Objective: Operative techniques for minimally invasive cardiac surgery (MICS) have evolved dramatically over the past decade to include a wide demographic of patients. Mastering a variety of cannulation techniques is of paramount importance in performing a safe perfusion strategy and operation. Our aim is to describe cannulation strategies utilized in various MICS procedures. Methods: We review numerous cannulation strategies and their application in different minimally invasive procedures. Results: Cannulation strategies will vary depending on the MICS procedure and other anatomical variations and obstacles. Utilizing the appropriate cannulation strategy will allow for a safe and effective operation. Conclusions: Mastering the art of cannulation will provide surgeons with a toolbox to choose from when performing MICS in a wide variety of procedures.

The use of segmentectomy for peripheral T ≤2 cm, N0 non-small cell lung cancer (NSCLC) has increased in the last decade. We sought to compare clinical outcomes and overall survival between robotic, video-assisted thoracoscopic surgery (VATS), and open segmentectomy. The National Cancer Database was queried for patients with clinical T ≤2 cm, N0 NSCLC who underwent segmentectomy via robotic, thoracoscopic (VATS), and open approaches (2010 to 2015). Univariate and Cox regression analyses were used to compare surgical approaches and to evaluate predictors of overall survival. Statistical analyses were done using SPSS Version 21.0. Segmentectomy was performed in 3,888 patients during the study period with 406 robotic, 1,837 VATS, and 1,645 open patients. VATS and robotic segmentectomy were performed more often at academic or comprehensive community cancer programs as compared to community programs (P < 0.05). Conversion to open thoracotomy was similar between robotic and VATS groups when stratified by hospital volume. Lymph node yield was significantly higher for robotic (median = 6), compared to VATS (median = 5) or open (median = 4; P < 0.001). Length of stay was decreased for robotic versus open (P < 0.01). No differences in 30-day readmissions (P = 0.12) were observed among the 3 modalities. Overall survival was similar among groups (P = 0.18). Robotic segmentectomy provides similar clinical outcomes compared to other standardized approaches for clinical T ≤2 cm, N0 NSCLC. A higher lymph node yield in robotic segmentectomy was not associated with improved survival in this study population.

Introduction: Aortic valve disease is the most common valvular heart disease. Aortic valve replacement (AVR) is the treatment of choice for aortic valve stenosis (AS). Multiple options have been developed to treat AS, corresponding to the steadily growing AVR case volume. The increased adoption of minimally invasive aortic valve replacement (mini-AVR) techniques, despite being technically challenging, is reflected in its advantageous outcomes. Continuous device development can add a critical value to the technical expertise and advance the proficiency of mini-AVR. Areas covered: The literature related to Mini-AVR is reviewed for the current state-of-the-art approach to treating valvular diseases. The latest technologies to treat AS were reviewed and compared with outcomes. A brief expert review of the current state of structural heart and valvular surgery programs is discussed to address collaboration and future challenges. Expert commentary: The treatment of aortic valve disease has evolved in a manner which cardiac surgeons and cardiologists would have never imagined. Advances in surgical techniques and increased training courses have improved adoption of minimally invasive aortic valve procedures. In addition, the recent development of facilitating devices has significantly improved the exposure necessary to perform an expeditious and safe operation.

Objective: Risk-scoring systems for surgical aortic valve replacement (AVR) were largely derived from sternotomy cases. We evaluated the accuracy of current risk scores in predicting outcomes after minimally invasive AVR (mini-AVR). Because transcatheter AVR (TAVR) is being considered for use in low-risk patients with aortic stenosis, accurate mini-AVR risk assessment is necessary. Methods: We reviewed 1,018 consecutive isolated mini-AVR cases (2009 to 2015). After excluding patients with Society of Thoracic Surgeons Predicted Risk of Mortality (STS-PROM) scores ≥4, we calculated each patient’s European System for Cardiac Operative Risk Evaluation (EuroSCORE) II, TAVR Risk Score (TAVR-RS), and age, creatinine, and ejection fraction score (ACEF). We compared all 4 scores’ accuracy in predicting mini-AVR 30-day mortality by computing each score’s observed-to-expected mortality ratio (O:E). Area under the receiver operating characteristic (ROC) curves tested discrimination, and the Hosmer–Lemeshow goodness-of-fit tested calibration. Results: Among 941 patients (mean age, 72 ± 12 years), 6 deaths occurred within 30 days (actual mortality rate, 0.6%). All 4 scoring systems overpredicted expected mortality after mini-AVR: ACEF (1.4%), EuroSCORE II (1.9%), STS-PROM (2.0%), and TAVR-RS (2.1%). STS-PROM best estimated risk for patients with STS-PROM scores 0 to <1 (0.6 O:E), ACEF for patients with STS-PROM scores 2 to <3 (0.6 O:E), and TAVR-RS for patients with STS-PROM scores 3 to <4 (0.7 O:E). ROC curves showed only fair discrimination and calibration across all risk scores. Conclusions: In low-risk patients who underwent mini-AVR, current surgical scoring systems overpredicted mortality 2-to-3-fold. Alternative dedicated scoring systems for mini-AVR are needed for more accurate outcomes assessment.

