Ministernotomy versus conventional sternotomy for aortic valve replacement: A systematic review and meta-analysis

Outcomes of minimally invasive mitral valve surgery in patients with an ejection fraction of 35% or less

OBJECTIVE

We evaluated the outcomes of minimally invasive mitral valve surgery via a right anterior thoracotomy approach in patients with isolated severe mitral regurgitation and severely reduced left ventricular systolic function.

METHODS

We retrospectively reviewed all minimally invasive mitral valve surgeries for mitral regurgitation in patients with an ejection fraction of 35% or less performed at our institution between December 2008 and June 2011. The operative times, lengths of stay, postoperative complications, and mortality were analyzed.

RESULTS

We identified a total of 71 patients with severe mitral regurgitation and an ejection fraction of 35% or less who underwent minimally invasive mitral valve surgery. The mean ± SD age was 67 ± 10 years, and 44 of the patients were men (62%). The mean ± SD left ventricular ejection fraction was 27% ± 6%, and 28 patients (39%) had previous heart surgery. The median aortic cross-clamp and cardiopulmonary bypass times were 62 [interquartile range (IQR), 50-80) and 98 minutes (IQR, 92-124), respectively. There was no mitral regurgitation noted in any patient on postoperative transesophageal echocardiogram. The median intensive care unit length of stay was 51 hours (IQR, 42-86), and the median postoperative length of stay was 6 days (IQR, 5-9).

CONCLUSIONS

Minimally invasive mitral valve surgery for severe functional mitral regurgitation in patients with severe left ventricular dysfunction can be performed with a low morbidity and mortality.

Facilitated aortic valve replacement with complete sternotomy and minimal skin incision using endoscopy: a case of surgical report

Although median sternotomy is the accepted approach to the heart for cardiac surgery, minimally invasive approaches including partial sternotomies have recently been developed. However, such strategies might lead to sternal overriding, instability, and fracture or division of the internal thoracic arteries. Furthermore, a full sternotomy would be required to address unpredictable intra- or postoperative complications. This article describes minimally invasive aortic valve replacement via full sternotomy and minimal skin incision using an endoscope.

Aortic stenosis in high-risk patients. Surgical therapy

Conventional aortic valve replacement is the standard approach for treating aortic stenosis, it is performed via a full or partial sternotomy, and is associated with low risks for patients and with excellent long-term outcomes. This also holds true for octogenarians, if they present without relevant comorbidities. After resection of the calcified native leaflets, biological prostheses with good functionality and durability are implanted. Elderly patients with an increasing risk profile, however, should be treated by a heart team using transcatheter approaches including cardiac surgery.

Almanac 2012: adult cardiac surgery: the national society journals present selected research that has driven recent advances in clinical cardiology

This review covers the important publications in adult cardiac surgery in the last few years, including the current evidence base for surgical revascularisation and the use of off-pump surgery, bilateral internal mammary arteries and endoscopic vein harvesting. The changes in conventional aortic valve surgery are described alongside the outcomes of clinical trials and registries for transcatheter aortic valve implantation, and the introduction of less invasive and novel approaches of conventional aortic valve replacement surgery. Surgery for mitral valve disease is also considered, with particular reference to surgery for asymptomatic degenerative mitral regurgitation.

Aortic valve replacement via right anterolateral thoracotomy in the case of a patient with extreme mediastinal right-shift following pneumonectomy

We report on the case of a 68-year-old male patient with the history of right pneumonectomy due to bronchial carcinoma, who was referred for aortic valve replacement due to severe calcified aortic stenosis. Pre-operative chest X-ray and computed tomography (CT) revealed an unusually pronounced mediastinal shift to the right. Despite this unusual anatomy, we decided to perform surgery using the right anterolateral thoracotomy following thorough pre-operative planning using 3D-volume rendering of the CT data-set. This approach yielded excellent exposure of the aortic root and the ascending aorta, respectively. Following an uneventful operative and post-operative course the patient could be discharged on post-OP day 6.Although only occasionally described for aortic valve replacement a right anterolateral thoracotomy may represent a valuable surgical approach, particular in patients with unusual anatomy, e.g. a mediastinal right-shift. However, thorough pre-operative planning, i.e. using visualization and planning techniques such as 3D-volume rendering should be mandatory as it provides information crucial to facilitate surgical steps and thus, may help avoid severe surgical complications.

