortality and morbidities. Overall survival did not differ significantly during the follow-up period (mean, 43.9 ± 24.4 months). The amount of chest tube drainage was significantly lower in the MICS group on the first postoperative day (mean, 224.0 ± 122.7 mL v 334.0 ± 187.0 mL in the sternotomy group; p = 0.022). The mean hemoglobin level was significantly higher in the MICS group on the day of operation (11.7 ± 1.3 mg/dL v 10.6 ± 2.0 mg/dL in the sternotomy group; p = 0.042) and the first postoperative day (12.3 ± 1.8 mg/dL v 11.2 ± 1.9 mg/dL; p = 0.032). CONCLUSIONS: MICS for JW patients showed favorable early outcomes and mid-term survival compared to conventional sternotomy. MICS may be a viable option for JW patients who decline blood transfusions.

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Background: Even though the optimal management of a moderate or large residual shunt following patent foramen ovale (PFO) closure is open to question, recent data confirmed that it is associated with an increased risk of stroke recurrence. Case summary: A 48-year-old woman, a migraineur with visual aura, was diagnosed with a PFO associated with a huge multifenestrated atrial septal aneurysm (mfASA) and a moderate right-to-left shunt, detectable only after a Valsalva maneuver on contrast-transthoracic echocardiography. Brain magnetic resonance imaging showed a 1-mm silent white matter lesion in the right frontal lobe. Although the indication was not supported by guidelines, a transcatheter PFO closure was performed at another center with implantation of a large, equally sized, double-disc device (Figulla UNI 33/33 mm). At 6-month follow-up, a 2D/3D transesophageal echocardiography (TEE) color Doppler showed incorrect orientation of the device, which was not parallel to the interatrial septum, with two discs failing to capture the aortic muscular rim and partially protruding in the right atrium; furthermore, a 4 mm × 7 mm ASA fenestration was documented with a residual bidirectional shunt. Thereafter, the same team performed a minimally invasive cardiac surgery under femoro-femoral cardiopulmonary bypass; however, the procedure proved ineffective and was complicated by postoperative pericarditis with pericardial effusion, requiring further rehospitalization 1 month later due to persistent pericarditis, bilateral pleuritis, phrenic nerve palsy, and atrial flutter, which was treated with amiodarone. The patient asked for a second opinion, and our multidisciplinary heart team decided to offer a percutaneous redo intervention. An uneventful implantation of a regular PFO occluder (Figulla Flex II 16/18 mm) across the septal defect was performed successfully. Twelve-month follow-up with 2D TTE color Doppler and contrast transcranial Doppler showed correct position and good interaction between the two devices, with no residual shunt. Discussion: In addition to the incorrect indication for PFO closure and the failure of minimally invasive surgery, the procedural mishap in this case could have been due to the inappropriate implantation of the first large device within the tunnel. It would have been better to deploy the same large device in the most central fenestration, covering the PFO and a greater part of the remaining mfASA at the same time.

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Objectives: Enhanced recovery after surgery (ERAS) is a growing phenomenon in all surgical disciplines and aims to achieve a faster functional recovery after major operations. Minimally invasive cardiac surgery (MICS) therefore integrates well into core ERAS values. Surgical access routes in MICS include right anterolateral mini-thoracotomy (MT) as well as partial upper mini-sternotomy (PS). We seek to compare outcomes in these two cohorts, both of which were enrolled in an ERAS scheme. Methods: 358 consecutive patients underwent MICS and perioperative ERAS at our institution between 01/2021 and 03/2023. Patients age >80 years, with BMI > 35 kg/m², LVEF ≤ 35%, endocarditis or stroke with residuum were excluded. Retrospective cohort analysis and statistical testing was performed on the remaining 291 patients. The primary endpoint was successful ERAS, secondary endpoints were the occurrence of major bleeding, ERAS-associated complications (reintubation, return to ICU) as well as access-related complications (wound infection, pleural and pericardial effusions). Results: 170 (59%) patients received MT for mitral and/or tricuspid valve surgery (n = 162), closure of atrial septal defect (n = 4) or resection of left atrial tumor (n = 4). The remaining 121 (41%) patients had PS for aortic valve repair/replacement (n = 83) or aortic root/ascending surgery (n = 22) or both (n = 16). MT patients' median age was 63 years (IQR 56-71) and 65% were male, PS patients' median age was 63 years (IQR 51-69) and 74% were male. 251 (MT 88%, PS 83%, p = 0.73) patients passed through the ERAS program successfully. There were three instances of reintubation (2 MT, 1 PS), and three instances of readmission to ICU (2 MT, 1 PS). Bleeding requiring reexploration occurred six times (3 MT, 3 PS). There was one death (PS), one stroke (MT), and one myocardial infarction requiring revascularization (MT). There were no significant differences in any of the post-operative outcomes recorded, except for the incidence of pericardial effusions (MT 0%, PS 3%, p = 0.03). Conclusions: Despite different surgical access routes and underlying pathologies, results in both the MT and the PS cohort were generally comparable for the recorded outcomes. ERAS remains safe and feasible in these patient groups.

