Heart Teams are increasingly confronted with decision‐making in anatomically and clinically complex surgical candidates. Herein, we discuss the versatility of the endoaortic occlusion device (Intraclude; Edwards Lifesciences Inc) for the management of a various array of complex primary and reoperative cardiac cases. Three clinical scenarios are illustrated (ascending aortic pseudoaneurysm, mitral valve surgery after previous CABG, extensive thoracic aortic surgery with continuous visceral perfusion), suggesting the effectiveness of the patient‐specific strategy to minimize operative morbidity. Evolution of surgical techniques needs to be considered in decision‐making among alternative treatment strategies.
Purpose Left atrial appendage (LAA) closure is an interventional procedure increasingly used to prevent stroke in patients with permanent atrial fibrillation and contraindications to anticoagulation therapy. As this procedure requires a relatively immobile patient and performance of continuous and prolonged transesophageal echocardiography (TEE), it is usually performed under general anesthesia. In this case series, we describe the feasibility of prolonged TEE for percutaneous LAA closure using a new noninvasive ventilation device that can avoid the need for endotracheal intubation and general anesthesia. Clinical features Percutaneous LAA closure was performed under deep sedation in three elderly patients with permanent atrial fibrillation. Sedation was obtained with a combination of midazolam, propofol, and remifentanil. Continuous intraoperative TEE was performed through the port of the newly available Janus mask (Biomedical Srl; Florence, Italy), allowing for noninvasive ventilation (pressure support = 12-16 cm H 2 O; positive end-expiratory pressure = 7 cm H 2 O; FIO 2 = 0.3) in these spontaneously breathing patients. The total procedure times ranged from 75-90 min. The patients reported excellent satisfaction with the sedation received in terms of discomfort experienced during the procedure, capacity to recall the procedure, and comfort with the mask. The operators also rated the procedural conditions as excellent.
ConclusionDeep sedation with noninvasive ventilation may be a reasonable and safe alternative to general endotracheal anesthesia in patients requiring prolonged TEE for noninvasive cardiac procedures, including LAA closure.
RésuméObjectif La fermeture de l'appendice auriculaire gauche (AAG) est une procédure interventionnelle de plus en plus utilisée pour prévenir les accidents vasculaires cérébraux chez les patients souffrant de fibrillation auriculaire chronique ou présentant des contre-indications à l'anticoagulothérapie. Comme cette intervention requiert que le patient soit relativement immobile et une échocardiographie transoesophagienne (ETO) continue et prolongée, elle est habituellement réalisée sous anesthésie générale. Dans cette série de cas, nous décrivons la faisabilité d'une ETO prolongée pour la fermeture Electronic supplementary material The online version of this article
Aims To evaluate the safety/effectiveness of a recently established robotic-assisted mitral surgery program.Methods Cohort study with prospective collection of clinical data of 59 consecutive recipients (May 2019-August 2021) of robotic-assisted (fourth-generation platform, DaVinci X) mitral valve repair for degenerative disease, using a totally endoscopic technique. Patients' selection was based on defined anatomical and clinical criteria. We established a dedicated multidisciplinary protocol to facilitate postoperative fast-tracking, and a systematic in-house clinical and echocardiographic follow-up at 3, 6, and 12 postoperative months.Results All patients (89.8% men, average age 58 W 12 years) received mitral valve repair; there was no operative mortality, one conversion to sternotomy (1.7%) and one stroke (1.7%). Extubation within the operative theater occurred in 28.8%; average mechanical ventilation time and ICU stay was 2.8 W 4.1 and 32.5 W 15.8 h (after exclusion of one outlier, learning-curve period, suffering from perioperative stroke); average postoperative hospital stay was 6.8 W 3.4 days and 96.6% of patients were discharged home. One patient was transfused (1.7%); there were no other complications. Follow-up revealed stability of the results of mitral repair, with one (1.7%) persistent (>2R/4R) mitral regurgitation, and stability of coaptation height over time. We observed optimal functional results (NYHA class I was 98% at 3 months and 96% at 12 months). Quarterly case load consistently increased during the experience.
ConclusionThis initial experience suggests the reliability and clinical safety of a recently established local roboticassisted mitral surgery. This strategy can facilitate faster postoperative recovery, and its positioning in the therapeutic armamentarium needs to be defined.
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