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

Less invasive replacement of aortic root, ascending aorta and hemiarch via partial upper sternotomy: a propensity-score-matched comparison with full sternotomy

OBJECTIVES

Less invasive surgery has emerged as an option for aortic pathologies. The current study compared our experience on early postoperative results of patients with aortic surgery between partial upper sternotomy (PUS) and full sternotomy (FS).

METHODS

We performed a retrospective analysis of the data of patients undergoing aortic root surgery with concomitant ascending aorta and hemiarch replacement. Exclusion criteria were type A aortic dissection and other concomitant major cardiac surgery. After propensity score matching, we compared the perioperative outcomes of patients undergoing surgery with PUS versus FS.

RESULTS

A total of 161 patients operated on between January 2013 and September 2022 met the inclusion criteria (PUS: n = 22, FS: n = 139). Propensity score matching yielded 22 pairs with a balanced distribution of propensity scores and covariates between the compared groups. There was no evidence that PUS affects cardiopulmonary bypass [108 (67-119) vs 113 (87-148) min, P = 0.154; PUS vs FS] and circulatory arrest duration [9 (7-10) vs 9 (8-13) min, P = 0.264; PUS vs FS]. There was a reduced cross-clamp duration in the PUS group [88 (58-96) vs 92 (71-122) min, P = 0.032]. Cumulative sum charts have shown consistently low cross-clamp and circulatory arrest duration for 2 experienced surgeons who performed 20 of the procedures in the PUS group (10 each). Perioperative mortality and morbidity were low, with no in-hospital mortality in the PUS group [0 vs 1(4.5%), P > 0.999] and absence of strokes in both groups.

CONCLUSIONS

In summary, our initial experience suggests that less invasive aortic root, ascending aorta and hemiarch replacement via PUS could be performed in our patient cohort as safely as via full sternotomy. Advantages for the patient are reduced surgical trauma, improved cosmetic results and-presumably-less pain.

Minimally Invasive Approach for Replacement of the Ascending Aorta towards the Proximal Aortic Arch

Objectives: In recent years, minimally invasive approaches have been used with increasing frequency, even for more complex aortic procedures. However, evidence on the practicability and safety of expanding minimally invasive techniques from isolated operations of the ascending aorta towards more complex operations such as the hemiarch replacement is still scarce to date. Methods: A total of 86 patients undergoing elective surgical replacement of the ascending aorta with (n = 40) or without (n = 46) concomitant proximal aortic arch replacement between 2009 and 2023 were analyzed in a retrospective single-center analysis. Groups were compared regarding operation times, intra- and postoperative complications and long-term survival. Results: Operation times and ventilation times were significantly longer in the hemiarch replacement group. Despite this, no statistically significant differences between the two groups were observed for the duration of the ICU and hospital stay and postoperative complication rates. At ten-year follow-up, overall survival was 82.6% after isolated ascending aorta replacement and 86.3% after hemiarch replacement (p = 0.441). Conclusions: Expanding the indication for minimally invasive aortic surgery towards the proximal aortic arch resulted in comparable postoperative complication rates, length of hospital stay and overall long-term survival compared to the well-established minimally invasive isolated supracommissural ascending aorta replacement.

Tailored surgical strategies for mini-access open total arch repair

Objective

Open arch repair is perceived as a challenging, high-risk procedure, with a barrier against the use of a minimally invasive approach. We aimed to present a mini-access total arch replacement performed by stratified approaches and to evaluate perioperative outcomes to contribute to the body of evidence.

Methods

We evaluated 40 consecutive patients (aged 69.5 years; interquartile range, 65.6-76.3 years) undergoing elective total arch replacement using 5- to 8-cm upper mini-sternotomy between 2018 and 2022. Surgical strategies, including arterial inflow site and methods of branching vessel reconstruction, were systematically selected at the individual level. To evaluate comparative outcomes, contemporary cases undergoing total arch replacement via sternotomy with similar eligibility criteria served as a control group, and the inverse-treatment-weighting method was used to adjust for baseline characteristics.