Sutureless Aortic Valve Implantation through an Upper V-Type Ministernotomy: An Innovative Approach in High-Risk Patients

Objective

Aortic valve replacement in minimally invasive approach has shown to improve clinical outcomes even with a prolonged cardiopulmonary bypass and aortic cross-clamp (ACC) time. Sutureless aortic valve implantation may ideally shorten operative time. We describe our initial experience with the sutureless 3f Enable (Medtronic, Inc, ATS Medical, Minneapolis, MN USA) aortic bioprosthesis implanted in minimally invasive approach in high-risk patients.

Methods

Between May 2010 and May 2011, thirteen patients with severe aortic stenosis underwent aortic valve replacement with the 3f Enable bioprosthesis through an upper V-type ministernotomy interrupted at the second intercostal space. The mean ± SD age was 77 ± 3.9 years (range, 72–83 years), 10 patients were women, and the mean ± SD logistic EuroSCORE was 15% ± 13.5%. Echocardiography was performed preoperatively, at postoperative day 1, at discharge, and at follow-up. Clinical data, adverse events, and patient outcomes were recorded retrospectively. The median follow-up time was 4 months (interquartile range, 2–10 months).

Results

Most of the implanted valves were 21 mm in diameter (19–25 mm). The CPB and ACC times were 100.2 ± 25.3 and 66.4 ± 18.6 minutes. At short-term follow-up, the mean ± SD pressure gradient was 14 ± 4.9 mm Hg; one patient showed trivial paravalvular leakage. No patients died during hospital stay or at follow-up.

Conclusions

The 3f Enable sutureless bioprosthesis implanted in minimally invasive approach through an upper V-type ministernotomy is a feasible, safe, and reproducible procedure. Hemodynamic and clinical data are promising. This innovative approach might be considered as an alternative in high-risk patients. Reduction of CPB and ACC time is possible with increasing of experience and sutureless evolution of actual technology.

The year in Cardiothoracic and Vascular Anesthesia: selected highlights from 2011

There have been rapid advances in oral anticoagulation. The oral factor Xa inhibitors rivaroxaban and apixaban and the oral direct thrombin inhibitor dabigatran recently have been rigorously evaluated. These novel anticoagulants will usher in a new paradigm for perioperative anticoagulation. Perioperative blood conservation in cardiac surgery recently has been highlighted in the updated guidelines by the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. These recommendations reflect a comprehensive evaluation of the recent evidence to optimize transfusion practice. Transcatheter mitral valve repair continues to mature. Transcatheter aortic valve implantation for aortic stenosis has entered the clinical mainstream, with randomized trials showing its superiority over medical management and its equivalency to surgical valve replacement in high-risk patients. This transformational technology represents a major leadership opportunity for the cardiac anesthesiologist. Minimally invasive valve surgery has shown effectiveness in high-risk patients. Radial access is equivalent to femoral access for percutaneous coronary intervention in acute coronary syndromes but significantly reduces the risk of local vascular complications. Recent trials have further clarified the roles of medical therapy, percutaneous coronary intervention, and coronary artery bypass surgery in patients with significant coronary artery disease and left ventricular dysfunction. The past year has witnessed major advances in cardiovascular practice with new drugs, new devices, and new guidelines. The coming year most likely will advance these achievements to enhance the care of patients.

Surgery of the ascending aorta, root remodelling and aortic arch surgery with circulatory arrest through partial upper sternotomy: results of 50 consecutive cases

OBJECTIVES

Partial upper sternotomy is a routine approach to aortic valve surgery. For surgery of the ascending aorta or the aortic arch, this method is not well established yet.