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Background: The internal mammary artery (IMA) is the most commonly used graft in coronary artery bypass grafting (CABG) because of its superior long-term patency rate. However, its small diameter poses challenges in handling, and any vascular damage that may occur during harvesting can significantly affect surgical outcomes. The primary focus during IMA harvesting is to ensure safe and effective hemostasis without direct vascular injury, while ensuring secure and reliable ligation of the vascular branches. Various methods using multiple surgical instruments have been used for this purpose. Unlike traditional instruments, the shear-tip Harmonic scalpel offers more precise vessel branching control, while minimizing damage to surrounding tissues. In this study, we assessed the utility of the shear-tip Harmonic scalpel in patients undergoing minimally invasive coronary artery bypass grafting (MICABG). Methods: From April 2019 to May 2023, a total of 40 patients underwent MICABG. The IMA was harvested using the shear-tip Harmonic scalpel with a clipless skeletonized technique. In this cohort, 5 patients underwent complete endoscopic harvesting, while 34 patients underwent direct visualization harvesting through minimal thoracotomy. Graft patency was assessed by measuring a Doppler flowmeter in the bypass conduit. Results: Successful graft patency was achieved in all patients. The mean duration of IMA harvesting was 87 min. In total, 38 of the 40 patients underwent MICABG without the need for cardiopulmonary bypass, ensuring a stable procedure. There were no graft-related events or complications observed in any of the patients, and all were discharged without any issues. During a median follow-up period of 15.2 months, only one patient experienced graft occlusion necessitating intervention. Conclusions: The utilization of shear-tip Harmonic scalpel for IMA harvesting in MICABG is feasible and yields stable early results.

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The development and adoption of minimally invasive techniques has revolutionized various surgical disciplines and has also been introduced into cardiac surgery, offering patients less invasive options with reduced trauma and faster recovery time compared to traditional open-heart procedures with sternotomy. This article provides a comprehensive overview of the anesthesiologic management for minimally invasive cardiac surgery (MICS), focusing on preoperative assessment, intraoperative anesthesia techniques, and postoperative care protocols. Anesthesia induction and airway management strategies are tailored to each patient's needs, with meticulous attention to maintaining hemodynamic stability and ensuring adequate ventilation. Intraoperative monitoring, including transesophageal echocardiography (TEE), processed EEG monitoring, and near-infrared spectroscopy (NIRS), facilitates real-time assessment of cardiac and cerebral perfusion, as well as function, optimizing patient safety and improving outcomes. The peripheral cannulation techniques for cardiopulmonary bypass (CPB) initiation are described, highlighting the importance of cannula placement to minimize tissue as well as vessel trauma and optimize perfusion. This article also discusses specific MICS procedures, detailing anesthetic considerations and surgical techniques. The perioperative care of patients undergoing MICS requires a multidisciplinary approach including surgeons, perfusionists, and anesthesiologists adhering to standardized treatment protocols and pathways. By leveraging advanced monitoring techniques and tailored anesthetic protocols, clinicians can optimize patient outcomes and promote early extubation and enhanced recovery.