Results

Arch-first anastomosis using trifurcate graft, distal-first anastomosis using 4-branch graft, and island anastomosis were used in 18 (45%), 12 (30.0%), and 10 (25%) patients, respectively. Lower body and cardiac ischemic times were 23.4 minutes (interquartile range, 18.0-29.0 minutes) and 66.7 minutes (interquartile range, 50.1-78.2 minutes). There was no early (30-day or in-hospital) mortality, and 2 patients experienced disabling stroke (5.0%). The contemporary control group comprised 55 patients. After an adjustment, a mini-access group showed lower risks of stroke (odds ratio, 0.88; 95% CI, 0.78-1.00; P = .049) and a composite of major complications (odds ratio, 0.79; 95% CI, 0.68-0.92; P = .003), compared with a sternotomy approach.

Conclusions

Based on present results, mini-access total arch replacement may be performed with reasonable safety and efficiency.

Upper Hemisternotomy Versus Full Sternotomy for Replacement of the Supracoronary Ascending Aorta and Aortic Valve

OBJECTIVE

Upper hemisternotomy (UHS) for supracoronary ascending aorta replacement (scAAR) with concomitant aortic valve replacement (AVR) results in less trauma and potentially faster convalescence compared with full sternotomy (FS). Direct head-to-head studies are lacking. We compared a group of UHS patients with a matched group of FS patients undergoing scAAR and AVR.

METHODS

There were 198 patients who underwent scAAR and AVR procedures by a single surgeon between 1999 and 2020. After matching 6 preoperative characteristics, there were 50 UHS and 50 FS patients. Patients who required acute type A aortic dissection repair, reoperations, concomitant procedures, or hypothermic circulatory arrest were excluded.

RESULTS

In the matched sample, the hospital mortality rate was 1% (1 of 100). The median cardiopulmonary bypass time was 150 (interquartile range [IQR], 131 to 172) min and 164.5 (IQR, 138 to 190) min, respectively, for the UHS and FS groups (P = 0.08). The median aortic cross-clamp time was 121 (IQR, 107 to 139) min during UHS and 131 (IQR, 115 to 159) min during FS (P = 0.05). The median ventilation time was 7 (IQR, 3 to 14) h versus 17 (IQR, 10 to 24) h, respectively, after UHS and FS (P = 0.005). The median hospital length of stay was 7 (IQR, 6 to 9) days after UHS and 8 (IQR, 7 to 11) days after FS (P = 0.05).

CONCLUSIONS

The low morbidity and mortality support the wider use of UHS for scAAR and AVR in appropriately selected patients. Larger studies are needed to confirm these initial findings.

Hybrid total arch replacement via ministernotomy for Stanford type A aortic dissection

Background

Type A aortic dissection (TAAD) is a cardiovascular emergency condition with high mortality rate. Hybrid total aortic arch replacement using endovascular graft for the descending aorta repair results in favorable outcomes and has been recommended as an alternative procedure for the higher-risk category patients. Our institution started applying the upper ministernotomy incision technique for the hybrid procedures back in 2018.

Methods

We collected patients who underwent hybrid total arch replacement (HTAR) via ministernotomy (96) and total arch replacement with frozen elephant trunk (TAR + FET) procedures (99), between 2018 and 2021. The baseline information, intraoperative and postoperative characteristics have been compared. Kaplan-Meier analysis was used for survival evaluation. Cox regression were applied to identify the independent predictor of mortality.

Results

The baseline characteristics between the two patient groups were compared and found similar, except that RBC counts were higher (p = 0.038) and the ascending aorta diameter was smaller (P = 0.019) in the "HTAR" group relative to the "TAR + FET" group. The cardiopulmonary bypass time (P < 0.001), the aortic cross clamp time (P < 0.001), the operation duration (P = .029), ICU (P = 0.037) and postoperative hospital stay (P = 0.002) were shorter in the "HTAR" group. The "HTAR" group exhibited also significantly lower levels of intraoperative transfusion (all <0.001) characteristics than the "TAR + FET" group. The hospital mortality and 1-year mortality revealed similar patterns in both groups.

Conclusion

HTAR via ministernotomy have similar short term prognosis, and also reduced the ICU and postoperative hospital stay. In all, The application of the ministernotomy technique in HTAR was safe and technically feasible and may benefit individual patients as well as hospitals in general.

