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Background. Robotic cardiac surgery (RCS) has emerged as a promising alternative in clinical practice to overcome the limitations of minimally invasive techniques. However, the integration of RCS with surgical process management is key in taking full advantage of its benefits. Aim. We assess the performance of RCS interventions as a function of operating room (OR) layout, using a discrete-event simulation (DES) tool, which allows the simulation of different RCS procedures in different layouts. Methods. A DES model was developed for 2 types of RCS, atrial fibrillation ablation and mitral valve repair, to analyze them in the presence of different OR layouts. Data on the activities and timings of all operators in the OR, used to feed the DES, were collected on site at Humanitas Gavazzeni Hospital, Bergamo, Italy, through direct recording during RCS procedures. Results. The advantages and disadvantages of different OR layouts were highlighted and quantified through a series of key performance indicators and qualitative outcomes, including the overall duration of the entire surgical process, the distance covered by the surgical team, and their utilization. Specifically, the characteristics of a new, larger OR in the considered hospital were assessed prior to the actual transfer of the RCS department in the new OR. Conclusion. This work provided valuable insights and recommendations to RCS operators, which were put in practice, specifically tailoring OR configurations to RCS procedural characteristics. Highlights Discrete event simulation (DES) is used for the first time to improve the performance of robotic cardiac surgery (RCS), an application that presents unique challenges. The flexible DES model for RCS can parametrize various factors related to both operating rooms and procedures. The impact of these factors is evaluated on a set of KPIs. New insights into the positioning of equipment and personnel in the OR are provided, allowing to formulate informed recommendations for RCS providers.

Background and objective Renewed interest in robot-assisted cardiac procedures has been demonstrated by several studies. However, concerns have been raised about the need for a long and complex learning curve. In addition, the COVID-19 pandemic in 2020 might have affected the learning curve of these procedures. In this study, we investigated the impact of COVID-19 on the learning curve of robotic-assisted mitral valve surgery (RAMVS). The aim was to understand whether or not the benefits of RAMVS are compromised by its learning curve. Materials and Methods Between May 2019 and March 2023, 149 patients underwent RAMVS using the Da Vinci® X Surgical System at the Humanitas Gavazzeni Hospital, Bergamo, Italy. The selection of patients enrolled in the study was not influenced by case complexity. Regression models were used to formalize the learning curves, where preoperative data along with date of surgery and presence of COVID-19 were treated as the input covariates, while intraoperative and postoperative data were analyzed as output variables. Results The age of patients was 59.1 ± 13.3 years, and 70.5% were male. In total, 38.2% of the patients were operated on during the COVID-19 pandemic. The statistical analysis showed the positive impact of the learning curve on the trend of postoperative parameters, progressively reducing times and other key indicators. Focusing on the COVID-19 pandemic, statistical analysis did not recognize an impact on postoperative outcomes, although it became clear that variables not directly related to the intervention, especially ICU hours, were strongly influenced by hospital logistics during COVID-19. Conclusions Understanding the learning curve of robotic surgical procedures is essential to ensure their effectiveness and benefits. The learning curve involves not only surgeons but also other health care providers, and establishing a stable team in the early stage, as in our case, is important to shorten the duration. In fact, an exogenous factor such as the COVID-19 pandemic did not affect the robotic program despite the fact that the pandemic occurred early in the program.

Aims . We described our advancement in the field of robotic cardiac surgery, particularly in the context of coronary revascularization. We will outline how the application of the Da Vinci® X Surgical System in coronary surgery is safe, feasible, and reproducible after an adequate familiarization with the docking system, that could come from a previous mitral valve robotic program, and after a sufficient learning time period. Methods . Between February 2021 and December 2023, a cohort of 33 patients underwent coronary artery revascularization surgery, involving robotic harvesting of the left mammary artery and off‐pump hand‐direct bypass to the left descending coronary artery or marginal coronary artery. In cases of hybrid revascularization, percutaneous coronary intervention with drug‐eluting stent placement was performed either before or after surgery. Results . There were no mortalities within 30 days and at 1 year of follow‐up after surgery. Notably, 70% of patients were extubated in the operating room immediately following the surgical procedure. The median postoperative mechanical ventilation time was 0 [0–4] hours, and the median length of stay in the intensive care unit was 21 [20–48] hours. A progressive reduction of the console and instrumental Da Vinci® X Surgical System was underling after the 21 st patient. Conclusion . The promising outcomes observed in this series highlight that robotic‐assisted coronary artery bypass represents a well‐established technique that could be reproducible, especially when integrated into a hybrid strategy. Initiating a program in robotic‐assisted coronary artery bypass surgery can be effectively attained in particularly when a well‐established background in Da Vinci® X Surgical System utilization is achieved.