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Background: EuroSCORE II (ES2) is a reliable tool for preoperative cardiac surgery mortality risk prediction; however, a patient's age, a surgical procedure's weight and the new devices available may cause its accuracy to drift. We sought to investigate ES2 performance related to the surgical risk and late mortality estimation in patients who underwent aortic valve replacement (AVR) with sutureless valves. Methods: Between 2012 and 2021, a total of 1126 patients with isolated aortic stenosis who underwent surgical AVR by means of sutureless valves were retrospectively collected from six European centers. Patients were stratified into three groups according to the EuroSCORE II risk classes (ES2 < 4%, ES2 4-8% and ES2 > 8%). The accuracy of ES2 in estimating mortality risk was assessed using the standardized mortality ratio (O/E ratio), ROC curves (AUC) and Hosmer-Lemeshow (HL) test for goodness-of-fit. Results: The overall observed mortality was 3.0% (predicted mortality ES2: 5.39%) with an observed/expected (O/E) ratio of 0.64 (confidential interval (CI): 0.49-0.89). In our population, ES2 showed a moderate discriminating power (AUC 0.65, 95%CI 0.56-0.72, p < 0.001; HL p = 0.798). Good accuracy was found in patients with ES2 < 4% (O/E ratio 0.54, 95%CI 0.23-1.20, AUC 0.75, p < 0.001, HL p = 0.999) and for patients with an age < 75 years (O/E ratio 0.98, 95%CI 0.45-1.96, AUC 0.76, p = 0.004, HL p = 0.762). Moderate discrimination was observed for ES2 in the estimation of long-term risk of mortality (AUC 0.64, 95%CI: 0.60-0.68, p < 0.001). Conclusions: EuroSCORE II showed good accuracy in patients with an age < 75 years and patients with ES2 < 4%, while overestimating risk in the other subgroups. A recalibration of the model should be taken into account based on the complexity of actual patients and impact of new technologies.

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Totally video-guided thorascopic cardiac surgery (TVTCS) represents one of the most minimally invasive access routes to the heart. Its feasibility and safety can be guaranteed by an experienced surgeon with skilled operative techniques under the guidance of a video signal via thoracoscopy and the imaging from transesophageal echocardiography. At present, this surgical approach has been applied for atrioventricular valve disease, atrial septum defects plus and partial anomalous pulmonary venous drainage, cardiac tumors, hypertrophic obstructive cardiomyopathy, aortic valve disease, and atrial fibrillation. Multimodality cardiovascular imaging, including echocardiography, X-ray, computed tomography (CT), magnetic resonance imaging (MRI) and cardiac catheterization, provides morphologic characteristics and function status of the cardiovascular system and a comprehensive view of the target anatomy. In this review, the benefits of multimodality cardiovascular imaging are summarized for the clinical practice of TVTCS, including the preoperative preparation, intraoperative guidance and postoperative supervision. The disease categories are also individually reviewed on the basis of multimodality cardiovascular imaging, to ensure the feasibility and safety for TVTCS. Cardiovascular imaging technologies not only confirm who is a candidate for this surgical technique, but also provide technical support during the procedure and for postop follow to assess the clinical outcomes. Multimodality cardiovascular imaging is instrumental to provide the requirements to solve the problems for conduction of TVTCS; and to provide individualized protocols with high-resolution and real-time dynamic imaging fusion.

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PURPOSE: Although minimally invasive cardiac surgery (MICS) procedures are widely performed throughout Japan, nationwide data regarding treated cases are limited. Up-to-date results for cardiovascular surgery are vital for quality control in clinical practice. Presented here is the 2021 annual report based on data from the Japan Cardiovascular Surgery Database (JCVSD). METHODS: Records noted in the JCVSD of patients who underwent mitral valve surgery, aortic valve replacement (AVR), coronary artery bypass grafting (CABG), atrial septum defect (ASD) closure, or cardiac tumor resection via right or left minithoracotomy, as well as thoracoscopic- or port-assisted, or robotic-assisted approaches, in 2021 were examined. Perioperative parameters including mortality and morbidity was evaluated. RESULTS: The 30-day and in-hospital mortalities for isolated mitral valve repair (n = 1211) were 0.1% and 0.2%, respectively, while those for all mitral valve repair (n = 2017) were 0.05% and 0.2%, respectively. More than 100 facilities were found to perform fewer than five MICS mitral valve surgery cases per year. As for MICS-AVR, 30-day and in-hospital mortalities for isolated AVR (n = 818) were 0.5% and 0.5%, respectively, while those for all AVR (n = 987) were 0.6% and 1.1%, respectively. Additionally, those for MICS-CABG (n = 400) were 0.8% and 0.5%, respectively. Those for ASD (n = 183) and cardiac tumor (n = 96), were 0.5% and 0.5%, respectively, and 0% and 1.0%, respectively. CONCLUSION: This is the first report of MICS results of procedures performed in Japan based on the 2021 JCVSD data. Additional results obtained with a similar data collection method are expected and details on MICS are being collected starting 2024.

