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Zwischenberger BA, Gaca JG, Milano C, Carr K, Glower DD. Late Survival After Redo Mitral Operation With Minithoracotomy Compared With Sternotomy. Ann Thorac Surg 2024; 117:353-359. [PMID: 37930297 DOI: 10.1016/j.athoracsur.2023.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 07/14/2023] [Accepted: 08/15/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The long-term effectiveness of minithoracotomy over redo median sternotomy for reoperative mitral operation is not well described. Here we present long-term survival after reoperative mitral operation based on operative approach. METHODS Adults undergoing mitral valve operation with previous sternotomy by redo sternotomy and minithoracotomy were reviewed from our prospectively maintained institutional database from 1997 to 2022. Propensity score matching was performed to compare short- and long-term outcomes. RESULTS Of 750 consecutive patients, thoracotomy was performed in 503 (67%). Median follow-up was 5.0 years (interquartile range, 0-23 years). Intraoperatively, sternotomy patients were more likely to have central aortic cannulation (205 of 223 [93%] vs 265 of 481 [56%]), cardioplegic arrest (220 of 223 [99%] vs 124 of 481 [26%]), and mitral valve replacement (190 of 223 [85%] vs 358 of 481 [74%]). Thoracotomy patients were older (63 ± 13 vs 58 ± 14 years) with elective presentation (387 of 503 [77%] vs 128 of 247 [52%]). Sternotomy patients were more likely to have endocarditis (52 of 247 [21%] vs 45 of 503 [9%], P < .001). At 10 years, thoracotomy patients experienced improved survival (52% ± 3% vs 46% ± 4%, P = .004). After propensity matching, 10-year survival was significantly higher for thoracotomy patients compared with sternotomy patients (60% ± 5% vs 42% ± 5%, P = .0006). The greatest difference in survival was at the first 6 months after operation (96% ± 1% vs 81% ± 3%, P < .001). CONCLUSIONS For patients undergoing reoperative mitral valve operation, minimally invasive right anterior thoracotomy can significantly decrease risk of death in the first 6 months, with durable survival benefit out to 10 years. We present a large single-center series to suggest an important opportunity to durably improve outcomes after reoperative mitral operation through wider use of right minithoracotomy.
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Affiliation(s)
| | - Jeffrey G Gaca
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Carmelo Milano
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Keith Carr
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Donald D Glower
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina
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2
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Shirke MM, Ravikumar N, Shawn TJX, Mutsonziwa N, Soh V, Harky A. Mitral valve surgery via repeat median sternotomy versus right mini-thoracotomy: A systematic review and meta-analysis of clinical outcomes. J Card Surg 2022; 37:4500-4509. [PMID: 36335611 DOI: 10.1111/jocs.17101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/14/2022] [Indexed: 11/07/2022]
Abstract
BACKGROUND Redo mitral valve surgeries have high mortality and morbidity and can be physically demanding for patients. Median sternotomy remains the gold standard for most cardiac surgeries. To tackle certain risks with a re-sternotomy, alternative procedures such as the right anterolateral minithoracotomy have been explored. This review aims to compare the clinical outcomes of re-sternotomy (MS) versus right mini thoracotomy (MT) in mitral valve surgery. METHODS A systematic, electronic search was performed according to Preferred Reporting items for Systematic Reviews and Meta-analysis guidelines to identify relevant articles that compared outcomes of the MS versus MT procedures in patients who have had cardiac surgery via a MS approach. RESULTS Twelve studies were identified, enrolling 4514 patients. Length of hospital stay(MD = -3.71, 95% confidence interval [CI] [-4.92, -2.49]), 30-day mortality(odds ratio [OR] = 0.59, 95% CI [0.39, 0.90]), and new-onset renal failure(OR = 0.38, 95% CI [0.22, 0.65]) were statistically significant in favor of the MT approach. Infection rates(OR = 0.56, 95% CI[0.25, 1.21]) and length of intensive care unit (ICU) stay (MD = -0.55, 95% CI[-1.16, 0.06]) was lower in the MT group; however, the difference was not significant. No significant differences were observed in the CPB time(MD = -2.33, 95% CI [-8.15, 3.50]), aortic cross-clamp time MD = -1.67, 95% CI[-17.07, 13.76]), and rates of stroke(OR = 1.03, 95% CI[0.55, 1.92]). CONCLUSION Right MT is a safe alternative to the traditional re-sternotomy for patients who have had previous cardiac surgery. The approach offers a reduced length of hospital stay, ICU stay, and a lower risk of new-onset renal failure requiring dialysis. This review calls for robust trials in the field to further strengthen the evidence.
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Affiliation(s)
- Manasi Mahesh Shirke
- Department of Medicine, Queen's University Belfast, School of Medicine, Belfast, UK
| | - Nidhruv Ravikumar
- Department of Medicine, Queen's University Belfast, School of Medicine, Belfast, UK
| | - Tan Jia Xiang Shawn
- Department of Medicine, Queen's University Belfast, School of Medicine, Belfast, UK
| | - Nyasha Mutsonziwa
- Department of Medicine, Queen's University Belfast, School of Medicine, Belfast, UK
| | - Vernie Soh
- Department of Medicine, Queen's University Belfast, School of Medicine, Belfast, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest, Liverpool, UK.,Department of Integrative Biology, Faculty of Life Science, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart and Chest Hospital, Liverpool, UK
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3
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Kutlubaev MA, Nikolaeva IE, Oleinik BA, Kutlubaeva RF. [Perioperative strokes in cardiac surgery]. Zh Nevrol Psikhiatr Im S S Korsakova 2021; 121:10-15. [PMID: 33908226 DOI: 10.17116/jnevro202112103210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The frequency of perioperative stroke in cardiosurgical practice may reach up to 10%. The risk of stroke is especially high after coronary artery bypass surgery and valve replacement. Perioperative stroke is related to embolism with the fragments of atherosclerotic plaque, arterial hypotension, cardiac arrhythmias, hypercoagulation, etc. The likelihood of stroke can be reduced by preoperative assessment of the patient. It is important to control blood pressure and saturation during the surgery. The manipulation on aorta should be minimized in order to reduce the risk of perioperative stroke. Important role belongs to timely identification of those who developed stroke after surgery. The only possible method of reperfusion therapy in perioperative stroke is mechanical thrombectomy.
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Affiliation(s)
| | - I E Nikolaeva
- Bashkir State Medical University, Ufa, Russia.,Republican Cardiological Center, Ufa, Russia
| | - B A Oleinik
- Bashkir State Medical University, Ufa, Russia.,Republican Cardiological Center, Ufa, Russia
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4
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Abstract
PURPOSE OF REVIEW This review overviews perioperative stroke as it pertains to specific surgical procedures. RECENT FINDINGS As awareness of perioperative stroke increases, so does the opportunity to potentially improve outcomes for these patients by early stroke recognition and intervention. Perioperative stroke is defined to be any stroke that occurs within 30 days of the initial surgical procedure. The incidence of perioperative stroke varies and is dependent on the specific type of surgery performed. This chapter overviews the risks, mechanisms, and acute evaluation and management of perioperative stroke in four surgical populations: cardiac surgery, carotid endarterectomy, neurosurgery, and non-cardiac/non-carotid/non-neurological surgeries.
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Affiliation(s)
- Megan C Leary
- Department of Neurology, Lehigh Valley Hospital and Health Network, 1250 S Cedar Crest Blvd, Suite 405, Allentown, PA, 18103-6224, USA. .,Morsani College of Medicine, University of South Florida, Tampa, FL, USA.