Background. We conducted a cost and effectiveness analysis comparing robotic vs minimally invasive mitral valve surgery (RMVS vs MIMVS). The aim was to assess whether the higher cost of the robotic technique could be mitigated by the clinical advantages. Methods. We included 118 patients undergoing RMVS and 233 patients undergoing MIMVS. Initially, RMVS experience was developed during the COVID-19 pandemic. A propensity score matching analysis was performed. Postoperative outcomes and cost of care were compared. Results. RMVS patients had significantly shorter ICU and hospital lengths of stay. They also had a significantly earlier return to home. The cost of the total hospitalization and healthcare services were also significantly lower. Conclusion. Shorter hospitalization and lower cost of postoperative healthcare services may mitigate the initial investment cost to purchase and maintain the robot. These benefits are all the more relevant considering that several RMVS treatments were carried out during the COVID-19 pandemic.

The growing popularity of minimally invasive treatment of atrial fibrillation (AF) has shown increasing interest in concomitant left atrial appendage occlusion (LAAO). Surgical robotic technology adds advantages such as magnified visualization, enhanced dexterity of movement and decreased invasiveness. The aim of this study is to evaluate the effectiveness and early outcomes of robotic-assisted LAAO. This is an observational, multicentre, retrospective study of patients with AF who underwent robotic-assisted LAAO. In-hospital mortality, perioperative complications, length of stay (LOS) and imaging-driven (cardiac CT scan, transesophageal echocardiography [TEE]) efficacy at 3-month follow-up were analysed. Between August 2019 and June 2024, 194 patients with documented AF (70.4% male, mean age 67.7 ± 10.1) underwent robotic-assisted epicardial LAAO. The procedure was performed under TEE guidance in 193 patients without complications. In one patient with previous sternotomy, LAAO was not feasible. Blood product transfusion was necessary in one patient, due to significant chest wall bleeding requiring thoracoscopic re-exploration. No stroke or thromboembolic events were observed. Left hemidiaphragm paralysis requiring plication occurred in 3 patients (1.5%). Hospital mortality was 0%. Mean LOS time was 2.2 days (range 1-10 days) and all patients were discharged home. Imaging follow-up was complete in 157 cases (81%) and was achieved by TEE in 91 patients while the remaining 66 underwent cardiac CT scan. Two patients had residual flow in the left atrial appendage and oral anticoagulant was continued at follow-up. Robotic-assisted LAAO is safe with satisfactory outcome both in an isolated setting and with concomitant hybrid ablating procedures for patients with AF.

Background/Objectives: Elevated RDW has emerged in cardiac surgery as a potential means of preoperative risk stratification with the capacity to predict short- and long-term postoperative mortality, acute kidney injury, and postoperative atrial fibrillation. The question as to whether perioperative hemodynamic instability may be predicted by such a marker remains a topic of ongoing debate. The aim of this study was to explore the relationship between preoperative RDW and prolonged postoperative catecholamine use in minimally invasive mitral valve surgery. Methods: We performed a retrospective monocentric cohort study in an academic hospital; we enrolled patients who had undergone minimally invasive mitral valve surgery (including both robot-assisted and non-robot-assisted procedures) between January 2019 and December 2022. We considered the use of inotropes and/or vasopressors for at least twelve hours after post-surgery ICU admission to qualify as the prolonged postoperative use of catecholamines (PPUC). The RDW was obtained from the routine full blood count analysis performed upon admission or a maximum of 72 h before surgery. We also performed a multivariable logistic regression analysis with PPUC as the dependent variable. Results: We finally enrolled 343 patients. Upon multivariate analysis, RDW >14.4% was independently associated with prolonged postoperative catecholamine use when compared to the reference group (OR 2.62 [1.06–4.84]; p = 0.03). Moreover, the EuroSCORE II score (OR 1.38 [1.03–1.85]; p = 0.03), the cross-clamp time (OR 1.01 [1.01–1.02]; p < 0.01), and robot-assisted mitral valve surgery (OR 0.53 [0.30–0.93]; p < 0.03) were independently associated with the prolonged postoperative use of catecholamines. Conclusions: This study identified that an elevated preoperative RDW (>14.4%), the EuroSCORE II score, and the cross-clamp time independently predict prolonged postoperative catecholamine use in minimally invasive mitral valve surgery patients. Conversely, the robot-assisted approach was associated with a smaller hemodynamic impairment.

