OBJECTIVE:Data on chest tube output following robotic totally endoscopic coronary artery bypass grafting (TECAB) are limited. We aimed to quantify chest tube drainage following robotic TECAB and identify factors associated with increased output. METHODS:A total of 125 consecutive patients undergoing robotic TECAB from September 2021 to July 2025 were retrospectively analyzed. Chest tube output was recorded over 96 h postoperatively. Univariable and multivariable linear regression analyses were performed to identify predictors of increased drainage. RESULTS:Median chest tube output over 4 days was 945 mL (interquartile range: 703 to 1,400 mL). Median chest tube duration was 3 (2 to 4) days. Drainage volumes were lower than those reported for open coronary artery bypass grafting (CABG) and comparable with mixed robotic cardiac surgery cohorts. Increased chest tube output correlated positively with the number of transfused red blood cell units (rs = 0.336, P < 0.001) and the number of postoperative chest radiographs (rs = 0.378, P < 0.001). On multivariable regression analysis, age (B = 14.2 mL/year, P = 0.049), male sex (B = 353 mL, P = 0.037), and longer procedure time (B = 1.6 mL/min, P = 0.019) were independent factors associated with increased output. CONCLUSIONS:Chest tube output after robotic TECAB appears comparable with values reported in mixed robotic cardiac surgery and lower than those reported for open CABG. Operative strategy including single versus multivessel TECAB, arrested versus beating heart, and hybrid coronary revascularization did not significantly influence output. Chest tube output after robotic TECAB was driven by age, gender, and procedure time, and higher output was associated with higher resource use.
OBJECTIVE:To introduce a new method to enhance the visualization of renal arteries and the accuracy of graft deployment during CO2-assisted endovascular (EV) aneurysm repair (EVAR). METHODS:A retrospective observational study of consecutive EVAR cases assisted with CO2 angiography (CO2Angio) was conducted. This nonrandomized design reflects real-life progressive attempts to enhance the reliability of CO2 and intravascular ultrasound (IVUS), minimizing the use of iodinated contrast (IC) and radiation, respectively. Cases were divided into 3 groups according to consecutive periods: CO2Angio (n = 7), CO2Angio and balloon occlusion of the infrarenal aorta (CO2Angio + EVclamp, n = 11), and CO2Angio + EVclamp + IVUS (n = 18). IC was permitted in case of insufficient visualization with CO2Angio during any phase of the procedure. Demographic, clinical, and procedure variables (volume of IC and CO2, radiation, fluoroscopy time, leaks) were collected from electronic clinic histories and statistically analyzed. RESULTS:A significant decrease was found in the third group, after introducing both techniques, for total radiation (air kerma; 3,039 ± 2,792.3 vs 3,434.7 ± 1,289.2 vs 2,284.6 ± 841.5 mGy, P = 0.041), radiation per area, dose area product (47 ± 34.7 vs 54.5 ± 15.3 vs 41.3 ± 12.8 mGy×m2, P = 0.03), and IC volume (104.3 ± 102.4 vs 89.2 ± 53.9 vs 15.4 ± 27.4 mL, P < 0.001), arriving at the goal of "zero contrast" in the last 12 patients. No significant differences were detected in fluoroscopy time, total operative time, total CO2 volume, or change in renal function. CONCLUSIONS:The introduction of endoluminal occlusion with a balloon and the use of IVUS in CO2-assisted EVAR enabled us to achieve the objective of zero contrast and a progressive decrease in radiation dose.
