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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.

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.

Mitral valve therapy is rapidly evolving. In this context, there is a clear evolution towards the diffusion of minimally invasive techniques for surgical mitral valve replacement or repair, namely in the context of primary mitral regurgitation. The robotic-assisted mitral surgery strategy allows the greatest reduction in surgical trauma to the patients, as well as improved ergonomics and video-assistance for performance of the mitral procedure. We currently observe a rapid diffusion of robotic-assisted mitral valve surgery across Europe, which rightfully forms part of the treatment modalities available to multidisciplinary Mitral Teams. However, the development of a robotic cardiac surgery program should be established maintaining reproducibility and patient safety. Adequate training and preparation are essential to initiate and sustain a robotic-assisted mitral valve surgery program. Herein, we address its main steps: fundamentals, multidisciplinary approach, risk management, team management, development and consolidation. We also present the initial clinical results in our Center, and analyze some learning-curve aspects.

Il trattamento della patologia mitralica evolve rapidamente. In questo contesto assistiamo ad una chiara evoluzione verso le tecniche mini-invasive per la riparazione o sostituzione della valvola mitrale nel contesto dell’insufficienza mitralica primitiva. La strategia di assistenza mediante piattaforma robotica consente la massima riduzione del trauma chirurgico a carico del torace del paziente, oltre ad una migliorata ergonomia di lavoro sulla valvola. Si assiste attualmente in Europa ad una rapida diffusione di questa strategia chirurgica, che si iscrive a pieno titolo tra le modalità terapeutiche a disposizione del “Mitral Team” multidisciplinare. Tuttavia, lo sviluppo di un programma di cardiochirurgia robotica deve svolgersi nelle migliori condizioni di riproducibilità dei risultati e di sicurezza per i pazienti. L’inquadramento pedagogico e formativo è fondamentale all’avvio e al consolidamento di un programma di chirurgia mitralica robotica. In questo testo ne esponiamo le tappe fondamentali: requisiti essenziali, modalità della formazione dell’equipe alla tecnica e alla gestione della piattaforma robotica, funzionamento multidisciplinare, gestione dei rischi, gestione di equipe, sviluppo e consolidamento del programma. Presentiamo inoltre i risultati clinici iniziali ottenuti presso il nostro Centro, analizzando alcuni aspetti relativi alla curva di apprendimento.

Graphene-based nanomaterials exhibit exceptional physicochemical properties that facilitate a range of diverse biomedical applications, including liquid biopsy. In this study, graphene-based magnetic units, termed MAGU (MAGnetic Units), were specifically engineered for the selective isolation of exosomes. Total extracellular vesicles were first enriched using ultracentrifugation, followed by immunomagnetic capture of CD9+ exosomes. MAGU functionalized with anti-CD9 antibody (MAGU-anti-CD9) efficiently recovered a CD9-positive exosome subpopulation expressing canonical markers ALIX, CD147, TSG101, and Flotillin-1, thereby confirming selective isolation performance. To investigate viral associated signaling, 293T cells were transduced with SARS-CoV-2 spike pseudovirus. This pseudovirus was engineered to express the SARS-CoV-2 spike protein, enabling simulation of viral entry and assessment of potential alterations in the exosomal profile induced by viral binding. Exosomes released by pseudovirus-transduced 293T cells were analyzed and compared to those from non-transduced controls. The MAGU-anti-CD9 complex selectively isolated a defined subset of CD9-positive vesicles enriched in the multifunctional transmembrane glycoprotein CD147, which has been proposed as a cofactor in SARS-CoV-2 entry. Comprehensive molecular profiling of selectively captured exosome subpopulations is expected to further support the application of MAGU technology in virus–host interaction research and liquid-biopsy-based diagnostics.

Peripheral artery disease (PAD) remains underdiagnosed in patients with coronary artery disease (CAD) and barriers persist to measure screening PAD in routine clinical practice. We assessed the prevalence of PAD in patients with CAD in Italian primary care setting using an easy automatic instrument to measure ankle brachial pressure index (ABI). A multicenter, observational study was conducted with 32 General Practitioners (GPs). Prevalence of PAD was calculated dividing the number of patients with abnormal ABI value, or with symptoms associated with PAD or history of lower limb revascularization procedures, over the total number of patients included in the study. Incidence of major CV clinical events and all-cause death was also evaluated at 12 months in both CAD and CAD + PAD groups. In total, 713 CAD patients were included in the study, 148 (20.8%) patients had also PAD, asymptomatic in nearly 15% of them (106). The 35.4% of patients had ABI value ≤ 0.9 and 46.0% > 1.3 ABI. A significantly higher incidence of major CV events and all-cause death was seen in patients with PAD than in those without. Over 80% of patients received the therapy for secondary CV prevention and difference was seen between groups. Our findings showed that the use of an easy automatic instrument to measure ABI, easily managed by nurses, allowed to detect PAD in a relevant proportion of CAD patients who otherwise would not have been recognized. This encourages performing PAD screening in primary care setting to optimize the management of major CV risk factors associated with PAD. NCTumber: NCT03921905 Graphical abstract