Minimally invasive direct access heart valve surgery

Aortic Root Replacement via Lower Hemisternotomy After an Esophageal Operation

A 68-year-old man with a history of esophageal resection and reconstruction by gastric tube in substernal fashion required aortic root replacement for annuloaortic ectasia and severe aortic regurgitation. The gastric tube attached closely at the manubrium of the sternum and around the xiphoid process, but it positioned leftward slightly at the body of the sternum. At the operation of the aortic root replacement, we decided the lower hemisternotomy approach to avoid injury of the gastric tube. The lower hemisternotomy to access the aortic root provides a useful alternative approach in some cases with substernal reconstruction after surgery of esophageal cancer.

First-in-Man Transcervical Surgical Aortic Valve Replacement Using the CoreVista System

OBJECTIVE

This study aimed to evaluate a novel device system for surgical aortic valve replacement (SAVR) using a unique new less invasive access approach. The hypothesis is that SAVR can be performed through a short transverse incision in the neck, similar to that used for transcervical thymectomy avoiding chest disruption.

METHODS

A new device system was developed to provide retraction, step-by-step illumination, and on-screen visualization for the new approach. Preliminary feasibility studies were performed in cadavers. Comprehensive risk analysis was performed, and training was implemented in Thiel preserved cadavers. For the first-in-man clinical case, a 63-year-old woman with symptomatic critical aortic stenosis (The Society of Thoracic Surgeons risk, 11%) and heavily calcified aortic valve was selected. A short transverse incision was made in the neck; the device was introduced, and the sternum was elevated; femorofemoral cardiopulmonary bypass was established; substernal dissection was guided by the sequenced illumination, and high-definition visualization was provided by the device, allowing for optimal exposition of the aorta and aortic valve; and a 23-mm Medtronic ENABLE sutureless valve prosthesis was implanted. Procedure success was evaluated according to the standardized composite end point definition of "device success" proposed by the Valve Academic Research Consortium.

RESULTS

Access, delivery, and deployment of the valve prosthesis were successful. The correct position and intended performance of the valve were demonstrated (mean gradient, 6 mm Hg; aortic valve area, 2.5 cm) with the absence of moderate or severe prosthetic aortic regurgitation. Only one valve prosthesis was used.

CONCLUSIONS

Transcervical SAVR with sutureless valve is feasible using this novel access system. The new approach has potential to offer patients substantially shorter stay and fewer, less serious complications, as has been observed in transcervical thymectomy. Further studies are merited.

Reversed L-type Upper Partial Sternotomy in Aortic Valve Replacement: an Initial Experience

Introduction:

Degenerative aortic stenosis (AS) is the most frequent cause among aortic valve stenotic changes. Mini Sternotomy Aortic Valve Replacement is a replacement of aortic valve through upper partial sternotomy.

Aim:

The aim of this approach is to improve postoperative convalescence by leaving pleural spaces closed and do not compromise respiratory function, to decrease bleeding, and reduce post op ventilation time and ICU stay. All these advantages decrease cost during hospital stay by reducing ICU stay, respiration time, bleeding and using blood products, pain killers and shortening hospital stay. Esthetic effect is also considerable result of this method.

Case report:

This case report presents an initial experience with Reversed L-Type Upper Partial Sternotomy in Aortic Valve Replacement. The goal is to demonstrate that minimally invasive advanced cardiac surgery procedures can be performed in our country.

Anterolateral minithoracotomy versus median sternotomy for mitral valve disease: a meta-analysis

OBJECTIVE

Mitral valve disease tends to be treated with anterolateral minithoracotomy (ALMT) rather than median sternotomy (MS), as ALMT uses progressively smaller incisions to promote better cosmetic outcomes. This meta-analysis quantifies the effects of ALMT on surgical parameters and post-operative outcomes compared with MS.

METHODS

One randomized controlled study and four case-control studies, published in English from January 1996 to January 2013, were identified and evaluated.

RESULTS

ALMT showed a significantly longer cardiopulmonary bypass time (P=0.001) and aortic cross-clamp time (P=0.05) compared with MS. However, the benefits of ALMT were evident as demonstrated by a shorter length of hospital stay (P<0.00001). According to operative complications, the onset of new arrhythmias following ALMT decreased significantly as compared with MS (P=0.05); however, the incidence of peri-operative mortality (P=0.62), re-operation for bleeding (P=0.37), neurologic events (P=0.77), myocardial infarction (P=0.84), gastrointestinal complications (P=0.89), and renal insufficiency (P=0.67) were similar to these of MS. Long-term follow-up data were also examined, and revealed equivalent survival and freedom from mitral valve events.