| | - Preet Varade
- Department of Neurology, Lehigh Valley Hospital and Health Network, 1250 S Cedar Crest Blvd, Suite 405, Allentown, PA, 18103-6224, USA.,Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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5
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Zia K, Mangi AR, Bughio H, Tariq K, Chaudry PA, Karim M. Initial Experience of Minimally Invasive Concomitant Aortic and Mitral Valve Replacement/Repair at a Tertiary Care Cardiac Centre of a Developing Country. Cureus 2019; 11:e5707. [PMID: 31720175 PMCID: PMC6823070 DOI: 10.7759/cureus.5707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction Minimally invasive double valve replacement (DVR) surgery through a small transverse anterior thoracotomy is an alternate technique to sternotomy for concomitant aortic and mitral valve (AVR, MVR) surgery. The aim of this study was to evaluate the in-hospital and early outcomes of direct vision minimal invasive double valve surgery (DVMI-DVR) at a tertiary care cardiac center of a developing country. Methods This study was conducted at the National Institute of Cardiovascular Diseases Karachi, Pakistan from January 2018 to September 2018. Nineteen consecutive patients undergoing DVMI-DVR for aortic and mitral disease without any prior cardiac surgery were included in this study. For all procedures, access was obtained through small transverse anterior thoracotomy incision with wedge resection (Chaudhry’s Wedge) of sternum opposite to the third and fourth costosternal joints. Patients were observed during their hospital stay and the following variables were observed the length of hospital stay (LOHS), ventilator support, intensive care unit (ICU) stay, pain score, and mortality. The pain score was assessed using the visual analog scale (VAS). Results The male/female ratio was 11:8 with a mean age of 35 ± 12 years with mean EuroSCORE of 6.6 ± 3.5%. The mean total bypass time was 129.8 ± 23.83 min (range: 98-181 minutes). The mean mechanical ventilation time was 3.16 ± 1.12 hours (range: 2-6 hours). The mean intensive care unit (ICU) stay was 41.84 ± 8.36 hours. The mean post-operative LOHS was 5.63 ± 1.12 days (range: 4-8 days). We had zero frequency of wound infection and surgical mortality. The mean pain score was 4.32 (on a predefined pain scale of one to nine with a high value indicating severe pain). Conclusion Minimally invasive DVR surgery is a safe and reproducible technique with comparable outcomes such as postoperative pain score (4.32 ± 2.05), ventilation time (3.16 ± 1.12 hours), ICU stay (41.84 ± 8.36 hours), and hospital stay (5.63 ± 1.12 days). In terms of mortality, operative times, ICU stay, and hospital stay, the minimally invasive DVR is at least comparable to those achieved with median sternotomy. Further prospective randomized studies are needed to validate our findings.
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Affiliation(s)
- Kashif Zia
- Cardiac Surgery, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Ali R Mangi
- Cardiac Surgery, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Hafeezullah Bughio
- Cardiac Surgery, National Institute of Cardiovascular Disease, Karachi, PAK
| | - Khuzaima Tariq
- Cardiac Surgery, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Pervaiz A Chaudry
- Cardiac Surgery, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Musa Karim
- Miscellaneous, National Institute of Cardiovascular Diseases, Karachi, PAK
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6
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Patel NC, Hemli JM, Seetharam K, Graver LM, Brinster DR, Pirelli L, Scheinerman SJ, Hartman AR. Reoperative mitral valve surgery via sternotomy or right thoracotomy: A propensity‐matched analysis. J Card Surg 2019; 34:976-982. [DOI: 10.1111/jocs.14170] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 05/28/2019] [Accepted: 06/22/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Nirav C. Patel
- Department of Cardiovascular & Thoracic Surgery, Northwell HealthLenox Hill Hospital New York New York
| | - Jonathan M. Hemli
- Department of Cardiovascular & Thoracic Surgery, Northwell HealthLenox Hill Hospital New York New York
| | - Karthik Seetharam
- Department of Cardiovascular & Thoracic Surgery, Northwell HealthLenox Hill Hospital New York New York
| | - L. Michael Graver
- Department of Cardiothoracic Surgery, Northwell HealthNorth Shore University Hospital Manhasset New York
| | - Derek R. Brinster
- Department of Cardiovascular & Thoracic Surgery, Northwell HealthLenox Hill Hospital New York New York
| | - Luigi Pirelli
- Department of Cardiovascular & Thoracic Surgery, Northwell HealthLenox Hill Hospital New York New York
| | - S. Jacob Scheinerman
- Department of Cardiovascular & Thoracic Surgery, Northwell HealthLenox Hill Hospital New York New York
| | - Alan R. Hartman
- Department of Cardiothoracic Surgery, Northwell HealthNorth Shore University Hospital Manhasset New York
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7
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Orlov OI, Kaleda VI, Shah VN, Nguyen C, Orlov CP, Sicouri S, Takebe M, Goldman SM, Plestis KA. Ministernotomy aortic valve surgery in patients with prior patent mammary artery grafts after coronary artery bypass grafting. Eur J Cardiothorac Surg 2019; 55:1174-1179. [PMID: 30649235 DOI: 10.1093/ejcts/ezy442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 11/19/2018] [Accepted: 11/24/2018] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Patients with patent internal thoracic artery (ITA) grafts after prior coronary artery bypass grafting surgery who require aortic valve replacement (AVR) pose unique technical challenges for safe and optimal myocardial protection. The purpose of this study is to review our short- and long-term outcomes with redo minimally invasive AVR in patients with patent in situ ITA grafts. METHODS From 2008 to 2016, 48 patients with at least 1 patent in situ mammary artery graft underwent minimally invasive AVR. Preoperative computed tomography was performed in all patients to evaluate the relationship of patent grafts to the sternum. Retrograde coronary sinus and pulmonary vent catheters were placed via the right internal jugular vein. The in situ ITA grafts were not clamped during AVR. Transverse aortotomy, taking care to avoid the grafts arising from the aorta, was performed to expose the aortic valve. RESULTS The median age of the patients was 78 years [Quartile 1 (Q1)-Quartile 3 (Q3): 71-81]. Thirty-nine (81%) patients were men, and 46 (96%) patients had aortic stenosis. The median cardiopulmonary bypass and cross-clamp times were 124 (Q1-Q3: 108-164) and 92 (Q1-Q3: 83-116) min, respectively. Moderate hypothermia at 28-30°C was used in all patients. Most patients received cold blood cardioplegia with antegrade induction and continuous retrograde delivery. Four patients received only retrograde delivery due to some degree of aortic insufficiency. Thirty-day mortality was 4% (2 of 48 patients). There was no conversion to full sternotomy, and no reoperations were performed for postoperative bleeding or sternal wound infection. Excluding the 2 patients who died in the hospital, the median postoperative length of stay was 7 days (Q1-Q3: 5-8). Overall survival at 1, 5 and 10 years was 94%, 87% and 44%, respectively. CONCLUSIONS Percutaneous retrograde cardioplegia combined with antegrade cardioplegia and moderate hypothermia, without interruption of ITA flow, is a safe and reliable strategy in patients with patent ITA grafts undergoing aortic valve replacement. This strategy combined with a minimally invasive approach may reduce surgical trauma, and is a safe and effective technique in these challenging patients.
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Affiliation(s)
- Oleg I Orlov
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Wynnewood, PA, USA.,Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Wynnewood, PA, USA
| | - Vasily I Kaleda
- Department of Cardiac Surgery, Central Clinical Hospital, Moscow, Russian Federation
| | - Vishal N Shah
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Wynnewood, PA, USA.,Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Wynnewood, PA, USA
| | - Catherine Nguyen
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Wynnewood, PA, USA
| | - Cinthia P Orlov
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Wynnewood, PA, USA.,Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Wynnewood, PA, USA
| | - Serge Sicouri
- Department of Cardiac Surgery Research, Lankenau Institute for Medical Research, Wynnewood, PA, USA
| | - Manabu Takebe
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Wynnewood, PA, USA
| | - Scott M Goldman
- Department of Cardiothoracic Surgery, Lankenau Medical Center, Wynnewood, PA, USA
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8
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Dziubek M, Pierrakos C, Chebli L, Demanet H, Sanoussi A, Wauthy P. Para-prosthetic Leaks Following Mitral Valve Replacement: Case Analysis on a 20-year Period. Curr Cardiol Rev 2018; 14:15-24. [PMID: 29141552 PMCID: PMC5872258 DOI: 10.2174/1573403x13666171110110344] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2017] [Revised: 10/19/2017] [Accepted: 11/03/2017] [Indexed: 11/22/2022] Open
Abstract
Background: Mitral para-prosthetic leaks are rare but major complications of mitral heart valve replacements. When they must be re-operated, they are burdened with high mortality rates. We proposed to review our surgical experience in terms of approach and type of operation carried out. Methods: Demographic, preoperative, intraoperative and postoperative characteristics of 34 patients benefited from a surgical treatment of mitral paravalvular leak, at the Brugmann University Hospital between 1996 and 2016, have been analysed retrospectively. We analysed the data to identify the risk factors of postoperative mortality. We then compared the data depending on the approach and the type of surgical treatment in order to compare the morbidity-mortality. Results: The postoperative mortality rate was 11.7%. The presence of endocarditis and increase in lactate dehydrogenase were predictive factors of mortality. Cardiac complications and acute kidney failure were significantly more common in the decease population. Direct mitral paravalvular leak su-turing was more frequently performed on early apparition, anterior and isolated leaks, whereas a mi-tral heart valve replacement was most often performed to cure active primary endocarditis. The inci-dence of complications and mortality rates were identical according to the approach and the type of operation performed. A mitral para-prosthetic leak recurrence was observed in 33% of the cases. Conclusion: Surgical treatment of mitral para-prosthetic leaks is accompanied by a high mortality rate. The operative strategy plays a major role and can influence the morbidity-mortality encountered in those patients.