Expanding the Minimally Invasive Approach towards the Ascending Aorta-A Practical Overview of the Currently Available Techniques

Minimally invasive techniques have gained immense importance in cardiovascular surgery. While minimal access strategies for coronary and mitral valve surgery are already widely accepted and often used as standard approaches, the application of minimally invasive techniques is currently expanded towards more complex operations of the ascending aorta as well. In this new and developing field, various techniques have been established and reported ranging from upper hemisternotomy approaches, which allow even extensive operations of the ascending aorta to be performed through a minimally invasive access to sternal sparing thoracotomy strategies, which completely avoid sternal trauma during ascending aorta replacements. All of these techniques place high demands on patient selection, preoperative planning, and practical surgical implementation. Application of these strategies is currently limited to high-volume centers and highly experienced surgeons. This narrative review gives an overview of the currently available techniques with a special focus on the practical execution as well as the advantages and disadvantages of the currently available techniques. The first results demonstrate the practicability and safety of minimally invasive techniques for replacement of the ascending aorta in a well-selected patient population. With success and complication rates comparable to classic full sternotomy, the proof of concept for minimally invasive replacement of the ascending aorta is now achieved.

Minimal access compared to sternotomy for aortic root and arch surgery

INTRODUCTION

Partial upper sternotomy is an established technique for aortic valve surgery in numerous centers. Based on the favorable results, this access can be extended for more complex procedures. We assessed the outcomes of aortic root and arch surgery through partial versus full sternotomy.

PATIENTS AND METHODS

From January 2013 to December 2020, 100 patients underwent proximal aortic surgery. The minimal access approach was used in 73 patients. Operative variables and outcomes were retrospectively analyzed and compared between both groups.

RESULTS

There was no significant difference in cross-clamping and extracorporeal circulation times, as well as no difference in postoperative acute renal failure, stroke, myocardial infarction, and re-exploration for bleeding. However, there was a significant difference in favor of partial upper sternotomy in red blood cell transfusion (0 vs. 234 mL; p = 0.01), postoperative drainage volume (300 vs. 750 mL; p < 0.001), ventilation time (median 3 vs. 24 h; p < 0.001), sepsis (1 [1.4%] vs. 4 [14.8%]; p = 0.02), intensive care unit (median 2 vs. 4 days; p = 0.002) and hospital stay (median 7 vs. 10 days; p < 0.001). Only one patient required intraoperative conversion due to massive bleeding. There was no difference in 30-day mortality between both groups.

CONCLUSION

The partial upper sternotomy approach is safe and feasible for aortic root and arch surgery with morbidity and mortality rates similar to full sternotomy, with the advantages of less blood loss and transfusions need, faster extubation, and shorter length of hospital stay.

Mini-Invasive Bentall Procedure Performed via a Right Anterior Thoracotomy Approach With a Costochondral Cartilage Sparing

Objectives

A right minithoracotomy approach with a sternal sparing technique is a minimally invasive option for surgeons performing aortic root surgery. This report presents our initial clinical results of the right minithoracotomy Bentall procedure.

Methods

Clinical data of 15 patients were retrospectively analyzed who underwent the minimally invasive Bentall procedure through the right anterior thoracotomy via the second intercostal incision without any costochondral cartilage invasion at our institution between October, 2019 and June, 2021. The operative time, length of intensive care unit stay and postoperative hospital stay, perioperative outcomes, and follow-up results were analyzed.

Results

The median aortic cross-clamping time was 95.0 (85.5–98.8) min. Three (21.4%) patients received blood transfusion. The median drainage volume in the first 24 h was 200.0 ml, with no redo for bleeding. The median duration of mechanical ventilation was 12.5 (11.0–25.0) h, and median length of intensive care unit stay was 1.5 (1.0–3.0) day. All patients discharged 5.8 ± 1.2 days following surgery, with no dead patients found. At 6 months following surgery, all patients survived with an improved New York Heart Association (NYHA) functional class.

Conclusion

The right minithoracotomy Bentall procedure may be performed safely with low morbidity and mortality. This approach should be considered as an option in carefully selected patients requiring aortic root replacement.

Minimally invasive approach: is this the future of aortic surgery?