CONCLUSIONS

Current clinical data suggest that ALMT is a safe and effective alternative to the conventional approach and is associated with better short-term outcomes and a trend towards longer survival.

Minimally invasive approaches versus conventional sternotomy for aortic valve replacement: a propensity score matching study

Background

The aim of this study is to evaluate our institutional results of the aortic valve replacement through minimally invasive approaches compared with conventional sternotomy.

Materials and Methods

From August 1997 to July 2010, 838 patients underwent primary isolated aortic valve replacement. Of them, 73 patients underwent surgery through minimally invasive approaches (MIAS group) whereas 765 patients underwent surgery through the conventional sternotomy (CONV group). Clinical outcomes were compared using a propensity score matching design.

Results

Propensity score matching yielded 73 pairs of patients in which there were no significant differences in baseline profiles between the two groups. Patients in the MIAS group had longer aortic cross clamp than those in the CONV group (74.9±27.9 vs.. 66.2±27.3, p=0.058). In the MIAS group, conversion to full sternotomy was needed in 2 patients (2.7%). There were no significant differences in the rates of low cardiac output syndrome (4 vs. 8, p=0.37), reoperation due to bleeding (7 vs. 6, p=0.77), wound infection (2 vs. 4, p=0.68), or requirements for dialysis (2 vs. 1, p=0.55) between the two groups. Postoperative pain was significantly less in the MIAS group than the conventional group (pain score, 3.79±1.67 vs. 4.32±1.56; p=0.04).

Conclusion

Both minimally invasive approaches and conventional sternotomy had comparable early clinical outcomes in patients undergoing primary isolated aortic valve replacement. Minimally invasive approaches significantly decrease postoperative pain.

Minimally Invasive Surgery for Valve Disease

Heart valve surgery evolved since the early 1960s toward routine clinical application with good patient outcome. Different surgical techniques and valve prostheses have been developed. Thus standard procedures were continuously established. The different surgical procedures have now gained widespread clinical acceptance with good patient outcomes. Aortic valve stenosis and mitral valve incompetence are the most frequently acquired heart valve lesions in the western communities. Usually such lesions reach clinical significance in patients during their fifth to eighth decade of life. Standard surgical techniques of aortic valve repair and mitral valve replacement or repair result in persistent cure of the disease. Surgical access was gained using conventional lateral thoracotomies in the early days and later on using median sternotomy. Minimally invasive techniques, mostly by a partial sternotomy for the aortic and a lateral minithoracotomy for the mitral position, have been increasingly applied to improve patient outcome since the mid 1990s. At specialized centers these techniques have evolved as clinical standard allowing all different valve procedures to be safely performed. Patient recovery is fast leading to a significant improvement in the individual's quality of life. Minimally invasive valve surgery can be considered the standard approach and will reach more widespread clinical application.

Combined percutaneous coronary intervention and valve surgery

PURPOSE OF REVIEW

This article reviews unique advantages emerging in valvular heart disease as the technology of invasive cardiology and cardiac surgery begin to merge.

RECENT FINDINGS

Minimally invasive valve surgery is increasing in popularity and has helped to reduce morbidity. In addition, preoperative or intraoperative treatment of coronary artery disease by a percutaneous approach has simplified operations and allowed more liberal use of non-traditional incisions.

SUMMARY

Percutaneous intervention with drug-eluting stents has provided early evidence for decreased restenosis and improved long-term patency rates. At the same time, cardiac surgery has moved toward less invasive approaches performed in new imaging arenas known as 'hybrid' operating rooms. Combining these technological advances is providing unique solutions to valvular heart disease also requiring revascularization, and will likely become the next horizon for strategies in cardiovascular medicine.

Robotic Resection of an Aortic Valve Papillary Fibroelastoma

Robotic technology has been applied to multiple cardiac surgical procedures. Purported benefits include decreased tissue trauma, reduced postoperative bleeding, fewer blood product transfusions, and shorter lengths of stay. We describe the case of a 50-year-old man with an incidentally discovered 1-cm mobile mass on the edge of the aortic valve noncoronary leaflet. The patient underwent robotic minimally invasive resection. The pathologic examination revealed papillary fibroelastoma.

Minimally Invasive Port Access Versus Conventional Mitral Valve Surgery: Prospective Randomized Study

BACKGROUND

We compared the port access mitral valve surgery with the conventional procedure through median sternotomy in a prospective randomized study.