Background: Postoperative myocardial injury, as detected by an elevated concentration of high-sensitivity cardiac troponin I (hs-cTnI), is a common complication in cardiac surgery that may be linked to mortality. The primary aim of this study was to assess the risk factors associated with increased myocardial injury in patients undergoing minimally invasive mitral valve surgery. Methods: In this retrospective monocentric cohort study, we analyzed all patients who underwent elective minimally invasive mitral valve surgery between January 2019 and December 2022 and were subsequently admitted to our intensive care unit. The study population was divided into two groups based on the peak hs-cTnI level: the “lower myocardial injury” group comprised patients whose peak serum hs-cTnI level was less than 499 times the 99th percentile, while the “higher myocardial injury” group included those patients who exhibited hs-cTnI levels equal to or greater than 500 times the 99th percentile. A multivariable logistic regression analysis was performed to identify independent risk factors associated with higher myocardial injury. Results: In our final analysis, we enrolled 316 patients. Patients with higher myocardial injury (48; 15%) more frequently had a preoperative New York Heart Association (NYHA) class ≥3 compared to those with lower myocardial injury [33 (69%) vs. 128 (48%); p < 0.01—OR 2.41 (95% CI 1.24–4.64); p < 0.01]. Furthermore, cardiopulmonary bypass and aortic cross-clamp time were significantly longer in the higher myocardial injury group compared to the lower myocardial injury group [117 (91–145) vs. 86 (74–100) min; p < 0.01—OR 1.05 (95% CI 1.03–1.06); p < 0.01]. Moreover, patients who underwent robotic-assisted mitral valve surgery experienced lower myocardial injury rates [9 (19%) vs. 102 (38%); p = 0.01—OR 0.38 (95% CI 0.18–0.81); p = 0.01] than others. These findings remained consistent after adjustment in multivariate logistic regression. In terms of postoperative outcomes, patients with higher myocardial injury exhibited the highest lactate peak in the first 24 h, a higher incidence of postoperative acute kidney injury and a longer duration of mechanical ventilation. Although no patients died in either group, those with higher myocardial injury experienced a longer hospital length of stay. Conclusions: Higher myocardial injury is relatively common after minimally invasive mitral valve surgery. Prolonged aortic cross-clamp duration and higher NYHA class were independently associated with myocardial injury, while robotic-assisted mitral valve surgery was independently associated with lower postoperative myocardial injury.

Abstract Objectives Repairing severe mitral regurgitation (MR) in patients with degenerative bileaflet prolapse and reduced left ventricular ejection fraction (LVrEF) is challenging. The Free Margin Running Suture (FMRS) technique offers a non-resectional approach, but mid-term data are limited. Methods We analysed 28 patients with bileaflet degenerative MR and LVrEF (≤40%) undergoing FMRS. Primary outcomes were mid-term survival and MR recurrence; secondary outcomes included LVEF, in-hospital complications, transmitral gradient, coaptation length, and mitral valve orifice area. Results Mean age was 59.3 ± 12.8 years; 69.4% were male. No perioperative deaths; 1 patient required ECMO. Mean aortic cross-clamp time was 47 ± 18.6 min. Over 4.7 years, survival was 100%, with 1 case of moderate MR recurrence. At follow-up, LVEF improved to 43.04 ± 2.26 (P < 0.001), and all patients were NYHA I-II. Conclusions FMRS is a minimally invasive, reproducible technique providing durable repair, symptomatic improvement, and excellent mid-term survival. Mitral valve (MV) repair is the surgical intervention of first choice in degenerative primary mitral regurgitation (MR). Graphical Abstract