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Affiliation(s)
- Melvin Dziubek
- Department of Cardiac Surgery, Brugmann University Hospital, Universite Libre de Bruxelles, Bruxelles, Belgium
| | - Charalampos Pierrakos
- Department of Intensive Care, Brugmann University Hospital, Universite Libre de Bruxelles, Bruxelles, Belgium
| | - Louis Chebli
- Department of Cardiac Surgery, Brugmann University Hospital, Universite Libre de Bruxelles, Bruxelles, Belgium
| | - Helene Demanet
- Department of Cardiac Surgery, Brugmann University Hospital, Universite Libre de Bruxelles, Bruxelles, Belgium
| | - Ahmed Sanoussi
- Department of Cardiac Surgery, Brugmann University Hospital, Universite Libre de Bruxelles, Bruxelles, Belgium
| | - Pierre Wauthy
- Department of Cardiac Surgery, Brugmann University Hospital, Universite Libre de Bruxelles, Bruxelles, Belgium
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9
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Minimally invasive mitral valve surgery through right anterolateral thoracotomy—review and personal experience. Indian J Thorac Cardiovasc Surg 2018. [DOI: 10.1007/s12055-018-0644-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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10
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Daemen JHT, Heuts S, Olsthoorn JR, Maessen JG, Sardari Nia P. Right minithoracotomy versus median sternotomy for reoperative mitral valve surgery: a systematic review and meta-analysis of observational studies. Eur J Cardiothorac Surg 2018; 54:817-825. [DOI: 10.1093/ejcts/ezy173] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/26/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Jean H T Daemen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, Netherlands
| | - Samuel Heuts
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, Netherlands
- Faculty of Health, Medicine and Life Sciences, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Jules R Olsthoorn
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, Netherlands
| | - Jos G Maessen
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, Netherlands
- Faculty of Health, Medicine and Life Sciences, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Peyman Sardari Nia
- Department of Cardiothoracic Surgery, Maastricht University Medical Center+ (MUMC+), Maastricht, Netherlands
- Faculty of Health, Medicine and Life Sciences, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
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11
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Bouhout I, Morgant MC, Bouchard D. Minimally Invasive Heart Valve Surgery. Can J Cardiol 2017; 33:1129-1137. [DOI: 10.1016/j.cjca.2017.05.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 05/22/2017] [Accepted: 05/22/2017] [Indexed: 11/26/2022] Open
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12
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Fudulu D, Lewis H, Benedetto U, Caputo M, Angelini G, Vohra HA. Minimally invasive aortic valve replacement in high risk patient groups. J Thorac Dis 2017; 9:1672-1696. [PMID: 28740685 DOI: 10.21037/jtd.2017.05.21] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Minimally invasive aortic valve replacement (AVR) aims to preserve the sternal integrity and improve postoperative outcomes. In low risk patients, this technique can be achieved with comparable mortality to the conventional approach and there is evidence of possible reduction in intensive care and hospital length of stay, transfusion requirement, renal dysfunction, improved respiratory function and increased patient satisfaction. In this review, we aim to asses if these benefits can be transferred to the high risk patient groups. We therefore, discuss the available evidence for the following high risk groups: elderly patients, re-operative surgery, poor lung function, pulmonary hypertension, obesity, concomitant procedures and high risk score cohorts.
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Affiliation(s)
- Daniel Fudulu
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Harriet Lewis
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Umberto Benedetto
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Massimo Caputo
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Gianni Angelini
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
| | - Hunaid A Vohra
- Department of Cardiac Surgery, University Bristol Hospitals NHS Foundation Trust, Bristol, UK
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13
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Sakaguchi T. Minimally invasive mitral valve surgery through a right mini-thoracotomy. Gen Thorac Cardiovasc Surg 2016; 64:699-706. [PMID: 27638268 DOI: 10.1007/s11748-016-0713-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 09/09/2016] [Indexed: 11/29/2022]
Abstract
Since its introduction in the mid-1990s, minimally invasive mitral valve surgery (MIMVS) has been shown to be a feasible alternative to a conventional full-sternotomy approach, and several studies have reported excellent clinical outcomes with low perioperative morbidity and mortality. As a result, MIMVS is being increasingly employed as a routine procedure worldwide. On the other hand, several issues have been raised, including complications specific to this technique and its steep learning curve, while there are also concerns regarding the durability of a mitral valve repair through a limited access. In this study, the current status and future perspectives of MIMVS were examined.
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Affiliation(s)
- Taichi Sakaguchi
- Department of Cardiovascular Surgery, The Sakakibara Heart Institute of Okayama, 2-5-1 Nakai-cho, Kita-ku, Okayama, Okayama, 700-0804, Japan.
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14
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Miura T, Tanigawa K, Matsukuma S, Matsumaru I, Hisatomi K, Hazama S, Tsuneto A, Eishi K. A right thoracotomy approach for mitral and tricuspid valve surgery in patients with previous standard sternotomy: comparison with a re-sternotomy approach. Gen Thorac Cardiovasc Surg 2016; 64:315-24. [PMID: 26968540 DOI: 10.1007/s11748-016-0638-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 03/02/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND To compare the outcomes of mitral and/or tricuspid valve surgery in patients with previous sternotomy between those who underwent a right thoracotomy and those who underwent re-sternotomy. METHODS Between October 2009 and May 2015, eighteen patients underwent a right thoracotomy (R group) and 28 underwent re-sternotomy (re-S group). The right thoracotomy was prioritized for previous coronary artery bypass grafting. Follow-up was 100 % complete with a mean follow-up of 1.9 ± 1.5 years for the R group and 2.5 ± 1.4 years for the re-S group (p = 0.2137). RESULTS Hypothermic ventricular fibrillation was applied in 33.3 % in the R group and in 7.1 % in the re-S group (p = 0.0424). Hospital mortality, the median intensive care unit stay, and the median postoperative hospital stay were 0 % versus 7.1 % (p = 0.5130), 3 days versus 2 days (p = 0.2370), and 28 days versus 29.5 days (p = 0.8043) for the R group versus the re-S group, respectively. Although the rate of major complications was comparable (R group 33.3 % versus re-S group 25.0 %, p = 0.5401), those contents were not equal. Deep sternum infection developed only in the re-S group (3.6 %) and reoperation for bleeding was required only in the R group (11.1 %). No significant difference was observed in the 2-year cardiac-related mortality-free rate (R group 93.3 ± 6.4 % versus re-S group 90.8 ± 6.4 %, p = 0.7516). CONCLUSIONS Given study limitations, the right thoracotomy approach after previous sternotomy provided favorable outcomes as well as re-sternotomy. When selecting a right thoracotomy for re-do mitral and/or tricuspid surgery, the surgical strategy needs to be thoroughly planned.
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Affiliation(s)
- Takashi Miura
- Department of Cardiovascular Surgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan.