METHODS

Forty elective patients with mitral valve disease were prospectively randomized to undergo minimally invasive (group I) or conventional (group II) mitral valve operation. The patients of group I had limited access through right small anterior thoracotomy and a femorofemoral cardiopulmonary bypass system using the endoclamp technique. To assess the efficiency and safety of the procedure, intraoperative and postoperative clinical data and markers of myocardial, cerebral, and lower limb ischemia were collected. Pulmonary function tests were performed to compare the preservation of pulmonary function. Neuropsychological tests were conducted for quantification of neurological and cognitive disorders.

RESULTS

Mitral valve reconstructions were performed in 28 patients (70%) in both groups. Intraoperative procedure-associated problems were experienced in 9 patients (45%) in group I, and 6 of them (30%) had to be converted to direct transthoracic aortic clamping. Markers of myocardial and cerebral damage as well as pulmonary and neuropsychological tests did not show statistically significant difference between groups.

CONCLUSIONS

The minimally invasive port access technique for mitral valve surgery can be done with similar clinical safety as procedures through median sternotomy. The problems with endoclamping have forced us to change our practice to the more simple and economic transthoracic aortic clamping technique.

Minimally invasive valve surgery: different techniques and approaches

Less invasive approaches to cardiac surgical procedures are being developed in an effort to decrease patient morbidity and enhance postoperative recovery in comparison with conventional methods. Although full median sternotomy has been the standard surgical approach to the heart for more than 30 years, minimally invasive techniques using limited incisions are rapidly gaining acceptance. Potential advantages of a small skin incision include less trauma and tissue injury, leading to a less painful and quicker overall recovery, as well as shorter hospital stays for patients. Decreasing the size of the skin incision for minimally invasive valve surgery to significantly less than the cardiac size requires specific access to the valve to be repaired or replaced. Thus, various minimally invasive techniques and approaches have been described for aortic and mitral valve surgery. This article will review the different minimally invasive techniques and approaches, as well as early results and outcomes for aortic and mitral valve surgery.

Minimally invasive aortic valve surgery in the elderly: a case-control study

INTRODUCTION

Although minimally invasive aortic valve surgery (MIAVR) is performed in many centers, few studies have compared its results to a standard sternotomy (SS) approach. We assessed the hypothesis that, when compared with SS in the elderly population, MIAVR has similar morbidity and mortality and allows faster hospital recovery.

METHODS AND RESULTS

From January 1995 through February 2002, 515 patients over age 65 underwent isolated aortic valve replacement. Using data gathered prospectively, 189 MIAVR patients were matched with 189 SS patients by age, ventricular function, valvular pathology, urgency of operation, diabetes, previous cardiac surgery, renal disease, and history of stroke. In each group, 56.1% of patients underwent non-elective procedures, and 28% were >or=80 years old. Hospital mortality (6.9%) and freedom from postoperative morbidity (82.5% versus 81.5%, P=0.79) were similar. Multivariate analysis revealed that urgent procedures [Odds Ratio (OR)=3.97; P=0.03], congestive heart failure (OR=3.94; P=0.03), and ejection fraction <30% (OR=4.16; P=0.03) were significant predictors of hospital mortality. Prolonged length of stay was associated with age (P=0.05), preoperative stroke (OR=3.5,P=0.001), CHF (OR=2.2, P=0.004), and sternotomy approach (OR=2.3,P=0.002) by multivariate analysis. More MIAVR patients were discharged home (52.6% versus 38.6%,P=0.03) rather than to rehabilitation facilities. Three year actuarial survival revealed no difference between groups.

CONCLUSIONS

Minimally invasive aortic valve surgery is safe in elderly patients, with morbidity and mortality comparable to sternotomy approach. The shorter hospital stay and greater percentage of patients discharged home after MIAVR reflect enhanced recovery with this technique.

Minimal access aortic valve replacement: effects on morbidity and resource utilization

BACKGROUND

The aim of this study was to compare outcomes in patients undergoing minimal access versus conventional aortic valve replacement (AVR).

METHODS

We reviewed prospectively gathered data on all patients who were undergoing first-time AVR, with or without replacement of the ascending aorta, over a 1-year period at our institution.