METHODS

From October 2007 to October 2010, 50 consecutive patients underwent procedures of the ascending aorta and the aortic arch using partial upper sternotomy. Thirty-six patients underwent replacement or tightening of the ascending aorta, 11 patients received additional replacement of the proximal arch and in 3 cases, a complete replacement of the aortic arch was performed. Thirty-nine patients underwent additional aortic valve surgery.

RESULTS

Mean operation time was 249 ± 51 min. Mean aortic cross-clamp and cardiopulmonary bypass time were 95 ± 27 and 141 ± 35 min, respectively. No conversion to conventional sternotomy was performed. All valves appeared competent on postoperative echocardiography. Survival was 100%. One re-exploration for bleeding was necessary. One stroke (2%) occurred, one pacemaker was implanted due to third-degree AV block and 16 patients (32%) experienced atrial fibrillation. One patient suffered from sternal wound infection. One patient needed reoperation due to severe aortic insufficiency on postoperative day 13. Median postoperative ventilation time was 13 h, median intensive care unit (ICU) and hospital stay were 22 h and 7 days, respectively.

CONCLUSIONS

Results show that minimally invasive surgical procedures of the ascending aorta and the aortic arch may be performed safely, with an excellent clinical outcomes and superior cosmesis. Short ICU and hospital stay indicate the beneficial effects of reduced surgical trauma for patient recovery.

Anterolateral minithoracotomy versus median sternotomy for the treatment of congenital heart defects: a meta-analysis and systematic review

Background

Anterolateral Minithoracotomy (ALMT) for the radical correction of Congenital Heart Defects is an alternative to Median Sternotomy (MS) due to reduce operative trauma accelerating recovery and yield a better cosmetic outcome after surgery. Our purpose is to conduct whether ALMT would bring more short-term benefits to patients than conventional Median Sternotomy by using a meta-analysis of case–control study in the published English Journal.

Methods

6 case control studies published in English from 1997 to 2011 were identified and synthesized to compare the short-term postoperative outcomes between ALMT and MS. These outcomes were cardiopulmonary bypass time, aortic cross-clamp time, intubation time, intensive care unit stay time, and postoperative hospital stay time.

Results

ALMT had significantly longer cardiopulmonary bypass times (8.00 min more, 95% CI 0.36 to 15.64 min, p = 0.04). Some evidence proved that aortic cross-clamp time of ALMT was longer, yet not significantly (2.38 min more, 95% CI −0.15 to 4.91 min, p = 0.06). In addition, ALMT had significantly shorter intubation time (1.66 hrs less, 95% CI −3.05 to −0.27 hrs, p = 0.02). Postoperative hospital stay time was significantly shorter with ALMT (1.52 days less, 95% CI −2.71 to −0.33 days, p = 0.01). Some evidence suggested a reduction in ICU stay time in the ALMT group. However, this did not prove to be statistically significant (0.88 days less, 95% CI −0.81 to 0.04 days, p = 0.08).

Conclusion

ALMT can bring more benefits to patients with Congenital Heart Defects by reducing intubation time and postoperative hospital stay time, though ALMT has longer CPB time and aortic cross-clamp time.

Minimally invasive surgery for aortic stenosis in the geriatric patient: where are we now?

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.

Minimally invasive transaortic repair of the mitral valve

OBJECTIVE

We retrospectively evaluated the results of an edge-to-edge repair (Alfieri stitch) of the mitral valve performed via a transaortic approach in patients who were undergoing minimally invasive aortic valve replacement.

METHODS

From January 2010 to September 2010, 6 patients underwent minimally invasive edge-to-edge repair of the mitral valve via a transaortic approach with concomitant aortic valve replacement. The patients were considered to be candidates for this procedure if they were deemed by the surgeon to be high-risk for a double valve procedure and if on preoperative transesophageal echocardiogram the mitral regurgitation jet originated from the middle portion (A2/P2 segments) of the mitral valve.