| | - Kazuyoshi Tanigawa
- Department of Cardiovascular Surgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
| | - Seiji Matsukuma
- Department of Cardiovascular Surgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
| | - Ichiro Matsumaru
- Department of Cardiovascular Surgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
| | - Kazuki Hisatomi
- Department of Cardiovascular Surgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
| | - Shiro Hazama
- Department of Cardiovascular Surgery, Sasebo General Hospital, Nagasaki, Japan
| | - Akira Tsuneto
- Department of Cardiology, Nagasaki University Hospital, Nagasaki, Japan
| | - Kiyoyuki Eishi
- Department of Cardiovascular Surgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki City, Nagasaki, 852-8501, Japan
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Moscarelli M, Fattouch K, Casula R, Speziale G, Lancellotti P, Athanasiou T. What Is the Role of Minimally Invasive Mitral Valve Surgery in High-Risk Patients? A Meta-Analysis of Observational Studies. Ann Thorac Surg 2016; 101:981-9. [DOI: 10.1016/j.athoracsur.2015.08.050] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 07/30/2015] [Accepted: 08/07/2015] [Indexed: 11/16/2022]
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Minimally Invasive Mitral Valve Surgery in Truly High-Risk Patients: Are We Pushing the Boundaries?: An Observational Study. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015; 10:328-33. [PMID: 26575380 DOI: 10.1097/imi.0000000000000197] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study aimed to assess in a retrospective series of truly high-risk patients who underwent minimally invasive mitral valve surgery: (1) postoperative and long-term results and (2) logistic EuroSCORE and EuroSCORE II discrimination power. METHODS Between 2003 and 2013, we reviewed in our institution patients who underwent minimally invasive mitral valve surgery with or without tricuspid valve repair via right minithoracotomy with logistic EuroSCORE of 20 or higher. RESULTS Among a total number of 1604, 88 patients were identified. Median logistic and EuroSCORE II was 27.29 (interquartile range, 15.3) and 12.7% (11.3%), respectively. Mean (SD) age was 71.9 (8.4) years; 42 were female (47.7%); 60 patients (68.1%) underwent previous sternotomy. Mitral valve was replaced in 59 (67%) and repaired in 29 (32.9%) patients; tricuspid valve repair was performed in 23 patients (26.1%). Median cardiopulmonary bypass and cross-clamp times were 157 minutes (interquartile range, 131-187 minutes) and 83 minutes (81-116 minutes), respectively; conversion to sternotomy and reopening for bleeding was necessary in 4 (4.5%) and 3 (3.4%) patients; permanent and transient neurological injuries were reported in 6 (6.8%) and 3 (3.4%) patients; acute kidney injury was reported in 13 patients (14.7%); 15 patients (17%) had pulmonary complications. Ten patients died while in the hospital (11.2%). Survival at 6 years was 78% (95% confidence interval, 69-88). CONCLUSIONS In this series of truly high-risk patients, minimally invasive mitral surgery was associated with acceptable early mortality and morbidity as well as long-term outcomes; both logistic and EuroSCORE II showed suboptimal discrimination power.
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Moscarelli M, Casula R, Speziale G, Athanasiou T. Can we use minimally invasive mitral valve surgery as a safe alternative to sternotomy in high-risk patients? Interact Cardiovasc Thorac Surg 2015; 22:92-6. [PMID: 26451001 DOI: 10.1093/icvts/ivv275] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 09/03/2015] [Indexed: 11/14/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether minimally invasive mitral valve surgery (MIMVS) should be considered as an alternative to conventional sternotomy (ST) in high-risk patients. Eighty-six papers were found by a systematic search, of which seven were comparing MIMVS with ST in high-risk patients and addressing the clinical question. Five were retrospective observational and two were propensity-matched studies. One paper included patients with infective endocarditis, one with preoperative renal failure, two papers the elderly, three papers compared redo surgery. Author, journal, date, patient group, country of publication, relevant outcomes, results and study weaknesses were tabulated. In total, these seven studies included 1254 high-risk patients (n = 523 MIMVS, 731 ST) undergoing mitral valve surgery, either repair or replacement. End-points of interest were mortality, intraoperative and postoperative outcomes and survival. With regard to MIMVS group, in-hospital mortality was lower in three studies and with no statistically significant differences in the other four; cardiopulmonary bypass (CPB) times were similar in one study, but were longer in three other studies. MIMVS led to reduced postoperative complications in six studies (one did not report complications); among studies that included late mortality, one reported better survival in the MIMVS group whereas the other two did not report differences. We conclude that, although MIMVS may be associated with longer CPB and cross-clamp times, it is at least as safe as ST in terms of both mortality and morbidity, in these high-risk groups.
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Affiliation(s)
- Marco Moscarelli
- Honorary Research Fellow, National Heart Lung Institute (NHLI) London, UK Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Roberto Casula
- Honorary Research Fellow, National Heart Lung Institute (NHLI) London, UK Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
| | - Giuseppe Speziale
- Division of Cardiac Surgery, Anthea Hospital, GVM Care and Research, Bari, Italy
| | - Thanos Athanasiou
- Honorary Research Fellow, National Heart Lung Institute (NHLI) London, UK Department of Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, Hammersmith Hospital, London, UK
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Moscarelli M, Margaryan R, Cerillo A, Kallushi E, Farneti P, Solinas M. Minimally Invasive Mitral Valve Surgery in Truly High-Risk Patients: Are We Pushing the Boundaries? An Observational Study. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2015. [DOI: 10.1177/155698451501000507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Marco Moscarelli
- Pasquinucci Hospital, Ospedale del Cuore, Fondazione Monasterio, Massa, Italy
- NHLI, Imperial College of London, London, United Kingdom
| | - Rafik Margaryan
- Pasquinucci Hospital, Ospedale del Cuore, Fondazione Monasterio, Massa, Italy
| | - Alfredo Cerillo
- Pasquinucci Hospital, Ospedale del Cuore, Fondazione Monasterio, Massa, Italy
| | - Enkel Kallushi
- Pasquinucci Hospital, Ospedale del Cuore, Fondazione Monasterio, Massa, Italy
| | - Pierandrea Farneti
- Pasquinucci Hospital, Ospedale del Cuore, Fondazione Monasterio, Massa, Italy
| | - Marco Solinas
- Pasquinucci Hospital, Ospedale del Cuore, Fondazione Monasterio, Massa, Italy
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Phan K, Zhou JJ, Niranjan N, Di Eusanio M, Yan TD. Minimally invasive reoperative aortic valve replacement: a systematic review and meta-analysis. Ann Cardiothorac Surg 2015; 4:15-25. [PMID: 25694972 DOI: 10.3978/j.issn.2225-319x.2014.08.02] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2014] [Accepted: 07/20/2013] [Indexed: 11/14/2022]
Abstract
BACKGROUND With prolonged life expectancy and more frequent use of biological prostheses, an increasingly higher proportion of patients are undergoing aortic valve replacement (AVR) after previous sternotomy. We critically appraised the quantity and quality of evidence to demonstrate the efficacy and safety of the minimally invasive (MIrAVR) versus conventional (CrAVR) approaches for reoperative AVR. METHODS Electronic searches were performed using six databases from their inception to April 2014. Relevant studies utilizing a MIrAVR were identified. Data were extracted and analyzed according to predefined clinical endpoints. RESULTS Four single-arm and seven comparative observational studies including a total of 441 MIrAVR patients were included for quality assessment, data extraction and analysis. In-hospital mortality ranged from 0-9.5%, and was similar between the MIrAVR and CrAVR groups (RR, 0.77; 95% CI, 0.39-1.54; P=0.46). Stroke rates ranged from 2.6-8% and were also similar between the two cohorts. The rates of pacemaker implantation, renal failure and reoperation for bleeding were not significantly different between the two groups. There were no reports of myocardial infarctions in the included studies. No significant difference in hospital stay was observed for the MIrAVR versus CrAVR group. CONCLUSIONS The current literature suggests that MIrAVR has similar efficacy and mortality outcomes compared to CrAVR without compromise to myocardial protection or hospitalization duration. It appears to be a valid alternative option for patients requiring reoperative AVR.
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Affiliation(s)
- Kevin Phan
- 1 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia ; 2 Westmead Hospital, Sydney Medical School, University of Sydney, Sydney, Australia ; 3 Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy ; 4 Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Jessie J Zhou
- 1 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia ; 2 Westmead Hospital, Sydney Medical School, University of Sydney, Sydney, Australia ; 3 Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy ; 4 Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Nithya Niranjan
- 1 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia ; 2 Westmead Hospital, Sydney Medical School, University of Sydney, Sydney, Australia ; 3 Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy ; 4 Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Marco Di Eusanio
- 1 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia ; 2 Westmead Hospital, Sydney Medical School, University of Sydney, Sydney, Australia ; 3 Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy ; 4 Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Tristan D Yan
- 1 The Collaborative Research (CORE) Group, Macquarie University, Sydney, Australia ; 2 Westmead Hospital, Sydney Medical School, University of Sydney, Sydney, Australia ; 3 Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy ; 4 Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
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Botta L, Cannata A, Bruschi G, Fratto P, Taglieri C, Russo CF, Martinelli L. Minimally invasive approach for redo mitral valve surgery. J Thorac Dis 2014; 5 Suppl 6:S686-93. [PMID: 24251029 DOI: 10.3978/j.issn.2072-1439.2013.10.12] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 10/18/2013] [Indexed: 11/14/2022]
Abstract
Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Mitral valve re-operations can be particularly demanding in patients with patent coronary artery bypass grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, perivalvular leaks, or thrombosis). Risk of graft injuries, hemorrhage, the presence of dense adhesions and complex valve exposure can make redo valve operations challenging through a median sternotomy. In this review article we provide an overview of minimally invasive approaches for redo mitral valve surgery discussing indications, techniques, outcomes, concerns and controversies. Scientific literature about minimally invasive approach for redo mitral surgery was reviewed with a MEDLINE search strategy combining "mitral valve" with the following terms: 'minimally invasive', 'reoperation', and 'alternative approach'. The search was limited to the last ten years. A total of 168 papers were found using the reported search. From these, ten papers were identified to provide the best evidence on the subject. Mitral valve reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space termed "mini" thoracotomy or "port access". The greatest potential benefit of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, avoiding the risk of injury to cardiac structures or patent grafts. Good percentages of valve repair can be achieved. Mortality is low as well as major complications. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of minimally invasive access and continuous myocardial perfusion. Less invasive trans-catheter techniques could be considered as the natural future evolution for management of structural heart disease and mitral reoperations. The safety and efficacy of these procedures has never been compared to open reoperations in a randomized trial, although published case series and comparisons to historical cohorts suggest that they are an effective and feasible alternative. Ongoing follow-up on current series will further define these procedures and provide valuable clinical outcome data.
