Is tri-port totally thoracoscopic surgery for mitral valve replacement a feasible approach?

Thoracoscopic closure of atrial septal defect in perfused beating hearts

OBJECTIVE

This study aims to characterize the mid and long-term clinical outcomes of 856 atrial septal defect cases that underwent closure using MTCST without the assistance of a robotic system.

METHODS

From June 2009 to September 2023, a total of 856 cases at our center underwent selective repair of a secundum-type atrial septal defect using MTCST without Da Vinci robotic assistance. According to whether the operation was performed during an arrested heart or not, patients were divided into arrested heart group (n = 110) and beating heart group (n = 746). Cardiopulmonary bypass was established peripherally. Three-port incisions in the right chest were conducted first, followed by a pericardiotomy, superior and inferior vena cava snaring, atriotomy, and the closure of atrial septal defect under a thoracoscope. Patients were followed up from 3 months to 12 years postoperatively.

RESULTS

The exclusively MTCST for atrial septal defect closure was successfully performed without any in-hospital mortality in both groups. None of the procedures required an alternative technique for the closure. There were significant learning curves for cardiopulmonary bypass time and operation time. No residual shunt was observed in all patients during the follow-up transthoracic echocardiography at 5-day and 3-month timepoints postoperatively.

CONCLUSIONS

This study demonstrates that an exclusively MTCST for atrial septal defect repair is safe, simple, and minimally invasive. Exclusively MTCST is a new desirable alternative beside robotic-assisted atrial septal defect repair.

Comparative efficacy of totally thoracoscopic, mini-thoracotomy, and mini-sternotomy approaches in aortic valve replacement

Aortic valve replacement (AVR) is a critical procedure for patients with aortic valve diseases. This study compares the effectiveness of three minimally-invasive surgical approaches for AVR: totally thoracoscopic (TT), right anterior mini-thoracotomy, and upper mini-sternotomy. We analyzed retrospective data from 130 patients who underwent one of these surgeries, focusing on various factors such as duration of hospital stay, operation time, times for cardiopulmonary bypass and aortic cross-clamping, postoperative complications, levels of cardiac biomarkers, pain intensity using the Visual Analog Scale, and mid-term survival rates. Results show that while the TT method had the longest operation times, it also had the shortest hospital stays and faster pain reduction post-surgery. Although the TT group initially showed higher cardiac biomarker levels after surgery, these levels normalized by the third day, similar to the other groups. There were no significant differences in mid-term survival and major adverse cardiac and cerebrovascular event (MACCE) rates among the groups. These findings suggest that the TT method, despite longer surgical times, offers a quicker initial recovery, making it a viable option for AVR.

Technique and early outcomes of total thoracoscopic double-valve replacement

Objective

Reports on aortic and mitral double-valve replacement through total thoracoscopy are scarce, with surgical techniques constantly evolving. We aimed to compare the feasibility and safety between total thoracoscopic double-valve replacement and median sternotomy double-valve replacement.

Methods

From November 2021 to March 2023, we performed double-valve replacements in 76 patients using the total thoracoscopic double-valve replacement. The control group comprised 77 patients who underwent median sternotomy double-valve replacement. We analyzed data on baseline characteristics, perioperative events, and early postoperative outcomes.

Results

In the total thoracoscopic double-valve replacement group, the cardiopulmonary bypass and aortic crossclamping times were 174.20 ± 38.87 minutes and 120.20 ± 19.54 minutes, respectively; both were significantly longer compared with those in the median sternotomy double-valve replacement group (cardiopulmonary bypass: 123.65 ± 15.33 minutes; aortic crossclamping: 82.86 ± 9.51 minutes, P < .001). The total thoracoscopic double-valve replacement group exhibited an extended operative duration, with a mean of 4.40 ± 0.76 hours, in contrast to 3.21 ± 0.68 hours in the median sternotomy double-valve replacement group (P < .001). Postoperatively, the total thoracoscopic double-valve replacement group demonstrated a significantly shorter mechanical ventilation duration (9.29 ± 3.12 hours) and reduced intensive care unit stay time (24.31 ± 7.29 hours) than the median sternotomy double-valve replacement group (11.49 ± 4.27 hours and 26.76 ± 5.89 hours, respectively; P values of .019 and .040, respectively). Furthermore, the total thoracoscopic double-valve replacement group experienced a shorter postoperative hospitalization time, averaging 6.21 ± 1.58 days, than the median sternotomy double-valve replacement group (8.35 ± 1.07 days, P < .001). The total thoracoscopic double-valve replacement group also exhibited significantly lower chest drainage volume (average 223.91 ± 53.93 mL) than the median sternotomy double-valve replacement group (382.56 ± 61.87 mL, P < .001). In terms of transfusion rates, the total thoracoscopic double-valve replacement group (9.21%) showed a marked reduction compared with the median sternotomy double-valve replacement group (36.36%, P < .001). Both groups had similar major complications.

Conclusions

The initial results of the total thoracoscopic double-valve replacement underscore its safety and efficacy. This approach extends the applicability of total thoracoscopic cardiac surgery and warrants deeper exploration.

Totally thoracoscopic surgical resection of left ventricular benign tumor

OBJECTIVE

The study objective was to explore the feasibility and safety of totally endoscopic resection of a left ventricular tumor through small chest incisions without robotic assistance.

METHODS

Four patients with a left ventricular tumor (1 papillary fibroelastoma, 1 lipoma, and 2 myxomas) underwent surgery with peripheral cardiopulmonary bypass. The mean age of patients was 58 ± 15 years. There were 3 female patients and 1 male patient. Through 3-port incisions in the right chest, pericardiotomy, bicaval cannulation, cardiac arrest, and atriotomy, left ventricular tumor resection was performed under thoracoscopy.

RESULTS

All patients had successful resections. The cardiopulmonary bypass and aortic crossclamp times were 110 ± 14 minutes and 58 ± 19 minutes, respectively. The length of stay in the intensive care unit was 38 ± 27 hours. There were no mortalities or complications in this cohort. Patients were discharged 7 days after the operation. Transthoracic echocardiography showed that the cardiac tumor was completely removed without any residue 3 months after surgery.

CONCLUSIONS

Totally endoscopic left ventricular tumor resection without a robotically assisted surgical system is feasible and reproducible. This technique could minimize surgical trauma and achieves complete tumor resection.

Total Thoracoscopic versus Robotic Surgery for Repair of Atrial Septum Defect: A Propensity Matching Score Analysis

Robotic surgery can provide less surgical trauma than conventional surgery, but differences between robotic and thoracoscopic surgery for atrial septal defect (ASD) repair are not well documented. To explore whether ASD can be repaired by thoracoscopic surgery or robotic surgery, which procedure is less invasive, and the difference in outcomes between these two procedures, this article studies 160 patients undergoing ASD repair at our institution. Sixty-five patients underwent total thoracoscopic surgery and 95 patients underwent total endoscopic robotic surgery. Propensity score matching yielded 64 well-matched patient pairs. Surgical data and early postoperative outcomes between the two matched groups were analyzed and compared. The results show that thoracoscopic and robotic surgery to repair ASD are both safe and reliable, and the early curative effect is good. However, regardless of similar complication rates, robotic surgery has a shorter time, less postoperative drainage, and faster recovery than thoracoscopic surgery.