RESULTS

A total of 176 patients underwent minimal access and 258 underwent conventional AVR. The conventional group was older, had more incidence of diabetes, and more aortic stenosis (all p < 0.05). Eight minimal access AVR patients (2%) required conversion to a complete sternotomy. Minimal access AVR patients had longer aortic crossclamp times than conventional AVR patients (60 +/- 22 vs 55 +/- 23 minutes, p = 0.03) but similar CPB times (93 +/- 38 vs 88 +/- 42 minutes, p = 0.20). Postoperative creatine kinase-MB levels were similar for the two groups. Total postoperative blood loss was significantly lower in the minimal access group, and these patients received less red blood cell and fresh frozen plasma transfusions. Minimal access AVR patients were less likely to have postoperative respiratory failure (3% vs 10%); they had shorter intensive care unit stays (3.7 +/- 5.4 vs 4.5 +/- 5.6 days) and shorter hospital stays (10 +/- 6 vs 12 +/- 7 days, all p < 0.05). Mortality was lower in patients undergoing minimal access surgery (3% vs 9%, p = 0.008) by univariate analysis. Multivariate predictors of mortality were age, hypertension, and CPB time.

CONCLUSIONS

Although patient selection may have influenced some of the observed differences between our patient groups, minimal access surgery appears to be associated with decreased morbidity and resource use when compared to conventional AVR.

Minimal access aortic root, valve, and complex ascending aortic surgery

We report our entire experience with minimal access aortic root, valve, and complex ascending aortic surgery. A total of 290 consecutive patients underwent aortic root, valve, and ascending aortic surgery between July 1996 and February 2000. Four groups were identified: isolated aortic valve replacement (AV group, n = 227), aortic root replacement (AR group, n = 44), aortic valve replacement with concomitant replacement of the supracoronary ascending aorta (V/A group, n = 9), and isolated ascending aortic replacement (AA group, n = 10). The procedures were performed through a partial upper hemisternotomy (87%) or a right parasternal approach (13%). Overall mortality was 3.1% (n = 7) for the AV group, 2.3% (n = 1) for the AR group, 0% for the V/A group, and 10.0% (n = 1) for the AA group. Complications included reoperation for bleeding in 10 (4.5%), two (4.7%), one (11.1%), and one (11.1%) for the four groups respectively; and sternal wound infection in eight (3.6%) patients of the AV group and one (2.3%) patient of the AR group. Five (2.3%) patients of the AV group suffered stroke. Isolated or more complicated aortic valve, root and ascending aortic surgery is feasible and safe through a minimally invasive approach with acceptable incidence of complications and mortality, without compromising the efficacy of the procedure.

Partial upper re-sternotomy for aortic valve replacement or re-replacement after previous cardiac surgery

OBJECTIVE

We developed techniques for 'inverted T' partial upper re-sternotomy for aortic valve replacement (AVR) or re-replacement (AVreR) after previous cardiac surgery. We previously reported on decreased blood loss, transfusion requirements and total operative duration when compared to conventional full re-sternotomy. This report updates our series, one of the few to document a substantial benefit from a 'minimally-invasive' approach, refines a number of technical aspects of this new approach and reports follow-up.

METHODS

Between November 1996 and December 1999, we performed 34 AVRs or AVreRs after previous cardiac surgery by use of an 'inverted T' partial upper re-sternotomy. There were 25 (74%) men. Median ejection fraction was 54%, range 15-80%. Median age was 72, range 38-93. All were New York Heart Association functional class (NYHA) functional class II or III. Twenty-one (62%) had previous coronary artery bypass grafts (CABG) while 14 (41%) had previous valve surgery. Follow-up was 100% complete for a total of 593 patient months (median 19 months).

RESULTS

Twenty-three (66%) underwent AVR of the native aortic valve while 11 (33%) underwent AVreR of a prosthetic aortic valve. There were no intraoperative or valve-related complications, and no conversion to full re-sternotomy was necessary. There were two (5.9%) operative deaths from an arrhythmia on postoperative day 4 and a large stroke during surgery, respectively. Twenty-four (75%) patients were free of major complications. There was no need for reoperation for bleeding and patients required a median of two units of packed red blood cells. Complications included new atrial fibrillation (n=3, 9%), pacemaker implantation (n=3, 9%) and deep sternal wound infection (n=2, 6%). Median lengths of stay in the intensive care unit (ICU) and in the hospital were 1 and 7 days, respectively. There was one (3%) late deep sternal wound infection and 2/32 (6%) late deaths due to congestive heart failure at 22 months and myocardial infarction at 23 months, respectively.

CONCLUSIONS

Partial upper re-sternotomy presents a safe and effective alternative approach to AVR and AVreR after previous cardiac surgery, and is associated with low morbidity and mortality.