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Affiliation(s)
- Luca Botta
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, Niguarda Cà Granda Hospital, Milano, Italy
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Ward AF, Grossi EA, Galloway AC. Minimally invasive mitral surgery through right mini-thoracotomy under direct vision. J Thorac Dis 2014; 5 Suppl 6:S673-9. [PMID: 24251027 DOI: 10.3978/j.issn.2072-1439.2013.10.09] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Accepted: 10/14/2013] [Indexed: 11/14/2022]
Abstract
In the 1990s, the success of 'minimally invasive' laparoscopic operations in other surgical subspecialties sparked an interest in minimally-invasive approaches for cardiac surgery, specifically for mitral valve repair. In 1996 at New York University (NYU) we began our experience with minimally invasive mitral valve repair performed through a small right anterior mini-thoracotomy incision using the Port-Access system in a phase I clinical trial. This was the beginning of our extensive right mini-thoracotomy experience for mitral valve repair at NYU. Currently at our institution the preferred approach for the right mini-thoracotomy mitral valve surgery is through the 3rd or 4th interspace mini-thoracotomy incision. Perfusion is accomplished with direct aortic or femoral cannulation, long femoral venous cannula drainage, and a retrograde cardioplegia catheter placed trans-atrialy in the coronary sinus under TEE guidance. An antegrade cardioplegia and venting needle is placed in the ascending aorta and direct external aortic clamping is achieved with one of several specialized crossclamps. With over four decades of experience, more than 4,000 patients have undergone mitral valve repair at NYU including 1,922 performed through a right mini-thoracotomy. We have reported an overall operative mortality of 1.3%, 8-year freedom from reoperation of 95%, freedom from reoperation or severe recurrent mitral regurgitation of 93%, and freedom from all valve-related complications of 90% for our initial series of 1,071 right mini-thoracotomy mitral valve repair. Based on our extensive experience we believe that mitral valve repair through a right mini-thoracotomy provides a durable and safe alternative to a traditional sternotomy with the benefits of improved cosmesis, reduced post-operative pain, less blood loss with fewer blood transfusions, fewer infections, shorter length of stay, and faster return to activity. It is our standard of care approach for mitral valve surgery.
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Affiliation(s)
- Alison F Ward
- Department of Cardiothoracic Surgery, New York University School of Medicine, New York, NY 10016, USA
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Mandal K, Alwair H, Nifong WL, Chitwood WR. Robotically assisted minimally invasive mitral valve surgery. J Thorac Dis 2014; 5 Suppl 6:S694-703. [PMID: 24251030 DOI: 10.3978/j.issn.2072-1439.2013.11.01] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Accepted: 11/02/2013] [Indexed: 11/14/2022]
Abstract
Increased recognition of advantages, over the last decade, of minimizing surgical trauma by operating through smaller incisions and its direct impact on reduced postoperative pain, quicker recovery, improved cosmesis and earlier return to work has spurred the minimally invasive cardiac surgical revolution. This transition began in the early 1990s with advancements in endoscopic instruments, video & fiberoptic technology and improvements in perfusion systems for establishing cardiopulmonary bypass (CPB) via peripheral cannulation. Society of Thoracic Surgeons data documents that 20% of all mitral valve surgeries are performed using minimally invasive techniques, with half being robotically assisted. This article reviews the current status of robotically assisted mitral valve surgery, its advantages and technical modifications for optimizing clinical outcomes.
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Affiliation(s)
- Kaushik Mandal
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore MD 21287, USA; ; Department of Cardiovascular Surgery, East Carolina Heart Institute at East Carolina University, Greenville NC 27834, USA
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Kang WS, Kim SH, Chung JW. Comparison of pulmonary gas exchange according to intraoperative ventilation modes for mitral valve repair surgery via thoracotomy with one-lung ventilation: a randomized controlled trial. J Cardiothorac Vasc Anesth 2014; 28:908-13. [PMID: 24480179 DOI: 10.1053/j.jvca.2013.10.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Impaired pulmonary gas exchange after cardiac surgeries with cardiopulmonary bypass (CPB) often occurs, and the selection of mechanical ventilation mode, pressure-controlled ventilation (PCV) or volume-controlled ventilation (VCV), may be important for preventing hypoxia and improving oxygenation. The authors hypothesized that patients with PCV would show better oxygenation, compared with VCV, during one-lung ventilation (OLV) for mitral valve repair surgery (MVP) via thoracotomy. DESIGN Randomized controlled trial. SETTING University teaching hospital. PARTICIPANTS Sixty patients in each group. INTERVENTIONS MVP was performed using thoracotomy with OLV by PCV or VCV. MEASUREMENTS AND MAIN RESULTS Arterial partial pressure of oxygen (PaO2) and fraction of inspired oxygen (FIO2) were measured before anesthesia induction (T0), at skin incision (T1), after administration of heparin (T2), at 30 minutes after CPB weaning (T3), just before departure from the operating room to the intensive care unit (ICU) (T4), and 1 hour after ICU admission (T5), and PaO2/FIO2 ratio was calculated. Peak inspiratory pressure (PIP) and mean inspiratory pressure (Pmean) were recorded at T1, T2, T3, and T4. No significant difference was noted in the PaO2/FIO2 ratio between the groups at any measured point. PIP in the PCV group at all measured points was lower than that in the VCV group (T1, p<0.001; T2, p<0.001; T3, p<0.001; T4, p=0.025, respectively). Pmean was not different between the two groups at any measured point. CONCLUSIONS PCV during OLV in patients undergoing MVP via a thoracotomy with OLV showed lower PIP compared with VCV, but this did not improve pulmonary gas exchange.
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Affiliation(s)
- Woon-Seok Kang
- Department of Anaesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University Medical Center; Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea
| | - Seong-Hyop Kim
- Department of Anaesthesiology and Pain Medicine, Konkuk University Hospital, Konkuk University Medical Center; Research Institute of Medical Science, Konkuk University School of Medicine, Seoul, Korea.
| | - Jin Woo Chung
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
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Mariscalco G, Musumeci F. The Minithoracotomy Approach: A Safe and Effective Alternative for Heart Valve Surgery. Ann Thorac Surg 2014; 97:356-64. [DOI: 10.1016/j.athoracsur.2013.09.090] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Revised: 09/22/2013] [Accepted: 09/24/2013] [Indexed: 10/26/2022]
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Kaneko T, Loberman D, Gosev I, Rassam F, McGurk S, Leacche M, Cohn L. Reoperative aortic valve replacement in the octogenarians—minimally invasive technique in the era of transcatheter valve replacement. J Thorac Cardiovasc Surg 2014; 147:155-62. [DOI: 10.1016/j.jtcvs.2013.08.076] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 07/29/2013] [Accepted: 08/21/2013] [Indexed: 11/25/2022]
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Kaneko T, Leacche M, Byrne J, Cohn L. Reoperative minimal access aortic valve replacement. J Thorac Dis 2013; 5 Suppl 6:S669-72. [PMID: 24251026 DOI: 10.3978/j.issn.2072-1439.2013.09.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 09/26/2013] [Indexed: 11/14/2022]
Abstract
Reoperative minimal access aortic valve replacement (AVR) is performed through an upper hemisternotomy with peripheral cannulation. This approach limits dissection of mediastinum and especially the left internal mammary artery (LIMA) graft in patients with previous coronary artery bypass grafting (CABG) thus minimizing trauma to the patient. This approach is safe and feasible and may have some benefit over conventional full sternotomy in terms of mortality and morbidity.