Isolated tricuspid valve surgery is uncommon and associated with high perioperative morbidity and mortality. We aimed to study the overall outcomes of patients who underwent minimally invasive right thoracotomy tricuspid valve surgery (Mini-TVS), consisting of either tricuspid valve repair (TVre) or replacement (TVR). We performed a retrospective analysis of all Mini-TVS procedures (2017-2022), through which we identified isolated tricuspid valve surgeries. We examined in-hospital outcomes, survival analysis over a 4-year period, and competing risk analysis for reoperative surgery. Among a total of 51 patients, the average age was 60 ± 16 years, and 67% (n = 34) were female. Severe tricuspid regurgitation was present in all cases. Infective endocarditis was noted in 7.8% (n = 4), and 24% (n = 12) had preexisting pacemakers. Mini-TVS included TVre in 18 patients (35%) and TVR in 33 patients (65%). The in-hospital and 30-day mortality rates were 4% (n = 2) and 6% (n = 3), respectively. At 4 years, the overall TVS survival was 76% (confidence interval, 62-93%), with no significant difference between TVre and TVR (91% vs 69%, P = .16). At follow-up, 3 patients required repeat surgery for recurrent regurgitation after 2.6, 3.3, and 11 months, with a reoperation rate of 7.3% (confidence interval, 2.4-22%) at 2 years. Factors associated with worse overall survival included nonelective surgery, right ventricular dysfunction, serum creatinine >2 g/dL, and concomitant left-sided valve disease. A nonsternotomy minimally invasive approach is a feasible option for high-risk patients. Midterm outcomes were similar in repair or replacement. Patients with right ventricular dysfunction and left-sided disease had worse outcomes.

Objective: Isolated tricuspid valve surgery (TVR) is rarely performed, and literature reports are confined to small sample sizes and old studies. Thus, the advantage of repair over replacement could not be determined. We aimed to evaluate repair and replacement outcomes along with predictors of mortality for TVR on a national level. Methods: All adult patients (18+ years old) who underwent TVR from 2011 to 2020 were identified using the National Inpatient Sample dataset. The primary outcome was in-hospital mortality. Secondary outcomes included complications, length of stay (LOS), hospitalization cost, and discharge disposition. Results: Over a 10-year period, 37,931 patients had TVR and predominantly underwent repair ( n = 25,027, 66.0%). In comparison with patients who underwent tricuspid replacement, more patients with a history of liver disease and pulmonary hypertension presented for repair surgery, and fewer patients had endocarditis and rheumatic valve disease ( P < 0.001). The repair group had less mortality, less stroke, shorter LOS, and reduced cost, while the replacement group had fewer myocardial infarctions ( P < 0.05). However, the outcomes were not different for cardiac arrest, wound complications, or bleeding. After excluding congenital TV disease and adjusting for relevant factors, TV repair was associated with a reduced in-hospital mortality by 28% (adjusted odds ratio [aOR] = 0.72, P = 0.011). Older age increased mortality risk by 3-fold, prior stroke by 2-fold, and liver diseases by 5-fold ( P < 0.001). Patients undergoing TVR in recent years had a better chance of survival (aOR = 0.92, P < 0.001). Conclusions: TV repair has better outcomes than replacement does. Patient comorbidities and late presentation play an independently significant role in determining outcomes.