Median sternotomy incision has shown to be a safe and efficacious approach in patients who require thoracic aortic interventions and still represents the gold-standard access. Nevertheless, over the last decade, less invasive techniques have gained wider clinical application in cardiac surgery becoming the first-choice approach to treat heart valve diseases, in experienced centers. The popularization of less invasive techniques coupled with an increased patient demand for less invasive therapies has motivated aortic surgeons to apply minimally invasive approaches to more challenging procedures, such as aortic root replacement and arch repair. However, technical demands and the paucity of available clinical data have still limited the widespread adoption of minimally invasive thoracic aortic interventions. This review aimed to assess and comment on the surgical techniques and the current evidence on mini thoracic aortic surgery.

Early results of total arch replacement under partial sternotomy

OBJECTIVE

Partial sternotomy with limited skin incision has been utilized for cardiac surgery. We, therefore, started to apply the partial sternotomy for total arch replacement since 2013 in selected cases. The aim of this study reported the results of our early experiences.

METHODS

Between July 2013 and December 2015, we retrospectively reviewed 15 cases (median age 72, range 67-84, 15 male) who underwent total arch replacement thorough partial sternotomy. All procedures were performed under hypothermic circulatory arrest with selective cerebral perfusion.

RESULTS

Median skin incision was 9 cm (range 7-15 cm, 5.3% of height) and partial sternotomy consisted of 14 upper and 1 lower partial sternotomy (L shape 8 and T shape 7 cases). Median operation time, cardiopulmonary bypass time, ischemic heart time, selective cerebral perfusion time and hypothermic circulatory arrest time were 485 [360-770], 223 [1174-270], 146 [100-163], 154 [116-189], and 69 [45-90] minutes, respectively. Median duration of mechanical ventilator dependent time was 12 h [5-38]. Median length of ICU stay and hospital stay were 3 [1-7], and 18 [13-76] days, respectively. Thirty days and in-hospital mortality were 0% without any neurological complications. There are two aorta-related reoperation due to graft inducing hemolytic anemia and no aorta-related death during follow-up (median 954, range 702-1462 days).

CONCLUSION

The early results of total arch replacement through partial sternotomy were satisfactory. The partial sternotomy could be a good option for total arch replacement in selected patients.

Mini-Bentall: An Interesting Approach for Selected Patients

OBJECTIVE

Minimally invasive surgery through an upper hemisternotomy for aortic valve replacement has become the routine approach with excellent results. Actually, the same minimally invasive access is used for complex ascending aorta procedures only in few centers. We report our experience with minimally invasive approach for aortic valve and ascending aorta replacement using Bentall technique.

METHODS

From January 2010 to November 2015, a total of 238 patients received ascending aorta and aortic valve replacement using Bentall De Bono procedure at our institution. Low- and intermediate-risk patients underwent elective surgery with a minimally invasive approach. The "J"-shaped partial upper sternotomy was performed through a 6-cm skin incision from the notch to the third right intercostal space. Patients who had previous cardiac surgery or affected by active endocarditis were excluded. The study included 53 patients, 44 male (83 %) with a median age of 63 years [interquartile range (IQR), 51-73 years]. A bicuspid aortic valve was diagnosed in 27 patients (51%).

RESULTS

A biological Bentall using a pericardial Mitroflow or Crown bioprosthesis implanted in a Valsalva graft was performed in 49 patents. The remaining four patients were treated with a traditional mechanical conduit. Median cardiopulmonary bypass time and median cross-clamp time were respectively 84 (IQR, 75-103) minutes and 73 (IQR, 64-89) minutes. Hospital mortality was zero as well as 30-day mortality. Median intensive care unit and hospital stay were 1.9 and 8 days, respectively. The study population compared with patients treated with standard full sternotomy and similar preoperative characteristics showed similar results in terms of postoperative outcomes with a slightly superiority of minimally invasive group mainly regarding operative times, incidence of atrial fibrillation, and postoperative ventilation times.

CONCLUSIONS

A partial upper sternotomy is considered a safe option for aortic valve replacement. Our experience confirms that a minimally invasive approach using a partial upper J-shaped sternotomy can be a safe alternative approach to the standard in selected patients presenting with complex aortic root pathology.