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Affiliation(s)
- Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
The transition of mitral valve surgery away from the traditional sternotomy approach toward more minimally invasive strategies continues to evolve. The use of telemanipulative robotic arms with near 3-dimensional valve visualization has allowed for near complete endoscopic robotic-assisted mitral valve surgery, providing increased patient satisfaction and cosmesis. Studies have shown rapid recovery times without sacrificing perioperative safety or the durability of surgical repair. Although a steep learning curve exists as well as high fixed and disposable costs, continued technological development fueled by increasing patient demand may allow for further expansion in the use of robotic-assisted minimal invasive surgery.
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Affiliation(s)
- William Vernick
- Department of Anesthesiology and Critical Care, The Perelman School of Medicine at the University Hosptial of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Reser D, Sündermann S, Grünenfelder J, Scherman J, Seifert B, Falk V, Jacobs S. Obesity Should Not Deter a Surgeon from Selecting a Minimally Invasive Approach for Mitral Valve Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013. [DOI: 10.1177/155698451300800310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Diana Reser
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Simon Sündermann
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Jürg Grünenfelder
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Jacques Scherman
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Burkhardt Seifert
- Division of Biostatistics, ISPM, University of Zürich, Zürich, Switzerland
| | - Volkmar Falk
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
| | - Stephan Jacobs
- Department of Cardiovascular Surgery, University Hospital Zürich, Zürich, Switzerland
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29
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Obesity Should Not Deter a Surgeon from Selecting a Minimally Invasive Approach for Mitral Valve Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013; 8:225-9. [DOI: 10.1097/imi.0b013e3182a20e5a] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Objective Obesity is highly prevalent in modern patient populations. Several studies have published conflicting outcomes after minimally invasive surgery with regard to morbidity and mortality. Some instances consider obesity as a relative contraindication for this approach because of inadequate exposure of the surgical field. Our aim was to investigate the outcomes of minimally invasive mitral valve surgery through a right lateral minithoracotomy in patients with a body mass index (BMI) of 30 kg/m2 or greater. Methods We conducted a retrospective database review between January 1, 2009, and December 31, 2011. Preoperative, intraoperative, postoperative, and follow-up data of 225 consecutive patients were collected. Results The patients were stratified according to their BMI: 108 had a normal weight with a BMI of lower than 25 kg/m2 (18–24), 90 were overweight with a BMI of 25 to 29 kg/m2, and 27 were obese with a BMI of 30 kg/m2 (30–41) or greater. Statistical analysis showed significantly longer ventilation times in the obese group, whereas all other variables were similar. Survival, major adverse cardiac and cerebrovascular event-free survival, valve competency, and freedom from reoperation were also comparable. Conclusions Our data suggest that obesity should not deter a surgeon from selecting a minimally invasive approach. Despite longer postoperative ventilation times, a BMI of 30 kg/m2 or greater does not influence short- and medium-term outcome. Obese patients may even benefit from this approach because it avoids the need for sternotomy and therefore reduces the risk for sternal wound infection.
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30
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Chung JW, Chee HK, Kim JS. Two approaches for repeat cardiac surgery. J Cardiothorac Surg 2012; 7:114. [PMID: 23088417 PMCID: PMC3502480 DOI: 10.1186/1749-8090-7-114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 09/25/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With recent advances in post-operative care and surgical methods, the number of cardiovascular re-operations is increasing. We analyzed our institutional experience to evaluate the safety and efficacy of the approach methods for cardiac re-operations. METHODS Between September 2007 and December 2010, we performed 208 cardiac re-operations, defined as surgery which was not performed within a month from the previous operation or during the same hospitalization for the same disease and reviewed retrospectively. According to the surgical approach, we divided patients into two groups: median sternotomy group (S-group, n = 146), and thoracotomy group (T-group, n = 62). RESULTS There were no differences in sex or mean interval from the first surgery to re-operation between the two groups. Mean cardiopulmonary bypass, adhesion dissection time, bleeding control time, and operation time were significantly shorter in the T-group. The need for transfusion (p = 0.001) during adhesion dissection and the chest tube drainage (p < 0.001) were significantly lower in the T-group. There were 10 operative deaths in the S-group (6.8%) and 5 in the T-group (8.1%) (p = 0.757). Pneumonia was the most common cause of death in both groups. Post-operative bleeding did not result in death and there were no cases of wound infection in the T-group. CONCLUSIONS Two approaches for repeated cardiac surgery were safe and effective in terms of mortality, wound infection, bleeding, operation time, adhesion dissecting time, and bleeding control time. We were able to obtain a good visual field and perform safe surgery by applying the thoracotomy method in selective patients for cardiovascular re-operation.
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Affiliation(s)
- Jin Woo Chung
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, 4-12, Hwayang-dong, Gwangjin-gu, Seoul 143-701, South Korea
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Yu PJ, Galloway AC. Minimally invasive approach for mitral valve repair in a patient with prior pentalogy of Fallot repair. Semin Thorac Cardiovasc Surg 2012; 24:144-5. [PMID: 22920532 DOI: 10.1053/j.semtcvs.2012.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Pey-Jen Yu
- Department of Cardiothoracic Surgery, New York University School of Medicine, New York, New York, USA
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Kim DC, Chee HK, Song MG, Shin JK, Kim JS, Lee SA, Park JB. Comparative analysis of thoracotomy and sternotomy approaches in cardiac reoperation. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2012; 45:225-9. [PMID: 22880166 PMCID: PMC3413826 DOI: 10.5090/kjtcs.2012.45.4.225] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Revised: 11/01/2011] [Accepted: 11/11/2011] [Indexed: 11/29/2022]
Abstract
Background Reoperation of cardiac surgery via median sternotomy can be associated with significant complications. Thoracotomy is expected to reduce the risk of reoperation and to enhance the surgical outcomes. We retrospectively analyzed two operative approaches (thoracotomy vs. sternotomy) in cardiac reoperation. Materials and Methods From September 2007 to December 2010, 35 patients who required reoperation of the mitral valvular disease following previous median sternotomy were included. Average age of patients was 45.8±15.4 years (range, 14 to 76 years) and male-to-female was 23:12. Interval period between primary operation and reoperation was 135.8±105.6 months (range, 3.3 to 384.9 months). Results Comparative analysis was done dividing the patient group into two groups that are thoracotomy group (22 patients) and sternotomy group (13 patients). Thoracotomy group was significantly lower in operative time (415.2±90.3 vs. 497.5±148.0, p<0.05), bleeding control time (108.0±29.5 vs. 146.4±66.8, p<0.05) and chest tube drainage (287.5±211.5 mL vs. 557.3±365.5 mL, p<0.05) compared to sternotomy group. Conclusion The thoracotomy approach is superior to sternotomy in some variables, and it is considered as a valid alternative to repeat median sternotomy in patients who underwent a previous median sternotomy.
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Affiliation(s)
- Dong Chan Kim
- Department of Thoracic and Cardiovascular Surgery, Konkuk University Medical Center, Konkuk University School of Medicine, Korea
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Pineda AM, Santana O, Lamas GA, Lamelas J. Is a minimally invasive approach for re-operative aortic valve replacement superior to standard full resternotomy? Interact Cardiovasc Thorac Surg 2012; 15:248-52. [PMID: 22566512 DOI: 10.1093/icvts/ivr141] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
A best-evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'is a minimally invasive approach for re-operative aortic valve replacement (AVR) superior to standard full resternotomy?' A total of 193 papers were found using the reported search of which 13 represented the best evidence to answer the clinical question. The authors, country, journal and date of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that minimally invasive re-operative AVR can be performed with an operative morbidity and mortality at least similar to the standard full sternotomy approach. A shorter hospital length of stay and less blood product requirements are the main advantages of this technique. The incidence of prolonged ventilation, bleeding requiring re-operation, sternal wound infections and in-hospital mortality may be reduced with a minimally invasive approach. Prospective studies are required to confirm the potential benefits of minimally invasive surgery and, up to date, conventional full re-sternotomy is still the standard approach for re-operative AVR.
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Affiliation(s)
- Andrés M Pineda
- The Columbia University Division of Cardiology, Division of Cardiac Surgery, Mount Sinai Heart Institute, Miami Beach, FL 33140, USA
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Vernick WJ, Woo JY. Anesthetic considerations during minimally invasive mitral valve surgery. Semin Cardiothorac Vasc Anesth 2012; 16:11-24. [PMID: 22361820 DOI: 10.1177/1089253211434591] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Advances in instruments and visualization tools as well as circulatory systems for cardiopulmonary bypass during the late 1990s have stimulated widespread adoption of minimally invasive mitral valve surgery (MIMVS). Today, MIMVS is the standard approach for many surgeons and institutions. There are multiple benefits of MIMVS. Patient satisfaction and improved cosmesis are important. Additionally, studies have consistently shown faster recovery times and less associated pain with MIMVS. Statistically significant improvement in bleeding, transfusion, incidence of atrial fibrillation, and time to resumption of normal activities with MIMVS has also been shown when comparing MIMVS with conventional mitral surgery. Most important, these benefits have been achieved without sacrificing perioperative safety or durability of surgical repair. Although a steep learning curve still exists given the high level of case complexity, continued development fueled by increasing patient demand may allow for even further expansion in the use of minimal invasive techniques.