OBJECTIVE:To demonstrate a supra-annular implantation of a composite valve-graft (CVG) constructed from a sutureless aortic valve within a Dacron graft for aortic root replacement. The anatomic rationale, preclinical validation, and clinical outcomes of this novel technique are described. METHODS:The anatomic rational for sizing of the valve and graft was examined by ex vivo implantation of a Perceval Plus XL valve (Corcym, Milan, Italy) within a 28 mm Valsalva Dacron graft (Terumo Aortic, Inchinnan, UK). Hydrodynamic in vitro testing with a ViVitro pulse duplicator system (ViVitro, Victoria, BC, Canada) validated the integrity of the CVG. The CVG was implanted supra-annular to the native aortic annulus in a clinical setting. RESULTS:A Perceval XL valve within a 28 mm Valsalva Dacron graft provided 8% oversize of the valve inflow ring within the graft collar. In vitro testing showed valve stability within the Dacron graft under physiologic conditions. The first SUpra-annular PERceval Bentall (SUPERB) was performed in a 75-year-old male patient with concomitant aortic stenosis and aortic root aneurysm. The CVG was constructed by (1) suturing the graft to the aortic annulus, (2) construction of coronary buttons, and (3) deployment of the sutureless valve with the Dacron graft in a supra-annular position. CONCLUSIONS:SUPERB uses a Perceval XL valve within a 28 mm Valsalva Dacron graft for aortic root replacement. Positioning of the sutureless valve within the Dacron graft and supra-annular to the native aortic annulus decouples valve sizing from the restrictions of native aortic annular dimensions. This approach simplifies CVG sizing and potentially mitigates patient-prosthetic mismatch.
OBJECTIVE:Minimally invasive cardiac surgery (MICS) offers faster recovery and improved patient satisfaction compared with sternotomy, but limited exposure makes myocardial protection challenging. Use of del Nido cardioplegia (DNC), originally developed for pediatrics, is increasing in adults due to its single-dose administration and prolonged arrest. METHODS:Following PRISMA guidelines, PubMed was searched for studies published between September 1, 2015, and September 30, 2025, evaluating DNC in MICS or sternotomy-sparing cardiac surgery. Seven studies met inclusion criteria, including retrospective propensity-matched cohorts, 1 prospective randomized single-center trial, and 1 network meta-analysis. RESULTS:DNC was consistently linked to lower cardioplegia volume, fewer repeat doses, and shorter cross-clamp and bypass times compared with blood or histidine-tryptophan-ketoglutarate (HTK) solutions. Some studies reported reduced postoperative enzyme release, particularly with ischemic times <100 min. Safety outcomes, including mortality, complications, and recovery, were comparable across groups. Meta-analytic evidence suggested procedural efficiency advantages, while Custodiol ranked highest overall. CONCLUSIONS:DNC appears to be a safe alternative in MICS, offering workflow-related procedural efficiency while maintaining comparable myocardial protection. However, current evidence is mostly retrospective and single center. Large, multicenter, randomized trials are needed to establish its role versus HTK and Custodiol in sternotomy-sparing procedures.
OBJECTIVE:Telesurgery has the potential to overcome geographical barriers in surgical care, yet data transmission latency remains a major challenge, impairing operator performance. Although haptic feedback may mitigate latency effects, optimal parameters, such as applied force, have not been well defined in the context of robotic surgical procedures. This study aimed to investigate how varying visual feedback latency and applied force levels affect task performance in an endovascular simulation and assess whether lower applied forces can mitigate performance degradation under latency. METHODS:In this prospective, experimental, cross-sectional study, healthy volunteers aged 18 to 65 years performed guidewire advancement tasks using a custom-built endovascular simulator under 12 different combinations of latency (0, 100, 200, 400 ms) and applied force (0.6, 1.2, 1.8 N). The primary outcome was the duration (ms) during which participants maintained the target force during a 10-second period. RESULTS:A total of 116 participants participated in the study. The median performance time was 5,890 ms (interquartile range, 4,550 to 7,150 ms). Increased latency significantly reduced performance, with the most pronounced drop (-1,380 ms) between 100 ms and 200 ms (P < 0.05). Lower applied force (0.6 N) was associated with significantly better performance compared with higher force (1.8 N), independent of latency (-1,097.5 ms, P < 0.05). Younger participants (18 to 25 years) outperformed older participants (55 to 65 years) across all conditions (P < 0.05). CONCLUSIONS:This study confirms the detrimental effect of visual feedback latency on performance in simulated robotic surgical procedures and demonstrates that reduced applied force can partially compensate for increased latency. Therefore, optimizing force parameters may improve performance and safety in telesurgical systems, particularly for older operators.