Right Minithoracotomy Approach for Replacement of the Ascending Aorta, Hemiarch, and Aortic Valve

A minimally invasive right anterior thoracotomy approach is the preferred technique used at our institution for isolated aortic valve pathology. We have recently introduced more complex concomitant minimally invasive procedures through this access site. Here, we describe how we perform a replacement of the ascending aorta and aortic valve with and without the use of circulatory arrest through a 6-cm right minimally invasive thoracotomy incision.

Outcomes of Aortic Valve and Concomitant Ascending Aorta Replacement Performed via a Minimally Invasive Right Thoracotomy Approach

Objective

Replacement of the aortic valve with concomitant replacement of the ascending aorta performed via a minimally invasive right anterior thoracotomy approach has not been reported. We evaluated the feasibility and safety of this procedure.

Methods

We retrospectively reviewed all minimally invasive aortic valve replacements (AVRs) with concomitant replacement of the ascending aorta performed at our institution between January 1, 2012, and December 30, 2012. The operative times, intensive care unit and hospital lengths of stay, postoperative outcomes, as well as mortality were analyzed.

Results

A total of 20 consecutive patients who underwent minimally invasive AVR with concomitant replacement of the ascending aorta were identified. There were 16 men (80%), with a mean (SD) age of 61 (13) years. The mean (SD) left ventricular ejection fraction was 58% (8%). The aortic valve was bicuspid in 18 patients (80%), with 14 (70%) being stenotic. The median aortic cross-clamp and cardiopulmonary bypass times were 163 [interquartile range (IQR), 141–170] minutes and 291 (IQR, 177–215) minutes, respectively. Hypothermic circulatory arrest was required in 19 patients (95%), with a median hypothermic circulatory arrest time of 35 (IQR, 33–39.5) minutes. The median intensive care unit and hospital lengths of stay were 24 (IQR, 23–41) hours and 5 (IQR, 4–6) days, respectively. There were no strokes, reoperations for bleeding, or conversions to sternotomy. The 30-day mortality was zero.

Conclusions

Minimally invasive AVR with concomitant replacement of the ascending aorta, via a right anterior thoracotomy approach, can be performed with low morbidity and mortality.

Minimal-access aortic valve replacement with concomitant aortic procedure: a 9-year experience

OBJECTIVE

Minimal-access approaches through upper hemisternotomy is an established technique for aortic valve replacement (AVR) and aortic surgery in our institution. We assessed the outcome of undergoing AVR with concomitant aortic surgery through upper hemisternotomy.

METHODS

We retrospectively reviewed 109 patients from January 2002 to May 2011 who had AVR with concomitant aortic surgery through upper hemisternotomy. Aortic valve replacement with supracoronary ascending aortic replacement was performed in 65 patients; AVR with ascending and proximal arch replacement, in 8 patients; AVR with aortoplasty, in 11 patients; Bentall procedure, in 8 patients; and AVR with root enlargement, in 13 patients. In-hospital outcomes and 1- and 5-year survival were examined.

RESULTS

The mean age was 58.5 years (range, 23-89 years); 41.3% of patients had bicuspid aortic valve (n = 45). Of the patients, 82.6% had true aneurysm (n = 90), 2.8% had calcified aorta (n = 3), 8.3% had small annulus (n = 9), and 3.7% had calcified annulus (n = 4). There were 6 (5.5%) reoperations and 15 (13.8%) urgent cases. Mean perfusion time was 152 ± 61 minutes, and cross-clamp time was 108 ± 47 minutes. Nine cases were performed with deep hypothermic circulatory arrest (8.3%). Operative mortality was 2.8% (n = 3). There were 4 (3.7%) cases with reoperation for bleeding, 2 (1.8%) myocardial infarctions, and 2 (1.8%) new-onset renal failure. Mean length of stay was 7.1 ± 5.6 days. Kaplan-Meier analysis showed that 1-year postoperative survival was 96.2% and 5-year survival was 92.4%.

CONCLUSIONS

An upper hemisternotomy approach is safe and feasible for AVR and concomitant aortic surgery with good early and midterm outcomes. This approach is also associated with low morbidity rate and short length of stay.