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Affiliation(s)
- William J Vernick
- Department of Anesthesia and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
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McClure RS, Cohn LH. Minimally invasive surgery for aortic stenosis in the geriatric patient: where are we now? ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ahe.11.84] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Minimally invasive aortic valve surgery has evolved with time and become the routine approach for aortic surgery in select surgical centers. The success of these procedures in the nonelderly has led some to embark on using minimal access techniques in the geriatric population as well. With the geriatric community often inflicted with the greatest disease burden, suffering not only from a valvular process but also cumulative comorbidities, geriatric patients may be the patients most likely to derive benefit from a minimally invasive approach. Alternative therapies for symptomatic aortic stenosis include conventional full-sternotomy aortic valve replacement in addition to transcatheter aortic valve implantation. Each option has its advantages and disadvantages. The role of minimal access aortic valve surgery and its impact on the progressively aging population in the face of conventional surgery and transcatheter technology is discussed.
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Affiliation(s)
- R Scott McClure
- Harvard Medical School, Division of Cardiac Surgery, Brigham & Women’s Hospital, Boston, MA 02115, USA
| | - Lawrence H Cohn
- Harvard Medical School, Division of Cardiac Surgery, Brigham & Women’s Hospital, Boston, MA 02115, USA
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Kitamura T, Stuklis RG, Edwards J. Redo mitral valve operation via right minithoracotomy--"no touch" technique. Int Heart J 2011; 52:107-9. [PMID: 21483170 DOI: 10.1536/ihj.52.107] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Five patients who had had previous cardiac operations underwent minimally invasive beating heart mitral valve operations via a right minithoracotomy between November 2006 and February 2009. The mean age was 64 ± 10 years and 4 were female. Under general anesthesia with single-lumen ventilation, cardiopulmonary bypass was established using the right femoral artery and vein. Through right minithoracotomy, the left atrium was opened without dissection of pericardial adhesion. The aorta was not cannulated or clamped, using a so-called "No Touch" technique. Four patients had mitral valve replacement and one had mitral ring annuloplasty with the heart beating. Mean cardiopulmonary bypass time was 118 ± 38 minutes. There was no early mortality or confirmed stroke. One patient who underwent mitral ring annuloplasty for ischemic mitral regurgitation died 3 months after surgery due to renal failure. At follow-up, New York Heart Association functional class had improved in 3 patients. In conclusion, in our initial series, minimally invasive beating heart redo mitral valve surgery through right minithoracotomy was safely performed with no early mortality.
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Affiliation(s)
- Tadashi Kitamura
- Department of Cardiothoracic Surgery, University of Tokyo Hospital, Hongo, Bunkyo-ku, Tokyo, Japan
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Abstract
Over the past two decades, significant advances have been made in mitral valve surgery. Cardiac surgeons have successfully repaired degenerative and ischemic regurgitant mitral valves via a traditional midline sternotomy. In recent years, alternate incisions have yielded minimally invasive approaches to the mitral valve. Technological advances have made robotically assisted minimally invasive mitral valve surgery feasible. Decreased pain, more rapid return to work, diminished blood loss and reduced length of hospitalization have been witnessed following robotic mitral valve surgery when compared with a traditional sternotomy. Equivalent long-term mortality and freedom from recurrent mitral regurgitation are evident between mitral valve repair performed via a traditional sternotomy and minimally invasive and robotic techniques. As a result, an increasing number of patients and referring cardiologists are seeking minimally invasive approaches to mitral valve surgery.
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Affiliation(s)
- Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania School of Medicine, Silverstein 6, 3400 Spruce St, Philadelphia, PA 19104, USA
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Giordano V, Grandjean JG. Mitral Re-Repair and Right Coronary Fistula Closure Advantage of Minimally Invasive Approach. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2010; 5:456-9. [DOI: 10.1177/155698451000500614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A 51-year-old man developed severe mitral regurgitation 10 years after previous mitral valve repair; the echocardiographic images showed a remarkable eccentric jet toward posterior wall of left atrium associated with a high degree of pulmonary vein retrograde flow. The coronary arteriography pointed out no pathologic lesions but a coronary fistula from the proximal right coronary to the right atrium. The standard approach was avoided, and a right anterolateral minithoracotomy was chosen, providing an excellent view. Under cardiopulmonary bypass and mild hypothermia, the mitral valve was re-repaired, and a new ring was implanted. After aortic cross-clamp release, the right coronary fistula was closed through the right atrium. The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. In such a high-risk reintervention and concomitant procedure, we think that this different approach may represent a feasible and reliable alternative.
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Affiliation(s)
- Vincenzo Giordano
- Department of Cardio-Thoracic Surgery, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Jan G. Grandjean
- Department of Cardio-Thoracic Surgery, Thoraxcentrum Twente, Medisch Spectrum Twente, Enschede, The Netherlands
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Loforte A, Luzi G, Montalto A, Ranocchi F, Polizzi V, Sbaraglia F, Della Monica PL, Menichetti A, Musumeci F. Video-Assisted Minimally Invasive Mitral Valve Surgery External Aortic Clamp versus Endoclamp Techniques. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2010; 5:413-8. [DOI: 10.1177/155698451000500606] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective Video-assisted minimally invasive mitral valve surgery can be performed through different approaches. The aim of the study was to report our early results and compare the external transthoracic aortic clamping with the endoaortic balloon occlusion techniques according to our experience. Methods Between January 2000 and March 2010, 138 patients (103 women, aged 58.4 ± 10.2 years) underwent video-assisted mitral valve surgery through a right thoracotomy. Cardiopulmonary bypass was instituted by femoral arterial and bicaval cannulation with active venous drainage and normothermia; cardioplegic arrest achieved with intermittent blood cardioplegia. In group A (93 patients, 68 women, aged 58.8 ± 7.8 years, 72 MV replacement, 21 MV repair), aortic clamping was achieved using the external transthoracic aortic clamp. In group B (45 patients, 35 women, aged 58.1 ± 11.4 years, 33 MV replacement, 12 MV repair), aortic clamping was achieved with endoaortic balloon occlusion. Results Intraoperative procedure-associated problems were experienced in one patient (0.7%) in group A (one conversion to sternotomy for pleural adhesions and bad exposure). At a mean follow-up of 36 ± 18 months, 135 patients (97.8%) were in New York Heart Association class I to II, with satisfactory echocardiographic follow-up. In group A, two patients had noncardiac-related deaths. No perioperative deaths were observed in both groups. There were four (2.8%) transient ischemic attacks and one (0.7%) peripheral ischemic event (group A) during the early postoperative period. Mitral valve repair patients had a 5-year freedom from reoperation of 100% in both groups. There was no significant difference between the two groups regarding preoperative variables, such as age, sex, New York Heart Association class, and left ventricular ejection fraction (P ≥ 0.05). Postoperative levels of myocardial cytonecrosis enzymes (MB fraction, creatine kinase, and troponine I) as well as operative time, extracorporeal circulation, and aortic cross-clamping times or ventilation and intensive care unit times were not significantly different between the two groups (P ≥ 0.05). More microembolic events were observed in group A than in group B (total 143.4 ± 30.6 per patient vs 78.9 ± 28.6 per patient) by means of continuous automated intraoperative transcranial Doppler evaluations (P < 0.05) applied to part of population. Conclusions Both techniques proved safe and comparable with low risk of morbidity and mortality. Patients undergoing endoclamp technique resulted to be less subject to embolism.