Background: Pulmonary vein isolation is currently considered to be the gold standard for ablating paroxysmal atrial fibrillation. However, its efficacy is limited in patients with persistent atrial fibrillation. The convergent procedure has emerged as a hybrid ablation. This study aims, for the first time in the literature, to introduce a hybrid approach that includes epicardial ablation with cutting-edge robotic technology and subsequent electrophysiological study to verify and an endocardial ablation to complete the ablation lines. Methods: We present 18 cases of robotic-assisted epicardial hybrid ablation performed between April and December 2023 on patients with long-standing persistent atrial fibrillation (mean age: 64 ± 5 years; mean duration: 4 ± 2 years). All of the procedures were performed at “Humanitas Gavazzeni Hospital”, Bergamo, Italy. Robot-assisted epicardial ablation performed using the “Epi-Sense AtriCure” device was guided by monitoring electrogram morphology and point-by-point impedance drop. This approach also included left atrial appendage occlusion and the disconnection of the ligament of Marshall. An electrophysiological study and endocardial ablation were planned three months after the procedure. Results: The procedure was successfully executed in all patients with no major complications and a mean operative time of 142 ± 22 min. None of the cases required conversion to full sternotomy or minithoracotomy. The procedure was performed in all cases without extracorporeal circulation and on a beating heart. Fifteen patients (83%) were extubated in the operating room. The length of stay in the intensive care unit was less than 24 h. Acute restoration of sinus rhythm was achieved in 12 out of the 18 patients (67%); the median duration of their hospital stay was two days. In the electrophysiological study, seven pts had sinus rhythm, two had atrial fibrillation, and one patient developed atrial flutter at 3-month follow-up. Patients underwent transcatheter ablation to complete the lesion set and, at the time of discharge, were all in sinus rhythm. Conclusions: In our initial experience, surgical atrial fibrillation ablation consisting of a unilateral thoracoscopic technique facilitated by a robotic platform and continuous EGM monitoring has proven to be safe and feasible. For the electrophysiological study at 3 months, completing the gaps in the surgical ablation lines could improve the clinical results of the technique in terms of sinus rhythm stability. However, mid- and long-term follow-up is required to demonstrate this.

Objective Although bolus thermodilution technique for cardiac output (CO) measurement has widespread acceptance, new systems are currently available. We evaluated a continuous CO system (TruCCOMS, Aortech International Inc.) that operates on the thermal conservation principle and we compared it with the reference standard transit time flow measurement (TTFM). Materials and methods Nine consecutive cardiac surgery patients were evaluated. After general anesthesia and intubation, a TruCCOMS catheter was percutaneously placed in the pulmonary artery (PA). After median sternotomy and pericardiotomy, a TTFM probe was placed around the main PA. Right ventricular (RV) CO measurements were recorded with both TruCCOMS and TTFM at different times: before cardiopulmonary bypass (CPB) (T0), during weaning from CPB (T1), and prior to sternal closure (T2). Data analysis included paired student t test, Pearson correlation test, and Bland–Altman plotting. Results TruCCOMS CO values were significantly lower at T0 (TruCCOMS 4.0 ± 1.0 vs. TTFM 4.5 ± 1.0 L/min; P  < 0.0001) and T1 (TruCCOMS 3.6 ± 0.5 vs. TTFM 4.2 ± 0.7 L/min; P  < 0.0001), and comparable at T2 (TruCCOMS 4.5 ± 0.7 vs. TTFM 4.6 ± 0.8 L/min; P  = 0.4). Pearson test showed a significant correlation between TruCCOMS and TTFM CO measurements (RT0 = 0.9, RT1 = 0.8, RT2 = 0.6; P  < 0.0001). Bland–Altmann plotting showed a bias of −0.53 ± 0.43 L (−12%) at T0, −0.64 ± 0.43 L (−14.5%) at T1, and −0.1 ± 0.66 L (−0.8%) at T2. Conclusion Although TruCCOMS may significantly underestimate CO, measurement trends correlate with TTFM. For this reason, a negative trend in RV output should trigger more specific diagnostic procedures.