Interventional strategies to manage heart failure in patients with cancer

The unique clinical circumstances that are typically encountered by cardiology providers when caring for patients undergoing treatment for cancer require an in-depth understanding of the recommended treatments for the diagnosis and management of heart failure and ischemic heart disease. It is also recognized that there is not a broadly described clinical research basis from which to provide guidance when specific clinical decision making is required. Thus, it is imperative that cardiology and oncology closely collaborate when difficult patient decisions arise. Engaging each discipline together with active patient involvement in clinical care will undoubtedly provide optimal care for our patients.

Percutaneous and Minimally Invasive Valve Procedures

The incidence of valvular heart disease is expected to increase over the next several decades as a large proportion of the US demographic advances into the later decades of life. At the same time, the next several years can be anticipated to bring a broad transition of surgical therapy to minimally invasive (minithoracotomy and small port) access and the more gradual introduction of percutaneous approaches for the correction of valvular heart disease. Broad acceptance of these technologies will require careful and sometimes perplexing comparisons of the outcomes of these new technologies with existing standards of care. The validation of percutaneous techniques, in particular, will require the collaboration of cardiologists and cardiac surgeons in centers with excellent surgical and catheter experience and a commitment to trial participation. For the near term, percutaneous techniques will likely remain investigational and will be limited in use to patients considered to be high risk or to inoperable surgical candidates. Although current-generation devices and techniques require significant modification before widespread clinical use can be adopted, it must be expected that less invasive and even percutaneous valve therapies will likely have a major impact on the management of patients with valvular heart disease over the next several years.

Minimal Access Surgery of Ascending and Proximal Arch of the Aorta: A 9-Year Experience

BACKGROUND

Minimal access approaches are becoming readily accepted techniques for cardiac valve surgery. However, the safety or benefit of this approach for aortic surgery has not been well investigated.

METHODS

We retrospectively analyzed 128 consecutive patients who underwent ascending aortic replacement (n = 53), proximal aortic arch replacement (n = 7), aortic root replacement (n = 67), or sinus of Valsalva aneurysm repair (n = 1) through an upper hemisternotomy between August 1996 and May 2005. Using matched variables (age, type of procedure, redo operation, and use of circulatory arrest), we constructed two matched cohorts of 79 patients each: a minimally invasive (group A) and full sternotomy (group B) and compared outcomes.

RESULTS

The mean age for the minimally invasive group (n = 128) was 54 years (range, 25 to 83 years). There were six reoperations (4.7%), five (3.9%) urgent operations, and 16 (12.5%) deep hypothermic circulatory arrests. Operative mortality was zero, the median length of hospital stay was 5 days (range, 3 to 21 days), and 112 patients (82.4%) were discharged home. Actuarial survival at 5 years was 97.2%. On comparison between group A and B, there was no significant difference in operative times, mortality, and morbidity. However, group A had shorter median length of stay (5 versus 6 days, p = 0.020) and fewer median units of red blood cell transfusion than group B (2 versus 2.5, p = 0.020).

CONCLUSIONS

An upper hemisternotomy approach is safe and feasible for ascending aortic and proximal arch surgical procedures, with excellent early and late outcomes. This approach is associated with shorter hospital stay and less blood transfusion.

Minimally Invasive Valve Surgery

Minimally invasive heart valve surgery has evolved significantly over the past 10 years and now comprises safe and efficient operations for most patients. The main goals of minimally invasive heart valve surgery are to reduce surgical trauma, increase patient satisfaction, reduce morbidity, and lower costs while still providing durable and safe valve repair or replacement. After a decade of refinements, studies have shown that minimally invasive heart valve surgery is a safe and effective procedure with similar if not improved perioperative morbidity and mortality rates compared with conventional valve surgery. Patients derive a variety of tangible benefits from these new surgical approaches, including less pain, shorter lengths of hospital stay, and faster return to preoperative functional levels. Minimally invasive heart valve surgery should be an option for any patient undergoing heart valve surgery today.