RESULTS

There was no operative mortality. Mean cardiopulmonary bypass time was 137 minutes, and mean cross-clamp time was 111 minutes. There was a significant improvement in the mean mitral regurgitation grade, with a mean of 3.8 preoperatively and 0.8 postoperatively. The ejection fraction remained stable, with mean preoperative and postoperative ejection fractions of 43.3% and 47.5%, respectively. Follow-up transthoracic echocardiograms obtained at a mean of 33 days postoperatively (range, 8-108 days) showed no significant worsening of mitral regurgitation.

CONCLUSION

Transaortic repair of the mitral valve is feasible in patients undergoing minimally invasive aortic valve replacement.

Simplified closure of ministernotomy using thermoreactive sternal clips

An increasing number of aortic valve replacements are performed through a ministernotomy. Due to the small incision and partial fixation of the caudal sternum, the traditional wire closure can be complicated and even harmful to the surrounding tissue. In such cases, we recommend the use of nitinol clips for sternal closure. This technique, which we have used in 48 patients, is simple, safe, and fast, and results in excellent outcomes.

Outcomes of a minimally invasive approach compared with median sternotomy for the excision of benign cardiac masses

BACKGROUND

We hypothesize that for the excision of benign cardiac masses, a minimally invasive approach through a right minithoracotomy is safe and feasible, and has lower resource utilization when compared with a standard median sternotomy.

METHODS

We retrospectively analyzed 39 consecutive patients who underwent benign cardiac mass excision at our institution between December 1999 and April 2010. The in-hospital outcomes of patients who had a right minithoracotomy were compared with those of patients who underwent a standard median sternotomy.

RESULTS

Of the 39 patients, 22 had cardiac masses removed through a minimally invasive approach, and 17 had a median sternotomy. The type of masses resected included 26 myxomas (66.7%), 9 papillary fibroelastomas (23.1%), and 4 thrombi (10.2%). The aortic cross-clamp and cardiopulmonary bypass times were 43 minutes (interquartile range [IQR] 30 to 64) versus 31 minutes (IQR 23 to 47; p=0.20) and 78 minutes (IQR 55 to 88) versus 57 minutes (IQR 33 to 70; p=0.02) for the minimally invasive group and the median sternotomy group, respectively. There were no significant differences in postoperative complications including mortality. The mean intensive care unit and hospital lengths of stay were 27 hours (IQR 24 to 47) versus 60 hours (IQR 48 to 79; p=0.001) and 5 days (IQR 4 to 6) versus 7 days (IQR 6 to 8; p=0.03) for the minimally invasive and the median sternotomy group, respectively.

CONCLUSIONS

A minimally invasive approach through a right minithoracotomy for the resection of benign cardiac masses can be performed safely with lower resource utilization, and should be considered for these patients.

Outcomes of minimally invasive valve surgery versus median sternotomy in patients age 75 years or greater

BACKGROUND

Advanced age is a major predictor of poor outcome in patients undergoing valve surgery. We hypothesized that elderly patients who underwent minimally invasive valve surgery for aortic or mitral valve disease would do better when compared with those undergoing the standard median sternotomy.

METHODS

We retrospectively reviewed 2,107 consecutive heart operations at our institution and identified 203 patients, age 75 years or greater, who underwent isolated mitral or aortic valve surgery. Outcomes of those who had minimally invasive valve surgery through a right minithoracotomy were compared with those who had a median sternotomy.

RESULTS

Of the 203 patients, 119 (59%) underwent a minimally invasive approach, while 84 (41%) had a median sternotomy. The median postoperative length of stay was 7 days (interquartile range [IQR] 6 to 10) versus 12 days (IQR 9 to 20), p less than 0.001, and intensive care unit length of stay was 52 hours (IQR 44 to 93) versus 119 hours (IQR 57 to 193), p less than 0.001 for minimally invasive and median sternotomy, respectively. In-hospital mortality was 2 (1.7%) versus 8 (9.5%, p=0.01 and composite postoperative morbidity and mortality occurred in 25 (21%) versus 38 (45.2%), p less than 0.001, in minimally invasive versus median sternotomy, respectively. The difference was driven by the following: a lower incidence of acute renal failure, 1 (0.8%) versus 14 (16.7%), p<0.001; prolonged intubation 23 (19.3%) versus 32 (38.1%), p=0.003; wound infections 1 (0.8%) versus 5 (6%), p=0.034; and death.