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OBJECTIVE: Robot-assisted minimally invasive direct coronary artery bypass (RA-MIDCAB) is an attractive strategy for coronary revascularization. Growing evidence supports the use of total arterial grafting in coronary surgery. We evaluated total arterial left-sided coronary revascularization with bilateral internal thoracic artery (BITA) using RA-MIDCAB and compared it with a propensity score-matched (PSM) off-pump CAB (OPCAB) surgery population. METHODS: We retrospectively included all isolated OPCAB and RA-MIDCAB surgery using BITA without saphenous vein graft from January 1, 2015, to October 31, 2022. We analyzed all our RA-MIDCAB patients and performed PSM to compare them with our OPCAB population. Primary outcomes were major adverse cardiovascular and cerebrovascular events (MACCE) and mortality. Secondary outcomes were surgical parameters, length of hospital stay, and learning curve. RESULTS: We included 601 OPCAB and 77 RA-MIDCAB procedures, which resulted in 2 cohorts of 54 patients after PSM. Mortality and MACCE survival analysis showed no significant difference. There was less blood transfusion in the RA-MIDCAB (16.7%) compared with the OPCAB group (38.9%; P = 0.02). We observed fewer intensive care unit (ICU) admissions (24.1% vs 96.6%), shorter ICU stay (0.78 ± 1.7 vs 1.91 ± 1.01 days), and shorter hospital stay (6.78 ± 2.4 vs 8.01 ± 2.5 days) in the RA-MIDCAB versus OPCAB group (P < 0.01). Surgery time decreased from 400.0 ± 70.8 to 325.0 ± 38.0 min with more experience in RA-MIDCAB BITA harvesting (P < 0.01). CONCLUSIONS: This is a first publication of 77 consecutive RA-MIDCAB BITA harvesting for left coronary artery system revascularization. This technique is safe in terms of MACCE and mortality. Additional advantages are shorter length of hospital stay, fewer ICU admissions, and less blood transfusion.

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BACKGROUND: Historically, the majority of patients admitted to inpatient exercise-based cardiac rehabilitation (EBCR) have undergone open heart surgery (OHS). However, with advances in minimally invasive cardiac surgery (MICS), these patient groups are also increasingly referred for inpatient EBCR. Herein, we aimed to compare the progress of these groups during rehabilitation. METHODS: In this prospective, nonrandomized study, 403 inpatient EBCR patients were recruited from December 2022 until September 2023 and stratified into two groups: OHS, and MICS. Participants completed a 3-4-week certified EBCR program. The primary endpoint was defined as a change in the 6-minute walk test (6MWT). Moreover, a comprehensive panel of quality-of-life (QoL) assessments were performed at admission and discharge. RESULTS: At baseline, patients with OHS were older (66 years [IQR 59 - 72]), more often male (83%), and underwent emergency/urgent procedures more often (20%) than patients with MICS. Furthermore, patients with MICS showed a better 6MWT at admission (426 meters [IQR 336 - 483]) compared to patients with OHS (381 meters [IQR 299 - 453]). While all patients were able to increase the distance in the 6MWT, regression analyses in fully adjusted models showed no difference in improvements between the two groups (ß -5, 95% CI, -26 - 14, p = 0.58). Moreover, during EBCR, we observed significant improvements in all QoL measures in all groups. CONCLUSIONS: In this study, improvements in fitness, as assessed by the 6WMT were observed in all groups. Furthermore, multiple QoL measures improved equally across all groups. These encouraging results emphasize the importance of EBCR.

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Minimally invasive cardiac surgery off-pump coronary artery bypass (MICSOPCAB) has become increasingly prevalent, with devices like the heart positioner aiding in surgical precision. However, rare complications such as epicardial hematoma can occur. Here, we present a case of a 75-year-old man undergoing MICSOPCAB who developed an epicardial hematoma due to the heart positioner. The hematoma was successfully repaired intraoperatively with direct suturing and large felts. Postoperative recovery was uneventful, highlighting the importance of vigilant monitoring and prompt management of such complications. This case underscores the need for careful attention during the use of cardiac positioners to minimize adverse events and ensure favorable patient outcomes.