Minimally Invasive Surgery for Valve Disease

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

Impact of Concomitant Coronary Artery Bypass Grafting on Hospital Survival After Aortic Root Replacement

BACKGROUND

We examined the impact of concomitant coronary artery bypass grafting (CABG) on hospital survival after aortic root replacement. We sought to determine whether CABG procedures that were not originally planned but rather added after the aortic root procedure was completed (CABG/bailout) skewed the results to shift patients with bad outcomes to the CABG group, making the non-CABG group appear undeservedly low risk.

METHODS

Between May 1992 and January 2001, 369 consecutive patients underwent aortic root replacement. Concomitant CABG was required in 95 patients (26%). Indications for CABG were significant coronary artery disease in 73 patients (20%), active endocarditis or acute aortic dissection involving the coronary orifices in 14 patients (4%), and difficulty weaning from bypass because of regional wall motion abnormality from presumed but unconfirmed coronary artery disease or technical error at coronary ostial reimplantation (CABG/bailout) in 8 patients (2%).

RESULTS

Operative mortality for the entire cohort was 5.7% (21 patients). The operative mortality rate for the non-CABG group was 0.4% (1 of 274 patients), and for the CABG group, 21% (20 of 95 patients; p < 0.001). Independent predictors of operative mortality in the CABG group were New York Heart Association functional class III or IV (odds ratio, 3.9; 95% confidence interval, 1.07 to 14.5), active endocarditis (odds ratio, 9.2; 95% confidence interval, 2.06 to 41.5), acute aortic dissection (odds ratio, 7.6; 95% confidence interval, 1.81 to 32.0), and failure to use retrograde cardioplegia (odds ratio, 6.4; 95% confidence interval, 1.06 to 38.8). The use of CABG/bailout was not a predictor.

CONCLUSIONS

Adding CABG at the end of an aortic root procedure is a rare event, and because it is rare, there is no significant shift of risk as a result of the CABG/bailout patients on the overall CABG group.

Minimally invasive valve surgery: what the pathologist should know

Minimally invasive approaches in cardiac surgery have emerged as an alternative to standard techniques particularly in patients undergoing valvular surgery. Their established benefits for the patients are likely to cause their widespread use in the future. The purpose of this is to provide an overview of modern minimally invasive approaches in valvular surgery with an emphasis on aspects of the surgery relevant for cardiovascular pathologists.

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

INTRODUCTION

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Anaesthesia for minimally invasive cardiac surgery

Minimally invasive cardiac surgery is used for both extracardiac and intracardiac procedures. Extracardiac procedures, such as coronary artery bypass grafting, are often performed on a beating heart. Intracardiac procedures are done with the aid of cardiopulmonary bypass. The surgery is performed via a minithoracotomy or a ministernotomy. Thoracoscopic video-assisted surgery, often with robotic assistance, necessitates prolonged one-lung ventilation to optimize exposure. Port-access surgery will require appropriate positioning of various catheters to establish cardiopulmonary bypass. Adequate flow during cardiopulmonary bypass may require suction augmentation of venous return and may increase the risk of air emboli. Limited exposure of the heart during surgery poses challenges with management of arrhythmia, haemostasis, myocardial protection and de-airing at the end of surgery. Patient selection is important to avoid intra-operative and post-operative complications. Prolonged single-lung ventilation, incomplete revascularization in hybrid procedures, and limited access for rapid intervention pose challenges with patient management. Conversion to sternotomy that may be required occasionally and extension of portals over several dermatomal segments mandate a versatile analgesic technique.

Antibiotic prophylaxis in endoscopic and minimally invasive surgery

Infections are unusual following minimally invasive surgery but antibiotic prophylaxis is given in the same way as for the open surgery equivalents. Most prophylactic regimens have not been subjected to randomised placebo controlled trials. Antibiotic prophylaxis has been shown to be beneficial in transurethral resection of the prostate. In endoscopic retrograde cholangiopancreatography (ERCP) the incidence of bacteremia, but not cholangitis, is reduced by prophylaxis and some do not recommend its routine use. For arthroscopies and laparoscopies infection is too rare to warrant prophylaxis. There is a theoretical risk of infection in that endoscopes cannot withstand autoclaving so only high level disinfection can be used between patients. However, for most minimally invasive operations, the small wound size, reduced immune challenge and rapid recovery of the patient outweigh any disadvantages compared with open surgery.