CONCLUSIONS

Minimally invasive surgery for isolated valve lesions in elderly patients yields a lower morbidity and mortality when compared with median sternotomy and should be considered when such individuals require valve surgery.

Mini-sternotomy for aortic valve replacement reduces the length of stay in the cardiac intensive care unit: meta-analysis of randomised controlled trials

Background Mini-sternotomy for isolated aortic valve replacement aims to reduce operative trauma hastening recovery and improving the cosmetic outcome of cardiac surgery. The short-term clinical benefits from the mini-sternotomy are presumed to arise because the incision is less extensive and the lower half of the chest cage remains intact. The basic conduct of virtually all other aspects of the aortic valve replacement procedure remains the same. Therefore, similar long-term outcomes are to be expected. Objectives To conduct a meta-analysis of the only available randomised controlled trials (RCT) in the published English literature. Data sources Electronic search for relevant publications in MEDLINE, EMBASE and CENTRAL databases were performed. Four studies met the criteria. Study eligibility criteria RCT comparing minimally invasive (inverted C or L (J)-shaped) hemi-sternotomy versus conventional sternotomy for adults undergoing isolated aortic valve replacement using standard cardiopulmonary bypass technique. Methods Outcome measures were the length of positive pressure ventilation, blood loss, intensive care unit (ICU) and hospital stay. Results The length of ICU stay was significantly shorter by 0.57 days in favour of the mini-sternotomy group (CI -0.95 to -0.2; p=0.003). There was no advantage in terms of duration of ventilation (CI -3.48 to 0.36; p=0.11). However, there was some evidence to suggest a reduction in blood loss and the length of stay in hospital in the mini-sternotomy group. This did not prove to be statistically significant (154.17 ml reduction (CI -324.51 to 16.17; p=0.08) and 2.03 days less (CI -4.12 to 0.05; p=0.06), respectively). Limitations This study includes a relatively small number of subjects (n=220) and outcome variables. The risk of bias was not assessed during this meta-analysis. Conclusion Mini-sternotomy for isolated aortic valve replacement significantly reduces the length of stay in the cardiac ICU. Other short-term benefits may include a reduction in blood loss or the length of hospital stay.

Surgical Approaches to Aortic Valve Replacement and Repair-Insights and Challenges

Since 1960, surgical aortic valve replacement (sAVR) had been the only effective treatment for symptomatic severe aortic stenosis until the recent development of transcatheter aortic valve replacement (TAVR). TAVR has offered an alternative, minimally invasive treatment approach particularly for patients whose age or co-morbidities make them unsuitable for sAVR. The rapid and enthusiastic utilization of this new technique has triggered some speculation about the imminent demise of sAVR. We believe that despite the recent advances in TAVR, surgical approach to aortic valve replacement has continued to develop and will continue to be highly relevant in the future. This article will discuss the recent developments and current approaches for sAVR, and how these approaches will keep pace with catheter-based technologies.

Stentless Aortic Valve Implantation through an Upper Manubrium-Limited V-Type Ministernotomy

In this piece of work, we attempt to highlight our approach and early experience with minimally invasive aortic valve replacement with aortic Freedom Solo stentless bioprosthesis performed through an upper manubrium-limited ministernotomy in the second intercostal space. The novel suturing technique is required for stentless aortic bioprosthesis implantation, and this, in its turn, will predetermine and influence the surgeon's choice for operative access. In our department, the feasibility of the approach was first assessed; aortic valve was replaced by stentless bioprosthesis in a total of 23 patients (mean age 57 ± 12 years). In all cases, a cardiopulmonary bypass was established by a central ascending aorta cannulation and peripheral percutaneous venous cannula insertion. This approach was found to be technically reproducible and safe. The surgical technique used is described in this article.