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Affiliation(s)
- Antonio Loforte
- Department of Cardiac Surgery and Transplantation, San Camillo Hospital, Rome, Italy
| | - Giampaolo Luzi
- Department of Cardiac Surgery and Transplantation, San Camillo Hospital, Rome, Italy
| | - Andrea Montalto
- Department of Cardiac Surgery and Transplantation, San Camillo Hospital, Rome, Italy
| | - Federico Ranocchi
- Department of Cardiac Surgery and Transplantation, San Camillo Hospital, Rome, Italy
| | - Vincenzo Polizzi
- Department of Cardiac Surgery and Transplantation, San Camillo Hospital, Rome, Italy
| | - Fabio Sbaraglia
- Department of Cardiac Surgery and Transplantation, San Camillo Hospital, Rome, Italy
| | | | - Antonio Menichetti
- Department of Cardiac Surgery and Transplantation, San Camillo Hospital, Rome, Italy
| | - Francesco Musumeci
- Department of Cardiac Surgery and Transplantation, San Camillo Hospital, Rome, Italy
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Levin R, Leacche M, Petracek MR, Deegan RJ, Eagle SS, Thompson A, Pretorius M, Solenkova NV, Umakanthan R, Brewer ZE, Byrne JG. Extending the Use of the Pacing Pulmonary Artery Catheter for Safe Minimally Invasive Cardiac Surgery. J Cardiothorac Vasc Anesth 2010; 24:568-73. [DOI: 10.1053/j.jvca.2010.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2009] [Indexed: 11/11/2022]
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Schmitto JD, Mokashi SA, Cohn LH. Minimally-Invasive Valve Surgery. J Am Coll Cardiol 2010; 56:455-62. [DOI: 10.1016/j.jacc.2010.03.053] [Citation(s) in RCA: 210] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2009] [Revised: 03/05/2010] [Accepted: 03/09/2010] [Indexed: 11/25/2022]
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Morales D, Williams E, John R. Is resternotomy in cardiac surgery still a problem? Interact Cardiovasc Thorac Surg 2010; 11:277-86. [PMID: 20525761 DOI: 10.1510/icvts.2009.232090] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Multiple factors contribute to the growing number of reoperations for congenital and acquired cardiovascular diseases in the United States. Although the hazards are well-recognized, the health economic burden of resternotomy (RS) remains unclear and may be difficult to quantify. Contrary to published studies citing low frequencies of catastrophic hemorrhage and mortality, survey responses from practicing surgeons disclose higher rates of complications. Safety strategies in cardiac reoperation have generally involved efforts to maximize visualization during dissection, specialized surgical maneuvers and instrumentation, customized methods for establishing extracorporeal circulation, and techniques to prevent or avoid retrosternal adhesions. Yet, the relative cost-effectiveness of these strategies is largely unexplored. With the ongoing constraints in healthcare budgets, differentiating the value of existing and future approaches in terms of relative clinical benefits, costs, and impact on resource utilization will become increasingly important. We reviewed the relevant published literature in order to survey the morbidity and resource utilization associated with RS in cardiac reoperation and to identify key issues relevant for future studies.
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Affiliation(s)
- David Morales
- Division of Congenital Heart Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin St, MC-WT 19345H, Houston, TX 77030, USA.
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Totaro P, Zattera G, Alloni A, Cattadori B, Degani A, Massimiliano Grande A, Monterosso C, D'Armini AM, Vigano M. The axillary artery as an alternative site of cannulation for redo port access-assisted minimally invasive mitral valve surgery: early report of 2 cases. Perfusion 2009; 24:357-9. [DOI: 10.1177/0267659109353140] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The minimally invasive Heartport (HP)-assisted technique has become first choice option for mitral valve surgery in many centres.The pool of patients potentially treated using HP techniques, however, is still limited by the presence of peripheral vessel disease, expecially in the elderly population. Alternative approaches to using the HP technique safely in such a subset of patients, therefore, should be evaluated. Here, we present our preliminary experience using the axillary artery as an alternative site of cannulation for HP-assisted redo mitral valve surgery in patients with concomitant peripheral vessel disease.
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Affiliation(s)
| | | | - Alessia Alloni
- Cardiac Surgery, Foundation IRCCS San Matteo, Pavia, Italy
| | | | | | | | | | - Andrea Maria D'Armini
- Cardiac Surgery, Foundation IRCCS San Matteo, Pavia, Italy, School of Medicine, University of Pavia, Italy
| | - Mario Vigano
- Cardiac Surgery, Foundation IRCCS San Matteo, Pavia, Italy, School of Medicine, University of Pavia, Italy
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45
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Modi P, Rodriguez E, Hargrove WC, Hassan A, Szeto WY, Chitwood WR. Minimally invasive video-assisted mitral valve surgery: A 12-year, 2-center experience in 1178 patients. J Thorac Cardiovasc Surg 2009; 137:1481-7. [DOI: 10.1016/j.jtcvs.2008.11.041] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2008] [Revised: 10/21/2008] [Accepted: 11/21/2008] [Indexed: 10/21/2022]
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46
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Tabata M, Khalpey Z, Shekar PS, Cohn LH. Reoperative minimal access aortic valve surgery: Minimal mediastinal dissection and minimal injury risk. J Thorac Cardiovasc Surg 2008; 136:1564-8. [DOI: 10.1016/j.jtcvs.2008.07.043] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Revised: 07/21/2008] [Accepted: 07/28/2008] [Indexed: 11/26/2022]
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Dagenais F. Minimally invasive mitral valve surgery: evolution, techniques and outcomes. Future Cardiol 2008; 4:609-16. [DOI: 10.2217/14796678.4.6.609] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Surgical treatment of the mitral valve has evolved considerably since the 1920s. During the mid-1990s new approaches through small incisions have been proposed to access the mitral valve. We herein describe the evolution of mitral surgery, the development of minimally invasive mitral techniques and compare outcomes to a standard sternotomy approach.
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Affiliation(s)
- Francois Dagenais
- Laval Hospital, Department of Cardiac Surgery, 2725 chemin Sainte-Foy, Québec, Canada, G1V 4G5
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48
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Modi P, Hassan A, Chitwood WR. Minimally invasive mitral valve surgery: a systematic review and meta-analysis. Eur J Cardiothorac Surg 2008; 34:943-52. [PMID: 18829343 DOI: 10.1016/j.ejcts.2008.07.057] [Citation(s) in RCA: 334] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Revised: 07/19/2008] [Accepted: 07/28/2008] [Indexed: 10/21/2022] Open
Abstract
The mitral valve has been traditionally approached through a median sternotomy. However, significant advances in surgical optics, instrumentation, tissue telemanipulation, and perfusion technology have allowed for mitral valve surgery to be performed using progressively smaller incisions including the minithoracotomy and hemisternotomy. Due to reports of excellent results, minimally invasive mitral valve surgery has become a standard of care at certain specialized centers worldwide. This meta-analysis quantifies the effects of minimally invasive mitral valve surgery on morbidity and mortality compared with conventional mitral surgery and demonstrates equivalent perioperative mortality (1641 patients, odds ratio (OR) 0.46, 95% confidence interval 0.15-1.42, p=0.18), reduced need for reoperation for bleeding (1553 patients, OR 0.56, 95% CI 0.35-0.90, p=0.02) and a trend towards shorter hospital stays (350 patients, weighted mean difference (WMD) -0.73, 95% CI -1.52 to 0.05, p=0.07). These benefits were evident despite longer cardiopulmonary bypass (WMD 25.81, 95% CI 13.13-38.50, p<0.0001) and cross-clamp times (WMD 20.91, 95% CI 8.79-33.04, p=0.0007) in the minimally invasive group. Case-control studies show consistently less pain and faster recovery compared to those having a conventional approach. Data for minimally invasive mitral valve surgery after previous cardiac surgery are limited but consistently demonstrate reduced blood loss, fewer transfusions and faster recovery compared to reoperative sternotomy. Long-term follow-up data from multiple cohort studies are also examined revealing equivalent survival and freedom from reoperation. Thus, current clinical data suggest that minimally invasive mitral valve surgery is a safe and a durable alternative to a conventional approach and is associated with less morbidity.
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Affiliation(s)
- Paul Modi
- East Carolina Heart Institute, Greenville, NC 27834, USA
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Chiu KM, Wu CC, Wang MJ, Lu CW, Shieh JS, Lin TY, Chu SH. Local infusion of bupivacaine combined with intravenous patient-controlled analgesia provides better pain relief than intravenous patient-controlled analgesia alone in patients undergoing minimally invasive cardiac surgery. J Thorac Cardiovasc Surg 2008; 135:1348-52. [DOI: 10.1016/j.jtcvs.2008.01.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2007] [Revised: 01/04/2008] [Accepted: 01/28/2008] [Indexed: 12/18/2022]
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50
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Murtuza B, Pepper JR, DeL Stanbridge R, Jones C, Rao C, Darzi A, Athanasiou T. Minimal Access Aortic Valve Replacement: Is It Worth It? Ann Thorac Surg 2008; 85:1121-31. [DOI: 10.1016/j.athoracsur.2007.09.038] [Citation(s) in RCA: 171] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2007] [Revised: 09/17/2007] [Accepted: 09/18/2007] [Indexed: 11/26/2022]
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